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Table of Contents

Content Page

Table of Contents i
List of Tables ii
List of Figures v
Acknowledgement vi
I. Introduction 1
A. Rationale 3
B. Objectives 4
C. Scope and Limitation 5
II. Theoretical Framework 6
III. Assessment Data 11
A. Biographical Data 11
B. Reason for Seeking Healthcare/Chief Complaint 11
C. History of Present Illness 12
D. Past Health History 12
E. Family History (Genogram) 13
F. Growth and Development 14
G. Psychosocial Profile (Gordon’s Functional Pattern) 15
H. Review of Systems 25
I. Physical Assessment 29
IV. Doctor’s Order 40
V. Diagnostic Test and Laboratory Test 63
VI. Anatomy and Physiology 68
VII. Pathophysiology (Schematic Diagram) 72
VIII. Pharmacologic Management 86
IX. Nursing Management 100
X. Discharge Plan 168
XI. References 170
XII. Appendices 172
A. Vital Signs Monitoring 172
B. Intake and Output Records 204
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List of Tables
Tables Title Page
Table G.1 Gordon’s Functional Health Pattern 15

Table I.1 Physical Assessment 29

Table IV.1 Doctor’s Order 40

Table V.1 Chemistry Result (11-01-17) 63

Table V.2 Hematology Result (11-01-17) 63

Table V.3 Chemistry Result (11-01-17) 63

Table V.4 Chemistry Result (11-02-17) 64

Table V.5 Urinalysis Result (11-04-17) 64

Table V.6 Hematology Result (11-06-17) 65

Table V.7 Chemistry Result (11-07-17) 65

Table V.8 Chemistry Result (11-21-17) 65

Table V.9 Hematology Result (11-25-17) 66

Table V.10 Chemistry Result (11-25-17) 66

Table V.11 Ultrasound Report (11-20-17) 66

Table V.12 Radiologic Report (11-08-17) 66

Table V.13 Radiologic Report (11-19-17) 67

Table V.14 Electrocardiogram (11-15-17) 67

Table VIII.1 Drug Study (Ketorolac) 86

Table VIII.2 Drug Study (Dobutamine) 87

Table VIII.3 Drug Study (Aspirin) 88

Table VIII.4 Drug Study (Digoxin) 89

Table VIII.5 Drug Study (Omeprazole) 90

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Table VIII.6 Drug Study (Furosemide) 91

Table VIII.7 Drug Study (Norepinephrine) 92

Table VIII.8 Drug Study (Cetirizine) 93

Table VIII.9 Drug Study (Acetylcysteine) 94

Table VIII.10 Drug Study (Levofloxacin) 95

Table VIII.11 Drug Study (Spironolactone) 96

Table VIII.12 Drug Study (Ceftriaxone) 97

Table VIII.13 Drug Study (Ketoanalogue) 98

Table VIII.14 Drug Study (Amiodarone) 99

Table IX.1 Ideal NCP Decreased Cardiac Output 102

Table IX.2 Ideal NCP Ineffective Tissue Perfusion 108

Table IX.3 Ideal NCP Impaired Gas Exchange 111

Table IX.4 Ideal NCP Acute Pain 116

Table IX.5 Ideal NCP Imbalance Nutrition 121

Table IX.6 Ideal NCP Fluid Volume Excess 127

Table IX.7 Ideal NCP Activity Intolerance 129

Table IX.8 Ideal NCP Disturbed Thought Process 132

Table IX.9 Actual NCP Decreased Cardiac Output 136

Table IX.10 Actual NCP Ineffective Tissue Perfusion 142

Table IX.11 Actual NCP Impaired Gas Exchange 145

Table IX.12 Actual NCP Acute Pain 150

Table IX.13 Actual NCP Imbalance Nutrition 154

Table IX.14 Actual NCP Fluid Volume Excess 160

Table IX.15 Actual NCP Activity Intolerance 162

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Table IX.16 Actual NCP Disturbed Thought Process 165

Table X.1 Discharge Plan 168

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List of Figures
Figures Title Page
Figure II.1 Nightingale’s Framework 6
Figure II.2 Henderson’s Framework 7
Figure II.3 Orem’s Framework 10
Figure E.1 Genogram 13
Figure H.1 Review of Systems 28
Figure VI.1 Anatomy of the Heart 68
Figure VI.2 Anatomy of the Kidney 71
Figure VII.1 Schematic Diagram 72
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Acknowledgement

We the Student nurses would like to extend our sincere thanks

and gratitude to the following people who have contributed and
supported us on the fulfilment of our clinical case study.

To Mrs. Pilar V. Domagsang RN, MAN, Dean of College of

Nursing, for allowing us to have this clinical exposure and case
presentation.

To Mr. Karl Jay G. Guinitaran RN, MSCPH, and Mr. Al Duane

B. Ungab RN, MAN our clinical adviser who provided insight and
expertise that greatly assisted the research, for the patience and time
they extended in checking the manuscript and for sharing suggestions
and constructive criticisms and for guiding us during the clinical
exposure, which meant so much for the completion.

To the family of Maria Lily respondents of this study for being

approachable and cooperative and for spending their time in
answering all the question being asked.

We would also like to show gratitude to the Bardon and Lepon

family for sharing their support during the making of our family case
presentation. To our beloved family for their unending moral,
spiritual, and financial support.

And most of all, we would like to extend wholeheartedly the

gratitude and praise to ever loving and merciful God for touching and
bringing together those people who literally shared their abundant
resource, skills, time and effort for the completion of this family case
study.