OBJECTIVESA. General Objective After the discussion of this case presentation, the students will be able to deal and care for a patients with Aortic Aneurysm integrally by applying their knowledge, skills, and positive attitudes based on what they have learned out of the discussion.

B. Specific Objectives At the end of the case presentation, it is expected that the students will be able to: Skills 1. Deal patient with thoracic aortic aneurysm. 2. Provide proper care and intervention with limitation to stressful activities. 3. Conduct physical assessment and organize data efficiently. 4. Perform nursing procedures effectively and correctly to attain optimum level of wellness. Knowledge 1. Define Thoracic Aortic Aneurysm. 2. Have an overview about the diseases, including its causes and preventive measures. 3. Determine the signs and symptoms. 4. Review the anatomy and physiology of the organ affected. 5. Understand the pathophysiology of the disease. 6. Identify and enumerate the management needed depending on the severity and possible rupture of the aneurysm. 7. Formulate nursing care plans that will aid in the improvement of patient s condition. Attitudes 1. Develop a positive attitude in caring the patient with thoracic aortic aneurysm throughout the nursing Process. 2. To be able to establish rapport with the patient and folks. 3. To be able to develop respect and trust to the folks as well as in other health care team member in caring of clients with Thoracic Aortic Aneurysm.

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INTRODUCTIONA. DefinitionAn Aneurysm is a localized dilation or out pouching of

vessel wall or cardiac chamber. The Law of Laplace can provide an understanding of the hemodynamic of an aneurysm. Presumably, in myocardial infarction, a ventricular wall aneurysm forms when intraventricular tension stretches the non contracting infracted muscle. The stretching produces

infarct expansion, a weak and thin layer of necrotic muscle, and fibrous tissue that bulges with each systole. Aneurysm forms in the arteries when there is disruption of the wall of the vessel associated with changes in collagen and elastin that make the vessel more vulnerable to intravascular pressures. The aorta is particularly susceptible to aneurysm formation because of the constant stress on the vessel wall and the absence of penetrating vasa vasorum in the media layer. Three fourths of all aneurysms occur in the abdominal aorta. Atherosclerosis is the most common cause of arterial aneurysms because plaque formation erodes the vessel wall and contributes to inflammation and release of proteinases that can further weaken the vessel. Hypertension also contributes to aneurysm formation by increasing wall stress. Dissection of the arterial walls occurs when there is a tear in the intima and blood enters the wall of the artery. Dissection can involve any part of the aorta and can disrupt flow through arterial branches, thus creating a surgical emergency.

A Ruptured Aneurysm may cause massive hemorrhage and death.

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B. Statistics International:The following statistics relate to the prevalence of Aortic aneurysm: 5 to 7% of people over 60 have thoracic aortic aneurysms in the US

Incidence (annual) of Aortic aneurysm: 2,966 annual cases in Victoria 2008.

Incidence Rate: approx 1 in 1,537 or 0.07% or 176,913 people in USA

Deaths from Aortic aneurysm: 15,807 annual deaths in 2007 USA.

The term 'prevalence' of Aortic aneurysm usually refers to the estimated population of people who are managing Aortic aneurysm at any given time. The term 'incidence' of Aortic aneurysm refers to the annual diagnosis rate, or the number of new cases of Aortic aneurysm diagnosed each year.

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ANATOMY & PHYSILOGYIn a general sense, a Blood vessel is defined as a hollow utensil for carrying something: a cup, a bucket, a tube. Blood vessels, then, are hollow utensils for carrying blood. Located throughout your body, your blood vessels are hollow tubes that circulate your blood There are three major types of blood vessels: a. Arteries which carry the blood away from the heart

b. Capillaries which enable the actual exchange of water and chemicals between the blood and the tissues c. Veins which carry blood from the capillaries back toward the heart

The arteries and veins have different structures, veins having two layers and arteries having three:a.

Tunica intima It is the thinnest layer: a single layer of simple squamous endothelial cells glued by a polysaccharide intercellular matrix, surrounded by a thin layer of

subendothelial connective tissue interlaced with a number of circularly arranged elastic bands called the internal elastic lamina. Also the inner layer of the vessel.

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b.

Tunica media It is the thickest layer: circularly arranged elastic fiber, connective tissue, polysaccharide substances, the second and third layer are separated by another thick elastic band called external elastic lamina. The tunica media may (especially in arteries) be rich in vascular smooth muscle, which controls the caliber of the vessel. Also the middle layer of the vessel.

c.

Tunica adventitia It is entirely made of connective tissue. It also contains nerves that supply the vessel. Also the outer layer of the vessel.

Besides circulating blood, the blood vessels provide two important means of measuring vital health statistics: pulse and blood pressure. We measure heart rate, or pulse, by touching an artery. The rhythmic contraction of the artery keeps pace with the beat of the heart. Since an artery is near the surface of the skin, while the heart is deeply protected, we can easily touch the artery and get an accurate measure of the heart's pulse. When we measure blood pressure, we use the blood flowing through the arteries because it has a higher pressure than the blood in the veins

If you took all of the blood vessels out of an average child, and laid them out in one line, the line would be over 60,000 miles long! An adult's vessels would be closer to 100,000 miles long!

The aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries, the common iliac. The aorta distributes oxygenated blood to all parts of the body through the systemic circulation.

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The aorta gives off branches that go to the head and neck, the arms, the major organs in the chest and abdomen, and the legs. It serves to supply them all with oxygenated blood. The aorta is the central conduit from the heart to the body. The aorta is usually divided into five segments/sections:a.

Ascending aorta - It is the section between the heart and the arch of aorta

b.

Arch of aorta - It is the peak part that looks somewhat like an inverted "U"

c.

Descending aorta - It is the section from the arch of aorta to the point where it divides into the common iliac arteries. Thoracic aorta It is the half of the descending aorta above the diaphragm

Abdominal aorta It is the half of the descending aorta below the diaphragm. The abdominal aorta is the largest artery in the abdominal cavity. As part of the aorta, it is a direct continuation of the descending aorta in the thorax.

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THORACIC AORTIC ANEURYSM

A. DefinitionAn Aneurysm is a localized sac or dilation of an artery formed at a weak point in the vessel wall.

Types of Aortic Aneurysm: 1. Thoracic aortic aneurysm It is an aortic aneurysm that is present primarily in the thorax. 2. Abdominal Aortic Aneurysm It is a localized dilatation of the abdominal aorta exceeding the normal diameter by more than 50 percent, and is the most common form of aortic aneurysm. 3. Cerebral / Intracranial Aneurysm It is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall.

Sites of Thoracic Aortic Aneurysm: 1. Aortic root 2. Ascending Thoracic Aorta 3. Arc aorta 4. Descending Thoracic Aorta

Characteristics of Aneurysm: 1. False Aneurysm It is actually a pulsating hematoma. The clot and connective tissue are outside the arterial wall. 2. True Aneurysm One, two, or all three layers of the artery may be involved.

3. Fusiform Aneurysm Symmetric, spindle shaped expansion of entire circumference of involved vessel.

4. Saccular Aneurysm A bulbous protrusion of one side of the arterial wall.

5. Dissecting Aneurysm This is usually a hematoma that splits the layers of the arterial wall.

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B. Risk factorsGender Age Occurs frequently between ages of 40 70 years. Men are more affected than women.

Congenital Primary connective tissue disorders including Marfan s syndrome and Ehlers Danlos syndrome. Infectious Bacterial, fungal, spirochetal infection.

Traumatic Penetrating arterial injuries, blunt arterial injuries, pseudoaneurysms.

Inflammatory (non infectious) Associated with arteritis; Takayasu s disease, systemic Lupus Erythematosus.

Cigarette Smoking The primary cause of atherosclerosis. Atherosclerosis is the most common cause of arterial aneurysms because plaque formation erodes the vessel wall and contributes to inflammation and release of proteinases that can further weaken the vessel. Hypertension. Contributes to aneurysm formation by increasing wall stress.

C. Signs/Symptoms Symptoms are variable and depend on how rapidly the aneurysm dilates and how the pulsating mass affects surrounding intrathoracic structures. Yet, some do not produce symptoms.

From the Textbook Constant chest pain associated with a harsh breathing which may occur only in supine position. Dyspnea, cough (paroxysmal and brassy), or stridor

Manifested by the Patient

Rationale It results from the disruption of normal circulation in the thoracic region.

Hoarseness, weak voice or aphonia Dysphagia

It is the result of pressure of aneurysm sac against trachea, a main bronchus, or the lung itself. Resulting from the pressure against the laryngeal nerve. Due to impingement on the esophagus by the aneurysm.

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Edematous areas on chest wall Cyanosis

When large veins in the chest are compressed by the aneurysm, the superficial veins of the chest, neck, or arms become dilated. A result of pressure against the cervical sympathetic chain.

Unequal pupils

D. Diagnostic FindingsMost thoracic aortic aneurysms are detected by tests performed for other reasons, it may include: Chest x-ray It is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures and can show presence of any masses in the thorax. Echocardiogram

-

It is important for the evaluation of the aortic valve and also can be used to evaluate the size of the ascending aorta. Chest CT scan

-

This can show the size of the aorta and the exact location of the aneurysm. Aortogram

-

It is a special set of x-ray images made when dye is injected into the aorta that can identify the aneurysm and any branches of the aorta that may be involved.

E. PreventionTo prevent atherosclerosis: Control your blood pressure and blood lipid levels. Do not smoke. Exercise regularly.

F. Medical managementMedical or surgical management depends on the type of aneurysm. For a ruptured aneurysm, prognosis is poor and surgery is performed immediately. When surgery is delayed, medical measures include: Strict control of blood pressure and reduction in pulsatile flow. Correcting risk factors. Systolic pressure maintained at 100 to 120 mm Hg with antihypertensive drugs, such as: Nitroprusside (Nipride) Hydralazine (Apresoline)

Pulsatile flow reduced by medications that reduce cardiac contractility, such as: Propranolol

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G. Surgical ManagementRemoval of the aneurysm and restoration of vascular continuity with a graft is the goal of surgery and treatment of choice for aortic aneurysm. It is recommended if the aneurysm is larger than 5.5 cm (2 inches) in diameter or those that are enlarging. Intensive monitoring in the critical care unit is required. The surgical procedure includes: Thoracic Endovascular Grafting / stenting The endovascular grafts or stents are inserted into the t horacic aorta via various vascular access routes, including the femoral or iliac artery. This is a tiny metal or plastic tube that is used to hold an artery open and can be placed into the body without cutting the chest. Resection and Bypass Graft It involves removing theaneurysmal portion of the aorta and replacing it with an a rtificial Dacron tube. If the aortic valve is damaged it also need to be replaced or repaired. Replacement options include mechanical and tissue valves.

Pre operative assessment: Assessment is guided by the fact that the aneurysm may rupture Signs include persistent or intermittent back or abdominal pain that may be localized in the middle or lower abdomen or lower back. Establish functional capacity of all organ systems, recognizing possible cerebral, cardiovascular, pulmonary, and renal impairment due to atherosclerosis. Implement medical therapies to stabilize patient.

Post operative assessment Intensely monitor the pulmonary, cardiovascular, renal and neurologic systems. Monitor for complications: arterial occlusion, hemorrhage, infection, ischemic bowel, renal failure and impotence. Prescribe an exercise schedule after the recovery phase. Discouraged prolonged sitting

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H. Rupture of AneurysmRupture or dissection of these aneurysms produces dramatic symptoms. A ripping sensation within the chest accompanied by severe pain in the back between the shoulder blades is the most typical complaint during thoracic aortic dissection or rupture. Dizziness, difficulty walking and speaking can all accompany this acute event.

Patients with known aortic aneurysms experiencing such symptoms need to contact their physician or surgeon immediately and go to the nearest emergency room.

I. Nursing considerationsSmoking cessation Avoid carrying heavy objects to prevent pressure on the vessel wall. Strict compliance to antihypertensive medications to keep your blood pressure under control. Limit stressful physical activities Get regular exercise. Reduce cholesterol and fat in your diet.

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OVERVIEW of CONGESTIVE HEART FAILURE

Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to supply sufficient blood flow to meet the needs of the body. The most common causes of congestive heart failure are: Coronary artery disease Hypertension DM Obesity Longstanding alcohol abuse Disorders of the heart valves Unknown (idiopathic) causes, such as after recovery from myocarditis

Signs & Symptoms Right Sided Heart Failure Peripheral edema, Anasarca Nocturia Paroxysmal nocturnal dyspnea Ascites Fatigue Hepatomegaly Coagulopathy Cool extremities at rest. Confusion Left Sided Heart Failure Pulmonary congestion Dyspnea (SOB) Orthopnea Exercise intolerance Wheezing Dizziness

Diagnostic Examination Electrocardiogram (ECG) Is used to determine changes or variation in electrical activity of the heart.

Chest X-ray To detect previous heart attacks, arrhythmia, heart enlargement, and fluid in and around the lungs. Echocardiogram In which ultrasound is used to image the heart muscle, valve structures, and blood flow patterns. The echocardiogram is very helpful in diagnosing heart muscle weakness.

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B-type natriuretic peptid level This level can vary with age and gender but is typically elevated from heart failure and can aid in the diagnosis, and can be useful in following the response to treatment of congestive heart failure Coronary angiography It is a procedure that uses a special dye or contrast material and x-rays to see how blood flows through your heart.

Prevention Do not smoke. Do not drink alcohol. Reduce salt intake. Exercise as recommended by your health care provider.

Treatment Coronary artery bypass graft surgery Is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the hear. Angioplasty Is a term describing a procedure used to widen vessels narrowed by stenoses or occlusion.

Single or dual chamber pacemaker To help with slow heart rates or certain other heart signaling problems.

Biventricular pacemaker To help the left and right side of your heart contract at the same time.

Implantable cardioverter defibrillator To correct or prevent severe arrhythmias.

Intra-aortic balloon pump (IABP) A temporary device placed into the aorta

Left ventricular assist device (LVAD) Which takes over the role of the heart by pumping blood from the heart into the aorta; it's most often used by those who are waiting for a heart transplant.

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Pharmacologic Treatment ACE inhibitors Such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart Diuretics Including hydrochlorothiazide, chlorthalidone, chlorothiazide,furosemide, torsemide, bumeta nide, and spironolactone to help rid your body of fluid and salt (sodium) Digitalis glycosides To increase the ability of the heart muscle to contract properly and help treat some heart rhythm disturbances. Angiotensin receptor blockers (ARBs) Such as losartan and candesartan to reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors Beta-blockers Such as such as carvedilol and metoprolol, which are particularly useful for those with a history of coronary artery disease.

Nursing Management Take the medications as directed. Carry a list of medications with you wherever you go. Limit salt intake. Smoking Cessation Stay active. For example, walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise plan based on the degree of heart failure and how well you do on tests that check the strength and function of your heart. DO NOT exercise on days that the weight has gone up from fluid retention or if not feeling well. Lose weight if overweight. Provide enough rest, including after exercise, eating, or other activities. This allows the heart to rest as well. Keep your feet elevated to decrease swelling.

Here are some tips to lower your salt and sodium intake: Look for foods that are labeled low-sodium, sodium-free, no salt added, or unsalted.

Check the total sodium content on food labels. Be especially careful of canned, packaged, and frozen foods. A nutritionist can teach you how to understand these labels.

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Don t cook with salt or add salt to what you are eating. Try pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (like monosodium glutamate, MSG). Avoid foods that are naturally high in sodium, like anchovies, meats (particularly cured meats, bacon, hot dogs, sausage, bologna, ham, and salami), nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato and other vegetable juices, and cheese. Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese. Use oil and vinegar, rather than bottled dressings, on salads. Eat fresh fruit or sorbet when having dessert.

Prognosis With the availability of newer drugs to potentially favorably affect the progression of disease, the prognosis in congestive heart failure is generally more favorable than that observed just 10 years ago. In some cases, especially when the heart muscle dysfunction has recently developed, a significant spontaneous improvement is not uncommonly observed, even to the point where heart function becomes normal

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OVERVIEW of ACUTE MYOCARDIAL INFARCTION

Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia.

Etiology Atherosclerosis Age Sex Family history of premature coronary heart disease Male-pattern baldness Dyslipidemia Smoking or other tobacco use Diabetes mellitus Hypertension Hypercholesterolemia and hypertriglyceridemia, including inherited lipoprotein disorders Obesity Sedentary lifestyle and/or lack of exercise Psychosocial stress Poor oral hygiene Type A personality

Signs & Symptoms Pain, fullness, and/or squeezing sensation of the chest Jaw pain, toothache, headache Nausea, vomiting, and/or general epigastric discomfort Sweating Heartburn and/or indigestion Arm pain Upper back pain General malaise Shortness of breath

Diagnostic Studies Electrocardiogram(ECG) Is a recording of the electrical activity of the heart. Abnormalities in the electrical activity usually occur with heart attacks and can identify the areas of heart muscle that are deprived of oxygen and/or areas of muscle that have died.

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Blood tests Cardiac enzymes are proteins that are released into the blood by dying heart muscles. These cardiac enzymes are creatine phosphokinase (CPK) and troponin I, and their levels can be measured in blood. A series of blood tests for the enzymes performed over a 24-hour period are useful not only in confirming the diagnosis of heart attack, but the changes in their levels over time also correlates with the amount of heart muscle that has died.

Treatment Thrombolytic / fibrinolytic therapy Has been shown to reduce death from heart attacks similarly in men and women; however, the complication of strokes from the thrombolytic therapy may be slightly higher in women than in men. Percutaneous transluminal coronary angioplasty ( PTCA) Or coronary stenting for acute heart attack The use of a balloon-tipped catheter to enlarge a narrowed artery. Coronary Artery Bypass Graft (CABG) A surgery creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscle.

Nursing Management Patients with active symptoms of ACS should be instructed to call emergency services and should be brought in by emergency medical services personnel, not by themselves, family, or friends. Patients should be instructed to come to the emergency department immediately if the suspected ACS symptoms last longer than 20 minutes at rest or are associated with near syncope or hemodynamic instability. If nitroglycerin is prescribed to a patient with suspected ACS, the patient should be instructed to take a dose if symptoms arise. If no relief is experienced 5 minutes after the first dose, the patient should contact emergency services. Educate post myocardial infarction patients about the role of a low-cholesterol and low-salt diet. Educate patients about the American Heart Association (AHA) dietary guidelines, including a lowfat, low-cholesterol diet. A dietitian should see and evaluate all patients post myocardial infarction prior to their discharge. Emphasize exercise training because current evidence demonstrates that cardiac rehabilitation post myocardial infarction results in lower rates of recurrent cardiovascular events.

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Following myocardial infarction, educate all patients regarding the critical role of smoking in the development of coronary artery disease. Smoking cessation classes should be offered to help patients avoid smoking after their myocardial infarction Prognosis Acute myocardial infarction is associated with a 30% mortality rate; half of the deaths occur prior to arrival at the hospital. An additional 5-10% of survivors die within the first year after their myocardial infarction. Approximately half of all patients with a myocardial infarction are rehospitalized within 1 year.

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OVERVIEW of HYPERTENSIVE ATHEROSCLEROSIS CARDIIOVASCULAR DISEASE

Athersclerotic cardiovascular disease is most commonly known as coronary heart disease. This condition involves the hardening of the heart arteries. Athersclerotic cardiovascular disease is attributed to the builds up of fat deposits, which essentially clog up the heart's arteries.

Treatment Dietary sodium restriction Regular moderate exercise Smoking cessation Weight reduction

Pharmacological Treatment ACE inhibitors Such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart Digitalis glycosides To increase the ability of the heart muscle to contract properly and help treat some heart rhythm disturbances. Angiotensin receptor blockers (ARBs) Such as losartan and candesartan to reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors Beta-blockers Such as such as carvedilol and metoprolol, which are particularly useful for those with a history of coronary artery disease.

Nursing Management Maintain the healthiest lifestyle possible. This means eating a healthy and nutritious diet. Getting a good amount of physical activity in your daily schedule Sodium restriction and low-fat diet Encourage to stop smoking

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VITAL IBFORMATION

Name Sex Age Address Civil Status Religion Occupation Educational Attainment Date & Time Admitted

J.B Male 60 years old North Natividad, Pilar, Capiz Married Roman Catholic Fisherman Elementary Graduate June 29, 2011 4:20 pm

Ward Chief complaint Admitting Diagnosis

St. Catherine Laboure SOB T/C CAP MR, T/C aortic aneurysm, CHF 2 AMI, HACVD, S/P AMI

Diet Attending Physicians

Full diet, low cholesterol Dr. M. B. Referral to: Dr. B.

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CLINICAL ASSESSMENT

A. Nursing HistoryFor almost nine (9) years, Mr. J.B is very compliant to all of his medications as maintenance and regular check up to Dr. B. However, a month ago, Mr. J.B was not able to meet the recommended

medications for his maintenance due to lack of knowledge. He thought that he is fine since his blood pressure was always ranging to 130 / 80 to 140 / 90. He also stopped seeing his doctor for regular check up because of the long distance travel and has the belief of the routine medical advice. Pareho malang gyapon ang ginahimo kag ginareseta sa akon as verbalized. Moreover, three weeks prior to his admission, Mr. J.B. experienced sudden onset of shortness of breath especially if placed on supine position associated with harsh breathing. Also, he experienced occasional nape pain and full to heavy chest pain as described. These complaints continued until his admission to St. Anthony College Hospital. On the day prior to Mr. J.B s admission, June 29, 2011 at around 4:20 pm, he sought consultation with his attending physician, and was advised for intensive care unit admission. During this time, Mr. J.B needs an intensive care for he is suspected to have an aneurysm which is a medical emergency case.

B. Past Health ProblemMr. J.B is a known chain smoker during his time; he can consume 3 packs of cigarettes (Hope) a day. He considers himself as a moderately alcoholic drinker : 5 to 6 shots of alcoholic beverage were enough for him just to relieve his fatigue from all the day s work. In addition, he also drinks coffee every morning. Furthermore, on the year 2001, Mr. J.B was admitted at St. Anthony College of Roxas, Inc. (Hospital) due to mild stroke with his attending physician, Dr. B. Because of that incidence, Mr. J.B stayed in the Intensive Care Unit (ICU) for almost five days. Following his stay in the ICU, he was transferred to a private room where in care was being rendered until optimum wellness was achieved. That incidence in his life forced him to totally stop smoking, drinking alcoholic and caffeinated beverage.

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C. Family Genogram

F.B

R.B

G.B

B.B

R.B

J.B

H.B

C.B

D.B

N.B

LEGEND:PatientJ.B

Aortic Aneurysm, AMI, HACVD, HypertensionJ.B

MaleR.B

Diabetes Mellitus II

Female

HypertensionF.B

DeathR.B

Aging

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PATTERNS OF FUNCTIONING

Nutritional History a. Drinking Patterns HOME Mr. J.B is fond of drinking water. He drinks water before and after meals, as well as when there is a feeling of dry mouth and thirst. Mr. J.B is not fond of drinking neither soft drinks nor coffee and a beverage at all. He can consume not less than 8 glasses of water a day. HOSPITAL His fluid intake was limited for he cannot tolerate large amount of fluids. He only consumes 350cc of water per shift during our care.

b. Eating Pattern HOME Mr. J.B had a very good appetite. He can tolerate large amount of food; is able to consume his meal and have extra rice every meal. Since Mr. J.B lives in Pilar, there viand most of the time is sea foods which is rich in sodium. Yet, he also likes to eat vegetables. His wife prepares vegetables 3 or 4 times a week and sometimes fruits. HOSPITAL Mr. J.B loses his desire for foods. He had a poor appetite and can only consume 1/3 of the meal served. Mr. J.B cannot tolerate large amount of foods. The meals being served to him was full diet and low in cholesterol.

c. Breathing Patterns HOME Mr. J.B experienced an episode of shortness of breath associated with harsh breathing when in supine position before he was admitted. HOSPITAL Mr. JB had oxygen of 1 L breaths per minute via nasal cannula. Sometimes, he complained of shortness of breath with a respiratory rate ranging from 22 24 breaths per minute.

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d. Circulation Temperature Pulse rate Respiration rate Blood pressure Apical rate 36C 88 bpm 24 bpm 160/100 mmHg 90 bpm IVF Left carpal vein Side Drip # 2 PNSS 1L x KVO AC Drip: 500 ml D5 water + 2 Apresoline + 2 Catapres @ 15 gtts / min (Maintain systolic blood pressure of 140 to 150, titrate 5 ugtts / min and stop side drip for Bp of 140).

Daily Activity Patterns: a. Rest and Sleeping Patterns HOME Mr. J. B usually sleeps at night after watching television news with long intervals. He slept at about 8 - 9 in the evening and wake up at 5 6 in the morning to have walking at the seashore. He also slept at noon time to rest in his small hut. HOSPITAL Mr. J.B has a difficulty in sleeping at night; he claimed that he can only slept at night in a short interval due to dizziness and coming in and out of nurses in the room. He slept at 10 - 11 pm and woke up at 6 in the morning.

b. Personal Hygiene HOME At home, Mr. J. B takes a bath every day and does his oral hygiene once a day by himself. HOSPITAL In hospital, Mr. J. B takes a bath occasionally and does his oral hygiene once a day after dinner with assistance from the student nurse assigned or the folks. Sponge bath is also rendered by his wife every day or when he did not take a bath.

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c. Elimination Patterns Bowel Movement FREQUENCY Home Hospital PROBLEMS / DIFFICULTIES Home Hospital

Once or twice a day every morning or after lunch

Once every 2 or 3 days and there is no BM during our care.

He experienced sometimes having constipation or diarrhea.

None

Urination FREQUENCY Home Hospital PROBLEMS / DIFFICULTIES Home Hospital

Urinates whenever feels the urge and approximately 5 times a day.

Urinates whenever feels the urge with a urine output approximately 620 cc during our 8 hour care.

None

None

A. Educational Background - Mr. J.B is an elementary graduate at Dulangan Elementary School. B. Occupational Background - Mr. J.B is a fisherman. C. Religious practices - Mr. J.B does not attend regular masses every Sunday except during Holy days of obligations. Yet, he said that he is praying before sleeping and before eating his meals. D. Economic status - They belong in the middle class of economic level in this society.

SOCIO-CULTURAL HEALTH A. Cultural Health Mr. J.B participates when they have their fiesta in their barrio. They also prepare foods for their visitors. He did not consider superstitious beliefs. Rather, he believes that everything happens in God s will.

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B. Recreational Pattern Mr. J.B loves to have walking every morning and during sunset in the seashore. For him, breathing fresh air is the best way that he could relax himself. Other than that, he is also fond of watching news in ABS-CBN and stay in his nipa hut to have rest. He also listens to the music or news in Bombo station through his favourite radio.

C. Environmental Pattern Their house is located in between of the road and coastal area. It is also at the front of basketball court and chapel. As what we have observed, the environment there is conducive to make Mr. J.B feel relax.

D. Interaction Pattern Through the help of his grandchildren, Mr. J.B forgot that he has health problem. When they are all in, they tend to have conversation with each other and have humours. Kasadya gid kong makita ko sila tanan , as what Mr. J.B told us. According to him, his family is his strengths and being with them, is the most treasure he had.

E. Coping Pattern Mr. J.B had no idea about his aneurysm; all he knew was that he is only suffering from a high blood pressure associated with a cardiac problems. From that information he had, he tried to maintain and lower down his blood pressure through a long period of rest, a strict compliance to all the medications, and avoiding stressful stimuli like noises. They have a strong bond in their family. All of her children as well as his wife participate in the plan of care for him. Actually, they monitor the blood pressure of Mr. J.B, taking good care of his feelings and asking him not to perform those activities that need effort. They also accompanied Mr. J.B when he likes to walk in the seashore. Because of his situation, they decided to keep the real status of Mr. J.B s condition.

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CLINICAL INSPECTION

Vital SignsUpon Admission Temperature 36.1C Respiratory rate 25 bpm Apical pulse 105 bpm Radial pulse 100 bpm Blood pressure 220/140 & 230/150 mmHg

During our Care September 16, 2010 Time Temperature (C) Respiratory rate (bpm) (bpm) 7:00 8:00 9:00 10:00 11:00 12:00 1:00 2:00 36.1 22 86 82 36 24 90 88 160/100 150/100 160/100 160/100 150/100 140/100 140/100 140/100 (bpm) (mmHg) Apical pulse Radial pulse Blood pressure

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PHYSICAL ASSESSMENT

General Appearance Mr J.B is awake and consciously lying on bed at a high fowler s position which appears weak,

fatigue, with shortness of breath, and pale but still oriented and in an appropriate mood; with an ongoing IVF of #2 PNSS 1 L x KVO infusing well on the right carpal vein at the level of 500 cc, a secured AC drip of 500 ml D5 water + 2 Appresoline + 2 Catapres @ 15 ugtts / min; this is to maintain systolic blood pressure of 140 to 150 mmHg and to be titrated at 5 ugtts / min, and O2 inhalation of 1 LPM via nasal cannula. He is coherent, physically and mentally conscious wherein responsiveness to any stimuli is observed, and with non edematous lower & upper extremities are not noted.

CephalocaudalBody Parts Method of Assessment Skin Inspection Poor skin turgor Due to physiologic changes of aging; limited physical activity and range of motion. Findings Interpretation

Skin is warm and dry, (-) pallor, (-) cyanosis. Skin is intact and wrinkled Fair complexion. Skin is soft and no scar, bruise or petechiae noted.

Normal

Head

Inspection

Normocephalic, , hair is evenly distributed, black in color, straight, smooth and short Symmetrical feature of the face. Normal

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Facial grimace

(+) chest pain when in supine position; It results from the disruption of normal circulation in the thoracic region.

Palpation Absence of nodules Normal

Nails

Inspection

Capillary refill of 4 seconds

Due to the disturbance of circulation in the periphery.

(-) of clubbing with an angle of about 160 degrees. Eyes Inspection Pupil size R = 2mm L = 1.5 Sluggish pupil reaction Reddish sclera & conjunctiva Moderately reactive to light and accommodation.

Normal

A result of pressure against the cervical sympathetic chain.

Palpation Ears Inspection

(-) Tenderness and lumps Color same as facial skin Auricle is aligned with the outer cantus of the eye Responsive to moderate voices

Normal

Normal

Nose

Inspection

Symmetric with the nasal septum at the center O2 @ 1 liter per minute

Normal

Neck

Inspection

Coordinated, smooth movements with no discomfort No lumps or swollen glands

Normal

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Chest and Thorax

Inspection

RR= 24 bpm (+) Shortness of breath Nonproductive, intense cough

It is the result of pressure of aneurysm sac against trachea, a main bronchus, or the lung itself.

Auscultation

(+) Chest pain Pain scale = 5 to 6

It results from the disruption of normal circulation in the thoracic region.

(-) adventitious breath sounds Abdomen Inspection Abdominal wall is uniform in color and round.

Normal

Normal

Auscultation

No abdominal bowel sounds

Due to limited physical activity and bed rest.

Palpation

Soft bulgy abdomen (-) tenderness Liver is not palpable

Normal

Extremities

Inspection

Capillary refill of 4 seconds

Due to the disturbance of circulation in the periphery.

Lesions and wounds Cardiovascular Inspection Chest pain

Normal It results from the disruption of normal circulation in the thoracic region.

Bp = 160/100 mmHg

Due to atherosclerosis and continues decreased in the passage way of blood as a result of

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compression from aneurysm.

HR = 90 bpm PR = 88 bpm Genitourinary Inspection Voids freely in the comfort room with no complaints of pain and difficulties. The urine output during our care is 620 cc. Urine is clear and aromatic Musculuskeletal Inspection Able to ambulate with assistance Limited physical activity

Normal

Normal

Due to his condition. This is to provide rest and prevent stressors that could cause an increase in blood pressure result to rupture of aneurysm.

A. General Appraisal

i.

Speech

-

He is oriented and converses appropriately without any problem in his speech.

ii. Language He knows Ilonggo, Tagalong and a little in English.

iii. Hearing He can hear moderate sound and interpret auditory stimuli appropriately.

iv. Emotional status He is slightly worried about his condition. He all knows that he had only hypertension and he worries about it when his blood pressure is above normal. His medical condition was decided by Mr. J.B s family to keep it from him. This is the reason why he did not know about the extent of thoracic aortic aneurysm and the effects of it in his lifestyle. v. Mental status

-

He is conscious, alert, coherent, and able to comprehend instructions and commands. He is also oriented to person, time, place and events occurring in the environment and sometimes he asks about his condition.

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LABORATORY &DIAGNOSTIC DATA

Date: June 29, 2011 Chest X Ray View: Anterior Posterior Impression: Cardiomegaly. Mild Pulmonary congestion. Bibasal Pneumonia. Left hilar mass vs. Aortic Aneurysm. Atheromatous aorta. Hyperthrophic Degenerative Osteoarthropathy, thoracic spine.

Fluid Serum Test Result Normal Values Sodium Calcium Magnesium Creatinine 143 mmol/L 2.39 mmol/L .9 mmol/L 126.8 umol/L 136 145 2.12 2.52 .74 - .99 53 115 Normal Normal Normal Reduced blood flow to the kidney due to disturbed arterial circulation. Potassium 3.5 mmol/L 3.5 5.1 Normal Significance

Troponin I Determination (miniVIDAS) Normal: