MANILA DOCTORS COLLEGE

Pres. Diosdado Macapagal Boulevard

Metropolitan Park, Pasay City

In partial fulfilment
Of the Requirements of the
College of Nursing in
Related Learning Experience

CVD infarct

Submitted by:
Caberte, Iris D

Group CA5
BSN III – A2

Submitted to:
Didith Javier Germono, RN
 MANILA DOCTORS COLLEGE
Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay city

I. ASSESSMENT

A. General Data

Resident’s Initials: H.K.. Sex: Male

Address: Paranaque city
Age: 63 yrs. old Civil Status: Single
# of days in the Hospital: 5 days Occupation: Retired
Place of Birth: Japan Date of Birth: 01/03/1947
Date of Admission: 07/17/10
Order of Admission: Ambulatory
Informant: Y.K.
Date of History Taking: 07/21/10

B. Chief Complaint

The client is experiencing left side weakness and was rushed to the hospital.

C. History of Present Illness

1 week prior to the confinement, the client felt pain in his neck and cannot
flexed or hyperextend his neck.

5 hours prior to the confinement, the client has weakness in his left side and
has difficulty in standing up or ambulates.

D. Past History
1. Childhood Illness/es: None
2. Adult Illnesses: None
3. Immunization: Unrecalled
4. Previous Hospitalization: He was confined due to the operation in the
right eye last November 1954.
5. Operation/s: Glass prosthetic eye surgery when he was 7 years old
(November 1954)
6. Injuries: None
7. Medications taken prior to confinement: None
8. Allergies: None

E. Systems Review- Gordon’s Eleven Functional Health Pattern (July 21,

2010)

A. Health Perception- Health management

Prior to confinement, According to his daughter he rarely gets illness.

HK’s health has been good prior to confinement. He experienced to be confined
in the hospital because of the operation on the right eye. He experienced fever and
his remedies for it were enough rest and intake of plenty amounts of water. He
smokes 30 sticks per day and drinks alcoholic beverages occasionally.

During confinement, According to his daughter, the client eats well and is
not particular on the foods that are served. He is in low salt, low fat, high fiber
diet.
B. Nutritional-Metabolic Pattern

Prior to confinement, According to his daughter, the client had no eating

problems such as difficulty in swallowing and has no restrictions in diet. He has
good appetite. Most of the time, he eats fish, raw foods and anything that were
served to him. He eats 3 times a day and his meal would consist of a cup of rice
and a serving of viand. He also had snacks such as biscuits, noodles, or sometimes
prepared foods in there house in between meals. He wears dentures on the upper
molar. The patient stated that his wounds heal just fine.

During Confinement, According to his daughter, the client eats the food
served by the hospital and eats plenty of bananas and water. He would only drink
about 7 - 8 glasses of water a day. The patient weighs 66 kilos and according to
him, he neither loss nor gain weight for the past months. The patient weighs 66
kilograms and his height is 5’5” or 65 inches. His body mass index is 24.2 kg/m2
his body is in normal range.

C. Elimination Pattern

Prior to confinement, the client had no problems in urinating and

defecating. She does not use laxatives and does not feel any discomfort. He
defecates regularly every afternoon. The client had no odor problems and no
excessive perspiration.

During confinement, the client defecates twice a week and urinates 6-7
times a day. The client does not perspire a lot because of decreased activity. The
client’s stool is brown in color and soft in form while the client’s urine is
yellowish in color.

D. Activity – Exercise Pattern

Prior to confinement, the client had no form of exercise other than walking
and sometimes gardening and cooking. During his spare time, he stays at home
watching television and playing cards.

During confinement, the client spends most of his time in his room
playing cards and watching TV. The doctor ordered him for a complete best rest
with bathroom privileges.

Client’s Perceived and Demonstrated Ability:

Feeding- 0 Cooking- 0

Bathing- 0 Shopping- 0

Toileting- 0

Bed mobility- 0

Dressing- 0

Grooming- 0

General mobility- 0

House maintenance- 0
Functional level codes:
Level 0: Full self care
Level 1: Requires use of equipment or devices
Level 2: Requires assistance/ supervision from another person
Level 3: Requires assistance/ supervision from another person and
equipment/device
Level 4: Is dependent and does not participate

E. Sleep-Rest Pattern

Prior to confinement, according to the client’s daughter, the client usually

sleeps from 11 PM and wakes up 6 PM with a total of 5 hours. He sleeps while
watching TV.

During confinement, the client is not well rested. According his daughter,
the client’s sleeping pattern is intermittent because of the vital signs which is
every 2 hours. He usually sleeps at

F. Cognitive- Perceptual Pattern

Prior to confinement, the client’s vision on the left side is 35 while his
right eye is prosthetics. “I was stabbed in my right eye with a knife when I was 7
years old and I was rushed in the hospital for eye replacement surgery” translated
by his daughter. He does not use eyeglasses. He keeps asking to repeat the words
when he cannot understand or hear. He does not use hearing aids. The client uses
Japanese when speaking and a little bit of Filipino.

During confinement, the client’s vision and hearing is still the same.
Client can is oriented with time & date, people around his and the place.

G. Self Perception- Self Concept Pattern

Prior to confinement, the client feels calm, happy, and good about himself.
He doesn’t get angry or annoyed easily. He is always full of hope when problems
arise, and is very optimistic because for her

During confinement, the client feels good about himself. The client’s eye contact is
consistent. The client is relaxed most of the time. The patient’s body posture is quite relaxed
and assertive.

H. Roles-Relationships Pattern

Prior to confinement, according to the client’s daughter, his wife and his 2
sons were in Japan. His daughter, niece, and grandparents were left in the house.
They share responsibility in house hold chores. He is not a member of any social
group.

During confinement, the client’s roles and relationship is the same.

I. Sexuality- Reproductive Pattern

Prior to confinement, the client has a wife who’s married for 40 years.
They are not active anymore.

During confinement, the client established a good relationship with other

residents and staff nurse.
J. Coping-Stress Tolerance Pattern

Prior to confinement, according to his daughter, the client is able to cope

with different situations because he is optimistic. Whenever problems arise, he
seeks and consults to her partner. They also pray together and asks for forgiveness
and guidance. He remains calm and relaxed when tough times come because he
believes that all problems have a solution.

During confinement, the client stated that he wants to go home. He is most

of the time relaxed lying on the bed watching TV.

K. Values Belief Pattern

Prior to confinement, according to her daughter, he neither goes to church
nor pray at night. The client’s religion is Buddhist but his family are Christians.
He believes that people control their faith and destiny.

During confinement, the client’s belief is still the same.

F. Family Assessment

EDUCATIONAL
NAME RELATION AGE SEX OCCUPATION
ATTAINMENT
H.K. Client 63 M Retired College graduate
High school
E.M. Father 90 M Retired
graduate
High school
R/M/ Mother 87 F Retired
graduate
Y.K. Daughter 19 F None College student
L.B. Niece 21 F None College graduate

G. Heredo – Familial Illness

Maternal: Alzheimer’s
Paternal: None

H. Developmental History
 Theory (Theorist) Age Developmental Task Patient’s Description
Psychosexual 13 yrs. Genital Stage The client has a wife and 3
(Sigmund Freud) old and . children. They are 40 years
above married and not sexually active
because they are both old. His
wife lives in Japan with his 2
sons an him left in the
Philippines with his daughter,
his niece, and his grandparents.
Psychosocial 41 Generativity vs. Stagnation Measure
(Erik Erikson) years accomplishments/failures. “Am I
old and satisfied or not?” The need to
above assist the younger generation.
The client assists his offspring
for the next generation.

Cognitive 12 and Formal Operations Stage The client is mature enough to

(Jean Piaget) above make his own decisions based
on what is best for his family.
He consults his family first if his
decision is in favourable for all
family members and he is open
up for any opinion. He is able to
determine what is right from
wrong.
Moral 35 and Post conventional Level There is a growing realization
(Kohlberg) above that individuals are separate
entities from society, and that
the individual’s own perspective
may take precedence over
society’s view; they may
disobey rules inconsistent with
their own principles. These
people live by their own abstract
principles about right and wrong
—principles that typically
include such basic human rights
as life, liberty, and justice.
Because of this level’s “nature
of self before others”, the
behavior of post-conventional
individuals, especially those at
stage six, can be confused with
that of those at the pre-
conventional level.

Spiritual 21- 45 Stage 4 Individuative- He as an individual takes

( James Fowler) yrs.old Reflective faith personal responsibility for
their beliefs and feelings.
I. Physical Examination (July 21, 2010)
Vital Signs
BP = 140/90 PR = 72 bpm
RR = 19 bpm T = 36.5 °C

Anthropometric Measurements:
Actual Weight: 66 kg
Actual Height: 5’ 5”

Regional Examination:
A. Skin
Inspection:
-Skin colour is fair white and wrinkled.
-No presence of rashes or any lesions
-Absence of edema
Palpation:
-No presence of rashes or any lesions
-Absence of edema
-Skin is dry and warm to touch
-Poor skin turgor
-Absence of palpable mass and nodules

B. Nails
Inspection:
-Clean with minimum length of nails
-Nail bed colour is pale pink
Palpation:
-Smooth in texture.
-Capillary refill about 4-5 seconds

D. Hair
Inspection:
-Evenly distributed
-Scanty white in colour
-Presence of body hair and evenly distributed
-Little visible dandruff
-No infestation of lice

C. Head and Face

Inspection:
-Normocephalic and symmetric
-With symmetrical facial movements
 -No swelling
Palpation:
-Smooth skull contour
-Absence of nodules and masses

D. Eyes
Inspection:
-Brown eyelids with no presence of lesions.
-Brows are symmetric and have equal hair distribution.
-Eyelashes are curved outward and evenly distributed
-Upper and lower conjunctiva pale pink in colour
-Sclera appears white
-Cornea is transparent and appears shiny and smooth
-Pupil of left eye is black in colour, round, reactive to light and
accommodation.
-the right eye is already a prosthetic

Palpation:
-Absence of edema, masses and nodules
-No tenderness noted
-Visual fields: client can see objects in periphery on the left eye
-Extra ocular movement test: able to follow six directions of gaze
on the left eye
-Visual acuity test: able to read newsprint on the left eye

E. Ears
Inspection:
-Colour same as surrounding skin
-Symmetrical
-No presence of cerumen or any discharges.
-Absence of masses
-Hearing Acuity test: ask people to hear words
-Weber's test: bone conduction is greater than air conduction
Palpation:
-No tenderness noted

F. Nose
Inspection:
-Located at the midline.
-Same colour as surrounding skin
-No swelling or inflammation.
-No presence of exudates and mucus secretions.
Palpation:
-No tenderness noted

G. Mouth and Pharynx

Inspection:
-Dry mouth
-Lips light pink in colour
-Absence of swelling, lesions and ulcerations
-Tongue able to move freely
-False teeth visible on upper molar

H. Neck
Inspection:
-Located at the midline.
-Able to flex and hyper extend neck without discomfort
 Palpation:
-No tenderness noted
-No palpable lymph nodes

I. Spine
Inspection:
-Straight
-No signs of bulging or deviations.
Palpation:
-No presence of lumps or masses.

J. Thorax and Lungs

Inspection:
-Do not use accessory muscle to breathe.
-Normal rate and rhythm of respiration
Palpation:
-Symmetrical chest excursions.
-No presence of abnormal masses and deformities.
-Absence of tenderness over the chest wall
Percussion:
-Symmetrical resonant sounds heard
Auscultation:
-Wheezing sound heard on both lungs.

K. Cardiovascular/Heart
Inspection:
-No visible pulsation.
-No exaggerated lifts and thrills in the area.
-No distended and bulging veins

Palpation:
-No presence of lumps and masses.
Auscultation:
-Cardiac rate and rhythm normal
-Absence of heart murmurs and bruits

L. Breasts
Inspection:
-Colour same as surrounding skin
-Round shape, symmetrical and intact skin
-Nipples are round, equal in size, same colour and both nipples
points in same direction
-No discharge noted
-Absence of masses
Palpation:
-Absence of tenderness

M. Abdomen
Inspection:
-Uniform colour of the abdomen
-Round in shape
-No prominent pulsation
-No presence of any distention or any bulging.
-Umbilicus is located at the midline with no presence of discharges
Auscultation:
-Presence of bowel sounds
Percussion:
 -Tympani over the abdomen
Palpation:
-Absence of tenderness

N. Extremities
Inspection:
-Symmetrical body parts.
-Performs Pill Rolling
Palpation:
-Firm and smooth.
-No swelling or any nodules.
-No muscle tenderness
O. Genitals
- Not Assessed

P. Rectum and Anus

- Not Assessed

Q. Neurological
July 17 – 18: Glaucoma scale score is 15/15. Sensorium is always awake. Both
left arm and leg is experiencing weakness.
July 19 – 20: Glaucoma scale score is 15/15. Sensorium is always awake. Both
left arm and leg is experiencing normal power.

II. Personal/Social History

Hobbies: He likes playing cards, watching, gardening, and cooking.
Vices: He smokes 30 sticks per day and drinks alcohol occasionally.
Social Affiliation: None

Client’s usual day like: The client usually wakes up at 5 am doing their normal
routine like morning care, cooks breakfast and eating breakfast. Every Friday and
Sunday she and her co-residents do the laundry. If there were student nurses in the
pavilion, they would provide the residents different activities. She eats dinner at
7pm and usually sleeps at 11 pm.
Rank/Order in the family: Father
Travel: Japan, Cabanatuan
Educational Attainment: College graduate
Occupation: He was a chef before he retired.

III. Environmental History

Before confinement the patient lives at a two storey house. Their house is
well constructed. Services such as electricity, water supply, and regular garbage
collection are present. Their house is accessible to health care facilities such as
Health Centre, Hospital, and Pharmacy. Commercial Establishments is also
accessible. Means of transportation such as jeepney, bus, taxi, pedicab, and
tricycle are present.

IV. O.B. GYNE History (Not Applicable)

V. Pediatric History (Not Applicable)

 VII. Laboratory Tests

HEMATOLOGY (July 17, 2010)

Normal
Components Results Interpretation
Values
Decreased, With iron deficiency,
bone marrow iron stores are
140-175 rapidly decreases and the
Hemoglobin 123
g/L erythrocytes produced by the
marrow are small and low in
haemoglobin.
Decreased,Hematocrit represents
Hematocrit 0.42-0.50 0.40 the percentage of red blood cells
found in 100 ml of whole blood.
Decreased, RBC is a cellular
component of blood involved in
the transport of oxygen and
Red Blood Cell 4.50-5.90
4.15 carbon dioxide. The patient’s
Count x 1012/L
RBC is below the normal range
which indicates a shortage called
anemia.
Normal WBC or leukocyte
White Blood 4-10.50 x protects the body from invasion
6.57
Cell Count 109/L by bacteria and other foreign
entities
Differential Count
Normal, A neutrophil is a fully
mature WBC capable of
phagocytosis and essential in
Neutrophil 0.36-0.66 0.62
preventing and limiting bacterial
infection

Lymphocyte 0.24-0.44 0.31 Normal, Lymphocytes produce

substances that aid in attacking
foreign material. One group is T
lymphocyte which kills foreign
cells directly or releases a variety
of lymphokines, substances that
enhance the activity of
phagocytic cells. The other group
is B lymphocyte which is capable
 of differentiating into plasma
cells
Normal, Monocytes are
Monocyte 0.02-0.12 0.05 considered to be the largest
among the leukocytes
Normal, eosinophils play a role
in fighting viral infections, which
is evident from the abundance of
RNAses they contain within their
Eosinophil 0.02-0.05 0.02 granules, and in fibrin removal
during inflammation. Eosinophils
along with basophils and mast
cells, are important mediators of
allergic responses and asthma.

COAGULATION & HEMOSTASIS (July 17, 2010)

Normal
Components Results Interpretation
Values
Protime
Normal, PTT measures the extrinsic
pathway of coagulation. They are
Prothrombin time 11.65-14.60 used to determine the clotting
13.4
– Patient secs tendency of blood, in the measure
of warfarin dosage, liver damage,
and vitamin K status.
Prothrombin time 11.65-14.60
13.13 Normal.
– Control secs
Prothrombin time
70-100% 96 Normal.
– Activity
APPT
Activated Partial
Thrombopl 26.66 –
30.8 Normal.
astin – 34.55 secs
Patient
Activated Partial
26.66 –
Thromboplastin – 31.6 Normal.
34.55 secs
Control

SAMPLE SERUM (July 17, 2010)

Normal
Components Results Interpretation
Values
Normal, The blood urea nitrogen test is a
measure of the amount of nitrogen in the
3.20 – 7.10 blood in the form of urea, and a
BUN 4.66
mmol/L measurement of renal function. Urea is a
substance secreted by the liver, and
removed from the blood by the kidneys.
Normal, Alanine transaminase is
an enzyme found in the highest amounts in
ALT/SGPT 21 – 72 u/L 24
the liver. Injury to the liver results in release
of the substance into the blood.
AST/SGOT 17 – 59 u/L 24 Normal, AST (aspartate aminotransferase)
is an enzyme found in high amounts in heart
 muscle and liver and skeletal muscle cells. It
is also found in lesser amounts in other
tissues.
Normal, Creatinine is a breakdown product
of creatine, which is an important part of
58 – 110 muscle. Creatinine is removed from the
Creatinine 66
ummol/L body entirely by the kidneys. This article
discusses the test done to measure the
amount of creatinine in your urine.
Normal, Sodium is both an electrolyte and
a mineral. It helps keep the water and
135 – 145 electrolyte balance of the body. Sodium is
Sodium 136
mmol/L also important in how nerves and muscles
work.

Decrease, Potassium is a very important

mineral for the proper function of all cells,
tissues, and organs in the human body. It is
also an electrolyte, a substance that
3.6 – 5 conducts electricity in the body, along with
Potassium 3.5
mmol/L sodium, chloride, calcium, and magnesium.
Potassium is crucial to heart function and
plays a key role in skeletal and smooth
muscle contraction, making it important for
normal digestive and muscular function.

SAMPLE SERUM (July 18, 2010)

Normal
Components Results Interpretation
Values
Normal, A fasting blood sugar (FBS) level
70.3 – 100
FBS 82.88 is one of the tests used to diagnose diabetes
mg/dL
mellitus.
Normal, Cholesterol is a chemical
compound that is naturally produced by the
0 – 200.77 body and is a combination of fat and steroid.
Cholesterol 200.77
mg/dL Cholesterol is a building block for cell
membranes and for hormones like estrogen
and testosterone.
Increased, Triglycerides are the chemical
form in which most fat exists in food as well
as in the body. They're also present in blood
0 – 200
Triglycerides 242.48 plasma and, in association with cholesterol,
mg/dL
form the plasma lipids. Elevated
triglycerides may be a consequence of other
disease, such as untreated diabetes mellitus.
Decreased, It is called the "good
cholesterol" because HDL cholesterol
38.61 – particles prevent atherosclerosis by
HDL 61.78 29.73 extracting cholesterol from the artery walls
mg/dL and disposing of them through the
liver. Low levels of HDL cholesterol are
risk factors for atherosclerosis,
LDL 0 – 150.58 121.24 Decreased, It is called "bad" cholesterol,
mg/dL because elevated levels of LDL cholesterol
 are associated with an increased risk of
coronary heart disease. LDL lipoprotein
deposits cholesterol on the artery walls,
causing the formation of a hard, thick
substance called cholesterol plaque.

X-RAY RESULTS: CHEST AP (July 17, 2010)

Impression: An apicolordotic view (ALV) is suggested to further evaluate the left
upper lobe.

CT SCAN OF THE HEAD (July 17, 2010)

Impression: Hyperacute infarct in the right capsuloganglionic region is
considered. Age related cerebral atrophy.

TRANSCRANIAL DOPPLER (July 19, 2010)

Findings: Normal flow velocities and wave form patterns bilateral MCAs, PCAs,
ACAs, ophthalmic arteries, carotid siphons, and vertebra – basilar circulation.

Interpretation: Present TCD exam show no evidence of significant stenosis in all

the intracranial arterial segments insonated.

CEREBROVASCULAR INVESTIGATION (July 19, 2010)

1) 50 – 69% right internal carotid artery stenosis with type I plaque morphology.
2) < 50% left internal carotid artery stenosis with type II plaque morphology.
3) Insignificant bilateral external carotid arteries.
4) Tortuous bilateral internal carotid arteries.
5) Antegrade bilateral vertebral artery flow; consider distal right vertebral artery
stenosis

Type I > Uniformly echolucent with thin echogenic cap

(homogenous hypoechoic)
*high risk of plague rupture and embolism

Type II>heterogenous hypoechoic

Substatially echolocent

Type III> Hetero hyperechoic

Dominantly echolocent

Type IV> Uniformly echogenic

Homo hyperechoic

Type V> calcified

B. On-going Appraisal

July 17, 2010, H.K. was admitted in MDH at 7F under the provision of Dr.
Bravo. Citicoline given 500 mg 1 cap bid, Nevramin 1 tab bid, Preracid 30 mg 1
tab OD, Simvastatin 40 mg 1 tab OD-HS, Lilac 30 cc OD-HS, Ectrin 300 mg 1
tab bid, Kalium Durule 1 durule bid for 2 days, Clopidogrel 75 mg 1 tab OD,
Zinnat 500 mg 1 tab bid for 7 days, and Iberet FA 1 tab OD. On hold Norvasc 5
mg 1 tab OD if systolic BP < 130, Clexane SC 0.4 cc Q12 if systolic < 140,
Catapres SC 75 mcg ½ tab if MAP > 120. Blood test, bleeding time, serum
samples, x-ray, and CT scan requested by the physician. Neurological status is
monitored.

July 18, 2010, Discontinued Catapres SC 75 mcg ½ tab if MAP > 120.

July 19, 2010, Discontinued Kalium Durule 1 durule bid. Transcranial Doppler
and Cerebrovascular Investigation requested by the physician.

July 20, 2010, Discontinued Preracin 30 mg 1 tab OD, and Ectrin 300 mg 1 tab
bid. Discontinued neurological status monitoring.

July 21, 2010, Possible discharge on July 22 after doctors rounds.

July 22, 2010, The client was discharged.

C. Discharge Plan

M – edications
Continue ongoing medications: Citicoline given 500 mg 1 cap bid,
Nevramin 1 tab bid, Simvastatin 40 mg 1 tab OD-HS, Clopidogrel 75 mg
1 tab OD, Clexane SC 0.4 cc Q12 if systolic < 140, Norvasc 5 mg 1 tab
OD.

E – xercise
Any form of exercise that the client wishes to perform as long as it is
contraindicated to her condition. A concrete example would be walking
for 30 minutes or more every morning.

T – reatment
1.) Continue nebulization to the patient.
2.) Eat frequent small meals.
3.) Treatment regarding prescribed medications.
4.) Avoid drinking caffeine
H – ealth Teachings
1.) Avoid fatty foods such as pork, beef, and others to avoid further
blockage of the artery.
2.) Avoid salty foods such as sauces, chips, pretzels, bacon, canned
foods, processed meats, and garnishes.
3.) Eat foods rich in potassium such as banana, honeydew, peanuts,
spinach, canopy, wheat, potatoes, etc.

O – PD
Refer to Physician/Psychiatrist for OPD follow-ups.

D – iet
1.) Avoid eating food rich in sugar, such as candies, chocolates etc
2.)Avoid fatty foods such as pork, beef, and others to avoid further
blockage of the artery.
3.)Avoid salty foods such as sauces, chips, pretzels, bacon, canned foods,
processed meats, and garnishes.
3.) Drink plenty amount of water, at least 8 glasses a day
4.) Eat foods rich in potassium such as banana, honeydew, peanuts,
spinach, canopy, wheat, potatoes, etc.

S – igns and symptoms

Educate the family and significant others of client about the signs and
symptoms of patients with CVD infarct such as:

Positive Symptoms – Hypertension, dyspnea, wheezing lung sounds

Educate the family and significant others of client about the side effects of
the anti-hypertensive and potassium supplement drugs.