Presentation Lion Heart

Marian School of Nursing and
Midwifery
In Partial Fulfillment of the
Requirements
In
Curative and Rehabilitative Nursing
(NCM 104)
A Case Presentation
EAC BSN IV – Section 27 Group C
 Magat, Federico Jr. O.

 Magtira, Anna Riza F.
 Marquez, Shanelle Erika M.
 Mercado, Jenilyn L.
 Moncayo, Michelle B.
 Navarro, Lovely Naden C.
 Nomos, Jesse O.
 Paglicawan, Mc Richard V.
 Paler, Carmela Ruah C.
November 29, 2008

I. INTRODUCTION
We, the third year Nursing students of EMILIO
AGUINALDO COLLEGE in Manila, Section 27 have
prepared a clinical study utilizing the NURSING
PROCESS.
This is case of C.S.O. a 91 year old woman. She belongs

to a very simple and large family of extended type.
She was admitted at OSPITAL NG MUNTINLUPA last
20th of November 2008 due to body malaise.
Upon admission the patient was diagnosed with:

 Hypertension
 T/C CAP
 S/P Cardiovascular Accident last 2001 with residual.
She went through different laboratory procedures (CBG,

CBC, BUN, Urea, Na, Potassium, Urinalysis). But after a
series of treatment and medical attention given to
CSO, she died a day after her admission.
II . Patient’s Data
III. Nursing Health
History
A. History of present illness:
 6 days prior to admission
 (+) onset of cough nonproductive with on
and off fever, patient was given
carbocysteine which prompted
temporarily relief. Two days PTC, patient
was unable to speak, in respiratory
distress. Persistence prompted
consultation.
 2 days prior to admission
 Patient is unable to speak and in
respiratory distress. Persistence
B. Past medical history
 The patient had a previous mild stroke,
she was admitted to Binan Doctors in an
out patient department last 2001 and
taken prescribed medicines. (Vidastat 20
mg, Pletaal 50mg)
 The patient has a history of heart

disease, she has no history of cancer,
tuberculosis, bleeding, alcoholism and
mental disorder.
 However, the patient is a known

C. Medical history
 The patient is positive to
hypertension, had a previous stroke
(2001)
 With residue. She has no
maintenance medication.
D. Family Medical History

 The patient has a family with the
history of hypertension.
E. Gordon’s Functional Pattern
Health perception
 My client’s past perception about health is the act of

appreciating what God has given you and at the same
time a feeling of being good and free from illness. .
Wellness for him is the act of doing and enjoying
things by simply making the most of it, an activity of
performing an action with a strong and healthy body
condition with the absence of illness.
 My client’s present perception about health is very
significant. For her, health is not only feeling good
physically but as well as emotionally. Her feelings and
emotions affect the whole personality as a human.
 The client’s general health is poor; She is currently
experiencing non productive cough, body weakness
and difficulty of breathing. She also encountered
different illnesses in the past these are Mild stroke
and hypertension. She Exercises every morning
through walking and jogging in order to keep healthy
and strong. She eats pork and fish more frequently
than vegetables. There’s no such accidents that the
Nutritional and Metabolic Pattern
 Before, our patient really loves to eat

Pork and fish rather than vegetables. She
eats three meals per day. She doesn’t skip
to take her breakfast. She prefers to drink
juice rather than water (4-5 glasses a day).
She takes vitamin c to have a good
resistance against diseases and
microorganisms that are pathogenic. In
terms of her weight and height
measurements: she gains 20 lbs for a total
of 130 lbs. and 2 inches for a total of 5’5’’.
She eats 3 times a day.
 Now, right after the admission the patient
experiencing poor nutritional pattern. She
couldn’t eat anymore due to difficulty in
swallowing (dysphagia).
Elimination pattern
 Before, our patient eliminates

body waste twice a day and urinates
four times a day. She used laxatives
once when she experienced difficulty
in elimination. Their toilet facilities,
garbage disposal, pet waste disposal
are all in good condition.
 Now, the patient has a less
urination than normal ( oliguria ) and
an abnormal elimination pattern.
Activity Exercise Pattern
 Before, our client was very active
and she exercises every morning as
a part of her everyday routine to
keep and maintain her body organs
functional and to excrete all the
waste products out of the body.
 Now, our client couldn’t perform an
exercise due to hypertension as
manifested by body weakness,
fatigue and body malaise. She has a
very minimal movement. He has
passive leisure activities.
Perceived Ability (Code for Level) For:
 Feeding: 0
 Dressing:III
 Cooking: III
 Bathing: III
 Grooming: III
 Shopping: III
 Toileting: III
 General Mobility:II
 Bed Mobility: 0
 Home Maintenance: III
 Laundry:0
 Transportation:0
 Managing Money:II
 The patient posture is in upright position. All body parts

are complete. The patients range of motion ability needs
assistance due to body weakness and numbness. The
muscle is slightly firm that she couldn’t pick a pencil but
can hold it in a longer time. Hes pulse Rate is 83 beats per
minute, Respiration rate is 19 breaths per minute, Blood
pressure is 130/90 mmHg. The patient has a poor hygienic
appearance, poor grooming and energy level.
Sleep-rest pattern
 Before admission the patient has a normal
sleep pattern from 7-8 hours of sleep.
 Now, our patient has an abnormal sleep pattern
( maximum of 2 hours a day ) due to Difficulty of
breathing, high blood pressure and fatigue.
Cognitive perceptual pattern

 Before admission the patient has normal visions
of 20/20 and even hearing ability. She has the
ability to perform things in proper.
 Now, our client is experiencing problem on her
eyes due to cataract but the hearing ability
remains normal. The big decision that his family
made was the separation of his children from
them, but it was easily resolved through praying
and with a strong faith. Her family use Filipino
language as their medium of speaking sometimes
they use English to practice the international
Self-perception Self concept
pattern
 There are times that my client

feels good to his family when they
show some care to one another. The
general mood of the family is the act
of being happy because all of them
speaks well and can easily interact or
correlate with others. The general
mood state of the family is 1. They
are very educated and very careful
of what they are saying. The family is
Role-relationship patterns
 My client’s family relationship to

one another is good and has a great
bond/chemistry. The income is
sufficient to sustain each and
everyone. Once a month there is an
open conversation between the
family to unite everyone and to be
informed about the family members’
condition.
Sexuality reproductive pattern
 My client is already committed and

they’re living a life with happiness and
contentment. They are very satisfied with
their relationship. They do encounter
problem most of the time due to stress
after work but that problem is not really
complicated, they just easily resolve it.
They do use of the contraceptives as their
part of family planning. For them having a
great number of family members is one of
the big problems that most of the family is
currently encountering. Having a great
number of family leads to a financial
problem due to the inability to afford the
needs of the children included the
Coping stress tolerance pattern
 Our patient was admitted due to

Hypertension, asthma and t/c CAP and
prayer is the best way to make things
possible. If problem comes her way she
manages it through praying and with the
help of the family members.
Values-beliefs pattern
 Our client is a Christian who believes in
just only one God who created the whole
world. She goes to church every Sunday to
attend the mass and thank God for all the
blessings he has given.
V. PHYSICAL ASSESSMENT
(Head to Toe Assessment)
VI. Patterns of Functioning
VII. Laboratory Tests
VIII. Pathophysiology of
Hypertension
IX. DRUG STUDY
X. NURSING CARE PLAN
Thank You!
www.nursingdepartment.blogspot.com
Lionheart200

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Marian School of Nursing and

 Magat, Federico Jr. O.

November 29, 2008

This is case of C.S.O. a 91 year old woman. She belongs

Upon admission the patient was diagnosed with:

She went through different laboratory procedures (CBG,

 The patient has a history of heart

 However, the patient is a known

D. Family Medical History

 My client’s past perception about health is the act of

 Before, our patient really loves to eat

 Before, our patient eliminates

 The patient posture is in upright position. All body parts

Cognitive perceptual pattern

 There are times that my client

 My client’s family relationship to

 My client is already committed and

 Our patient was admitted due to

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