Case Study

In partial fulfillment of the requirements for

N_260 Adult Health Nursing

Nikko Martel V. Dio, RN

Biographic Data

Mr. Rodolfo is a 73 year-old male currently residing in Sta. Rita, Olongapo City. He is

widowed and a retired overseas Filipino worker. He was able to pursue his studies until second

year college and is a Roman Catholic. His son who is currently working also as an OFW is his

source of health care financing.

Chief Reason for Hospital Visit

The client seeks consultation in the CVS out patient department of Philippine General

Hospital on February 27 2018, due to intermittent dizziness lasting for 1 minute, usually on

exertion. Patient was admitted on the same day for temporary permanent insertion.

History of Present Illness

1 year prior to admission (March 2017), patient complains od abdominal pain, described

as abdominal fullness. Patient consulted a local physician and was diagnosed with complete heart

block. He was advised for pacemaker insertion but was unable to follow up due to financial

constraints. Patient experienced intermittent episodes of dizziness on exertion lasting for 30

seconds, no loss of consciousness was noted.

On October 2017 he was admitted for general workup and executive check up. 2D echo

showed dilated left ventricle with adequate wall motion and contractility, normal right ventricle

with adequate wall motion, slightly dilated left and right atrium and normal pulmonary artery.

Ejection fraction is 67%. Maintenance medications were stared he was given with Telmisartan,

Terbutaline, Aspitin, Sodium Bicarbonate, and Febuxostat.

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 Mr. Rodolfo still experiencing intermittent dizziness lasting for less than 1 minute,

usually on exertion, last episode was 1 day prior to admission. On the day of consult (February

27, 2018) patient was seen at CVS OPD in PGH then immediately admitted for TPI insertion.

Past Medical History

The client claims that he doesn’t have any measles, rubella, chicken pox or mumps

before. He also noted that he had no history of hepatitis, polio. Diarrhea was experienced from

time to time but often resolves within the day or week. He recalled that he cannot remember

which immunization he received when he was a child. No allergies to food or medicines are

noted.

Patient is known hypertensive for 1 year with the highest blood pressure recorded of

180/90. Initially treated with Amlodipine but resulted to bipedal edema, medication was shifted

to Telmisartan after the side effect. Recently shifted to Felodipine and became his maintenance

until admission. He was also diagnosed last October 2017 with stage four chronic kidney disease.

Initially maintained on sodium bicarbonate, ferrous sulfate, and ketoanalogues with good

compliance. Due to dyslipidemia and hyperurecimia noted on his executive check-up he was

started with Simvastatin and Febuxostat respectively

Aside from his current temporary pacemaker insertion, surgery was performed to him

once back in 1973 for vasectomy. He did the procedure for family planning.

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Family History of Disease

History of hypertension was noted in both sides of the client’s relatives. The client’s

spouse died due to pneumonia last 2017. No familial history of rheumatic fever, tuberculosis,

diabetes or mental illness and other inheritable diseases are noted.

Gordon’s Functional Health Patterns

This assessment tool is a very important instrument to measure not just the objective data

observed by the health care providers but to give importance for what the client perceives on his

current health status.

Health Perception and Health Management Pattern

The general health of the patient as he describes was good as he doesn’t feel any

symptoms or any weakness as of now, and is currently satisfied wit his usual health status. He

mentioned that he never been hospitalized ever before aside from his current admission. 100%

percent compliance to medication is observed. Client does not have any history of cigarette

smoking, drug abuse and drinking alcohol. He is a retired OFW and spent most of his time at

home, taking care of his grandchildren. Living conditions at home are not that bad since his his

three child are working full time.

The client believe that his hospitalization was due to his habit of overeating. He usually

eats 2 cups of rice per meal prior to the symptom appearance. After he experience dizziness and

near-syncope experience he then consulted a local physician. He followed the doctor’s advise

except for the temporary pacemaker insertion since he wasn’t able to pay for the operation and

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don’t want to be a burden to his children. He wasn’t aware about the need of of testicular

examination.

Nutritional and Metabolic Pattern

The prescribed diet to the patient is low salt, low fat and less fruits diet. He usually eats

complete 3 meals all eaten with rice. Patient stands 5 feet and 8 inches weighing 59 kilograms.

His BMI is normal with the value of 19.7. The calculated kcal per day in order to maintain his

current weight is 1500. Upon reviewing his 24 hour’s food recall, it it found out that the client is

400 kcal deficient from his daily requirement. Food is usually bought and chosen by the client,

food coming from the dietary was usually consumed by the relative as he is a picky eater. The

24-hour food recall and their nutritional contents are seen in Figure 1.

6-7 glasses of water a day are usually consumed and he verbalized that he wants to gain

more weight to achieve his ideal weight. The client reported that he has no current problem with

chewing and swallowing even though the two lower third molar and the upper left first molar are

already missing. No reported nausea, vomiting and indigestion is currently experienced by the

client.

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 Breakfast Lunch Dinner

½ cup steamed mixed 1 piece chicken, drumstick, 1 cup monngo

vegetables tinola 232 kcal
59 kcal 267 kcal 21 g CHO
13 g CHO 26 g CHO 22 g CHON
2 g CHON 21 g CHON 6 g fat
0 g fat 14 g fat

1 cup rice, boiled 1 cup rice, boiled 1 cup rice, boiled

205 kcal 205 kcal 205 kcal
28 g CHO 28 g CHO 28 g CHO
2 g CHON 2 g CHON 2 g CHON
0 g fat 0 g fat 0 g fat

Figure 1. 24-hour Food Recall of Mr. Roberto for March 4, 2018

Elimination Pattern

Client’s bowel movement is less frequent than pre admission status. Stool consistency is

soft, black in color (patient on ferrous sulfate), no active bleeding was noted.

Client usually voids 2 – 3 time a day without difficulty. No pain, burning sensation, and

excessive perspiration is experienced by the client during urination. He use a urinal due to

complete bed rest status.

Activity and Exercise Pattern

The client is partially dependent with his relatives on his activities of daily living. He

needs partial assistance with his feeding, bathing, dressing, toileting, shopping, bed mobility,

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general mobility and home maintenance. Due to complete bed rest status he can’t do these

activities alone and needs the assistance of her family in order to carry out these activities

Sleep and Rest Pattern

Client usually sleeps for about 6-8 hours a day with naps in the morning. He generally

feels rested and has no problem in attaining and maintaining sleep. He does not take any

medications and didn’t use any relaxation technique to achieve sleep.

Cognitive and Perceptual Pattern

Mr. Roberto reported that he hears better on his right ear than on the left side. Glasses are

use to aid vision. His right eye is graded 250 while his left eye is 100. He usually wears his

eyeglasses only when needed during reading. No changes in memory so far, does not experience

any discomfort or pain. No abnormality is noted in his decision making skills and cognitive

level.

Self-perception and Self-concept Pattern

When asked about his perspective about himself, he states that he is currently happy with

his general appearance but wants to gain a little bit of weight, but not to the point that it already

bothers him. He said that is usually angered by persons who keeps on doing negative things to

other people. He fears death but is not losing hope that he will be discharge and feel better after

the pacemaker insertion.

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Role-relationship Pattern

Client is currently living with one of his daughters, Ruby and 5 grand children. His wife

died a year ago due to pneumonia. His two other children, Bernadeth and Richard are currently

working overseas who support him financially. He is generally happy with his family situation;

problems sometimes arise but usually has no difficulty on resolving it. The client though

verbalized that he might be unable to resolve problems in the house due to his hospitalization. He

is still usually consulted by his children whenever a hard decision should be made. He has no

current social groups, no contact with his friends since his residence is too far away from the

hospital. Even though, he doesn’t feel lonely due to the companion of his daughter Ruby.

Sexuality and Reproductive Pattern

He doesn’t engage in sexual activity anymore, he said that it is not his priority as of now.

No history of any prostate, penile discharge, bleeding and lesions are noted by the client.

Coping-Stress Tolerance Pattern

The most stressful event happened to him so far was the lost of his spouse. He has a good

way of handling stress by distracting himself and do other things that matter than keep on

thinking on the problem he has no control of. He said that he doesn’t usually got tensed unless a

big problem arise.

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Value and Belief Pattern

After being admitted the patient wasn’t able to go to church as what he usually do prior to

admission. As a Roman Catholic, he usually goes to church during Sundays together with his

family. He would appreciate if a priest visits him once in a while to hear the word of God and

receive the holy communion. As of today, he is generally satisfied with his overall situation and

is positive about the outcome of his upcoming permanent pacemaker insertion surgery.

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 Physical Examination

A cephalocaudal approach of physical assessment was done with the aid of inspection,

palpation, percussion, and auscultation in order to deliver it comprehensively and organized.

Cardiovascular system was put on emphasis in order to provide more information regarding the

patient’s condition.

Vitas Signs and Anthropometric Measurements

The client was afebrile, with an axillary temperature of 37.1 C. His blood pressure taken

lying on his left arm rendered 110/70 mmHg. His peripheral pulses are present, not bounding nor

weak, all sides equal. Pulse rate taken from his left radial arm is 62 beats per minute. His heart

rate also counts 62 bpm with a full minute count, same with his cardiac monitor that shows a

normal paced rhythm. Respirations are slightly above the normal range at 24 respirations per

minute with normal depth and rhythm.

According to him he stands 5 feet and 8 inches tall, and weighs about 59 kilograms.

Computed body mass index (BMI) is 19.8kg/𝑚2 , which translates to normal proportion of

weight for his height.

General Survey

The client is conscious, coherent and oriented to person, time, and place, appears calm

and no signs of distress noted. His build is well and looks according to age. Gait was not

assessed since it is contraindicated on his current status of complete bed rest.

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Skin

General color of the client is fair and normal looking, skin is slightly warm to touch, with

smooth texture and has a good turgor. Oiliness of the skin is noted except on the right foot where

in dry skin or xerosis is noted. Mole is also seen at the right chest of the client.

Head

The head was normocephalic, with no visible deformities, masses or depressions. Hair

was fine, well distributed and black in color. Scalp was clean and with no dandruff or any other

lesions.

Eyes

Eyelids were symmetrical, no periorbital edema, conjunctiva is pinkish and sclera is

normal looking. Corneas were smooth, clear and has positive corneal reflex. Pupils are equal

around 3 cm, round in shape, reactive to light and accommodation. Gross vision was intact but

needs to wear glasses when reading. Peripheral visual fields are intact. Extraocular muscle

movements are coordinated. Eyebrows were thick and distributed evenly.

Nose

Nasolabial fold was symmetrical. Septum was midline. Pinkish nasal mucosa was seen

without any abnormal discharge. Both nares were patent and able to smell coffee on right and

left nostrils. Frontal and maxillary sinuses were nontender.

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Ears

External pinnae are symmetrical and aligned with the outer canthus of the eyes. No

abnormal discharge was present. The client seems to have no general hearing problem while

talking with him face to face. Weber and Rinne test were performed and it was found out that he

is weber positive, sound waves lateralizes on left. Air conduction is greater than bone condution

upon doing the rinne’s test. This concludes that the patient is suffering from conductive hearing

loss.

Mouth and Pharynx

Mucosa and gums were pinkish in color upon assessment. Lips are normal in color, no

dryness or any sore present. Tongue was in midline and no sign of weakness noted. Right and

left lower third molar is missing, same as with the left upper first premolar. Tonsils were not

inflamed. Uvula in midline.

Neck

Trachea was at midline. Lymph nodes and thyroid glands are nonpalpable and nontender.

Neck ROM was normal. No jugular vein distention or flatness was found.

Chest and Lungs

Inspiration expiration ratio is 1 second to 3 seconds. Anteroposteriolateral ratio was 1:2.

Respiratory rate was slightly tachypneic at 24 respirations per minute. Chest expansion and

tactile fremitus were both symmetrical. Client has clear breath sounds noted all over the lung

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fields. No adventitious breath sounds heard upon auscultation. Resonant sound was heard during

percussion. Chest excursion is around 4 centimeters.

Heart

Precordial area was normodynamic. Point of maximal impulse was located at the 5th

intercostal space, lateral to the left midclavicular line. Heart sounds were distinct and no

murmurs was heard upon auscultation. S1 hear sounds were louder than S2 at apex and vise

versa when auscultated at the base. Cardiac dullness heard from 3rd to 6th ICS.

Breasts and Axillae

Breasts were symmetrical, no masses or dimpling seen. Senile lentigo was noted but

other than that color is uniform. Areola and nipple are normal looking. Axillary lymph nodes

were nontender and nonpalpable.

Abdomen

Abdomen is flat and symmetrical, senile lentigo was also present on the abdomen.

Umbilicus was sunken. Bowel sounds were medium and hypoactive at 3 per minute and no

abdominal bruit was heard upon auscultation. Tympanic sound was heard upon percussion. Psoas

sign and obturator sign were absent upon assessment. Liver span is around 10 centimeters with

no tenderness upon palpation.

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Back and Extremities

Peripheral pulses are symmetrical and strong. Extremities are warm to touch. Nails were

pale and presence of clubbing is observed. Joints were nontender and had full range of motion.

Muscles were equal in size, with equal movement and muscle grading over 5 over 5. Reflexes

are normal with a grade of 2. Fine motor was smooth and accurate. Spine was in midline.

Genito-Urinary System

This was not assessed.

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 Laboratory and Diagnostic Examinations

BLOOD CHEMISTRY

Indicator Normal Values Actual Findings

Sodium 136 – 144 mmol/L 141

Potassium 3.6 – 5.1 mmol/L 4.2

Chloride 101 – 111 mmol/L 110

Calcium 2.23 – 2.58 mmol/L 2.1

Magnesium 0.7 – 1.0 mmol/L 1.1

Creatinine 39 – 91 mol/L 246

AST 8 – 48 U/L 24

ALT 7 – 55 U/L 23

INR <2.0 1.03

Figure 2. Results of Blood Chemistry on February 27, 2018.

Creatinine results are elevated, compatible with the patient’s history of chronic kidney

disease .

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COMPLETE BLOOD COUNT

Indicator Normal Values Actual Findings

WBC 4.5 – 11 x 109 /L 8.5

Hemoglobin 120 – 180 g/L 97

Hematocrit 0.4 – 0.54% 0.28

Platelet 150 – 450 x 109 / L 132

MCV 80 to 196 fL 93.2

MCH 27 – 31 pg 32.3

MCHC 320 – 360 g/L 346

Figure 3. Results of Complete Blood Count on February 27, 2018

Hemoglobin and hematocrit count is congruent with the patient’s chronic kidney disease

as the kidney’s function of forming RBC through the aid of erythropoietin aren’t working.

Patient was put on ferrous sulfate to increase the hemoglobin and hematocrit levels. Platelet

counts are in below normal level but not significant enough, this might be due to the aspirin

taking by the client.

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ELECTROCARDIOGRAM

Figure 4. Electrocardiogram done on February 27, 2018

ECG shows a sinus rhythm with complete heart block (third degree AV block), junctional

escape and right bundle branch block.

RANDOM BLOOD SUGAR

Test was done upon admission to rule out possible link of dizziness to hypoglycemia.

Test rendered a normal value of 111 mg/dL

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