II. PATIENTS PROFILE A. Mr.

C is a 72 years old male, Filipino, non-diabetic diagnosed with CHF secondary to IHD, with HPN stage 2, and CAP. He is a widow for four years and currently lives with his children and grandchildren. Before, at age 15 he worked as a fisherman. He is a Roman Catholic and actively attends mass every Sunday.

B. HISTORY OF PRESENT ILLNESS The client was admitted to the ER of RPH last June 27, 2011 with complains of difficulty of breathing and chest pain, wherein series of laboratory tests was done. He was then admitted to the infectious medical ward at bed 15 for monitoring, management and also to rule out moderate risk of Congestive heart failure secondary to Ischemic heart disease, with hypertension stage 2 and community acquired pneumonia. Mr. C. has been experiencing easy fatigability and shortness of breath three weeks prior to admission. He decided to go to the hospital for check up. The same diagnosis was given to him. Patient was compliant of his home medications until his condition worsened and was rushed again to the hospital.

C. HISTORY OF PAST ILLNESS Patient had undergone prostate surgery last February 15, 2011 due to prostate enlargement. Non asthmatic and has no allergies to food and drugs. Patient had a history of PTB.

Heredofamilial History DISEASES HPN DM CANCER CARDIO VASCULAR PATERNAL (-) (-) (-) (+) MATERNAL (+) (-) (-) (-)

DISEASES ALLERGIES

(-)

(-)

D. SOCIO ECONOMIC STATUS Patient start smoking at the age of 19 then ceased smoking during the year 1990. He was an alcoholic drinker, 1 bottle of liquor every other day but had been a moderate drinker since he had undergone prostate surgery.

III. LABORATORY RESULT

URINALYSIS

COLOR: yellow acidic

TRANSPARENCY: turbid

REACTION:

SPECIFIC GRAVITY: 1.000 WBC: Plenty ALBUMIN: Positive + SUGAR: Negative RBC: 3-4/ hpf EPITHELIAL CELL: -1

INTERPRETATION: Patients urine color is normal. Specific gravity is below normal which may indicate hydration or consistent with the concentrating defect. Presence of WBC, increased RBC and turbid transparency in the urine indicates infection. Uric acid will precipitate in acidic urine. Presence of protein in the urine can indicate kidney problem.

BLOOD CHEMISTRY CREATININE: SODIUM: POTASSIUM: 93.7 142.9 3.19

INTERPRETATION: Normal.

HEMATOLOGY

Hemoglobin: Hematocrit: WBC (leucocyte):

110 0.33 5.8

DIFFERENTIAL COUNT: SEGMENT: 0.70 LYMPHOCYTES: 0.30

INTERPRETATION:

NURSING ASSESSMENT Complete assessment on the status of the client was conducted on June 30, 2011. Physical Examination was also carried out on the same date by inspection, palpation, percussion, and auscultation.

In the health perception and health management pattern, the client reports that due to his age he is prone to have a disease. He always consults a physician whenever he feels any problem with his condition. He takes his medicines regularly and takes period of rest. He claims to have no traditional beliefs. According to the client the reason he felt ill is because he doesnt have any exercise and he always eat whatever he likes. Mr. C. claims that he felt more comfortable and relieved when he was admitted to the hospital. But still, he worries about financial problems.

In the nutritional pattern, Mr. C. reports that he eats 3 meals per day w/c are cooked at home, w/ the occasional snack in between. Though the physician

cautioned him to avoid fatty and salty foods, he still eats pork. The food he eats varies from vegetables, fruits and fish. He enjoys eating chicharon, balut and sauted peanuts.

In the elimination pattern, the client moves his bowel daily. Mr. C. urinates 3 times per day, w/o difficulty and pain. In addition the client does not suffer from diaphoresis. He describes his urine as clear, yellow color w/o foul smell.

In the activity- exercise pattern, the client claims the he has less energy than before to do his daily activities. He doesnt exercise anymore except walks around the house and stretching. The clients pastime was watching TV, & listening to radio. He is independent in doing his ADL like grooming, bathing, eating, elimination and etc.

In the sleep- rest pattern, during his 1st day of hospital admission Mr. C claims that he finds it difficult to sleep at night and morning. He only takes nap in between because he has not yet adapted to the hospital environment. However the following days, he reported that he was able to sleep well provided by moderate high back rest to sleep comfortably w/o difficulty of breathing.

In the cognitive- perceptual pattern, Mr. C has no hearing problem, he listens to the medical professionals for him to recover fast and have a good health. However he does have a visual problem. His memory was still intact.

In the role- relationship pattern, the family of the client is said to be extended, with Mr. C making decisions regarding health actions and daily sexpenditure. His children always contribute to his medical expenses. His grandchildren are the ones who accompany him and take care of him in the hospital. The usual problem of the family involves financial problem.

PHYSICAL ASSESSMENT

General Appearance Body built Posture

Normal Analysis Depends on age Was able to sit upright Symmetrical body movement Absence of body odor, neat

Actual Findings proportionate Patient can sit upright Coordinated body movement Patient doesnt smell unpleasant and looks neat BP: 130/90 mmHg RR: 20 CPM

Analysis Normal Normal

Gait

Normal

Hygiene

Normal

Vital signs

BP: 120/80 mmHg RR: 12-20 CPM PR: 60-100 BPM Temp: 36.537.5 C

Abnormal Normal

Normal PR: 63 BPM Normal Temp: 36.6 C

Mental Status Emotional Status Affect/ mood Language and communication Body parts Pleasant, calm Appropriate to situation Clear voice sounds The patient is cooperative Patients voice is loud and clear Normal Normal Patient is calm Normal

 Skull

Smooth skull contour Absence of mass and nodules

Smooth skull contour No tenderness felt No lesions noted, no tenderness noted, absence of lice and nits Hair distributed evenly Oval, symmetrical Not protruding, symmetrical

Normal

Normal

Scalp

No lesions, Smooth, Symmetrical and round

Normal

Hair

Fine strands, evenly hair distribution Soft and smooth, symmetrical Absence of erythema, blinking involuntarily at approximatel y 15- 20 blinks/ min., symmetrical Skin intact, symmetricall y aligned eyebrows

Normal

Face

Normal

Eyes

Normal

Eyebrows

Evenly distributed

Normal

 Eyelids

Lid margin moist and pink, symmetrical Evenly spaced and curled outside Pink w/o discharge Transparent, smooth and moist Round and equal, uniformed color, clear lenses Coordinated, moves in union and parallel alignment 20/20 vision Alignment of pinna w/ corner of the eye w/ 60 angle of vertical position, color same as

Meets completely when eyes are closed Short lashes and evenly spaced Pink in color, no discharge noted Transparent and moist

Normal

Eyelashes

Normal

Lower Palpebral conjunctiva Sclera and cornea Iris

Normal

Normal

Eye movement

Moves coordinately

Normal

Visual activity Ears

Poor vision Pinnas are aligned with the corners of the eye, same color with the skin

Abnormal Normal

 Hearing activity

facial skin Normal voice tones audible

Normal voice tones not audible No discharges noted, no deformities noted Moist and absence of lesion

Abnormal

Nose

Symmetrical appearance, no discharge in nares, with respiration Pink mucosa and moist w/ uniform color and no lesions Uniform in color, Pink gums, moist, clearly defined margins 32 teeth, pearly white

Normal

Internal nares

Normal

Lips Gums

Absence of lesion Slight gray gums

Normal Abnormal

Teeth

Missing teeth, yellow- brown in color No lesions, pink in color, can move freely No lumps noted No tenderness, symmetrical in shape

abnormal

Tongue

Pink, no lesions

Normal

Neck Posterior thorax

Absence of lumps No pain or tenderness, Chest is symmetric

Normal Normal

 Anterior thorax

Quiet, rhythmic & effortless respiration S1 follows the lung diastolic pause and corresponds to each carotid pulsation; S2 follows the short systolic phase and precede the lung diastolic

Presence of productive cough

Abnormal

Heart

Pulse rate is normal

Normal

Upper and lower extremities

Bilaterally symmetrical and equal, feet remain in straight position

Extremities are symmetrical with each other

Normal

Fingers and nails

Nails are round, hard; hands are lustrous, strong and elastic,

Nails in the little fingers are long

Abnormal

Range of motion Smooth coordinated movements; physical activity varies depending on age, condition and genetics

Patients movement is coordinated

Normal