d. Discharge Planning

A. General Condition

The patient was wearing a white shirt and maong pants. He manifests good

grooming and he appears neat. He shows increased strength and a relieved

condition. He is able to tolerate activities minimally as he experiences fatigue in

simple performance of ADLs.

B. METHOD

M> Advised to take home medications on time as prescribed such as::

Mixtard 22 ”u” SC am, 12 “u” pm

Clopidogrel 75mg/tab OD

Captopril 75mg 1/2 tab OD

Cordarone 200 mg TID for 2 days then BID

Atorvastatin 40 mg OD

Vastarel MR BID

Imdur 60mg ½ tab BID

Recormon 5,000 “u” to be given by Dr. Cunan on December 10, 2009

E> the patient is encouraged to have mild physical activity if tolerated.

T> None

H> the patient is advised to prevent emotional stress, avoid fatty, salty and sweet foods. Compliance to the home management planning is encouraged. Patient was advised to have some to take his blood pressure at home to monitor elevation on blood pressure which may precipitate another heart attack.

O> patient is advised to go back on December 10, 2009 for follow check up with Dr. Cunan.

D> the patient was encouraged to have a low salt, low fat diet.

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e. Follow – up Home Visits

Home Visit (December 22, 2009 - Tuesday)

Upon the assessment and interaction of the health care team with the patient, the

patient verbalized easy fatigability in doing even his activities of daily living, especially

during walking and taking bath. There is also visible weakness in long hours of

standing. The pt. manifested pale palpebral conjunctiva, cold clammy skin, good skin

turgor, dry skin, capillary refill of < 3 sec, with no edema, but with crackles on right lung

field.

T= 36ºC

RR= 21 cpm

PR= 65 bpm

BP= 130/80 mmHg

Health teachings were given such as to sit instead of standing during activities or

shower to conserve energy and to ask for assistance when doing extreme range of

motions. Upon interview, the patient revealed that there are some modifications and

changes on his medications:

Lasix 40mg ½ tab OD M-W-F

Aldactone 25mg/tab 1 tab OD

Losartan 50 mg 1 tab OD

Clopidogrel (Platexan) 1 tab OD

Amiodarone 500mg 1tab OD

Lanoxin 0.25mg ½ tab M-W-F

Imdur 300mg ½ tab od

Atorvastatin 40mg OD

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Mixtard 27/14

Home Visit (December 26, 2009 - Saturday)

Upon the assessment and interaction of the nursing students with the patient, the

patient verbalized easy fatigability in doing even his activities of daily living, especially

during walking and after taking bath. There is also visible weakness in long hours of

standing. The patient verbalized that he cannot perform his past daily regimens like

going jogging and exercising. The pt. manifested pale palpebral conjunctiva, cold

clammy skin, good skin turgor, dry skin, capillary refill of < 3 sec, with no edema.

T= 36ºC

RR= 20 cpm

PR= 70 bpm

BP= 130/80 mmHg

Health teachings were given such as to sit instead of standing during activities or

shower to conserve energy and to ask for assistance when doing extreme range of

motions.

Home Visit (December 28, 2009 - Monday)

Throughout the home visits, it was been noted by the researchers that the home

management plan are being followed strictly by the patient. Same with the previous

home visits the patient is still complaining of easy fatigability even with simple activities.

T= 36.8ºC

RR= 16 cpm

PR= 77 bpm

BP= 120/80 mmHg

161