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CLIENT – IN- CONTEXT
PRESENT STATE INTERVENTIONS OUTCOME
L.C., 82years old, female, was admitted for the fifth time at CVGH
accompanied by daughter per taxi per wheelchair last April 15, 2008 for
complaints of fever accompanied by headache and chills under the services of
Dr. Geselita Maambong, under the Department of Internal Medicine, co-
managed by Dr. Clifford John Aranas, of the Internal Medicine Department.
Previous Hospitalization:
2000- Pt was admitted at CVGH ICU because of dyspnea due to the
aspiration of an unrecalled cause, under the services of Dr. Maambong.
Diagnostic tests include CBC, U/A, and X-ray, as recalled by the S.O. She
July 1, 2008
ER blotter: time in 11:00 am, time out ? with the following vital signs:
BP: 110/60, PR: 64 bpm, T: 38 ºC/axilla, RR: 29 cpm
1. Fever 3. S/P CBG 2002
2. DM Type 2 4. ?Dyslifidemic
>CBG = HIGH 436 – 12:10
>IVF PNSS 1L @ 30 gtts – 11:00
was there for almost a month. Pt was diagnosed with Diabetes Mellitus Type2
and Essential Hypertension2. She was discharged with improved condition
with maintenance medications: Diamicron MR 30mg/tab 1tab OD, Imdur
60mg/tab 1/2tab BID, and Neurontin 100mg/capsule 1capsule BID, all taken
with good compliance.
2002- Pt was admitted at CVGH for complaints of chills and fever under the
services of Dr. Maambong. She was admitted for 2weeks. Again, diagnostic
tests include CBC, U/A, and X-ray, as recalled by the S.O. She was
discharged with an improved condition. No more fever and chills. With the
same set of maintenance medications taken with good compliance.
2004- Pt was again admitted at CVGH because of a wound in her left foot and
the surrounding area of the wound had turned dark. It was diagnosed to be a
gangrene. Pt underwent Debridement under the services of Dr. Busa of the
surgery department. Her hospitalization lasted for 3weeks and was discharged
with improved condition. S.O. claims that the medications were still the same
but an unrecalled antibiotic was added. S.O. reports to have let patient take
these medications with good compliance.
History of Present Illness:
3weeks PTA, patient’s daughter noticed a burn on the left side part of the
patient’s left dorsal foot. Daughter asked pt how she got it and patient
answered “napaso sa kalan” which was still hot and placed on the floor.
According to the S.O. “murag ga tubig cya sa sulod pariha adtong na una
niyang samad sauna.” S.O. pricked the blister and washed it with the water
extracted from boiled guava leaves. There was no pain felt by the patient but
there was redness and swelling around the sides. Patient also claimed it to be
rather itchy. After, S.O. treated it with Betadine and Tetracycline BID without
prescription.
2weeks PTA, the wound was getting deep. It looked like erosion. No
consult was done and the ritual treatment using Betadine and Tetralcycline
ointment BID continued.
1week PTA, S.O. noticed that the wound did not show signs of healing.
She then decided to have her mother get ready for a check-up with Dr.
Maambong. Initially, patient was hesitant. For her, there was nothing to be
worried about and it’s a waste of money. With her daughter’s persistence,
patient agreed to go for a medical check-up. There, she was prescribed with
Bactroban cream (Mupirocin), Betadine, and Hydrogen peroxide to clean the
wound BID. Patient was also prescribed Ciprofloxacin (Ciprobay) 500mg
OD.
4days PTA, pt experienced intermittent fever (highest at 38C) and chills.
>PUN 200cc of ___ IVF – 11:00
10’ 11” HR given - 11:00
ECG 12 leads – 11:00
>CBG, Crea, Na-, K+, SGPT HBAIC - 12:00
>CXR PA, CBG monitor hourly – relay all results
>blood culture 2 soltn n30 min apart ??
>please admit to IM Dept. under the service of Dr. Zanoria
>TPR q4
>Diet: blenderized feeding @ 1000 cal/day in 1500cc divided in 6 equal
feedings: low salt, low fat/cholesterol, diabetic @ CHO 240 CHON 80
>insert FBC and attach to urobag
>11:30 insert NGT
>monitor V/S every 2 hours and refer for ???? or HR > 100, RR > 20,
BP = 160/90
>I/O every 4 hours
PHYSICAL ASSESSMENT:
Date of Assessment: July 3, 2008 (Thursday)
Time performed: 10:00am
General Appearance:
Examined while lying on bed,, awake, conscious, unresponsive,
incoherent and afebrile, with FBC-CDU and IVF 4 D5.3NaCl @
20gtts/min infusing well at right arm with the following vital signs:
BP=130/80mmHg, PR=72bpm, RR=20cpm, T=36.8˚C/axilla,
Height=cm, Weight=kg; IBW=kg.
SKIN AND APPENDAGES: no lesions, brown complexion, (-)
jaundice, (-) cyanosis, (-) edema, hair evenly distributed, senile skin
turgor, warm to touch, pale nailbeds, no nail clubbing, no ingrown
toenails, presence of IV line on right arm, bruises on antecubital
area, (-) Chvostek’s sign
HEAD: normocephalic, symmetric, thinning gray hair, evenly
distributed hair, no masses, no lice infestation, (-) dandruff, scalp has no
lesions and no tenderness upon palpation
EYES: symmetrical, ,anicteric sclerae, pale palpebral conjunctivae,
eyebrows and lashes present bilaterally, equal distribution of eyebrows,
(+) Pupils Equally Round and Reactive to Light and Accomodation, (+)
S.O. remembered the same symptoms her mother experienced in her previous
hospitalizations and decided to seek consult with Dr. Maambong again.
Furthermore, patient manifested polyuria and nocturia as reported by S.O.
“mukalit ra ug pangihi”. Pt was advised to undergo CBC, U/A and Lipid
panel.
Morning PTA, the results were given. There was an increase in her
creatinine level (4.0mg/dl) which meant that the patient had kidney failure.
Aside from this, the wound was not healed and began to become deep. This
prompted Dr. Maambong, and with the patient’s consent, to let the patient
admit at CVGH for a closer observation.
Past Heath History
Pt. is diabetic and hypertensive (with highest BP of 240/110mmHg) for
8years as diagnosed by Dr. Maambong last 2000 with maintenance
medications: Diamicron MR 30mg 1 tab OD, Imdur 60 mg/ tablet, ½ tablet
two times a day, and Neurontin 100 mg/ capsule 1 capsule two times a day.
She is a nonsmoker and a nonalcoholic beverage drinker with no known food
and drug allergies.
Health-Perception Health-Management Pattern
Patient cannot describe health and cannot rate when asked to. She has
no regular medical checkups and would only seek consultation to Dr.
Maambong whenever the need arises. She believes in folk medicine as she,
herself, is a licensed “mananabang” and “manghihilot.” She uses Pau d’ Arco
to soothe muscle pains and aches. She also drank the water from “sibukaw”
and “wachichaw”, two glasses/day to promote urination. She also drinks the
CBW left from “dahon sa atis” to cure colds. Last year, she took Roch
1capsule per day for 15days because daughter heard over the radio and
thought it was effective. After the 15th day, the daughter stopped buying the
drug because saw that it was not effective and heard about the damage to the
liver caused by Roch herbal medicine. She doesn’t know how to performBSE
ever since and was taught by the student nurses on how to performit but no
response was noted. She’s not fully immunized and practices OTC
medications such as Paracetamol (Biogesic) 500mg for relieving minor
headaches and fever as reported by S.O. At home, it is her daughter who cuts
her nails but in bathing and dressing,the pt does it alone although she is being
watched by S.O.
During hospitalization, patient still cannot rate health. She claims that
she is alright and when asked how she feels, verbalizes “ok ra” or “maau
Cardinal gaze, no abnormal discharges
EARS: symmetrical, skin color is consistent with the facial skin color,
pinna is in line with the outer canthus ofthe eye, no swelling, no lesions,
no abnormal discharges,no foul odor, pinna is non-tenderupon
palpation, recoils after being folded, can hear low-pitched voice at 2 ft.
distance
NOSE AND SINUSES: Nasal septum is straight and perforated, no
nasal flaring, septum located at midline, symmetrical & proportional to
other facial features, no inflammation, no lesions, no swelling, no
bleeding, clear frontal & maxillary sinuses on transillumination, nares
are patent, no congestion
MOUTH AND THROAT: lips symmetrical and red in color, dry lips,
no cracks, no lesions, gums pinkish and moist, pinkish tongue, uvula in
the midline, no swelling or redness, no masses and ulcerations, (+) gag
reflex, no tonsil inflammation, uvula at midline, pinkish gums, has 11
teeth ( 6 upper and 5 lower), presence of plaque and dental caries,
decayed teeth
NECK: supple neck, no lesions, no masses, trachea at midline, lymph
nodes not palpable
CHEST AND THORAX: equal chest expansion, RR=20cpm, no
palpable masses, no lesions, normal tactile fremitus
HEART: distinct heart sounds S1 and S2 upon auscultation, no
murmurs, HR= 72bpm with regular rhythm.
BREAST AND AXILLAE: symmetrical, no abnormal nipple
discharges, no masses, non-tender, non-palpable axillary lymph nodes,
areola brown in color, nipples not inverted
ABDOMEN: flat and soft, umbilicus at midline, inverted, nontender,
scars present, (-) fluid wave test,(-) shifting dullness,nonpalpable
kidneys, 14 borborygmous sounds/minute auscultated at right lower
quadrant
GENITO-URINARY: grossly female, minimal pubic hair, no
discharges, no lesions, no purulent discharges, no itching, no rashes,
nako. Ganahan nako mu-uli”. S.O. further adds that her mother is “dili
reklamador ug agwantador” and is very “pasensyosa” even if she feels pain or
is feeling unwell already. Patient is a little bit aware of her condition because
every time the medicine or a procedure is given, it is explained by the
healthcare team about it. However, when asked about what she understands
about her case, she only looks at the student nurse and calls her daughter to
answer the questions instead. Her daughter is the one who cuts her toenails
and fingernails.
Nutritional – Metabolic Pattern
Before hospitalization, patient eats 5x/day with snacks in between (3full
meals and snacks for morning and afternoons). Occasionally, pt drinks
softdrinks at 240ml the most. Pt also eats fruits at least once a week such as
oranges and apples for these are easily available at the market and do not
need special temperature conditions for it to stay fresh. Water intake is also
more than 8glasses/day before hospitalization. She claims her body weight
was normal for her. She also takes in Musigor Vita 500mg OD as prescribed
by Dr. Maambong last year for loss of appetite.
CLIENT’S
DIET
24H
RECALL
USUAL
DIET
Breakfast Around
8am
1cup rice
30cc water
75g mashed
corned beef
6am
1pc
scrambled
egg,
75g corned
beef,
1/2cup rice
or oatmeal,
240ml
Anlene
milk
Lunch 12:30nn
1 cup rice,
1cup
mashed
sayote
guisado,
1 whole
12noon
100g salty
paksiw, 1
small bowl
of
malunggay
soup, and
?urine output=300-450cc/shift
RECTUM: no hemorrhoids, no abnormal discharges, no irritations and
itchiness
EXTREMITIES: no swelling, no lesions, (-) ROM on lower and
upper extremities (-) edema, CRT on upper extremity <2sec, CRT on
lower extremities are <2 seconds, pale nailbeds, weak and thready
pulses, (-) Trousseau’s sign
NEUROLOGIC ASSESSMENT
Cognitive: Does not respond to questions “Kaila ka ani niya mam?,
Kahibaw ka asa ka karun? Kanusa imong birthday? Pila imong
edad gi-dugo ka?”
Cerebellar: unable to perform finger to nose test, (-) thumb
opposition test, (-) Romberg test, (-) Tandem test, can’t walk without
assistance
Sensory: Does not respond to student nurse’s instructions
> (-) graphesthesia: can’t able to identify letter A & 2 on
her back and palm
>(-) 2point discrimination test: able to identify sharp from
dull (back of comb and tip of ballpen)
> (-) sterognosis: able to identify pen with eyes closed
>(-) kinesthesia: able to identify the directions to which
her toes and finger were moved (up and down)
CRANIAL NERVES
I. Olfactory: not able to distinguish any smell
II. Optic:
III. Occulomotor: (+) cardinal gaze = on lifesize objects such as
student nurse, (+) PERRLA
IV. Trochlear: (+) cardinal gaze = on lifesize objects such as
student nurse, (+) PERRLA
banana,
30cc water
1/2cup rice.
Dinner 6pm
1 cup rice,
150g
shredded
chicken
with
carrots,
30cc water
6pm
1 fish inun-
unan,
1/2cup rice,
and 100g of
caldereta
with
potatoes
and carrots.
Snacks 3pm
1pc orange
2-3pm
1 pc home-
made
sandwich or
1pack
biscuits
with 100ml
milk.
During hospitalization, patient still eats 3 full meals of only soft foods
(mostly with soups) and seldom eats snacks. She has a low salt, low fat, low
cholesterol diet with no simple sugars diet. She cannot swallow the tablets
whole as well (the student nurses administer it to her in powdered form). Her
favorite foods consist of pork as S.O. says “pakibaboy mana si mama gud”.
She is currently placed to limit her fluids at 800cc per day. Pt has difficulty
in chewing and swallowing and prefers her foods readily shred up for her.
She doesn’t have any regular dental check-ups. She once went to see a dentist
with her daughter because she complained of a little pain in her tooth. The
dentist, their friend, Dr. Pedro Achombre, told them that she cannot pull the
tooth unless the pt’s blood sugar will go back to normal. After a while the pt’s
blood sugar did go down but she no longer wanted to have her tooth pulled
for financial reasons and she wanted to wait for the rest of her teeth to
“tangtang ug iya-iya”. Furthermore, the S.O. reports that the patient only
brushes her teeth once a day or sometimes, only when she goes out of the
house.
Elimination Pattern
Before hospitalization, patient eliminates bowel everyday usually after she
V. Trigeminal:
Sensory: eyelids blink bilaterally at the touch of tissue on the
temporal area, can feel touch of object on forehead, chin, and
cheeks but can’t determine whether soft or hard
Motor: can masticate, can clenched teeth
VI. Abducens: (+) cardinal gaze = on lifesize objects such as
student nurse, (+) PERRLA
VII. Facial:
Sensory: can identify bitter taste by spitting the medicine
Motor: does not smile, can’t frown, can raise eyebrows, can’t
puff out cheeks, can wrinkle forehead
VIII. Vestibulocochlear: can hear low-pitched voice at 2ft distance
IX. Glossopharyngeal: able to swallow, (+)gag reflex, able to
distinguish taste at the posterior1/3 of tongue because she does
not spit out delicious food like spaghetti
X. Vagus: (+) gag reflex, can swallow
XI. Spinal Accessory: can’t shrug shoulders against resistance
XII. Hypoglossal: tongue at midline upon protrusion, unable to
move tongue from side to side and up and down
MUSCLE STRENGTH
1/5 3/5
1/5 3/5
SCALE FOR GRADING MUSCLE STRENGTH
5 – Full ROM against gravity, full resistance
4 – Full ROM against gravity, some resistance
3 – Full ROM with gravity
wakes up at around 5am. Her stools are yellow-brown in color and are well-
formed. She doesn’t take in laxatives and does not claim to experience
constipation. She voids 5-6 times per day with light yellow-colored urine
having a moderate flow approximately 20-40 ml per episode. She claims to
have no difficulty in voiding.
During hospitalization, patient voids 3-4times per day and her urine is
dark yellow amounting to 300-450cc/8hours. She only experienced nocturia
in the first few days of her hospitalization as confirmed by the S.O. Her
defecation pattern changed. At initial days of admission, pt claims to
experience constipation and S.O. claims that there was a time the patient was
not able to defecate in 2-3days. She was given Senna concentrate (Senokot)
2tabs OD qHS by AP. Right now, patient seems to defecate involuntarily.
Often times, fecal matter is found staining her bed linens. There was a time
when pt was able to verbalize “kalibangun ko” but when the student nurses
assisted her and checked, the linens were already soiled with fecal matter. Pt
also defecates more than twice per day with yellow-colored stools and
irregular timing.
Activity – Exercise Pattern
Patient wakes up at 5am, walks around the house using a cane, defecates,
eats breakfast prepared by her daughter at 6am. She takes her nap for about
2hours, eats lunch by 12nn and takes another 2-hour nap, eats dinner by 6pm,
and sleeps at 8pm. Patient has been a “manghihilot” and a licensed
“mananabang” all her life as far as she can remember. She only stopped
working after she was diagnosed with Essential Hypertension and Diabetes
Mellitus 2 last 2000. Patient tries to help in performing household chores by
sweeping the floor, wiping the table and window surfaces whenever she feels
well. Her daughter is the one who hinders the patient from performing these
things because she fears this will worsen her mother’s condition. Patient’s
usual leisure time includes strolling after rising, watching TV, sleeping and
listening to “drama” on the radio. To this question (patient’s leasure
activities), the S.O. also adds “badlong sa mga apo. Di nuon siya mangasaba
pero mubadlong siya kung nag-gara2 na.”
During hospitalization, pt. is most of the time asleep or watching TV. S.O.
says “di mana siya tulog gyud. Murag hinanok mana iya. Manokon na bya
matulog pud basta tiguwang. Sturyai lang, naminaw ramana siya.” Pt. can no
longer perform her ADLs as she did before. Now, student nurses and her
daughter facilitate in moving her from the bed to the chair, comb her hair,
assists her in changing her diapers, clothes, and underwear.
2 – Full ROM with gravity eliminated
(passive motion)
1 – Slight Reaction
0 – No Reaction
DEEP TENDON REFLEXES
(+1) biceps reflex, (+1) triceps reflex, (+1) brachioradialis reflex, (+1)
patellar reflex, (+1) Achilles Reflex
SCALE FOR GRADING REFLEX RESPONSES:
0 – No Reflex Response
+1 – Minimal Activity
+2 – Normal Response
+3 – More Active than Normal
+4 – Maximal Activity (Hyperactive)
?GLASGOW COMA SCALE
Response Score
Eye-opening response Spontaneous opening 4
To verbal response 3
To pain 2
None 1
Most appropriate Oriented 5
Verbal response Confused 4
Inapp. Words 3
Incoherent 2
None 1
Most appropriate Obeys commands 5
Motor response Localizes pain 4
Flexion to pain 3
Extension to pain 2
None 1
TOTAL SCORE 3-15
Sleep – Rest Pattern
Before hospitalization, patient usually sleeps around 8pm and wakes up at
5am everyday. Upon waking up, she feels “ok” and that her sleep is enough.
She uses a blanket and a pillow as her sleeping aid. She doesn’t take sedatives
to facilitate her sleep and has no problems in sleeping. She prays before
sleeping. Rituals include changing of clothes before sleeping and putting of
cologne after a bath.
During hospitalization, patient sleeps most of the time and looks fatigued
as shown in her weary facial expression. Aside from this, there is no more
definite time as to when she sleeps or wakes up. She also says her sleep is “ok
ra.” She has no rituals before sleeping. At first, patient is disturbed by
healthcare professionals who go inside the room often. But she says she has
adjusted to themalready.
Cognitive – Perceptual Pattern
Patient remembers things that happened a long time in the past such as
her menarche, her first sexual contact, and what her work was. She also
remembers things that have happened recently such as the food she ate for
lunch as confirmed by her S.O. Once, she even said to the student nurse when
there were about more than 8children in the room “daghan pani sila. Gamay
ra ni akong mga apo diri karun”and smiled which meant that she is still able
to remember her grandchildren. She has an educational level of kindergarten
because at that time, her parents did not give any importance to education.
Kindergarten at that time involved activities such as playing, singing songs,
and dancing. Patient comprehends Bisaya and speaks the language well. She
uses eyeglasses with unrecalled date as to when she started using it. S.O.
reports that the patient does not know how to read at all (with or without
glasses) but is able to write her signature when she was not hospitalized.
There are no changes before and during hospitalization except that when
asked to write her signature, only scribbles appear. Patient does not use
hearing aids. Her sense of smell and taste is still intact. Patient’s sense of
touch is diminished in the left leg.
Self-Perception – Self-Concept Pattern
Patient claims that she is satisfied with her life and that is contented as a
mother. She feels alright about her accomplishments such as raising
wonderful kids and letting them graduate with degrees. She says that her
family is very good to her even before hospitalization. To her, her physical
outlook is “ok”. She also feels good about herself and has no complaints
?Patient’s rating in GCS: 12points –Lethargic
Date performed: July 4, 2008 (Friday
Time performed: 10:00am
General Appearance:
Examined while lying on bed,, awake, conscious, unresponsive,
incoherent and afebrile, with NGT at left nostril and IVF 5 D5.3NaCl @
20gtts/min infusing well at right arm with the following vital signs:
BP=120/70mmHg, PR=73bpm, RR=20cpm, T=36.3˚C/axilla,
Height=cm, Weight=kg; IBW= kg.
SKIN AND APPENDAGES: pale nailbeds, presence of IV line on
right arm, bruises on antecubital area
EYES: pale palpebral conjunctivae
NOSE AND SINUSES: presence of NGT
MOUTH AND THROAT: has 11 teeth ( 6 upper and 5 lower),
presence of plaque and dental caries, decayed teeth
ABDOMEN:, scars present
Extremities: (-) ROM on lower and upper extremities, pale nailbeds,
weak and thready pulses
NEUROLOGIC ASSESSMENT
Cognitive: Does not respond to questions “Kaila ka ani niya mam?,
Kahibaw ka asa ka karun? Kanusa imong birthday? Pila imong
edad gi-dugo ka?”
Cerebellar: (-) finger to nose test, (-) thumb opposition test, (-)
Romberg test, (-) Tandem test, can’t walk without assistance
Sensory: (-) graphesthesia, (-) 2point discrimination test, (-)
sterognosis, (-) kinesthesia
CRANIAL NERVES
I. Olfactory: not able to distinguish any smell
II. Optic:
III. Occulomotor:
Motor: does not smile, can’t frown, can’t puff out cheeks
about herself. She says her worry right now is her illness but she strongly
believes that she will be cured. According to her S.O., pt is very
understanding, loving, caring, and generous. “Bisan mga silingan mangayo ug
bugas, muhatag gyud na dayun siya.” As a mother, the patient is a very good
one and has raisedher children well. According to the grandchildren, she is
not selfish. “Kung mangayo gain mi ug kwarta, hatagan dayun mi.”
Role – Relationship Pattern
Patient claims to have good and open relationship with her family until
now (to those still alive). She has been a widow for about 14 years already.
She has 15 children, 2 of which are dead. They use a switchboard type of
communication. She has a lot of friends and relatives with whom she
maintains a peaceful relationship with them. Breadwinners of the family are
her 2sons working abroad as a licensed practical nurse and another who is a
chef of a university. They are the ones supporting the treatment of the patient
and the expenses of the household. When asked if she is satisfied with her
relationship with her family, she says “oo.” And her S.O. reinforces the
question by adding “ pinangga kaau ni cya sa tanan. Contento na siya ky wa
gyuy kaaway nya nindot ra ug kahimtang iyng mga anak run” afterwhich the
patient nods in affirmation to the statement.
During hospitalization, patient can no longer see her other grandchildren
and children as often as she used to. Her communication with other family
members is also impaired because she does not talk much already.
Genogram:
Maternal Side Paternal side
*heart problem
*patient
*unrecalled cancer
*lung cancer
male
female
deceased
* History of both maternal and paternal sides are unrecalled but patient is sure
that both sides have a history of Hypertension and Diabetes Mellitus.
IV. Spinal Accessory: can’t shrug shoulders against resistance
V. Hypoglossal: unable to move tongue from side to side and
up and down
MUSCLE STRENGTH
1/5 3/5
1/5 3/5
?DEEP TENDON REFLEXES
(+1) biceps reflex, (+1) triceps reflex, (+1) brachioradialis reflex, (+1)
patellar reflex, (+1) Achilles Reflex
?Patient’s rating for GCS: 12points –Lethargic
Date performed: July 5, 2008(Saturday)
Examined while lying on bed, awake, conscious, unresponsive,
incoherent and afebrile, with IVF 6 D5.3NaCl @ 10gtts/min infusing
well at right arm with the following vital signs: BP=140/90mmHg,
PR=80bpm, RR=20cpm, T=36.3˚C/axilla, Height=cm, Weight=kg;
IBW= kg.
SKIN AND APPENDAGES: pale nailbeds, presence of IV line on
right arm, bruises on antecubital area
EYES: pale palpebral conjunctivae
MOUTH AND THROAT: has 11 teeth ( 6 upper and 5 lower),
presence of plaque and dental caries, decayed teeth
ABDOMEN:, scars present
Extremities: (-) ROM on lower and upper extremities, pale nailbeds,
weak and thready pulses
NEUROLOGIC ASSESSMENT
Cognitive: Does not respond to questions “Kaila ka ani niya mam?,
Kahibaw ka asa ka karun? Kanusa imong birthday? Pila imong
edad gi-dugo ka?”
Cerebellar: (-) finger to nose test, (-) thumb opposition test, (-)
Romberg test, (-) Tandem test, can’t walk without assistance
Sexuality-Reproductive Pattern
Patient had her menarche at 12yrs.old as manifested by brown spots on her
underwear. Her menstruation lasted for 4-5 days usually with moderate flow
and consumes 2-3 pasadors/day. Her 1st sexual contact was with her sole
partner (husband) at the age of 17years old. No hx of STD and uses no
contraceptives ever since. Currently, pt’s APGAR score is G15P150013 all
pregnancies did not undergo PNC and were delivered via licensed
“mananabang.” No problems in delivery were reported. Patient does not
know how t perfor BSE and has never tried undrergone any procdures such as
mammogram and pap smear. Patient had her menopause at 52 years old.
Personal information about the pt’s sexuality is disclosed as verbalized by the
S.O. “Grabiha ninyu dae noh din a lage mo ma.uwaw mangutana ug mga
ing.ana.” Pt also verbalized “mingawun ko usahay sa akng bana.”
Coping-Stress – Tolerance Pattern
When asked what stress is to her, patient only stared at the student nurse.
But when asked what “kapoy” is to her and if she feels any right now and
before hospitalization, she answered with “wala man” but sometimes also
replies with “ambot lang” and shakes her head slightly from side to side.
According to the daughter, who is the patient’s primary caregiver at home,
“di ka makadungog ni mama mureklamo gyud sa balay bisan nagsakit na na
siya dinha. Ako nalang mahibung nganu lain na iyang nilihukan ug sa ni
adtong hinay na siya ug samot.” Pt just lies down to relax if she feels such
and her problems and worries are alleviated. Family has a switchboard type of
communication but since the year 2000, her daughter is the one deciding for
the family in coordination with her brothers and sisters. Pt’s support systemis
her family.
Value – Belief Pattern
Patient has faith in God because she values masses highly. She watches
TV on Sundays because she can no longer tolerate the walking to get to
church to hear mass. She also prays every night before going to sleep. She has
no religious organizations. She has superstitious beliefs such as not taking a
bath after having fever because “makabughat”. There is no difference with
her values and beliefs before and after hospitalization. Values in the family
include close family ties, helping one another, being sensitive to one
another’s needs. During hospitalization, the sons of the patient calls during
weekends to ask about their mother’s condition. They also send money from
time to time to finance their mother’s hospitalization. “Magtinabangay gyud
Sensory: (-) graphesthesia, (-) 2point discrimination test, (-)
sterognosis, (-) kinesthesia
CRANIAL NERVES
I. Olfactory: not able to distinguish any smell
II. Optic:
III. Occulomotor:
Motor: does not smile, can’t frown, can’t puff out cheeks
IV. Spinal Accessory: can’t shrug shoulders against resistance
V. Hypoglossal: unable to move tongue from side to side and
up and down
MUSCLE STRENGTH
1/5 3/5
1/5 3/5
?DEEP TENDON REFLEXES
(+1) biceps reflex, (+1) triceps reflex, (+1) brachioradialis reflex, (+1)
patellar reflex, (+1) Achilles Reflex
?Patient’s rating for GCS: 12points –Lethargic
LABORATORY EXAMS:
BLOOD TYPING
(4/12/08)
Purpose: Blood typing are most commonly done to make certain that a
person who needs a transfusion will receive blood that matches (is
compatible with) his own. People must receive blood of the same blood
type; otherwise, a serious,even fatal, transfusion reaction can occur.
Blood type = B
Rh = +
Implications: the patient’s blood type is B+
URINALYSIS
Stanford Med and Diagnostic
(4/12/08)
mi” was what the S.O. said.
Environmental History
Pt. is currently residing in a one storey house in Suba, Lilo-an, Cebu for
three years with her eldest daughter’s family. House and lot is rented and
financed by the patient’s eldest son abroad. There are a total of 7 people
living in the house including the patient with 2 bedrooms and 8windows. Pt
sleeps with her 2grandchildren and daughter. While the other room is
occupied by her 2 older grandchildren and son-in-law. They have no pets in
the household but there are chickens from the neighbors that go to their
backyard. Location of the house is accessible to their basic necessities. It is a
10-15minute walk away from the Healthcare center, market and Barangay
Health Center (BHC), and church. The main road is a 5minute walk away
from the house. The location of the house is accessible to public
transportation such as their “trysikads”. Water is supplied by MCWD and
electricity is supplied by Visayan Electric Company(VECO). Pt. describes
neigborhood as peaceful and not congested. Garbage is disposed via
motorized collection systemevery other day and toilets are flush-type.
Purpose: Urine provides important information about a number of
physiologic processes,including renal disease,diabetes mellitus,
hydration status,and some liver disease. Most have a routine urine
examination upon admission to a hospital, and many outpatient settings.
Macroscopic
Color: slightly cloudy
Reaction: pH 5.0
Spec.grav. : 1.015
CHON: +1 (HAc)
Glucose: negative
Microscopic
RBC/hpf: 0-1
WBC/hpf: 4-6
Epithelial cells: few
Mucus threads:moderate
a. urates:few
Bacteria: few
Coarsely granular cast:0-1/hpf
Finely granular cast: 0-1/hpf
Implications: An increase of WBC in urine usually implies infection of
the urinary tract.
LIPID PANEL
(April 12, 2008)
Purpose: To determine if your blood glucose level is within healthy
ranges; to screen for, diagnose,and monitor hyperglycemia,
hypoglycemia, diabetes, and pre-diabetes. Total cholesterolassessesrisk
of CAD and evaluates fat metabolism. Triglycerides screens for
hyperlipemia, and helps identify nephrotic syndrome. The serum
creatinine level is used to indicate the renal function specifically the
ability of the kidney to secrete urea and proteins. The BUN test is
primarily used,along with the creatinine test,to evaluate kidney
function. This test measures the nitrogen function of urea.
Glucose: 83 mg/dl (normal= 75-115 mg/dl)
Cholesterol total: 180 mg/dl (up to 200 mg/dl)
Triglyceride: 164 mg/dl (up to 150 mg/dl)
HDL: 23 mg/dl (normal = 35-60 mg/dl)
LDL: 124mg/dl (normal = 0-150 mg/dl)
VLDL: 33 mg/dl (normal = 0-40 mg/dl)
Creatinine: 4 mg/dl (normal= 0.5-1.2 mg/dl)
BUN: 52.5 mg/dl (normal = 4.7 – 23.4 mg/dl)
BUA: 7.6 mg/dl (normal = 2.5 – 6.1 mg/dl)
SGOT: 25 u/L (up to 37 u/L)
SGPT: 14 u/L (up to 32 u/L)
Glycosylated Hgb: 5.7 % (normal= 4.5 – 6.3%)
(April 30, 2008)
Glu: 103 mg/dl (normal= 75-115 mg/dl)
Implications: Mild-to-moderate increase in serum triglyceride levels
indicates biliary obstruction,diabetes,nephrotic syndrome or
endocrinopathies.Low HDL-cholesterol levels are connected with
diabetes mellitus, and hypertension.Increased creatinine levels and BUN
in the blood suggest diseasesorconditions that affect kidney function.
High creatinine may be due to reduced blood flow to the kidney due to
shock, dehydration, congestive heart failure, atherosclerosis,or
complications of diabetes.Increased BUN may result from decreased
blood flow to the kidneys, such as shock or stress,and from conditions
that cause obstruction of urine flow.
BLOOD CHEMISTRY
Stanford Med and Diagnostic
(4/12/08)
Purpose: To determine if your blood glucose level is within healthy
ranges; to screen for, diagnose,and monitor hyperglycemia,
hypoglycemia, diabetes, and pre-diabetes. Total cholesterolassessesrisk
of CAD and evaluates fat metabolism. Triglycerides screens for
hyperlipemia, and helps identify nephrotic syndrome. The serum
creatinine level is used to indicate the renal function specifically the
ability of the kidney to secrete urea and proteins. The BUN test is
primarily used,along with the creatinine test,to evaluate kidney
function. This test measures the nitrogen function of urea.
Glucose: 83 mg/dl (normal= 75-115 mg/dl)
Cholesterol total: 180 mg/dl (up to 200 mg/dl)
Triglyceride: 164 mg/dl (up to 150 mg/dl)
HDL: 23 mg/dl (normal = 35-60 mg/dl)
LDL: 124mg/dl (normal = 0-150 mg/dl)
VLDL: 33 mg/dl (normal = 0-40 mg/dl)
Creatinine: 4 mg/dl (normal= 0.5-1.2 mg/dl)
BUN: 52.5 mg/dl (normal = 4.7 – 23.4 mg/dl)
BUA: 7.6 mg/dl (normal = 2.5 – 6.1 mg/dl)
SGOT: 25 u/L (up to 37 u/L)
SGPT: 14 u/L (up to 32 u/L)
Glycosylated Hgb: 5.7 % (normal= 4.5 – 6.3%)
Implications: Mild-to-moderate increase in serum triglyceride levels
indicates biliary obstruction,diabetes,nephrotic syndrome or
endocrinopathies.Low HDL-cholesterol levels are connected with
diabetes mellitus, and hypertension.Increased creatinine levels and BUN
in the blood suggest diseasesorconditions that affect kidney function.
High creatinine may be due to reduced blood flow to the kidney due to
shock, dehydration, congestive heart failure, atherosclerosis,or
complications of diabetes.Increased BUN may result from decreased
blood flow to the kidneys, such as shock or stress,and from conditions
that cause obstruction of urine flow. Increased blood uric acid may result
from certain medications like diuretics and antihypertensive drugs.It can
lead to deposits of uric acid in the kidneys (uric acid nephropathy).
COMPLETE BLOOD COUNT
Purpose: The CBC is a basic screening test and is one of the most
frequently ordered laboratory procedures. The findings in the CBC give
valuable diagnostic information about the hematologic and other body
systems,prognosis,response to treatment and recovery.
Stanford Med and Diagnostic
(4/12/08)
Hgb = 10 g/dl (normal = 12-16 g/dl)
Hct = 30 vol% (normal = 37-47 vol%)
WBC = 10.8 10^9/L (normal= 5.0-10.0 10^9/L)
Platelet count = 245,000 (normal= 150,000- 450,000/cumm)
RBC count = 7.70 10^12/L (normal= 4.0-5.5 10^12/L)
Differential count
Segments = 0.70 (normal: 0.5-0.7)
Lymphocytes = 0.30 (normal: 0.2-0.4)
RBC morphology
Anisocytosis rare
Red Cell Indices
MCV = 81 fl (normal: 80-96 fl)
MCH = 27.0 pg (normal: 27.0-33.0 pg)
MCHC = 33.3% (normal: 31.0-36.0%)
Cebu Velez General Hospital
DATE 4/23/08 4/24/08 4/28/08 5/2 NORMAL
VALUES
WBC 13 16.3 11.1 8.74 4.10-10.9 k/uL
NEU 10.4
80%
13.1
80.7%
8.71 6.46
78.2% 73.9%
2.50-7.50
47-80%N
LYM 1.37
10.5%
1.49
9.16%
1.14 1.49
10.2% 17.1%
1-4
13-14%L
MONO .884
6.78%
1.27
7.83%
1.06 0.477
9.52% 5.46%
.100-1.20
2-11%M
EOS .276
2.07%
.308
1.89%
.162 0.237
1.45% 2.71%
0.00-.5
0-5%E
BASO .078
.598%
.062
.379%
.063 0.74
.565% 0.846%
0-.100
0-2.10%B
RBC 3.04 3.71 3.67 3.74 4-5.20
HGB 9.03 10.6 10.7 10.7 12-16g/dL
HCT 25.4 30.8 30.8 31.3 36-46%
MCV 83.5 83 84.0 83.3 80-100fL
MCH 29.1 28.5 29.1 28.4 24-36pg
MCHC 35.6 34.4 34.7 34.1 31-36g/dL
RDW 14.7 13.9 14.5 14.7 11.6-18%
PLT 372 355 306 340 140-440k/uL
MPV 7.56 7.37 7.16 7.71 0-100gfL
Remarks:
4/23/08:few hypochromic red cells noted
4/24/08: low hypochromic RBCs noted.
Implications:.
An increase in WBC and neutrophil count is the body’s
reaction in response to the invading organism to fight off the
infection (foot debridement) and defend the body. An
elevated number of monocytes results from viral infection
A decrease in RBC production, Hgb and Hct level is a result
of damage of kidney (CKD) that results in the decrease in
the production of the hormone erythropoietin that stimulates
red blood cell production in the bone marrow.
BLOOD CHEMISTRY
(4/15/08)
Purpose: Serum or plasma tests for potassium levels are routinely
performed in most patients when they are investigated for any type of
serious illness. Also, because potassiumis so important to heart function,
it is usually ordered. Sodium test is a part of the routine lab evaluation of
most patients. It is one of the blood electrolytes, which are often ordered
as a group. Ionized Calcium is the calcium found in blood. This test
measures serum levels of phosphates. It helps store and utilize body
energy and help regulate calcium levels, carbohydrate and lipid
metabolism, and acid-base balance. It is also essential for bone
formation. Magnesium is the most abundant intracellular cation after
potassium. Vital to neuromuscular function, this helps regulate
intracellular metabolism, and activates many essential enzymes.
Creatinine is the byproduct of the breakdown of muscle creatine
phosphate resulting from energy metabolism. It is produced at a constant
rate depending of the muscle mass of the person and is removed fromthe
body by the kidney. This test diagnoses impaired renal function
BUN: Urea forms in the liver and along with CO2, constitutes the final
product of protein metabolism. The amount excreted urea varies directly
with protein intake. The test for Bun, which measure the nitrogen portion
of urea, is used as an index of glomerular function in the production and
excretion of urea.
Implications:
Elevated serum Creatinine levels may indicate renal disease that
has seriously damaged the nephrons. Increased creatinine levels in the
blood suggest diseases or conditions that affect kidney function or
reduced blood flow to the kidney due to atherosclerosis.
Increase in BUN levels indicates impaired function of the
kidneys (Chronic Kidney Disease) to filter and excrete urea leading to its
accumulation in the blood.
Abnormally low serum sodium levels may result from
inadequate sodium intake or excessive sodium loss due to profuse
sweating, diuretic therapy, adrenal insufficiency, or chronic renal
insufficiency
Below-normal potassium levels often result from loss of body
fluids (as in diuretic therapy). It may also result from chronic renal
insufficiency.
Elevated serum magnesium levels (hypermagnesemia) most
commonly occur in renal failure, when the kidneys excrete inadequate
amounts of magnesium.
Elevated levels of phosphorus (hyperphosphatemia) may result
from renal failure. Hyperphosphatemia is rarely clinically significant;
however, if prolonged, it can alter bone metabolismby causing abnormal
calcium phosphate deposits.
Normal V
15-
Apr
19-
Apr
23-
Apr
25-
Apr
28-
Apr
30-
Apr
2-
May
Crea 0.6.-1.6 mg/dl 4.7 5.3 4.2 3.7
BUN 7-18 mg/dl 75.5 58 57
K
4.0-5.6
mmol/L 4.5 5 4.8 4 3.7
Na
136-142
mmol/L 135 132 131 138 139
Mg 1.2-2.2 mg/dl 2.3
P
2.70-4.50
mg/dl 4.67 3.6
Ionized 4.5-5.16 mg% 4.76
Ca
(4/18/08)
Purpose: Amylase helps digest starch and glycogen in the mouth,
stomach, and intestine. It distinguishes between acute pancreatitis and
other causes of abdominal pain. Phosphates aids in diagnosis of renal
disorders and acid-base imbalance.
amylase = 89 u/L (normal = 25-100 u/L)
SGPT = 15 u/L (normal = 0-46.0 u/L)
Phosphates = 76 u/L (40 – 129 u/L)
Implications: Results are within normal limits.
ARTERIAL BLOOD GAS ANALYSIS
Purpose: ABG Analysis is a measurement of oxygen, carbon dioxide, as
well as the pH of the blood that provides a means of assessing the
adequacy of ventilation (PaCO2), oxygenation (PaO2) and it also allows
assessment ofthe acid-base (pH) status ofthe body – whether acidosis or
alkalosis is present, whether acidosis or alkalosis is respiratory or
metabolic in origin and to what degree (compensated or
uncompensated). This test is important because patient was having
dyspnea so the oxygenation of the body cells must be noted.
DATE 4/15/08
2:59
pm
4/26/08 4/29
2:17 pm 10:24am
Normal
values
temp 35.3 °C 36.8 °C 36.3 C 36.4-37.4C
Hgb 9.2 9.0 10.7 12-16 g/dl
pH 7.370 7.461 7.45 7.35 – 7.45
pCO2 25.6 28.1 36.2 32-42
mmHg
pO2 78.7 56.1 39.1 75-100
mmHg
HCO³ 14.8 19.8 25.0 20-24
mmol/L
TCO² 21 20.7 26.2 21-
25mmol/L
ABE -9.4 -2.9 1.4 -3.3(+)1.2
mmol/L
SatO2 97.8 91.1 78.4 95-98%
Reticulocyte
count
1.8% 0.5-1.5%
Implications:
(4/15/08)Results imply a fully compensated respiratory alkalosis with
adequate oxygenation. It is fully compensated because the pH is normal.
It may also be caused by respiratory stimulation by drugs, disease,
hypoxia, or fever. A high reticulocyte count indicates a bone marrow
response to anemia caused by hemolysis or blood loss.
(4/26/08) Results imply a partially compensated respiratory alkalosis
with mild hypoxemia. This is due to the impaired function of the kidneys
to excrete the hydrogen ions to maintain pH homeostasis. As a
compensatory mechanism, when more hydrogen ions are released in the
blood, the respiratory control centers are activated in breathing rate and
depth increases to exhale carbon dioxide to maintain pH homeostasis.
(4/29/08) Results show an acid-base balance with severe hypoxemia.
RESCREENING TEST RESULTS
(4/23/08)
HBsAg MEIA = 0.79
Cut off = 2.0
Interpretation = non-reactive
Anti HIV-MEIA = 0.37
Cut off = 1.0
Interpretation = non-reactive
Anti HIV-MEIA = 0.28
Cut off = 1.0
Interpretation = non-reactive
Remarks: VDRL and malarial smears not done due to technical reasons
and limitations.
ELECTROCARDIOGRAM
Purpose: to detect heart problems or blockages in the coronary arteries;
to draw a graft of the electrical impulses moving through the heart; to
record heart rate and the regularity of heart beats; to diagnose a possible
heart attack or other heart diseases.
April 18, 2008 (3:40pm)
Rate: atrial: 83/minute
ventricular: 83/minute
Rhythm: sinus
Axis: +33 degrees
PR interval: 0.16 seconds QRS: .06 seconds QT interval: .36 seconds
P wave: gen. upright
QRS: normal R wave progression
Transitional zone: V4
T wave: flat in II, depressed III, AVF
ST segment: isoelectric
Interpretation: Sinus rhythm
Inferior wall ischemia
Probable old anteroseptal myocardial infarction
April 19, 2008
Rate: atrial: 71/minute
ventricular: 71/minute
Rhythm: sinus
Axis: +32 degrees
PR interval: 0.28 seconds QRS: .04 seconds QT interval: .36 seconds
P wave: upright
QRS: normal R wave progression q II, AVF, II
Transitional zone: V2 – V3
T wave: flat II, AVF, V4, V5-V6
ST segment: isoelectric
Interpretation: sinus rhythm within normal limits. Consider an old
inferior wall scar.
LEFT FOOT APO
(4/15/08) – DR. BULLO
Left foot APO: examination reveals the bones are normal in density,
texture, and modeling. The joint space is well maintained. There is no
evidence of a fracture, bone erosion nor bone destruction.
Conclusion: (-) left foot
CHEST PA
(4/15/08) – DR. MAAMBONG
Purpose: To evaluate respiratory status and heart size.
Result: Examination reveals the lung fields are clear. The cardiac
silhouette is not enlarged. There are no bony abnormalities.
(4/16/08) – DR. MAAMBONG
Result: examination reveals there are reticular densities noted in both
lungs. The cardiac silhouette is not enlarged. There are no bony
abnormalities.
Conclusion: pneumonitis both lungs
(4/22/08) – DR. MAAMBONG
Chest AP: examination reveals there is hazy density noted in the right
lower lung and the right costrophrenic angle is obliterated.
Conclusion: pleural effusion right (hazy density)
(4/29/08)– DR. MAAMBONG
Chest PA: examination reveals there are hazy densities noted in both
lower lungs. The diaphragm is obliterated. The cardiac silhouette is
enlarged. The pulmonary vessels in the upper lung fields are prominent.
There are no bony abnormalities.
Conclusion: cardiomegaly, associated with pulmonary edema or
congestion
Chest Right Lateral Decubitus: examination of the right lateral
decubitus of the chest with horizontal beamreveals there is homegenous
density noted along the right lateral chest wall. The right hemidiaphragm
is obliterated
Conclusion: Pleural Effusion RIGHT
Chest PA: Examination reveals there is hazy density noted on both lung
bases. The pulmonary vessels are prominent. The cardiac silhouette is
difficult to evaluate
Conclusion: Pulmonary edema and congestion, pulmonary edema
secondary to heart failure
(4/30/08) – DR. MAAMBONG
Chest PA: Examination reveals there is hazy density noted on both lung
bases. The pulmonary vessels are prominent. The cardiac silhouette is
enlarged
Conclusion: Cardiomegaly, associated with pulmonary edema or
congestion
PERIPHERAL SMEAR EVALUATION
(4/15/08)– DR. MAAMBONG
Result: The peripheral blood smears shows a dimorphic population of
normocytic and microlytic normocromic to mildly hypocromic RBC. No
significant poikilocytosis is noted.No nucleated RBC’s seen; WBC are
heterogeneous lot and show basically normal adult morphology. A
relative predominance of segmentors is present.There are o blast cells
identified.
Platelets are within normal limits in number and morphology.
ARTERIAL DUPLEX SCAN
(4/15/08)
Conclusion: atherosclerotic and heavily calcified lower extremity
arterial segments
: severe (50-99%) arterial occlusive disease of the bilateral
posterior tibial and anterior tibial arteries
: moderate (20-49%) arterial occlusive disease of the mid-
segments of the right superficial femoral artery.
VENOUS DUPLEX SCAN: LOWER EXTREMITY
(4/15/08)DR. MAAMBONG
Venous duplex result: the visualized lower extremity venous segments
are compressible with adequate phasic.
Interpretation: no evidence of acute approximal deep vein thrombosis
bilaterally
: deep venous insufficiency involving the right common
femoral, superficial femoral and popliteal veins
: superficial venous insufficiency involving the right
greater saphenous vein and lesser saphenous vein.
WOUND DISCHARGE/ CULTURE
(4/16/08)
Gram staining: no microorganisms seen
P.R. No growth after 1 day
(4/17/08)
P.R. no growth after 2 days of incubation
(4/19/08)
P.R. smear of culture: Gram (+) bacillus
Culture: bacillus spp.
(2/20/08)
F.R remarks: no otherpathogens isolated
(4/21/08)
F.R remarks: sensitivity testing of culture:
Bacillus spp was not done since there is no definitive CLSI or NCCLS
guidelines for susceptibility testing.However, vancomycin,
ciprofloxacin, imiperum, and aminoglycosides may be effective.
Wheneverisolated from clinical specimens, the potential for the isolate
to be a contaminant must be strongly considered.
2 D ECHO
(4/16/08)– DR. MAAMBONG –
Conclusion: concentric left ventricular hypertrophy with regional
hypokinesia with borderline fan and Doppler evidence of stage 2
diastolic dysfunction.
: dilated left atrium
: mitral sclerosis with mitral regurgitation, mild, mitral
annular, calcification
: aortic sclerosis with aortic annular calcification
: tricuspid regurgitation, mild
: moderate pulmonary hypertension
ULTRASOUND
(4/19/08)– DR. MAAMBONG
Ultrasound upper abdomen
Purpose: to evaluate the kidneys, liver, gallbladder, pancreas,spleen,
abdominal aorta and other blood vessels ofthe abdomen; to help
diagnose a variety of conditions,such as abdominal pains, inflamed
appendix, enlarged abdominal organ, stones in the gallbladder or kidney;
to assist in the assessment ofdamage caused by illness.
Ultrasound upper abdomen:
Exam reveals the liver is normal in size and echopattern.There are no
dilated intrahepatic ducts or masses noted.The gallbladder is normal in
size. The gallbladder wall is not thickened. The common duct is not
dilated. There are no intraluminal stones noted.
The Pancreas is normal.
The Spleen is normal in size with transverse diameter of 6.3 cm.
Incidentally, there is fluid in the left hemithorax.
Conclusion: normal liver, gallbladder, pancreas,and spleen
Right pleural effusion
Ultrasound K.U.B
(4/16/08)– DR. MAAMBONG
Right kidney 7.4 x 4.2 cm
Cortical thickness 1.5 cm
Left kidney 8.2 x 4.5
Cortical thickness 1.9 cm
Examination reveals both kidney are in Normal in size, shape,
echogenicity and echopattern.There is no evidence of a stone,mass or
hynephrosis.The ureters are unremarkable. The urinary bladder is
normal.
Conclusion: normal K.U.B ultrasound.Examination reveals both
kidneys are normal in size, shape,echogenicity, and echopattern
DEBRIDEMENT
Purpose: Debridement speeds the healing of pressure ulcers,
burns, and other wounds. Wounds that contain non-living
(necrotic) tissue take longer to heal. The necrotic tissue may
become colonized with bacteria, producing an unpleasant
odor. Though the wound is not necessarily infected, the
bacteria can cause inflammation and strain the body's ability
to fight infection. Necrotic tissue may also hide pockets of
pus called abscesses. Abscesses can develop into a general
infection that may lead to amputation or death.
(4/26/08)
Debridement of left foot under local anesthesia at 9:30 AM under cardiac
monitor
LIVER FUNCTION TEST (April 30, 2008)
Purpose: Lactate dehydrogenase catalyzes the reversible conversion of
muscle lactic acid into pyruvic acid. This test aids in differential
diagnosis of MI, pulmonary infarction, and hepatic diseases.
LDH (lactate dehydrogenase):212u/L (normal=0-247 u/L)
Total CHON: 6.6 g/dl (normal=6.6-8.8 g/dl)
Pleural fluid
LDH (lactate dehydrogenase):76u/L (normal=0-247 u/L)
CHON: 1.8 g/dl (normal=6.6-8.8 g/dl)
Implications: Low total protein levels may result from essential
hypertension,uncontrolled diabetes mellitus, and malnutrition. Low
protein levels can suggest a kidney disorder, or a disorder in which
protein is not digested or absorbed properly.
CBG
Purpose: CBG consisting in measuring the glucose (sugar) content in
the blood is done on a regular basis in diabetes patients to determine
their glucose level (Normal = 70 – 120mg/dl). The purpose is to find out
if the doses of medicine which the patient is taking are correct and if his
diet is right or if corrections should be made.
Highest (4/16/08 9pm) 269 mg/dl
Lowest (4/17/08 5am) 84 mg/dl
KEY ISSUES:
1. Impaired gas exchange related to alveolar-capillary membrane
changes secondary to inflammation of lung parynchema as manifested
by shortness of breath, use of accessory muscles in breathing, (+)
wheezes, crackles heard upon auscultation, decreased Sat O2= 91.1
(mild hypoxemia) as of 04/26/08, hazy density noted in the right lower
lung and right pleural eff) on chest x-ray result as of 04/22.
SB:
Ventilation is impaired because of secretions of exudates from alveoli.
Secretions noted to be mobilized, loosened and expectorated in order to
provide an adequate gas exchange. Unless secretions are removed, the
alveoli becomes remained filled with exudates causing consolidation of
lung tissues and further interfering with gas exchange.” (Nursing Care
Planning Guidelines by Caine – Bufalino p.497)
In pleural effusion, lung expansion may be restricted, and the client may
experience dyspnea primarily on exertion, and a dry non-productive
cough caused by bronchial irritation or mediastinal shift. (Black, Joyce,
et. al, Medical-Surgical Nursing, 7th edition, Volume 2, p. 1873)
April 28, 2008
2. Decreased cardiac output related to increased viscosity of the blood
secondary to abnormally high blood sugarand impaired heart
contractility secondary to elevated blood pressure as manifested by skin
is dry and cold to touch,weak and thready peripheral pulses,2D Echo
results as of April 16, 2008 that reveal left ventricular hypertrophy
dilated left atrium, mitral sclerosis with mitral regurgitation, aortic
sclerosis with aortic annular calcification, mild tricuspid regurgitation,
and moderate pulmonary hypertension,cardiomegaly on chest x ray
(april 29, 2008)
SB: “The increased thickness of the heart muscle reduces the size of the
Independent Interventions:
1. Auscultated breath sounds
and assessed air movements.
R: To ascertain status and
note progress.
2. Elevated head of bed and
complied to positioning
schedule of patient.
R: To take advantage of
Desired Outcome:
Within 8 hours of
nurse-client
interaction, patient
will be able to
maintain patent
airway, demonstrate
good respiration and
improved oxygen
exchange.
ventricular cavities and causes the ventricles to take longer time to relax,
making it more difficult for the ventricles to fill with blood during the
first part of diastole and making them more dependent on atrial
contraction for filling” (Medical-Surgical Nursing, 10th Ed., Vol.1 p.773)
The left ventricle of the heart may become enlarged as it works to pump
blood against elevated pressure due to systemic vascularresistance and
excessive intravascular volume. Eventually, stroke volume, preload and
afterload are affected
(Brunner and Suddarth’s Textbook on Medical-Surgical Nursing 10th
edition pg. 856)
gravity decreasing pressure
on the diaphragm and
enhancing drainage and
ventilation to different lung
segments.
3. Positioned head midline.
R: To open or maintain open
airway.
4. Encouraged deep breathing
exercises.
R: To maximize effort.
5. Encouraged to expectorate
sputum.
R: To clear secretions.
6. Promoted adequate rest
periods.
R: To lessen fatigue.
Collaborative Interventions:
1. Administered supplemental
oxygen at 4L per minute.
R: To increase oxygen
available to tissues.
Independent Intervention:
1. Determined baseline v/s
including peripheral pulses;
and reviewed laboratory
values and diagnostic studies.
R: provides opportunities to
track changes
2. Assessed mental status
R: cerebral perfusion is
directly related to cardiac
output and aortic pressure
perfusion and is influenced
by electrolyte and acid-base
Actual Outcome:
04/28-30/08
After 8 hours of
nurse-client
interaction, patient
was able to maintain
a patent airway still
uses accessory
muscle in breathing,
crackles still heard
on both lung fields,
constant use of
supplemental O2.
Sat O2 as of april 29
has decreased to 78.
4 (moderate
hypoxemia)
05/2/08
After 8 days of
nurse-client
interaction, patient
still uses accessory
muscles in breathing,
O2 level has
decreased from 4 to
2 L/min.
supplemental O2
was also used when
difficulty in
breathing rises.
Desired Outcome:
Within 8 hours of
nursing intervention,
April 28, 2008
3. Ineffective Tissue Perfusion related to interruption of arterial and
venous flow and decreased HGB concentration as manifested by pale
nailbeds and pale palms of the hand and soles of the feet, pale palpebral
conjunctiva, weak and thready pulse on both upperand lower
extremities, CRT < 3secs on lower extremities, deep venous on venous
duplex scan result as of 04/15 and atherosclerotic and heavily calcified
lower extremity on Arterial duplex scan result as of 04/15; decreased
Hgb= 10.7 m/ul (04/28) and Hct = 30.8% (04/28)
SB:
“The delivery of oxygen to the muscle cells throughout the body depends
not only on the lungs but also on the ability of the blood to carry oxygen
and on the ability of the circulation to transport it.” (Merck Manual of
Medical Information, 2nd Home Ed., M. Beers et. al, p. 221)
The amount of blood flow needed by body tissues constantly changes.
The percentage of blood flow received by individual organs or tissues is
determined by the rate of tissue metabolism, the availability of oxygen
and function of tissues.
(S: Smeltzer, Suzanne C. and Brenda G. Bare. Medical-Surgical
Nursing. p 977)
variations.
3. Provided adequate rest by
decreasing stimuli and
providing quiet environment
R: To maximize sleep periods
4. Elevated legs
R: to promote venous return
5. Monitored I/O
R: To maintain adequate fluid
balance
6. Encouraged changing
positions slowly.
R: Reduce risk of orthostatic
hypotension.
7. Assisted in performing
self-care activities.
R: to decrease energy
consumption.
8. Altered environment such
as decreasing temperature of
air conditioner.
R: to maintain body
temperature in normal range.
9. Explained fluid
restrictions.
R: to promote cooperation of
patient and SO.
10. Assisted with frequent
position changes.
R: to avoid the development
of pressure sores.
Collaborative Intervention:
1. Administered oxygen
inhalation at 4L/min as
indicated.
R: To increase oxygen
available to tissues.
2. Administered ISMN/
Isosorbide mononitrate
the patient will
display stability in
blood pressure and
participate in
activities that reduce
the workload of the
heart such as
balanced activity/rest
plan.
Actual Outcome:
05/28-29/08
After 8 hours of
nursing intervention,
the patient’s BP=
130/80 mmHg.
Patient needs
assistance in rising
from bed and
transferring to
bedside commode.
Patient is cold to
touch, peripheral
pulses are weak and
not easy to palpate
05/2/08
After 8 hours of
nursing intervention,
the patient’s BP=
130/80 mmHg.
Patient was able to
sit on bed with little
assistance, and alert
at this time.
April 28, 2008
4. Fluid Volume Overload r/t excess fluid in pleural spaces secondary
to inability of the kidney to excrete fluid efficiently as manifested by use
of accessory muscles upon breathing, (+) wheezes, crackles heard on
both lung fields, hazy density noted in the right lower lung and pleural
effusion, right on chest x-ray result as of 04/22.
SB:Pleural effusion is the accumulation of fluid in the pleural space.
Nomally only a thin layer of fluid separates the 2 layers of the pleura. An
excessive amount of fluid may accumulate for many reasons, depending
on the cause.the most common symptoms are shortness of breath and
chest/ pleuritic pain.there are many causes of pleuritic pain including
viral and bacterial infections. (merck manual of medical information,
2nd ed., p.226,283.)
Pleural effusions may also be associated with the leakage of fluid due to
higher than normal pressures in the lung circulation, such as with
congestive heart failure (CHF) or from low protein in the blood, as in
liver disease,severe malnutrition, and in certain kidney conditions when
(Imdur) 60mg/tab ½ tab twice
a day by mouth
R: relaxes vascular smooth
muscles with a resultant
decrease in venous return
3. Administered Amlodipine
5 mg 1 tablet once a day after
breakfast by mouth
R: to depress myocardial
contractility, dilate coronary
arteries and arterioles and
peripheral arterioles
3. Administered Aluminum
Hydroxide (Alutab) 1 tablet
twice a day by mouth
R: binds with phosphate ions
in the intestine to form
insoluble aluminium-
phosphate complexes,
lowering phosphate in
hyperphospatemia
Independent Interventions:
1. Interviewed and reviewed
patient’s history and
determined the nature of the
problem.
R: to assess causative factor
2. Established baseline vital
signs, weight, and laboratory
values.
R: provide comparison with
current findings.
3. Measured capillary refill
time; palpated for presence or
absence and quality of pulses.
R: To note degree of
impairment.
4. Assessed for Homan’s sign
Desired Outcome:
Within the course
of nursing
intervention, patient
will be able to be
free from the signs
and symptoms of
infection like
swelling, fever,
redness, pain
protein is filtered into the urine.
(http://www.pcca.net/PleuralEffusion.html)
April 20, 3008
5. Imbalanced Nutrition, less than body requirements related to
increased metabolic rate and fatigue as manifested by body weight is not
ideal to her height: wt: 98 lbs; ht: 5”2, poor muscle tone,dry skin
SB: Undernutrition refers to an intake of nutrients insufficient to meet
daily energy requirement because of inadequate foot intake or improper
digestion and absoption offood. An inadequate food intake may be
caused by the inability to acquire and prepare food, balanced diet,
discomfort during or after eating. Improper digestion and absorption of
nutrients may be caused by an inadequate production of hormones or
enzymes or by medical contions resulting in inflammation or obstruction
R: to determine proper blood
circulation
3. Encouraged sleep and rest
R: decreases oxygen
consumption.
4. Provided comfort and
warmth through covering the
patient’s feet and hands with
blanket during cold
temperatures.
R: Increase blood circulation
to the peripheral areas.
5. Positioned patient in
moderate high back rest
R: Promoted optimum lung
expansion
6. Performed assistive or
passive range-of-motion
exercises
R: To maximize tissue
perfusion.
7. Discouraged sitting or
lying down for long periods,
wearing constrictive
clothing.
R: To maximize tissue
perfusion.
8. Encouraged patient to
elevate the legs, but avoid
sharp angulation of the hips
and or knees.
R: To maximize tissue
perfusion.
Collaborative Intervention:
1. Administered Diosmin +
Hesperidin (Daflon) 500 mg I
tab twice a day by mouth
R: significantly improves
disabling symptoms of
Actual Outcome:
After the course of
nursing intervention,
no signs of infection
such as fever,
redness, swelling,
itchiness were noted;
wound was kept
clean and dry; HGB
and HCT level were
still low; 3.74 m/uL
(05/02) and 31.3%
(05/2), respectively.
Patient was still pale,
cold to touch and
peripheral pulses are
still weak.
of GI tract
(Kozier, Barbara. Fundamentals of Nursing 7th edition. pg 1190)
venous insufficiency which
affect everyday active life
2. Administered Losartan
(Lifezar) 50 mg I tab once a
day after supper by mouth
R: blocks the
vasoconstricition effect of the
RAA system as well as the
release of aldosterone
3. Administered Amlodipine
5 mg I tab OP PO pc bfast
R: to depress myocardial
contractility, dilate coronary
arteries and arterioles and
peripheral arterioles
Independent Interventions:
1) Assessed skin, face and
dependent areas for edema
R: to evaluate degree of fluid
volume excess
2) Monitored input and
output
R: to determine renal function
and fluid replacement and
reducing risk of fluid
overload
3) Monitored Vital signs
R: tachycardia and
hypertension can occur
because of failure of kidneys
of excrete urine, changes in
RAA mechanism
4) Auscultated lung and heart
sounds
R: Fluid overload may lead to
pulmonary edema and heart
failure
Desired Outcome:
Within 4 hours of
nursing intervention,
the patient will
maintain an
appropriate urinary
output, vital signs
within normal range,
a stable weight, clear
lung fields, and
absence of edema
Actual Outcome:
05/28-30/08
After 4 hrs of
nursing intervention,
patient maintained a
normal output of 30-
60 cc/hour, blood
pressure was within
April 28, 2008
6. Ineffective Protection related to inadequate primary defense: break in
skin and secondary body defenses: decreased haemoglobin level as
manifested by 2 cm in dm and 1x1/2 in of open wounds on left foot,
decreased Hgb= 10.7 m/ul (04/28) and 3.74 m/uL (05/02) and Hct =
30.8% (04/28) and 31.3% (05/2).
SB: Any site in the body is susceptible to infection by organisms when
skin and tissue barriers are compromised by surgery, trauma or there is
tissue ischemia or necrosis. These infections are frequently caused by
post surgical wound infection, intra-abdominal abscess among others. (
Harrison’s Principles of Internal Medicine 9th Ed. Pg. 694-695)
R: to assess precipitating
factors
5) Assessed level of
consciousness
R: may reflect fluid shifts,
accumulation of toxins,
acidosis, electrolyte
imbalances or developing
hypoxia
7) Measured abdominal girth
R: to identify changes that
may indicate increasing fluid
retention
7) Positioned patient in semi-
fowler’s position
R: to facilitate movement of
diaphragm improving
respiratory effort
8) Limited oral fluids as
ordered to 300ml in the 7-3
shift, 300 ml in the 3-11 shift,
and 200 ml in the 11-7 shift
R: to allow timely alterations
in therapeutic regimen
Collaborative interventions:
1) administered Furosemide
40mg/tab ii tabs OD PO pc
bfast
R: to promote elimination of
excess fluid
3) administered O2 via nasal
cannula @ 4L/min
R: facilitates patient in
breathing
4) Assisted in performing
Thoracentesis
R: to remove the excess fluid
found in pleural
her normal range of
130/80, no edema
was noted, but heard
crackles on both
lung fields upon
auscultation.
045/02/08
After 4 hrs of
nursing intervention,
patient urinated
150cc/4hrs, no
edema was noted,
still crackles were
heard on both lung
fields.
April 28, 2008
7. Impaired SkinIntegrity related to mechanical factors such as trauma
to the skin secondary to S/P debridement on left foot as manifested by 2
cm in dm and 1x1/2 in of open wounds on left foot
SB: The skin serves as the primary defense against bacterial invasion.
When skin is incised for surgical procedure, this important line of
defense is lost. Strict adherence to aseptic technique during surgery and
in the days following the procedure is necessary to compensate for
impaired defense. (Maternal and Child Health Nursing, 4th edition by
Adele Pillitteri, p 613)
Independent Interventions:
1. Assessed weight,age, body
build, strength, and
activity/rest level
R: to provide comparative
baseline
2. Determined ability to
chew, swallow, and taste
R: to identify the factors that
can affect digestion of
nutrients.
3.Encouraged bed rest and/or
limited activities.
R: decrease metabolic needs
aids in preventing caloric
depletion and conserves
energy.
4.Recommended rest before
meals.
R: quiets peristalsis and
increases available energy for
eating.
5.Provided oral hygiene.
R: a clean mouth can enhance
the taste of the food.
6.Served food in a therapeutic
environment.
R: pleasant environment aids
in reducing stress and is more
conducive to eating.
7.Encouraged patient to
verbalize feelings concerning
resumption of diet.
R: hesitation to eat may be
result of fear that food will
cause exacerbation of
symptoms.
8. Emphasized importance of
well-balanced, nutritious
Desired Outcome:
Within 1 hour of
nursing intervention,
patient will
demonstrate
demonstrate
behavior and
lifestyle changes to
maintain weight at a
satisfactory level for
height, body build,
age and gender and
patient’s SO will
verbalize
understanding of the
health teachings
given
Actual Outcome
4/30/08
After 1 hour of
nursing intervention,
patient has a good
appetite, was able to
finish one serving of
every meal served..
Patient’s SO
expressed
understanding of the
health teaching given
as verbalized “ako
man jud na
dugmokon ang
pagkaon ni mama
para humok ug
sayon nya matulon
ang pagkaon”
5/2/08
After 1 hour of
April 30, 2008
8. Acute Pain related to surgical operation secondary to S/P left food
debridement as manifested by gnawing pain on left foot lasting for 30
seconds with a facial, relieved by rest, aggravated by stepping on the
floor, with a verbalization of “sakit kaayo”.
SB: Pain is an unpleasant sensory and emotional experience associated
with actual or potential tissue damage. It occurs with many disorders,
diagnostic tests and treatments and invasive procedures. (Medical
Surgical Nursing by Smeltzer and Bare, vol. 1, p. 217)
]
April 28, 2008
9. Fatigue related to decreased metabolic production, poor physical
condition and decreased hemoglobin level secondary to impairment of
kidney function as manifested by lethargy, disinterest in surroundings,
inability to perform ADL’s, verbalization of “kapoy sige’g higda” and
decreased Hgb= 10.7 m/ul (04/28) and and Hct = 30.8% (04/28)
Scientific Basis:
Fatigue, nausea, vomiting and overall itching of the skin commonly
intake
R: to provide information
regarding individual
nutritional needs
9. Instructed SO to serve soft
foods to the patient
R: to masticate food easily
Collaborative Intervention:
1. Administered Sodium
bicarbonate Gr X 2 tablet
thrice a day by mouth
R: to neutralize or reduce
gastric acidity, resulting in an
increase in the gastric pH,
which inhibits the proteolytic
activity of pepsin
2. Administered Mucosta
100mg/tab 1 tablet thrice a
day by mouth
R: exhibits a gastric
cytoprotective effect by
inhibiting mucosal damage
induced by ethanol, strong
acid and strong base
Independent Interventions:
1. Noted signs and symptoms
of infection
R: fever, chills, diaphoresis,
altered level of
consciousness, and positive
blood cultures may indicate
infection
2. Encouraged proper hand
washing techniques to client
nursing intervention,
patient was able to
finish one serving of
meal. She still has
poor muscle tone
and weight is
decreased from 98lbs
to 95lbs (not
accurate)
Desired Outcome:
Within 8 hours of
nursing intervention
develop in people who have kidney failure. These symptoms result from
the accumulation of metabolic waste including acids, which the diseased
kidneys are unable to excrete. Fatigue may also result from decreased
production of red blood cells, a frequent problem in chronic kidney
failure (Merck Manual of Medical Information, 2nd Home Ed., M. Beers
et. al, p. 748)
April 28, 2008
10, Partial SelfCare Deficit (dressing, feeding, bathing, grooming and
toileting.) related to fatigue and developmental age of 82 years old as
manifested by inability to wash body parts,inability to get in and out of
the bathroom, inability to pick up clothing, and inability to handle
utensils.
SB: People with disabilities frequently experience fatigue. Physical and
emotional weariness may be caused by discomfort and pain associated
with a chronic health problems, deconditioning associated with
and SO
R: a first line of defense
against nosocomial infection
or cross-contamination
3. Encouraged to check
wound for signs of
inflammation and drainage.
R: may indicate hematoma
formation and developing
infection
4. Encouraged and assisted in
ambulation
R: promotes wound healing
5. Instructed patient to keep
incision dry and clean
R: to prevent risk for
infection
6. Encouraged SO to let
patient eat food high in iron
and vitamin c such as green
leafy vegetables, organ meat,
orange, citrus fruit
R: to boost immunity and
enhance proper blood
circulation
Collaborative
Interventions:
1. Assisted in wound dressing
with Mupirocin (Bactroban)
R: to keep the wound are
clean and dry
2. Administered
Ciprofloxacin 500 mg/tab 1
tablet once a day by mouth
R: promotes breakage of
double-stranded DNA in
susceptible organisms and
inhibits DNA gyrase, which
px will be able to be
free from the signs
and symptoms of
infection like
swelling, fever,
redness, pain
Actual Outcome:
After the course of
nursing intervention,
no signs of infection
such as fever,
redness, swelling,
itchiness and warmth
on incision site were
noted; wound was
kept clean and dry;
hgb and hct level
were still low; 3.74
m/uL (05/02) 31.3%
(05/2), respectively.
prolonged periods of bed rest and immobility, impaired motor function
requiring excessive expenditure of energy to ambulate, the frustrations of
performing ADLs.
(S: Smeltzer, Suzanne C. and Brenda G. Bare. Medical-Surgical
Nursing. p 218)
With aging comes gradual reduction in the speed and power of skeletal
or voluntary muscle contraction and sustained muscular effort. Thus
elders often complain about their lack of strength and how they quickly
they tire.
(S: Smeltzer, Suzanne C. and Brenda G. Bare. Medical-Surgical
Nursing. p 402)
April 28, 2008
11. Impaired Physical Mobility related to decreased strength and
endurance as manifested by inability to get out of bed without assistance
and poor gait
Scientific Basis:
Paralysis, extreme weakness, pain, or any cause of decreased activity can
hinder a person’s ability to change positions independently and relieve
the pressure, even if the person can perceive pressure. (Kozier, et al,
Fundamentals of Nursing, 7th Ed., p 857)
is essential in reproduction of
bacterial DNA.
Independent Interventions:
1. Assessed wound for
presence of inflammation and
drainage.
R: Development of infection
delays wound healing.
2. Assessed wound for
unusualities such as
discoloration and swelling.
R: Infection is characterized
by a black discoloration of
the wound.
3. Monitored vital signs
especially temperature
elevation.
R: A rise in temperature
indicates presence of
inflammation, pyrogens, or
infection.
4. Kept area clean and dry.
R: To avoid infection.
5. Avoided use of plastic
materials and removed wet
and wrinkled linens promptly.
R: Moisture potentiates skin
breakdown.
6. Complied with the
positioning schedule of the
patient.
R: To prevent development of
pressure sores.
7. Avoided use of constricted
clothings.
R: To promote circulation to
the lower extremities.
Desired Outcome:
After 30 minutes of
nursing intervention,
patient will display
timely healing of
skin wounds without
complications and
prevent development
of pressure sores.
Actual Outcome:
5/28/2008
After 30 minutes of
nursing intervention,
patient’s wound was
covered with a clean
and dry gauze.
Wound is watery but
there was no pus
noted.
5/29/08
After 30 minutes of
nursing intervention,
patient’s SO
understood the
health teachings
given with a
verbalization of
“salamat kayo,
maintenahon lang
nako ug pakaon si
mama ug prutas”,
wound dressing
April 28, 2008
12. Risk for injury: falls related to poor physicalcondition
Cues: 82 years old, tremors on upper extremities, unable to do ADL’s
alone, impaired balance, difficulty with gait, s/p left foot debridement,
hyperphosphatemia
SB: “Weakness can occurwhen any part of the musculoskeletal system
is abnormal. If the muscle itself cannot contract,weakness occurs. If a
nerve does not adequately stimulate the muscle, the muscle contractions
are weak. If a joint is frozen and unable to move normally, the muscle
may not be adequately able to cause movement.” (The Merck Manual of
Medical Information, 2nd Home Ed., M. Beers et. al, p. 305)
8. Encouraged to eat food
high in Vitamin C such as
orange, citrus fruit and green
leafy vegetables
R: to promote wound healing
Collaborative
Interventions:
1. Assisted in wound dressing
with Mupirocin (bactroban)
once a day
R: to keep the wound are
clean and dry
2. Administered
Ciprofloxacin 500 mg/tab
once a day by mouth
R: promotes breakage of
double-stranded DNA in
susceptible organisms and
inhibits DNA gyrase, which
is essential in reproduction of
bacterial DNA.
Independent Intervention:
1) Monitored vital signs.
R: Alteration in vital signs
could indicate pain.
2) Frequently assessed pain
scale.
R: To rule out development
of complications.
3) Provided comfort measures
such as assuming patient
position (semi-Fowler’s
position) of comfort.
R: To provide non-
pharmacological pain
management.
4) Encouraged adequate rest
periods.
R: To prevent fatigue.
remained dry, intact
and presence of
blood on the edge
was noted.
4/30 and 5/2 /08
After 30 minutes of
nursing intervention,
patient’s dressing
was clean, dry and
intact. Wound is dry
and no purulent
discharges noted.
Desired Outcome:
Within 30 mins. of
nurse-client
interaction, the
patient will be able
to demonstrate
methods that provide
relief, report that
pain is relieved and
controlled, and pain
scale is reduced.
Actual Outcome:
April 30, 2008
13. Bowel Incontinence related to self-care deficit: inefficient toileting,
general decline in muscle tone secondary to increasing age as manifested
by inability to delay defecation, fecal staining on clothing, and inability
to recognize urge to defecate.
SB: Fecal Incontinence describes the involuntary passage of stoolfrom
the rectum. Factors that influence fecal continence include the ability of
the rectum to sense and accommodate the stool,the amount and
consistency ofstool, the integrity of the anal sphincter and musculature,
and rectal motility. It can result from neurologic disorders such as
diabetic neuropathy,or advancing age. Patients may have minor soiling,
occasional urgency,and loss of control.
(Smeltzer, Bare, Textbook of Medical-Surgical Nursing, 11th edition,
Lippincott Williams and Wilkins, 2008, page 1236)
5) Taught how to do deep
breathing exercise and
stressed to perform it every
time pain occurs.
R: To promote relaxation.
6) Encouraged expression of
feelings.
R: Helpful in establishing
individualized treatment
needs
7) Taught diversional
activities like watching
television.
R: to divert attention from
pain
Collaborative:
1. Administered Paracetamol
500mg/itab 1tablet as needed
R: for fever and pain
Independent Intervention:
1) Obtained a history of
condition including date of
onset,and significant findings
of present condition.
R: To provide a baseline data
for future comparisons.
2) Determined ability to
participate in activities or
level of mobility.
R: To assess patient’s degree
of fatigue.
3) Provided environment
conducive for rest and sleep.
R: To relieve fatigue.
4) Assisted with self-care
needs.
R: To limit occurrence of
04/30/08
After 30 mins. of
nursing
interventions, pain
was still noted with a
verbalization of
“sakit gamay”
5/2/08
After 2 days of
nursing
interventions, the
patient still reported
pain with a
verbalization of
“sakit kung tumban
nako, sakit kaayo
pero ako lang
antuson”
Desired Outcome:
Within 30 minutes
nursing intervention,
patient will be able
to perform ADLs
and display
improved ability to
April 30, 2008
14, Impaired dentition related to poor oral hygiene and lack of
knowledge regarding dental health and aging process as manifested by
presence of dental cavities, yellow-colored teeth, 6 lower and 4 upper
teeth
Scientific Basis:
Healthy teeth must be conscientiously and effectively cleaned on a daily
basis. The normal movement of the muscles of mastication and the
normal floe of saliva aid gently in keeping the teeth clean. Because many
ill patients do not eat adequate amounts of foods, they produce less
saliva, which in turn reduces the natural cleaning process of the teeth.
(Medical – Surgical Nursing by Brunner & Suddarth’s p. 810.)
Tooth enamel tends to wear away with age, making the teeth vulnerable
to damage and decay. Periodontal disease,however, is the major cause
of tooth loss. Periodontal disease is more likely to occur in people with
fatigue.
5) Scheduled activities
according to client’s ability.
R: To maximize participation.
6) Instructed SO to maintain a
quiet environment
conducive for rest and
sleep.
R: temperature and level of
humidity are known to affect
exhaustion
7) Instructed SO to minimize
number of visitors in the
room or to schedule visits.
R: to provide a calm and
quiet environment
8) Encouraged SO to let the
patient eat foods high in iron
such as liver, green leafy
vegetables, fish, beans, nuts,
eggs, raisins.
Collaborative Intervention:
1) Administered O2 @
4L/min via nasal cannula
R: to facilitate breathing and
promote ease in respiration.
Independent Interventions:
1. Assessed emotional and
psychologic factors affecting
the current situation such as
stress
R: to note any changes in
emotional status
2. Evaluated current
limitations or degree of
participate in desired
activities.
Actual Outcome:
4/28-30/08
After 30 minutes of
nursing intervention,
patient still appeared
weak and lethargic,
needed assistance in
perfoming ADL’s
and decreased
activity was still
noted.
5/2/08
After 30 minutes of
nursing intervention
,
patient demonstrated
improvement in
muscle strength from
poor ROM to
average weakness.
She was able to sit
on bed with little
assistance and
interactive with the
health care provider.
Patient’s HGB and
HCT level are still
low with 3.74 m/uL,
31.3% respectively
poor oral hygiene, smoker and poor nutrition. (Merck Manual of Medical
2nd ed. p.602)
deficit in the light of usual
status
R: provides comparative data
3. Established rapport with
patient and S.O.
R: To foster trust between the
nurse, the patient & S.O
4. Collaborated with the SO
of the client in caring for and
assisting the client.
R: Enhances coordination and
continuity of care, optimizing
outcomes
5. Planned care with rest
periods between activities
R: to reduce fatigue
6. Promoted comfort
measures
R: to enhance ability to
participate in activities
7. Provided positive
reinforcement when client
complies to nursing
interventions
R: Encourages continuation
of efforts.
8. Taught S.O safety concerns
such as raising of siderails at
all times, keeping away sharp
objects
R: to prevent injuries
9. Encouraged S.O to stay at
patient’s bedside at all times
R: To ensure safety and
attend patient’s needs
Independent Interventions:
1. Assessed emotional and
behavioural responses to
Desired Outcome:
After 8 hrs of
nursing
interventions, patient
will be able to
perform self-care
activities such as
dressing bathing,
toileting, feeding and
grooming, within the
level of her own
ability and
demonstrate
techniques to meet
self-care needs.
Actual Outcome:
4/28-30/08
After 8 hrs of
nursing
interventions, the
patient still needed
assistance of the care
provider and SO in
performing ADL’s
such as dressing,
bathing, toileting,
feeding, and
grooming.
5/2/08
problems of immobility.
R: Feelings of frustrations
and powerlessness may
impede attainment of goals.
2. Determined functional
level of classification.
R: Assess the functional
ability.
3. Positioned safely on bed
and raised side rails.
R: To promote safety.
4. Assisted with the activities
of ADL like transferring from
bed to bedside commode.
R: prevent complications.
5. Assisted in ambulation
R: to promote wellness
6. Promoted SO participation
in patient care.
R: Enhances coordination and
continuity of care.
7. Assisted in positioning
patient every 2hrs.
R: To prevent pressure sores
and promote comfort.
8. Supported affected body
part with a pillow.
R: To maintain position of
function and reduce risk of
pressure sores.
9. Promoted adequate rest
periods.
R: To reduce fatigue
10. Assisted in performing
active assistive ROM
exercises to the patient.
R: To stimulate peripheral
circulation.
After 8 hrs of
nursing
interventions, patient
was able to stand up
from bed to bedside
commode with
assistance for
defecation and
urination. She was
still in need of
assistance in
performing her
ADL’s.
Desired Outcome:
Within 8 hours of
nursing
interventions, patient
will be able to
demonstrate
progressive changes
in her mobility as
tolerated, and at the
same time SO will
be able to provide
the necessary needs
of the patient such as
changing position
and transferring from
bed to bedside
commode for
Independent Interventions:
1. Assessed age.
R: to evaluate degree of risk
in the individual situation.
2. Assessed client’s cognitive
status.
R: Affects ability to perceive
own limitations and risk for
falling.
3. Assessed mood, behaviour,
and personality styles.
R: Individual’s temperament
and typical behaviour can
affect attitude towards safety
issues.
4. Provided rails, pillows and
chair at sides of patient’s bed.
R: to prevent from falls
5. Visited frequently
R: to promote patient safety
6. Discussed to SO the need
for constant supervision
R: to maintain patient’s safety
Collaborative Interventions
1. Administered Gabapentin
(Reinin/Nevrontin)
100mg/cap 1capsule twice a
day by mouth
R: treatment for tremors;
depresses abnormal neuronal
changes in the CNS
Independent Interventions
1. Noted times of
incontinent occurrence.
R: Provides baseline data.
toileting
Actual Outcomes:
4/28-30 and 5/2/08
After 8 hours of
nursing
interventions, patient
cannot change
position and
ambulate without
assistance
Desired Outcome:
Within 8 hours of
nursing intervention,
the patient will be
safe and free from
injury and patient’s
SO will verbalize
understanding of the
2. Palpated abdomen.
R: to determine presence
of distention, masses,and
tenderness.
3. Auscultated bowel
sounds, noting locations
and characteristics.
R: To note presence,
location, characteristics
of bowel sounds.
4. Observed for abdominal
distention if bowel
sounds are decreased.
R: Loss of peristalsis
paralyzes the bowel,
creating bowel
distention.
5. Recorded frequencies,
characteristics, and
amount of stool.
R: Identifies degree of
impairment/ dysfunction
and level of assistance
required.
6. Encouraged SO to
record times at
which incontinence
occurs.
R: To note relationship to
meals, activity, and
client’s behavior.
7. Determined presence of
impaction.
R: Early intervention is
necessary to effectively
treat constipation or
retained stool and reduce
risk of complications.
8. Taught to lean forward
on commode.
safety measures
being taught by the
HC provider.
Actual Outcome:
04/28/07
Patient was free
from injury and SO
expressed
understanding of the
importance of safety
measures as
verbalized by “naa
man jud permi
kuyog si mama,
bantayan nako permi
si mama”
04/29-30/07
Patient was free
from injury. There
were no signs of
local infection such
as swelling, redness,
purulent discharges
noted on left foot;
slight tremor was
noted on upper
extremities.
05/02/08
Patient was free
from injury.
Patient’s wound is
dry and covered
properly with a clean
gauze. A tremor on
the upper extremities
was very noticeable.
R: To increase intra-
abdominal pressure
during defecation.
9. Encouraged fruit juices
such as apple and
pineapple juice.
R: Improves consistency
of stool for transit
through the bowel.
10 Encouraged activity
within individual ability
and up in bedside
commode as tolerated.
R: Improves appetite and
muscle tone, enhancing
GI motility.
8. Restricted intake of
grapefruit juice and
caffeinated beverages
such as tea, coffee, and
chocolates.
R: Diuretic effect can
reduce fluid available in
the bowel, increasing risk
of dry/hard formed stool.
9. Provided skin care.
R: loss of sphincter
control potentiates risk of
skin irritation/
breakdown.
Independent Intervention:
1) Noted presence or absence
of teeth and ascertain its
significance in terms of
nutritional needs.
R: to assess causative or
contributing factors
2) Evaluated current status of
Desired Outcome
Within 30 mins. of
student nurse-patient
interaction, the
patient will re-
establish satisfactory
bowel elimination
pattern.
Actual Outcome
04/30
After 30 mins of
nursing intervention,
the patient defecated
on her bed.
05/2
After 30 mins of
nursing intervention,
patient felt the urge
to defecate. She was
able to control it and
satisfactorily
defecated in the
bedside commode
dental hygiene and oral health
R: to assess causative or
contributing factors
3) Discussed the importance
of having dental check –up
R: to minimize oral or dental
tissue damage
4) Discussed the importance
of having good dental
hygiene.
R: to increase patient’s
awareness on dental care.
5) Instructed to use warm
saline gargle.
R: to promote good oral
hygiene.
Desired Outcome:
Within the 30 mins.
of nursing
intervention, SO and
patient will be able
to demonstrate
effective dental
hygiene skills and
gain knowledge on
the importance and
benefits of having a
good oral hygiene.
Actual Outcome:
04/30/08
After 30 mins. of
nursing intervention,
SO and client was
able to understand
and gain knowledge
of health teachings
given to SO by
nodding her head
and verbalizing “o
sige, salamat kaayo”
Patient also showed
understanding by
nodding her head.
05/2/08
After 30 mins. of
nursing intervention,
patient’s teeth is still
yellow in color;
presence of cavities
were noted.

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237754196 case-study

  • 1. Get Homework/Assignment Done Homeworkping.com Homework Help https://www.homeworkping.com/ Research Paper help https://www.homeworkping.com/ Online Tutoring https://www.homeworkping.com/ click here for freelancing tutoring sites CLIENT – IN- CONTEXT PRESENT STATE INTERVENTIONS OUTCOME L.C., 82years old, female, was admitted for the fifth time at CVGH accompanied by daughter per taxi per wheelchair last April 15, 2008 for complaints of fever accompanied by headache and chills under the services of Dr. Geselita Maambong, under the Department of Internal Medicine, co- managed by Dr. Clifford John Aranas, of the Internal Medicine Department. Previous Hospitalization: 2000- Pt was admitted at CVGH ICU because of dyspnea due to the aspiration of an unrecalled cause, under the services of Dr. Maambong. Diagnostic tests include CBC, U/A, and X-ray, as recalled by the S.O. She July 1, 2008 ER blotter: time in 11:00 am, time out ? with the following vital signs: BP: 110/60, PR: 64 bpm, T: 38 ºC/axilla, RR: 29 cpm 1. Fever 3. S/P CBG 2002 2. DM Type 2 4. ?Dyslifidemic >CBG = HIGH 436 – 12:10 >IVF PNSS 1L @ 30 gtts – 11:00
  • 2. was there for almost a month. Pt was diagnosed with Diabetes Mellitus Type2 and Essential Hypertension2. She was discharged with improved condition with maintenance medications: Diamicron MR 30mg/tab 1tab OD, Imdur 60mg/tab 1/2tab BID, and Neurontin 100mg/capsule 1capsule BID, all taken with good compliance. 2002- Pt was admitted at CVGH for complaints of chills and fever under the services of Dr. Maambong. She was admitted for 2weeks. Again, diagnostic tests include CBC, U/A, and X-ray, as recalled by the S.O. She was discharged with an improved condition. No more fever and chills. With the same set of maintenance medications taken with good compliance. 2004- Pt was again admitted at CVGH because of a wound in her left foot and the surrounding area of the wound had turned dark. It was diagnosed to be a gangrene. Pt underwent Debridement under the services of Dr. Busa of the surgery department. Her hospitalization lasted for 3weeks and was discharged with improved condition. S.O. claims that the medications were still the same but an unrecalled antibiotic was added. S.O. reports to have let patient take these medications with good compliance. History of Present Illness: 3weeks PTA, patient’s daughter noticed a burn on the left side part of the patient’s left dorsal foot. Daughter asked pt how she got it and patient answered “napaso sa kalan” which was still hot and placed on the floor. According to the S.O. “murag ga tubig cya sa sulod pariha adtong na una niyang samad sauna.” S.O. pricked the blister and washed it with the water extracted from boiled guava leaves. There was no pain felt by the patient but there was redness and swelling around the sides. Patient also claimed it to be rather itchy. After, S.O. treated it with Betadine and Tetracycline BID without prescription. 2weeks PTA, the wound was getting deep. It looked like erosion. No consult was done and the ritual treatment using Betadine and Tetralcycline ointment BID continued. 1week PTA, S.O. noticed that the wound did not show signs of healing. She then decided to have her mother get ready for a check-up with Dr. Maambong. Initially, patient was hesitant. For her, there was nothing to be worried about and it’s a waste of money. With her daughter’s persistence, patient agreed to go for a medical check-up. There, she was prescribed with Bactroban cream (Mupirocin), Betadine, and Hydrogen peroxide to clean the wound BID. Patient was also prescribed Ciprofloxacin (Ciprobay) 500mg OD. 4days PTA, pt experienced intermittent fever (highest at 38C) and chills. >PUN 200cc of ___ IVF – 11:00 10’ 11” HR given - 11:00 ECG 12 leads – 11:00 >CBG, Crea, Na-, K+, SGPT HBAIC - 12:00 >CXR PA, CBG monitor hourly – relay all results >blood culture 2 soltn n30 min apart ?? >please admit to IM Dept. under the service of Dr. Zanoria >TPR q4 >Diet: blenderized feeding @ 1000 cal/day in 1500cc divided in 6 equal feedings: low salt, low fat/cholesterol, diabetic @ CHO 240 CHON 80 >insert FBC and attach to urobag >11:30 insert NGT >monitor V/S every 2 hours and refer for ???? or HR > 100, RR > 20, BP = 160/90 >I/O every 4 hours PHYSICAL ASSESSMENT: Date of Assessment: July 3, 2008 (Thursday) Time performed: 10:00am General Appearance: Examined while lying on bed,, awake, conscious, unresponsive, incoherent and afebrile, with FBC-CDU and IVF 4 D5.3NaCl @ 20gtts/min infusing well at right arm with the following vital signs: BP=130/80mmHg, PR=72bpm, RR=20cpm, T=36.8˚C/axilla, Height=cm, Weight=kg; IBW=kg. SKIN AND APPENDAGES: no lesions, brown complexion, (-) jaundice, (-) cyanosis, (-) edema, hair evenly distributed, senile skin turgor, warm to touch, pale nailbeds, no nail clubbing, no ingrown toenails, presence of IV line on right arm, bruises on antecubital area, (-) Chvostek’s sign HEAD: normocephalic, symmetric, thinning gray hair, evenly distributed hair, no masses, no lice infestation, (-) dandruff, scalp has no lesions and no tenderness upon palpation EYES: symmetrical, ,anicteric sclerae, pale palpebral conjunctivae, eyebrows and lashes present bilaterally, equal distribution of eyebrows, (+) Pupils Equally Round and Reactive to Light and Accomodation, (+)
  • 3. S.O. remembered the same symptoms her mother experienced in her previous hospitalizations and decided to seek consult with Dr. Maambong again. Furthermore, patient manifested polyuria and nocturia as reported by S.O. “mukalit ra ug pangihi”. Pt was advised to undergo CBC, U/A and Lipid panel. Morning PTA, the results were given. There was an increase in her creatinine level (4.0mg/dl) which meant that the patient had kidney failure. Aside from this, the wound was not healed and began to become deep. This prompted Dr. Maambong, and with the patient’s consent, to let the patient admit at CVGH for a closer observation. Past Heath History Pt. is diabetic and hypertensive (with highest BP of 240/110mmHg) for 8years as diagnosed by Dr. Maambong last 2000 with maintenance medications: Diamicron MR 30mg 1 tab OD, Imdur 60 mg/ tablet, ½ tablet two times a day, and Neurontin 100 mg/ capsule 1 capsule two times a day. She is a nonsmoker and a nonalcoholic beverage drinker with no known food and drug allergies. Health-Perception Health-Management Pattern Patient cannot describe health and cannot rate when asked to. She has no regular medical checkups and would only seek consultation to Dr. Maambong whenever the need arises. She believes in folk medicine as she, herself, is a licensed “mananabang” and “manghihilot.” She uses Pau d’ Arco to soothe muscle pains and aches. She also drank the water from “sibukaw” and “wachichaw”, two glasses/day to promote urination. She also drinks the CBW left from “dahon sa atis” to cure colds. Last year, she took Roch 1capsule per day for 15days because daughter heard over the radio and thought it was effective. After the 15th day, the daughter stopped buying the drug because saw that it was not effective and heard about the damage to the liver caused by Roch herbal medicine. She doesn’t know how to performBSE ever since and was taught by the student nurses on how to performit but no response was noted. She’s not fully immunized and practices OTC medications such as Paracetamol (Biogesic) 500mg for relieving minor headaches and fever as reported by S.O. At home, it is her daughter who cuts her nails but in bathing and dressing,the pt does it alone although she is being watched by S.O. During hospitalization, patient still cannot rate health. She claims that she is alright and when asked how she feels, verbalizes “ok ra” or “maau Cardinal gaze, no abnormal discharges EARS: symmetrical, skin color is consistent with the facial skin color, pinna is in line with the outer canthus ofthe eye, no swelling, no lesions, no abnormal discharges,no foul odor, pinna is non-tenderupon palpation, recoils after being folded, can hear low-pitched voice at 2 ft. distance NOSE AND SINUSES: Nasal septum is straight and perforated, no nasal flaring, septum located at midline, symmetrical & proportional to other facial features, no inflammation, no lesions, no swelling, no bleeding, clear frontal & maxillary sinuses on transillumination, nares are patent, no congestion MOUTH AND THROAT: lips symmetrical and red in color, dry lips, no cracks, no lesions, gums pinkish and moist, pinkish tongue, uvula in the midline, no swelling or redness, no masses and ulcerations, (+) gag reflex, no tonsil inflammation, uvula at midline, pinkish gums, has 11 teeth ( 6 upper and 5 lower), presence of plaque and dental caries, decayed teeth NECK: supple neck, no lesions, no masses, trachea at midline, lymph nodes not palpable CHEST AND THORAX: equal chest expansion, RR=20cpm, no palpable masses, no lesions, normal tactile fremitus HEART: distinct heart sounds S1 and S2 upon auscultation, no murmurs, HR= 72bpm with regular rhythm. BREAST AND AXILLAE: symmetrical, no abnormal nipple discharges, no masses, non-tender, non-palpable axillary lymph nodes, areola brown in color, nipples not inverted ABDOMEN: flat and soft, umbilicus at midline, inverted, nontender, scars present, (-) fluid wave test,(-) shifting dullness,nonpalpable kidneys, 14 borborygmous sounds/minute auscultated at right lower quadrant GENITO-URINARY: grossly female, minimal pubic hair, no discharges, no lesions, no purulent discharges, no itching, no rashes,
  • 4. nako. Ganahan nako mu-uli”. S.O. further adds that her mother is “dili reklamador ug agwantador” and is very “pasensyosa” even if she feels pain or is feeling unwell already. Patient is a little bit aware of her condition because every time the medicine or a procedure is given, it is explained by the healthcare team about it. However, when asked about what she understands about her case, she only looks at the student nurse and calls her daughter to answer the questions instead. Her daughter is the one who cuts her toenails and fingernails. Nutritional – Metabolic Pattern Before hospitalization, patient eats 5x/day with snacks in between (3full meals and snacks for morning and afternoons). Occasionally, pt drinks softdrinks at 240ml the most. Pt also eats fruits at least once a week such as oranges and apples for these are easily available at the market and do not need special temperature conditions for it to stay fresh. Water intake is also more than 8glasses/day before hospitalization. She claims her body weight was normal for her. She also takes in Musigor Vita 500mg OD as prescribed by Dr. Maambong last year for loss of appetite. CLIENT’S DIET 24H RECALL USUAL DIET Breakfast Around 8am 1cup rice 30cc water 75g mashed corned beef 6am 1pc scrambled egg, 75g corned beef, 1/2cup rice or oatmeal, 240ml Anlene milk Lunch 12:30nn 1 cup rice, 1cup mashed sayote guisado, 1 whole 12noon 100g salty paksiw, 1 small bowl of malunggay soup, and ?urine output=300-450cc/shift RECTUM: no hemorrhoids, no abnormal discharges, no irritations and itchiness EXTREMITIES: no swelling, no lesions, (-) ROM on lower and upper extremities (-) edema, CRT on upper extremity <2sec, CRT on lower extremities are <2 seconds, pale nailbeds, weak and thready pulses, (-) Trousseau’s sign NEUROLOGIC ASSESSMENT Cognitive: Does not respond to questions “Kaila ka ani niya mam?, Kahibaw ka asa ka karun? Kanusa imong birthday? Pila imong edad gi-dugo ka?” Cerebellar: unable to perform finger to nose test, (-) thumb opposition test, (-) Romberg test, (-) Tandem test, can’t walk without assistance Sensory: Does not respond to student nurse’s instructions > (-) graphesthesia: can’t able to identify letter A & 2 on her back and palm >(-) 2point discrimination test: able to identify sharp from dull (back of comb and tip of ballpen) > (-) sterognosis: able to identify pen with eyes closed >(-) kinesthesia: able to identify the directions to which her toes and finger were moved (up and down) CRANIAL NERVES I. Olfactory: not able to distinguish any smell II. Optic: III. Occulomotor: (+) cardinal gaze = on lifesize objects such as student nurse, (+) PERRLA IV. Trochlear: (+) cardinal gaze = on lifesize objects such as student nurse, (+) PERRLA
  • 5. banana, 30cc water 1/2cup rice. Dinner 6pm 1 cup rice, 150g shredded chicken with carrots, 30cc water 6pm 1 fish inun- unan, 1/2cup rice, and 100g of caldereta with potatoes and carrots. Snacks 3pm 1pc orange 2-3pm 1 pc home- made sandwich or 1pack biscuits with 100ml milk. During hospitalization, patient still eats 3 full meals of only soft foods (mostly with soups) and seldom eats snacks. She has a low salt, low fat, low cholesterol diet with no simple sugars diet. She cannot swallow the tablets whole as well (the student nurses administer it to her in powdered form). Her favorite foods consist of pork as S.O. says “pakibaboy mana si mama gud”. She is currently placed to limit her fluids at 800cc per day. Pt has difficulty in chewing and swallowing and prefers her foods readily shred up for her. She doesn’t have any regular dental check-ups. She once went to see a dentist with her daughter because she complained of a little pain in her tooth. The dentist, their friend, Dr. Pedro Achombre, told them that she cannot pull the tooth unless the pt’s blood sugar will go back to normal. After a while the pt’s blood sugar did go down but she no longer wanted to have her tooth pulled for financial reasons and she wanted to wait for the rest of her teeth to “tangtang ug iya-iya”. Furthermore, the S.O. reports that the patient only brushes her teeth once a day or sometimes, only when she goes out of the house. Elimination Pattern Before hospitalization, patient eliminates bowel everyday usually after she V. Trigeminal: Sensory: eyelids blink bilaterally at the touch of tissue on the temporal area, can feel touch of object on forehead, chin, and cheeks but can’t determine whether soft or hard Motor: can masticate, can clenched teeth VI. Abducens: (+) cardinal gaze = on lifesize objects such as student nurse, (+) PERRLA VII. Facial: Sensory: can identify bitter taste by spitting the medicine Motor: does not smile, can’t frown, can raise eyebrows, can’t puff out cheeks, can wrinkle forehead VIII. Vestibulocochlear: can hear low-pitched voice at 2ft distance IX. Glossopharyngeal: able to swallow, (+)gag reflex, able to distinguish taste at the posterior1/3 of tongue because she does not spit out delicious food like spaghetti X. Vagus: (+) gag reflex, can swallow XI. Spinal Accessory: can’t shrug shoulders against resistance XII. Hypoglossal: tongue at midline upon protrusion, unable to move tongue from side to side and up and down MUSCLE STRENGTH 1/5 3/5 1/5 3/5 SCALE FOR GRADING MUSCLE STRENGTH 5 – Full ROM against gravity, full resistance 4 – Full ROM against gravity, some resistance 3 – Full ROM with gravity
  • 6. wakes up at around 5am. Her stools are yellow-brown in color and are well- formed. She doesn’t take in laxatives and does not claim to experience constipation. She voids 5-6 times per day with light yellow-colored urine having a moderate flow approximately 20-40 ml per episode. She claims to have no difficulty in voiding. During hospitalization, patient voids 3-4times per day and her urine is dark yellow amounting to 300-450cc/8hours. She only experienced nocturia in the first few days of her hospitalization as confirmed by the S.O. Her defecation pattern changed. At initial days of admission, pt claims to experience constipation and S.O. claims that there was a time the patient was not able to defecate in 2-3days. She was given Senna concentrate (Senokot) 2tabs OD qHS by AP. Right now, patient seems to defecate involuntarily. Often times, fecal matter is found staining her bed linens. There was a time when pt was able to verbalize “kalibangun ko” but when the student nurses assisted her and checked, the linens were already soiled with fecal matter. Pt also defecates more than twice per day with yellow-colored stools and irregular timing. Activity – Exercise Pattern Patient wakes up at 5am, walks around the house using a cane, defecates, eats breakfast prepared by her daughter at 6am. She takes her nap for about 2hours, eats lunch by 12nn and takes another 2-hour nap, eats dinner by 6pm, and sleeps at 8pm. Patient has been a “manghihilot” and a licensed “mananabang” all her life as far as she can remember. She only stopped working after she was diagnosed with Essential Hypertension and Diabetes Mellitus 2 last 2000. Patient tries to help in performing household chores by sweeping the floor, wiping the table and window surfaces whenever she feels well. Her daughter is the one who hinders the patient from performing these things because she fears this will worsen her mother’s condition. Patient’s usual leisure time includes strolling after rising, watching TV, sleeping and listening to “drama” on the radio. To this question (patient’s leasure activities), the S.O. also adds “badlong sa mga apo. Di nuon siya mangasaba pero mubadlong siya kung nag-gara2 na.” During hospitalization, pt. is most of the time asleep or watching TV. S.O. says “di mana siya tulog gyud. Murag hinanok mana iya. Manokon na bya matulog pud basta tiguwang. Sturyai lang, naminaw ramana siya.” Pt. can no longer perform her ADLs as she did before. Now, student nurses and her daughter facilitate in moving her from the bed to the chair, comb her hair, assists her in changing her diapers, clothes, and underwear. 2 – Full ROM with gravity eliminated (passive motion) 1 – Slight Reaction 0 – No Reaction DEEP TENDON REFLEXES (+1) biceps reflex, (+1) triceps reflex, (+1) brachioradialis reflex, (+1) patellar reflex, (+1) Achilles Reflex SCALE FOR GRADING REFLEX RESPONSES: 0 – No Reflex Response +1 – Minimal Activity +2 – Normal Response +3 – More Active than Normal +4 – Maximal Activity (Hyperactive) ?GLASGOW COMA SCALE Response Score Eye-opening response Spontaneous opening 4 To verbal response 3 To pain 2 None 1 Most appropriate Oriented 5 Verbal response Confused 4 Inapp. Words 3 Incoherent 2 None 1 Most appropriate Obeys commands 5 Motor response Localizes pain 4 Flexion to pain 3 Extension to pain 2 None 1 TOTAL SCORE 3-15
  • 7. Sleep – Rest Pattern Before hospitalization, patient usually sleeps around 8pm and wakes up at 5am everyday. Upon waking up, she feels “ok” and that her sleep is enough. She uses a blanket and a pillow as her sleeping aid. She doesn’t take sedatives to facilitate her sleep and has no problems in sleeping. She prays before sleeping. Rituals include changing of clothes before sleeping and putting of cologne after a bath. During hospitalization, patient sleeps most of the time and looks fatigued as shown in her weary facial expression. Aside from this, there is no more definite time as to when she sleeps or wakes up. She also says her sleep is “ok ra.” She has no rituals before sleeping. At first, patient is disturbed by healthcare professionals who go inside the room often. But she says she has adjusted to themalready. Cognitive – Perceptual Pattern Patient remembers things that happened a long time in the past such as her menarche, her first sexual contact, and what her work was. She also remembers things that have happened recently such as the food she ate for lunch as confirmed by her S.O. Once, she even said to the student nurse when there were about more than 8children in the room “daghan pani sila. Gamay ra ni akong mga apo diri karun”and smiled which meant that she is still able to remember her grandchildren. She has an educational level of kindergarten because at that time, her parents did not give any importance to education. Kindergarten at that time involved activities such as playing, singing songs, and dancing. Patient comprehends Bisaya and speaks the language well. She uses eyeglasses with unrecalled date as to when she started using it. S.O. reports that the patient does not know how to read at all (with or without glasses) but is able to write her signature when she was not hospitalized. There are no changes before and during hospitalization except that when asked to write her signature, only scribbles appear. Patient does not use hearing aids. Her sense of smell and taste is still intact. Patient’s sense of touch is diminished in the left leg. Self-Perception – Self-Concept Pattern Patient claims that she is satisfied with her life and that is contented as a mother. She feels alright about her accomplishments such as raising wonderful kids and letting them graduate with degrees. She says that her family is very good to her even before hospitalization. To her, her physical outlook is “ok”. She also feels good about herself and has no complaints ?Patient’s rating in GCS: 12points –Lethargic Date performed: July 4, 2008 (Friday Time performed: 10:00am General Appearance: Examined while lying on bed,, awake, conscious, unresponsive, incoherent and afebrile, with NGT at left nostril and IVF 5 D5.3NaCl @ 20gtts/min infusing well at right arm with the following vital signs: BP=120/70mmHg, PR=73bpm, RR=20cpm, T=36.3˚C/axilla, Height=cm, Weight=kg; IBW= kg. SKIN AND APPENDAGES: pale nailbeds, presence of IV line on right arm, bruises on antecubital area EYES: pale palpebral conjunctivae NOSE AND SINUSES: presence of NGT MOUTH AND THROAT: has 11 teeth ( 6 upper and 5 lower), presence of plaque and dental caries, decayed teeth ABDOMEN:, scars present Extremities: (-) ROM on lower and upper extremities, pale nailbeds, weak and thready pulses NEUROLOGIC ASSESSMENT Cognitive: Does not respond to questions “Kaila ka ani niya mam?, Kahibaw ka asa ka karun? Kanusa imong birthday? Pila imong edad gi-dugo ka?” Cerebellar: (-) finger to nose test, (-) thumb opposition test, (-) Romberg test, (-) Tandem test, can’t walk without assistance Sensory: (-) graphesthesia, (-) 2point discrimination test, (-) sterognosis, (-) kinesthesia CRANIAL NERVES I. Olfactory: not able to distinguish any smell II. Optic: III. Occulomotor: Motor: does not smile, can’t frown, can’t puff out cheeks
  • 8. about herself. She says her worry right now is her illness but she strongly believes that she will be cured. According to her S.O., pt is very understanding, loving, caring, and generous. “Bisan mga silingan mangayo ug bugas, muhatag gyud na dayun siya.” As a mother, the patient is a very good one and has raisedher children well. According to the grandchildren, she is not selfish. “Kung mangayo gain mi ug kwarta, hatagan dayun mi.” Role – Relationship Pattern Patient claims to have good and open relationship with her family until now (to those still alive). She has been a widow for about 14 years already. She has 15 children, 2 of which are dead. They use a switchboard type of communication. She has a lot of friends and relatives with whom she maintains a peaceful relationship with them. Breadwinners of the family are her 2sons working abroad as a licensed practical nurse and another who is a chef of a university. They are the ones supporting the treatment of the patient and the expenses of the household. When asked if she is satisfied with her relationship with her family, she says “oo.” And her S.O. reinforces the question by adding “ pinangga kaau ni cya sa tanan. Contento na siya ky wa gyuy kaaway nya nindot ra ug kahimtang iyng mga anak run” afterwhich the patient nods in affirmation to the statement. During hospitalization, patient can no longer see her other grandchildren and children as often as she used to. Her communication with other family members is also impaired because she does not talk much already. Genogram: Maternal Side Paternal side *heart problem *patient *unrecalled cancer *lung cancer male female deceased * History of both maternal and paternal sides are unrecalled but patient is sure that both sides have a history of Hypertension and Diabetes Mellitus. IV. Spinal Accessory: can’t shrug shoulders against resistance V. Hypoglossal: unable to move tongue from side to side and up and down MUSCLE STRENGTH 1/5 3/5 1/5 3/5 ?DEEP TENDON REFLEXES (+1) biceps reflex, (+1) triceps reflex, (+1) brachioradialis reflex, (+1) patellar reflex, (+1) Achilles Reflex ?Patient’s rating for GCS: 12points –Lethargic Date performed: July 5, 2008(Saturday) Examined while lying on bed, awake, conscious, unresponsive, incoherent and afebrile, with IVF 6 D5.3NaCl @ 10gtts/min infusing well at right arm with the following vital signs: BP=140/90mmHg, PR=80bpm, RR=20cpm, T=36.3˚C/axilla, Height=cm, Weight=kg; IBW= kg. SKIN AND APPENDAGES: pale nailbeds, presence of IV line on right arm, bruises on antecubital area EYES: pale palpebral conjunctivae MOUTH AND THROAT: has 11 teeth ( 6 upper and 5 lower), presence of plaque and dental caries, decayed teeth ABDOMEN:, scars present Extremities: (-) ROM on lower and upper extremities, pale nailbeds, weak and thready pulses NEUROLOGIC ASSESSMENT Cognitive: Does not respond to questions “Kaila ka ani niya mam?, Kahibaw ka asa ka karun? Kanusa imong birthday? Pila imong edad gi-dugo ka?” Cerebellar: (-) finger to nose test, (-) thumb opposition test, (-) Romberg test, (-) Tandem test, can’t walk without assistance
  • 9. Sexuality-Reproductive Pattern Patient had her menarche at 12yrs.old as manifested by brown spots on her underwear. Her menstruation lasted for 4-5 days usually with moderate flow and consumes 2-3 pasadors/day. Her 1st sexual contact was with her sole partner (husband) at the age of 17years old. No hx of STD and uses no contraceptives ever since. Currently, pt’s APGAR score is G15P150013 all pregnancies did not undergo PNC and were delivered via licensed “mananabang.” No problems in delivery were reported. Patient does not know how t perfor BSE and has never tried undrergone any procdures such as mammogram and pap smear. Patient had her menopause at 52 years old. Personal information about the pt’s sexuality is disclosed as verbalized by the S.O. “Grabiha ninyu dae noh din a lage mo ma.uwaw mangutana ug mga ing.ana.” Pt also verbalized “mingawun ko usahay sa akng bana.” Coping-Stress – Tolerance Pattern When asked what stress is to her, patient only stared at the student nurse. But when asked what “kapoy” is to her and if she feels any right now and before hospitalization, she answered with “wala man” but sometimes also replies with “ambot lang” and shakes her head slightly from side to side. According to the daughter, who is the patient’s primary caregiver at home, “di ka makadungog ni mama mureklamo gyud sa balay bisan nagsakit na na siya dinha. Ako nalang mahibung nganu lain na iyang nilihukan ug sa ni adtong hinay na siya ug samot.” Pt just lies down to relax if she feels such and her problems and worries are alleviated. Family has a switchboard type of communication but since the year 2000, her daughter is the one deciding for the family in coordination with her brothers and sisters. Pt’s support systemis her family. Value – Belief Pattern Patient has faith in God because she values masses highly. She watches TV on Sundays because she can no longer tolerate the walking to get to church to hear mass. She also prays every night before going to sleep. She has no religious organizations. She has superstitious beliefs such as not taking a bath after having fever because “makabughat”. There is no difference with her values and beliefs before and after hospitalization. Values in the family include close family ties, helping one another, being sensitive to one another’s needs. During hospitalization, the sons of the patient calls during weekends to ask about their mother’s condition. They also send money from time to time to finance their mother’s hospitalization. “Magtinabangay gyud Sensory: (-) graphesthesia, (-) 2point discrimination test, (-) sterognosis, (-) kinesthesia CRANIAL NERVES I. Olfactory: not able to distinguish any smell II. Optic: III. Occulomotor: Motor: does not smile, can’t frown, can’t puff out cheeks IV. Spinal Accessory: can’t shrug shoulders against resistance V. Hypoglossal: unable to move tongue from side to side and up and down MUSCLE STRENGTH 1/5 3/5 1/5 3/5 ?DEEP TENDON REFLEXES (+1) biceps reflex, (+1) triceps reflex, (+1) brachioradialis reflex, (+1) patellar reflex, (+1) Achilles Reflex ?Patient’s rating for GCS: 12points –Lethargic LABORATORY EXAMS: BLOOD TYPING (4/12/08) Purpose: Blood typing are most commonly done to make certain that a person who needs a transfusion will receive blood that matches (is compatible with) his own. People must receive blood of the same blood type; otherwise, a serious,even fatal, transfusion reaction can occur. Blood type = B Rh = + Implications: the patient’s blood type is B+ URINALYSIS Stanford Med and Diagnostic (4/12/08)
  • 10. mi” was what the S.O. said. Environmental History Pt. is currently residing in a one storey house in Suba, Lilo-an, Cebu for three years with her eldest daughter’s family. House and lot is rented and financed by the patient’s eldest son abroad. There are a total of 7 people living in the house including the patient with 2 bedrooms and 8windows. Pt sleeps with her 2grandchildren and daughter. While the other room is occupied by her 2 older grandchildren and son-in-law. They have no pets in the household but there are chickens from the neighbors that go to their backyard. Location of the house is accessible to their basic necessities. It is a 10-15minute walk away from the Healthcare center, market and Barangay Health Center (BHC), and church. The main road is a 5minute walk away from the house. The location of the house is accessible to public transportation such as their “trysikads”. Water is supplied by MCWD and electricity is supplied by Visayan Electric Company(VECO). Pt. describes neigborhood as peaceful and not congested. Garbage is disposed via motorized collection systemevery other day and toilets are flush-type. Purpose: Urine provides important information about a number of physiologic processes,including renal disease,diabetes mellitus, hydration status,and some liver disease. Most have a routine urine examination upon admission to a hospital, and many outpatient settings. Macroscopic Color: slightly cloudy Reaction: pH 5.0 Spec.grav. : 1.015 CHON: +1 (HAc) Glucose: negative Microscopic RBC/hpf: 0-1 WBC/hpf: 4-6 Epithelial cells: few Mucus threads:moderate a. urates:few Bacteria: few Coarsely granular cast:0-1/hpf Finely granular cast: 0-1/hpf Implications: An increase of WBC in urine usually implies infection of the urinary tract. LIPID PANEL (April 12, 2008) Purpose: To determine if your blood glucose level is within healthy ranges; to screen for, diagnose,and monitor hyperglycemia, hypoglycemia, diabetes, and pre-diabetes. Total cholesterolassessesrisk of CAD and evaluates fat metabolism. Triglycerides screens for hyperlipemia, and helps identify nephrotic syndrome. The serum creatinine level is used to indicate the renal function specifically the ability of the kidney to secrete urea and proteins. The BUN test is primarily used,along with the creatinine test,to evaluate kidney function. This test measures the nitrogen function of urea. Glucose: 83 mg/dl (normal= 75-115 mg/dl) Cholesterol total: 180 mg/dl (up to 200 mg/dl) Triglyceride: 164 mg/dl (up to 150 mg/dl)
  • 11. HDL: 23 mg/dl (normal = 35-60 mg/dl) LDL: 124mg/dl (normal = 0-150 mg/dl) VLDL: 33 mg/dl (normal = 0-40 mg/dl) Creatinine: 4 mg/dl (normal= 0.5-1.2 mg/dl) BUN: 52.5 mg/dl (normal = 4.7 – 23.4 mg/dl) BUA: 7.6 mg/dl (normal = 2.5 – 6.1 mg/dl) SGOT: 25 u/L (up to 37 u/L) SGPT: 14 u/L (up to 32 u/L) Glycosylated Hgb: 5.7 % (normal= 4.5 – 6.3%) (April 30, 2008) Glu: 103 mg/dl (normal= 75-115 mg/dl) Implications: Mild-to-moderate increase in serum triglyceride levels indicates biliary obstruction,diabetes,nephrotic syndrome or endocrinopathies.Low HDL-cholesterol levels are connected with diabetes mellitus, and hypertension.Increased creatinine levels and BUN in the blood suggest diseasesorconditions that affect kidney function. High creatinine may be due to reduced blood flow to the kidney due to shock, dehydration, congestive heart failure, atherosclerosis,or complications of diabetes.Increased BUN may result from decreased blood flow to the kidneys, such as shock or stress,and from conditions that cause obstruction of urine flow. BLOOD CHEMISTRY Stanford Med and Diagnostic (4/12/08) Purpose: To determine if your blood glucose level is within healthy ranges; to screen for, diagnose,and monitor hyperglycemia, hypoglycemia, diabetes, and pre-diabetes. Total cholesterolassessesrisk of CAD and evaluates fat metabolism. Triglycerides screens for hyperlipemia, and helps identify nephrotic syndrome. The serum creatinine level is used to indicate the renal function specifically the ability of the kidney to secrete urea and proteins. The BUN test is primarily used,along with the creatinine test,to evaluate kidney function. This test measures the nitrogen function of urea.
  • 12. Glucose: 83 mg/dl (normal= 75-115 mg/dl) Cholesterol total: 180 mg/dl (up to 200 mg/dl) Triglyceride: 164 mg/dl (up to 150 mg/dl) HDL: 23 mg/dl (normal = 35-60 mg/dl) LDL: 124mg/dl (normal = 0-150 mg/dl) VLDL: 33 mg/dl (normal = 0-40 mg/dl) Creatinine: 4 mg/dl (normal= 0.5-1.2 mg/dl) BUN: 52.5 mg/dl (normal = 4.7 – 23.4 mg/dl) BUA: 7.6 mg/dl (normal = 2.5 – 6.1 mg/dl) SGOT: 25 u/L (up to 37 u/L) SGPT: 14 u/L (up to 32 u/L) Glycosylated Hgb: 5.7 % (normal= 4.5 – 6.3%) Implications: Mild-to-moderate increase in serum triglyceride levels indicates biliary obstruction,diabetes,nephrotic syndrome or endocrinopathies.Low HDL-cholesterol levels are connected with diabetes mellitus, and hypertension.Increased creatinine levels and BUN in the blood suggest diseasesorconditions that affect kidney function. High creatinine may be due to reduced blood flow to the kidney due to shock, dehydration, congestive heart failure, atherosclerosis,or complications of diabetes.Increased BUN may result from decreased blood flow to the kidneys, such as shock or stress,and from conditions that cause obstruction of urine flow. Increased blood uric acid may result from certain medications like diuretics and antihypertensive drugs.It can lead to deposits of uric acid in the kidneys (uric acid nephropathy). COMPLETE BLOOD COUNT Purpose: The CBC is a basic screening test and is one of the most frequently ordered laboratory procedures. The findings in the CBC give valuable diagnostic information about the hematologic and other body systems,prognosis,response to treatment and recovery. Stanford Med and Diagnostic (4/12/08) Hgb = 10 g/dl (normal = 12-16 g/dl) Hct = 30 vol% (normal = 37-47 vol%) WBC = 10.8 10^9/L (normal= 5.0-10.0 10^9/L) Platelet count = 245,000 (normal= 150,000- 450,000/cumm)
  • 13. RBC count = 7.70 10^12/L (normal= 4.0-5.5 10^12/L) Differential count Segments = 0.70 (normal: 0.5-0.7) Lymphocytes = 0.30 (normal: 0.2-0.4) RBC morphology Anisocytosis rare Red Cell Indices MCV = 81 fl (normal: 80-96 fl) MCH = 27.0 pg (normal: 27.0-33.0 pg) MCHC = 33.3% (normal: 31.0-36.0%) Cebu Velez General Hospital DATE 4/23/08 4/24/08 4/28/08 5/2 NORMAL VALUES WBC 13 16.3 11.1 8.74 4.10-10.9 k/uL NEU 10.4 80% 13.1 80.7% 8.71 6.46 78.2% 73.9% 2.50-7.50 47-80%N LYM 1.37 10.5% 1.49 9.16% 1.14 1.49 10.2% 17.1% 1-4 13-14%L MONO .884 6.78% 1.27 7.83% 1.06 0.477 9.52% 5.46% .100-1.20 2-11%M EOS .276 2.07% .308 1.89% .162 0.237 1.45% 2.71% 0.00-.5 0-5%E BASO .078 .598% .062 .379% .063 0.74 .565% 0.846% 0-.100 0-2.10%B RBC 3.04 3.71 3.67 3.74 4-5.20 HGB 9.03 10.6 10.7 10.7 12-16g/dL HCT 25.4 30.8 30.8 31.3 36-46% MCV 83.5 83 84.0 83.3 80-100fL MCH 29.1 28.5 29.1 28.4 24-36pg MCHC 35.6 34.4 34.7 34.1 31-36g/dL RDW 14.7 13.9 14.5 14.7 11.6-18% PLT 372 355 306 340 140-440k/uL MPV 7.56 7.37 7.16 7.71 0-100gfL
  • 14. Remarks: 4/23/08:few hypochromic red cells noted 4/24/08: low hypochromic RBCs noted. Implications:. An increase in WBC and neutrophil count is the body’s reaction in response to the invading organism to fight off the infection (foot debridement) and defend the body. An elevated number of monocytes results from viral infection A decrease in RBC production, Hgb and Hct level is a result of damage of kidney (CKD) that results in the decrease in the production of the hormone erythropoietin that stimulates red blood cell production in the bone marrow. BLOOD CHEMISTRY (4/15/08) Purpose: Serum or plasma tests for potassium levels are routinely performed in most patients when they are investigated for any type of serious illness. Also, because potassiumis so important to heart function, it is usually ordered. Sodium test is a part of the routine lab evaluation of most patients. It is one of the blood electrolytes, which are often ordered as a group. Ionized Calcium is the calcium found in blood. This test measures serum levels of phosphates. It helps store and utilize body energy and help regulate calcium levels, carbohydrate and lipid metabolism, and acid-base balance. It is also essential for bone formation. Magnesium is the most abundant intracellular cation after potassium. Vital to neuromuscular function, this helps regulate intracellular metabolism, and activates many essential enzymes. Creatinine is the byproduct of the breakdown of muscle creatine phosphate resulting from energy metabolism. It is produced at a constant rate depending of the muscle mass of the person and is removed fromthe body by the kidney. This test diagnoses impaired renal function BUN: Urea forms in the liver and along with CO2, constitutes the final product of protein metabolism. The amount excreted urea varies directly
  • 15. with protein intake. The test for Bun, which measure the nitrogen portion of urea, is used as an index of glomerular function in the production and excretion of urea. Implications: Elevated serum Creatinine levels may indicate renal disease that has seriously damaged the nephrons. Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function or reduced blood flow to the kidney due to atherosclerosis. Increase in BUN levels indicates impaired function of the kidneys (Chronic Kidney Disease) to filter and excrete urea leading to its accumulation in the blood. Abnormally low serum sodium levels may result from inadequate sodium intake or excessive sodium loss due to profuse sweating, diuretic therapy, adrenal insufficiency, or chronic renal insufficiency Below-normal potassium levels often result from loss of body fluids (as in diuretic therapy). It may also result from chronic renal insufficiency. Elevated serum magnesium levels (hypermagnesemia) most commonly occur in renal failure, when the kidneys excrete inadequate amounts of magnesium. Elevated levels of phosphorus (hyperphosphatemia) may result from renal failure. Hyperphosphatemia is rarely clinically significant; however, if prolonged, it can alter bone metabolismby causing abnormal calcium phosphate deposits. Normal V 15- Apr 19- Apr 23- Apr 25- Apr 28- Apr 30- Apr 2- May Crea 0.6.-1.6 mg/dl 4.7 5.3 4.2 3.7 BUN 7-18 mg/dl 75.5 58 57 K 4.0-5.6 mmol/L 4.5 5 4.8 4 3.7 Na 136-142 mmol/L 135 132 131 138 139 Mg 1.2-2.2 mg/dl 2.3 P 2.70-4.50 mg/dl 4.67 3.6 Ionized 4.5-5.16 mg% 4.76 Ca
  • 16. (4/18/08) Purpose: Amylase helps digest starch and glycogen in the mouth, stomach, and intestine. It distinguishes between acute pancreatitis and other causes of abdominal pain. Phosphates aids in diagnosis of renal disorders and acid-base imbalance. amylase = 89 u/L (normal = 25-100 u/L) SGPT = 15 u/L (normal = 0-46.0 u/L) Phosphates = 76 u/L (40 – 129 u/L) Implications: Results are within normal limits. ARTERIAL BLOOD GAS ANALYSIS Purpose: ABG Analysis is a measurement of oxygen, carbon dioxide, as well as the pH of the blood that provides a means of assessing the adequacy of ventilation (PaCO2), oxygenation (PaO2) and it also allows assessment ofthe acid-base (pH) status ofthe body – whether acidosis or alkalosis is present, whether acidosis or alkalosis is respiratory or metabolic in origin and to what degree (compensated or uncompensated). This test is important because patient was having dyspnea so the oxygenation of the body cells must be noted. DATE 4/15/08 2:59 pm 4/26/08 4/29 2:17 pm 10:24am Normal values temp 35.3 °C 36.8 °C 36.3 C 36.4-37.4C Hgb 9.2 9.0 10.7 12-16 g/dl pH 7.370 7.461 7.45 7.35 – 7.45 pCO2 25.6 28.1 36.2 32-42 mmHg pO2 78.7 56.1 39.1 75-100 mmHg HCO³ 14.8 19.8 25.0 20-24 mmol/L
  • 17. TCO² 21 20.7 26.2 21- 25mmol/L ABE -9.4 -2.9 1.4 -3.3(+)1.2 mmol/L SatO2 97.8 91.1 78.4 95-98% Reticulocyte count 1.8% 0.5-1.5% Implications: (4/15/08)Results imply a fully compensated respiratory alkalosis with adequate oxygenation. It is fully compensated because the pH is normal. It may also be caused by respiratory stimulation by drugs, disease, hypoxia, or fever. A high reticulocyte count indicates a bone marrow response to anemia caused by hemolysis or blood loss. (4/26/08) Results imply a partially compensated respiratory alkalosis with mild hypoxemia. This is due to the impaired function of the kidneys to excrete the hydrogen ions to maintain pH homeostasis. As a compensatory mechanism, when more hydrogen ions are released in the blood, the respiratory control centers are activated in breathing rate and depth increases to exhale carbon dioxide to maintain pH homeostasis. (4/29/08) Results show an acid-base balance with severe hypoxemia. RESCREENING TEST RESULTS (4/23/08) HBsAg MEIA = 0.79 Cut off = 2.0 Interpretation = non-reactive Anti HIV-MEIA = 0.37 Cut off = 1.0 Interpretation = non-reactive Anti HIV-MEIA = 0.28 Cut off = 1.0 Interpretation = non-reactive Remarks: VDRL and malarial smears not done due to technical reasons and limitations.
  • 18. ELECTROCARDIOGRAM Purpose: to detect heart problems or blockages in the coronary arteries; to draw a graft of the electrical impulses moving through the heart; to record heart rate and the regularity of heart beats; to diagnose a possible heart attack or other heart diseases. April 18, 2008 (3:40pm) Rate: atrial: 83/minute ventricular: 83/minute Rhythm: sinus Axis: +33 degrees PR interval: 0.16 seconds QRS: .06 seconds QT interval: .36 seconds P wave: gen. upright QRS: normal R wave progression Transitional zone: V4 T wave: flat in II, depressed III, AVF ST segment: isoelectric Interpretation: Sinus rhythm Inferior wall ischemia Probable old anteroseptal myocardial infarction April 19, 2008 Rate: atrial: 71/minute ventricular: 71/minute Rhythm: sinus Axis: +32 degrees PR interval: 0.28 seconds QRS: .04 seconds QT interval: .36 seconds P wave: upright QRS: normal R wave progression q II, AVF, II Transitional zone: V2 – V3 T wave: flat II, AVF, V4, V5-V6 ST segment: isoelectric Interpretation: sinus rhythm within normal limits. Consider an old inferior wall scar. LEFT FOOT APO (4/15/08) – DR. BULLO Left foot APO: examination reveals the bones are normal in density, texture, and modeling. The joint space is well maintained. There is no
  • 19. evidence of a fracture, bone erosion nor bone destruction. Conclusion: (-) left foot CHEST PA (4/15/08) – DR. MAAMBONG Purpose: To evaluate respiratory status and heart size. Result: Examination reveals the lung fields are clear. The cardiac silhouette is not enlarged. There are no bony abnormalities. (4/16/08) – DR. MAAMBONG Result: examination reveals there are reticular densities noted in both lungs. The cardiac silhouette is not enlarged. There are no bony abnormalities. Conclusion: pneumonitis both lungs (4/22/08) – DR. MAAMBONG Chest AP: examination reveals there is hazy density noted in the right lower lung and the right costrophrenic angle is obliterated. Conclusion: pleural effusion right (hazy density) (4/29/08)– DR. MAAMBONG Chest PA: examination reveals there are hazy densities noted in both lower lungs. The diaphragm is obliterated. The cardiac silhouette is enlarged. The pulmonary vessels in the upper lung fields are prominent. There are no bony abnormalities. Conclusion: cardiomegaly, associated with pulmonary edema or congestion Chest Right Lateral Decubitus: examination of the right lateral decubitus of the chest with horizontal beamreveals there is homegenous density noted along the right lateral chest wall. The right hemidiaphragm is obliterated Conclusion: Pleural Effusion RIGHT Chest PA: Examination reveals there is hazy density noted on both lung bases. The pulmonary vessels are prominent. The cardiac silhouette is difficult to evaluate Conclusion: Pulmonary edema and congestion, pulmonary edema secondary to heart failure
  • 20. (4/30/08) – DR. MAAMBONG Chest PA: Examination reveals there is hazy density noted on both lung bases. The pulmonary vessels are prominent. The cardiac silhouette is enlarged Conclusion: Cardiomegaly, associated with pulmonary edema or congestion PERIPHERAL SMEAR EVALUATION (4/15/08)– DR. MAAMBONG Result: The peripheral blood smears shows a dimorphic population of normocytic and microlytic normocromic to mildly hypocromic RBC. No significant poikilocytosis is noted.No nucleated RBC’s seen; WBC are heterogeneous lot and show basically normal adult morphology. A relative predominance of segmentors is present.There are o blast cells identified. Platelets are within normal limits in number and morphology. ARTERIAL DUPLEX SCAN (4/15/08) Conclusion: atherosclerotic and heavily calcified lower extremity arterial segments : severe (50-99%) arterial occlusive disease of the bilateral posterior tibial and anterior tibial arteries : moderate (20-49%) arterial occlusive disease of the mid- segments of the right superficial femoral artery. VENOUS DUPLEX SCAN: LOWER EXTREMITY (4/15/08)DR. MAAMBONG Venous duplex result: the visualized lower extremity venous segments are compressible with adequate phasic. Interpretation: no evidence of acute approximal deep vein thrombosis bilaterally : deep venous insufficiency involving the right common femoral, superficial femoral and popliteal veins : superficial venous insufficiency involving the right greater saphenous vein and lesser saphenous vein. WOUND DISCHARGE/ CULTURE (4/16/08)
  • 21. Gram staining: no microorganisms seen P.R. No growth after 1 day (4/17/08) P.R. no growth after 2 days of incubation (4/19/08) P.R. smear of culture: Gram (+) bacillus Culture: bacillus spp. (2/20/08) F.R remarks: no otherpathogens isolated (4/21/08) F.R remarks: sensitivity testing of culture: Bacillus spp was not done since there is no definitive CLSI or NCCLS guidelines for susceptibility testing.However, vancomycin, ciprofloxacin, imiperum, and aminoglycosides may be effective. Wheneverisolated from clinical specimens, the potential for the isolate to be a contaminant must be strongly considered. 2 D ECHO (4/16/08)– DR. MAAMBONG – Conclusion: concentric left ventricular hypertrophy with regional hypokinesia with borderline fan and Doppler evidence of stage 2 diastolic dysfunction. : dilated left atrium : mitral sclerosis with mitral regurgitation, mild, mitral annular, calcification : aortic sclerosis with aortic annular calcification : tricuspid regurgitation, mild : moderate pulmonary hypertension ULTRASOUND (4/19/08)– DR. MAAMBONG
  • 22. Ultrasound upper abdomen Purpose: to evaluate the kidneys, liver, gallbladder, pancreas,spleen, abdominal aorta and other blood vessels ofthe abdomen; to help diagnose a variety of conditions,such as abdominal pains, inflamed appendix, enlarged abdominal organ, stones in the gallbladder or kidney; to assist in the assessment ofdamage caused by illness. Ultrasound upper abdomen: Exam reveals the liver is normal in size and echopattern.There are no dilated intrahepatic ducts or masses noted.The gallbladder is normal in size. The gallbladder wall is not thickened. The common duct is not dilated. There are no intraluminal stones noted. The Pancreas is normal. The Spleen is normal in size with transverse diameter of 6.3 cm. Incidentally, there is fluid in the left hemithorax. Conclusion: normal liver, gallbladder, pancreas,and spleen Right pleural effusion Ultrasound K.U.B (4/16/08)– DR. MAAMBONG Right kidney 7.4 x 4.2 cm Cortical thickness 1.5 cm Left kidney 8.2 x 4.5 Cortical thickness 1.9 cm Examination reveals both kidney are in Normal in size, shape, echogenicity and echopattern.There is no evidence of a stone,mass or hynephrosis.The ureters are unremarkable. The urinary bladder is normal. Conclusion: normal K.U.B ultrasound.Examination reveals both kidneys are normal in size, shape,echogenicity, and echopattern DEBRIDEMENT Purpose: Debridement speeds the healing of pressure ulcers, burns, and other wounds. Wounds that contain non-living (necrotic) tissue take longer to heal. The necrotic tissue may become colonized with bacteria, producing an unpleasant odor. Though the wound is not necessarily infected, the
  • 23. bacteria can cause inflammation and strain the body's ability to fight infection. Necrotic tissue may also hide pockets of pus called abscesses. Abscesses can develop into a general infection that may lead to amputation or death. (4/26/08) Debridement of left foot under local anesthesia at 9:30 AM under cardiac monitor LIVER FUNCTION TEST (April 30, 2008) Purpose: Lactate dehydrogenase catalyzes the reversible conversion of muscle lactic acid into pyruvic acid. This test aids in differential diagnosis of MI, pulmonary infarction, and hepatic diseases. LDH (lactate dehydrogenase):212u/L (normal=0-247 u/L) Total CHON: 6.6 g/dl (normal=6.6-8.8 g/dl) Pleural fluid LDH (lactate dehydrogenase):76u/L (normal=0-247 u/L) CHON: 1.8 g/dl (normal=6.6-8.8 g/dl) Implications: Low total protein levels may result from essential hypertension,uncontrolled diabetes mellitus, and malnutrition. Low protein levels can suggest a kidney disorder, or a disorder in which protein is not digested or absorbed properly. CBG Purpose: CBG consisting in measuring the glucose (sugar) content in the blood is done on a regular basis in diabetes patients to determine their glucose level (Normal = 70 – 120mg/dl). The purpose is to find out if the doses of medicine which the patient is taking are correct and if his diet is right or if corrections should be made. Highest (4/16/08 9pm) 269 mg/dl Lowest (4/17/08 5am) 84 mg/dl
  • 24. KEY ISSUES: 1. Impaired gas exchange related to alveolar-capillary membrane changes secondary to inflammation of lung parynchema as manifested by shortness of breath, use of accessory muscles in breathing, (+) wheezes, crackles heard upon auscultation, decreased Sat O2= 91.1 (mild hypoxemia) as of 04/26/08, hazy density noted in the right lower lung and right pleural eff) on chest x-ray result as of 04/22. SB: Ventilation is impaired because of secretions of exudates from alveoli. Secretions noted to be mobilized, loosened and expectorated in order to provide an adequate gas exchange. Unless secretions are removed, the alveoli becomes remained filled with exudates causing consolidation of lung tissues and further interfering with gas exchange.” (Nursing Care Planning Guidelines by Caine – Bufalino p.497) In pleural effusion, lung expansion may be restricted, and the client may experience dyspnea primarily on exertion, and a dry non-productive cough caused by bronchial irritation or mediastinal shift. (Black, Joyce, et. al, Medical-Surgical Nursing, 7th edition, Volume 2, p. 1873) April 28, 2008 2. Decreased cardiac output related to increased viscosity of the blood secondary to abnormally high blood sugarand impaired heart contractility secondary to elevated blood pressure as manifested by skin is dry and cold to touch,weak and thready peripheral pulses,2D Echo results as of April 16, 2008 that reveal left ventricular hypertrophy dilated left atrium, mitral sclerosis with mitral regurgitation, aortic sclerosis with aortic annular calcification, mild tricuspid regurgitation, and moderate pulmonary hypertension,cardiomegaly on chest x ray (april 29, 2008) SB: “The increased thickness of the heart muscle reduces the size of the Independent Interventions: 1. Auscultated breath sounds and assessed air movements. R: To ascertain status and note progress. 2. Elevated head of bed and complied to positioning schedule of patient. R: To take advantage of Desired Outcome: Within 8 hours of nurse-client interaction, patient will be able to maintain patent airway, demonstrate good respiration and improved oxygen exchange.
  • 25. ventricular cavities and causes the ventricles to take longer time to relax, making it more difficult for the ventricles to fill with blood during the first part of diastole and making them more dependent on atrial contraction for filling” (Medical-Surgical Nursing, 10th Ed., Vol.1 p.773) The left ventricle of the heart may become enlarged as it works to pump blood against elevated pressure due to systemic vascularresistance and excessive intravascular volume. Eventually, stroke volume, preload and afterload are affected (Brunner and Suddarth’s Textbook on Medical-Surgical Nursing 10th edition pg. 856) gravity decreasing pressure on the diaphragm and enhancing drainage and ventilation to different lung segments. 3. Positioned head midline. R: To open or maintain open airway. 4. Encouraged deep breathing exercises. R: To maximize effort. 5. Encouraged to expectorate sputum. R: To clear secretions. 6. Promoted adequate rest periods. R: To lessen fatigue. Collaborative Interventions: 1. Administered supplemental oxygen at 4L per minute. R: To increase oxygen available to tissues. Independent Intervention: 1. Determined baseline v/s including peripheral pulses; and reviewed laboratory values and diagnostic studies. R: provides opportunities to track changes 2. Assessed mental status R: cerebral perfusion is directly related to cardiac output and aortic pressure perfusion and is influenced by electrolyte and acid-base Actual Outcome: 04/28-30/08 After 8 hours of nurse-client interaction, patient was able to maintain a patent airway still uses accessory muscle in breathing, crackles still heard on both lung fields, constant use of supplemental O2. Sat O2 as of april 29 has decreased to 78. 4 (moderate hypoxemia) 05/2/08 After 8 days of nurse-client interaction, patient still uses accessory muscles in breathing, O2 level has decreased from 4 to 2 L/min. supplemental O2 was also used when difficulty in breathing rises. Desired Outcome: Within 8 hours of nursing intervention,
  • 26. April 28, 2008 3. Ineffective Tissue Perfusion related to interruption of arterial and venous flow and decreased HGB concentration as manifested by pale nailbeds and pale palms of the hand and soles of the feet, pale palpebral conjunctiva, weak and thready pulse on both upperand lower extremities, CRT < 3secs on lower extremities, deep venous on venous duplex scan result as of 04/15 and atherosclerotic and heavily calcified lower extremity on Arterial duplex scan result as of 04/15; decreased Hgb= 10.7 m/ul (04/28) and Hct = 30.8% (04/28) SB: “The delivery of oxygen to the muscle cells throughout the body depends not only on the lungs but also on the ability of the blood to carry oxygen and on the ability of the circulation to transport it.” (Merck Manual of Medical Information, 2nd Home Ed., M. Beers et. al, p. 221) The amount of blood flow needed by body tissues constantly changes. The percentage of blood flow received by individual organs or tissues is determined by the rate of tissue metabolism, the availability of oxygen and function of tissues. (S: Smeltzer, Suzanne C. and Brenda G. Bare. Medical-Surgical Nursing. p 977) variations. 3. Provided adequate rest by decreasing stimuli and providing quiet environment R: To maximize sleep periods 4. Elevated legs R: to promote venous return 5. Monitored I/O R: To maintain adequate fluid balance 6. Encouraged changing positions slowly. R: Reduce risk of orthostatic hypotension. 7. Assisted in performing self-care activities. R: to decrease energy consumption. 8. Altered environment such as decreasing temperature of air conditioner. R: to maintain body temperature in normal range. 9. Explained fluid restrictions. R: to promote cooperation of patient and SO. 10. Assisted with frequent position changes. R: to avoid the development of pressure sores. Collaborative Intervention: 1. Administered oxygen inhalation at 4L/min as indicated. R: To increase oxygen available to tissues. 2. Administered ISMN/ Isosorbide mononitrate the patient will display stability in blood pressure and participate in activities that reduce the workload of the heart such as balanced activity/rest plan. Actual Outcome: 05/28-29/08 After 8 hours of nursing intervention, the patient’s BP= 130/80 mmHg. Patient needs assistance in rising from bed and transferring to bedside commode. Patient is cold to touch, peripheral pulses are weak and not easy to palpate 05/2/08 After 8 hours of nursing intervention, the patient’s BP= 130/80 mmHg. Patient was able to sit on bed with little assistance, and alert at this time.
  • 27. April 28, 2008 4. Fluid Volume Overload r/t excess fluid in pleural spaces secondary to inability of the kidney to excrete fluid efficiently as manifested by use of accessory muscles upon breathing, (+) wheezes, crackles heard on both lung fields, hazy density noted in the right lower lung and pleural effusion, right on chest x-ray result as of 04/22. SB:Pleural effusion is the accumulation of fluid in the pleural space. Nomally only a thin layer of fluid separates the 2 layers of the pleura. An excessive amount of fluid may accumulate for many reasons, depending on the cause.the most common symptoms are shortness of breath and chest/ pleuritic pain.there are many causes of pleuritic pain including viral and bacterial infections. (merck manual of medical information, 2nd ed., p.226,283.) Pleural effusions may also be associated with the leakage of fluid due to higher than normal pressures in the lung circulation, such as with congestive heart failure (CHF) or from low protein in the blood, as in liver disease,severe malnutrition, and in certain kidney conditions when (Imdur) 60mg/tab ½ tab twice a day by mouth R: relaxes vascular smooth muscles with a resultant decrease in venous return 3. Administered Amlodipine 5 mg 1 tablet once a day after breakfast by mouth R: to depress myocardial contractility, dilate coronary arteries and arterioles and peripheral arterioles 3. Administered Aluminum Hydroxide (Alutab) 1 tablet twice a day by mouth R: binds with phosphate ions in the intestine to form insoluble aluminium- phosphate complexes, lowering phosphate in hyperphospatemia Independent Interventions: 1. Interviewed and reviewed patient’s history and determined the nature of the problem. R: to assess causative factor 2. Established baseline vital signs, weight, and laboratory values. R: provide comparison with current findings. 3. Measured capillary refill time; palpated for presence or absence and quality of pulses. R: To note degree of impairment. 4. Assessed for Homan’s sign Desired Outcome: Within the course of nursing intervention, patient will be able to be free from the signs and symptoms of infection like swelling, fever, redness, pain
  • 28. protein is filtered into the urine. (http://www.pcca.net/PleuralEffusion.html) April 20, 3008 5. Imbalanced Nutrition, less than body requirements related to increased metabolic rate and fatigue as manifested by body weight is not ideal to her height: wt: 98 lbs; ht: 5”2, poor muscle tone,dry skin SB: Undernutrition refers to an intake of nutrients insufficient to meet daily energy requirement because of inadequate foot intake or improper digestion and absoption offood. An inadequate food intake may be caused by the inability to acquire and prepare food, balanced diet, discomfort during or after eating. Improper digestion and absorption of nutrients may be caused by an inadequate production of hormones or enzymes or by medical contions resulting in inflammation or obstruction R: to determine proper blood circulation 3. Encouraged sleep and rest R: decreases oxygen consumption. 4. Provided comfort and warmth through covering the patient’s feet and hands with blanket during cold temperatures. R: Increase blood circulation to the peripheral areas. 5. Positioned patient in moderate high back rest R: Promoted optimum lung expansion 6. Performed assistive or passive range-of-motion exercises R: To maximize tissue perfusion. 7. Discouraged sitting or lying down for long periods, wearing constrictive clothing. R: To maximize tissue perfusion. 8. Encouraged patient to elevate the legs, but avoid sharp angulation of the hips and or knees. R: To maximize tissue perfusion. Collaborative Intervention: 1. Administered Diosmin + Hesperidin (Daflon) 500 mg I tab twice a day by mouth R: significantly improves disabling symptoms of Actual Outcome: After the course of nursing intervention, no signs of infection such as fever, redness, swelling, itchiness were noted; wound was kept clean and dry; HGB and HCT level were still low; 3.74 m/uL (05/02) and 31.3% (05/2), respectively. Patient was still pale, cold to touch and peripheral pulses are still weak.
  • 29. of GI tract (Kozier, Barbara. Fundamentals of Nursing 7th edition. pg 1190) venous insufficiency which affect everyday active life 2. Administered Losartan (Lifezar) 50 mg I tab once a day after supper by mouth R: blocks the vasoconstricition effect of the RAA system as well as the release of aldosterone 3. Administered Amlodipine 5 mg I tab OP PO pc bfast R: to depress myocardial contractility, dilate coronary arteries and arterioles and peripheral arterioles Independent Interventions: 1) Assessed skin, face and dependent areas for edema R: to evaluate degree of fluid volume excess 2) Monitored input and output R: to determine renal function and fluid replacement and reducing risk of fluid overload 3) Monitored Vital signs R: tachycardia and hypertension can occur because of failure of kidneys of excrete urine, changes in RAA mechanism 4) Auscultated lung and heart sounds R: Fluid overload may lead to pulmonary edema and heart failure Desired Outcome: Within 4 hours of nursing intervention, the patient will maintain an appropriate urinary output, vital signs within normal range, a stable weight, clear lung fields, and absence of edema Actual Outcome: 05/28-30/08 After 4 hrs of nursing intervention, patient maintained a normal output of 30- 60 cc/hour, blood pressure was within
  • 30. April 28, 2008 6. Ineffective Protection related to inadequate primary defense: break in skin and secondary body defenses: decreased haemoglobin level as manifested by 2 cm in dm and 1x1/2 in of open wounds on left foot, decreased Hgb= 10.7 m/ul (04/28) and 3.74 m/uL (05/02) and Hct = 30.8% (04/28) and 31.3% (05/2). SB: Any site in the body is susceptible to infection by organisms when skin and tissue barriers are compromised by surgery, trauma or there is tissue ischemia or necrosis. These infections are frequently caused by post surgical wound infection, intra-abdominal abscess among others. ( Harrison’s Principles of Internal Medicine 9th Ed. Pg. 694-695) R: to assess precipitating factors 5) Assessed level of consciousness R: may reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances or developing hypoxia 7) Measured abdominal girth R: to identify changes that may indicate increasing fluid retention 7) Positioned patient in semi- fowler’s position R: to facilitate movement of diaphragm improving respiratory effort 8) Limited oral fluids as ordered to 300ml in the 7-3 shift, 300 ml in the 3-11 shift, and 200 ml in the 11-7 shift R: to allow timely alterations in therapeutic regimen Collaborative interventions: 1) administered Furosemide 40mg/tab ii tabs OD PO pc bfast R: to promote elimination of excess fluid 3) administered O2 via nasal cannula @ 4L/min R: facilitates patient in breathing 4) Assisted in performing Thoracentesis R: to remove the excess fluid found in pleural her normal range of 130/80, no edema was noted, but heard crackles on both lung fields upon auscultation. 045/02/08 After 4 hrs of nursing intervention, patient urinated 150cc/4hrs, no edema was noted, still crackles were heard on both lung fields.
  • 31. April 28, 2008 7. Impaired SkinIntegrity related to mechanical factors such as trauma to the skin secondary to S/P debridement on left foot as manifested by 2 cm in dm and 1x1/2 in of open wounds on left foot SB: The skin serves as the primary defense against bacterial invasion. When skin is incised for surgical procedure, this important line of defense is lost. Strict adherence to aseptic technique during surgery and in the days following the procedure is necessary to compensate for impaired defense. (Maternal and Child Health Nursing, 4th edition by Adele Pillitteri, p 613) Independent Interventions: 1. Assessed weight,age, body build, strength, and activity/rest level R: to provide comparative baseline 2. Determined ability to chew, swallow, and taste R: to identify the factors that can affect digestion of nutrients. 3.Encouraged bed rest and/or limited activities. R: decrease metabolic needs aids in preventing caloric depletion and conserves energy. 4.Recommended rest before meals. R: quiets peristalsis and increases available energy for eating. 5.Provided oral hygiene. R: a clean mouth can enhance the taste of the food. 6.Served food in a therapeutic environment. R: pleasant environment aids in reducing stress and is more conducive to eating. 7.Encouraged patient to verbalize feelings concerning resumption of diet. R: hesitation to eat may be result of fear that food will cause exacerbation of symptoms. 8. Emphasized importance of well-balanced, nutritious Desired Outcome: Within 1 hour of nursing intervention, patient will demonstrate demonstrate behavior and lifestyle changes to maintain weight at a satisfactory level for height, body build, age and gender and patient’s SO will verbalize understanding of the health teachings given Actual Outcome 4/30/08 After 1 hour of nursing intervention, patient has a good appetite, was able to finish one serving of every meal served.. Patient’s SO expressed understanding of the health teaching given as verbalized “ako man jud na dugmokon ang pagkaon ni mama para humok ug sayon nya matulon ang pagkaon” 5/2/08 After 1 hour of
  • 32. April 30, 2008 8. Acute Pain related to surgical operation secondary to S/P left food debridement as manifested by gnawing pain on left foot lasting for 30 seconds with a facial, relieved by rest, aggravated by stepping on the floor, with a verbalization of “sakit kaayo”. SB: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It occurs with many disorders, diagnostic tests and treatments and invasive procedures. (Medical Surgical Nursing by Smeltzer and Bare, vol. 1, p. 217) ] April 28, 2008 9. Fatigue related to decreased metabolic production, poor physical condition and decreased hemoglobin level secondary to impairment of kidney function as manifested by lethargy, disinterest in surroundings, inability to perform ADL’s, verbalization of “kapoy sige’g higda” and decreased Hgb= 10.7 m/ul (04/28) and and Hct = 30.8% (04/28) Scientific Basis: Fatigue, nausea, vomiting and overall itching of the skin commonly intake R: to provide information regarding individual nutritional needs 9. Instructed SO to serve soft foods to the patient R: to masticate food easily Collaborative Intervention: 1. Administered Sodium bicarbonate Gr X 2 tablet thrice a day by mouth R: to neutralize or reduce gastric acidity, resulting in an increase in the gastric pH, which inhibits the proteolytic activity of pepsin 2. Administered Mucosta 100mg/tab 1 tablet thrice a day by mouth R: exhibits a gastric cytoprotective effect by inhibiting mucosal damage induced by ethanol, strong acid and strong base Independent Interventions: 1. Noted signs and symptoms of infection R: fever, chills, diaphoresis, altered level of consciousness, and positive blood cultures may indicate infection 2. Encouraged proper hand washing techniques to client nursing intervention, patient was able to finish one serving of meal. She still has poor muscle tone and weight is decreased from 98lbs to 95lbs (not accurate) Desired Outcome: Within 8 hours of nursing intervention
  • 33. develop in people who have kidney failure. These symptoms result from the accumulation of metabolic waste including acids, which the diseased kidneys are unable to excrete. Fatigue may also result from decreased production of red blood cells, a frequent problem in chronic kidney failure (Merck Manual of Medical Information, 2nd Home Ed., M. Beers et. al, p. 748) April 28, 2008 10, Partial SelfCare Deficit (dressing, feeding, bathing, grooming and toileting.) related to fatigue and developmental age of 82 years old as manifested by inability to wash body parts,inability to get in and out of the bathroom, inability to pick up clothing, and inability to handle utensils. SB: People with disabilities frequently experience fatigue. Physical and emotional weariness may be caused by discomfort and pain associated with a chronic health problems, deconditioning associated with and SO R: a first line of defense against nosocomial infection or cross-contamination 3. Encouraged to check wound for signs of inflammation and drainage. R: may indicate hematoma formation and developing infection 4. Encouraged and assisted in ambulation R: promotes wound healing 5. Instructed patient to keep incision dry and clean R: to prevent risk for infection 6. Encouraged SO to let patient eat food high in iron and vitamin c such as green leafy vegetables, organ meat, orange, citrus fruit R: to boost immunity and enhance proper blood circulation Collaborative Interventions: 1. Assisted in wound dressing with Mupirocin (Bactroban) R: to keep the wound are clean and dry 2. Administered Ciprofloxacin 500 mg/tab 1 tablet once a day by mouth R: promotes breakage of double-stranded DNA in susceptible organisms and inhibits DNA gyrase, which px will be able to be free from the signs and symptoms of infection like swelling, fever, redness, pain Actual Outcome: After the course of nursing intervention, no signs of infection such as fever, redness, swelling, itchiness and warmth on incision site were noted; wound was kept clean and dry; hgb and hct level were still low; 3.74 m/uL (05/02) 31.3% (05/2), respectively.
  • 34. prolonged periods of bed rest and immobility, impaired motor function requiring excessive expenditure of energy to ambulate, the frustrations of performing ADLs. (S: Smeltzer, Suzanne C. and Brenda G. Bare. Medical-Surgical Nursing. p 218) With aging comes gradual reduction in the speed and power of skeletal or voluntary muscle contraction and sustained muscular effort. Thus elders often complain about their lack of strength and how they quickly they tire. (S: Smeltzer, Suzanne C. and Brenda G. Bare. Medical-Surgical Nursing. p 402) April 28, 2008 11. Impaired Physical Mobility related to decreased strength and endurance as manifested by inability to get out of bed without assistance and poor gait Scientific Basis: Paralysis, extreme weakness, pain, or any cause of decreased activity can hinder a person’s ability to change positions independently and relieve the pressure, even if the person can perceive pressure. (Kozier, et al, Fundamentals of Nursing, 7th Ed., p 857) is essential in reproduction of bacterial DNA. Independent Interventions: 1. Assessed wound for presence of inflammation and drainage. R: Development of infection delays wound healing. 2. Assessed wound for unusualities such as discoloration and swelling. R: Infection is characterized by a black discoloration of the wound. 3. Monitored vital signs especially temperature elevation. R: A rise in temperature indicates presence of inflammation, pyrogens, or infection. 4. Kept area clean and dry. R: To avoid infection. 5. Avoided use of plastic materials and removed wet and wrinkled linens promptly. R: Moisture potentiates skin breakdown. 6. Complied with the positioning schedule of the patient. R: To prevent development of pressure sores. 7. Avoided use of constricted clothings. R: To promote circulation to the lower extremities. Desired Outcome: After 30 minutes of nursing intervention, patient will display timely healing of skin wounds without complications and prevent development of pressure sores. Actual Outcome: 5/28/2008 After 30 minutes of nursing intervention, patient’s wound was covered with a clean and dry gauze. Wound is watery but there was no pus noted. 5/29/08 After 30 minutes of nursing intervention, patient’s SO understood the health teachings given with a verbalization of “salamat kayo, maintenahon lang nako ug pakaon si mama ug prutas”, wound dressing
  • 35. April 28, 2008 12. Risk for injury: falls related to poor physicalcondition Cues: 82 years old, tremors on upper extremities, unable to do ADL’s alone, impaired balance, difficulty with gait, s/p left foot debridement, hyperphosphatemia SB: “Weakness can occurwhen any part of the musculoskeletal system is abnormal. If the muscle itself cannot contract,weakness occurs. If a nerve does not adequately stimulate the muscle, the muscle contractions are weak. If a joint is frozen and unable to move normally, the muscle may not be adequately able to cause movement.” (The Merck Manual of Medical Information, 2nd Home Ed., M. Beers et. al, p. 305) 8. Encouraged to eat food high in Vitamin C such as orange, citrus fruit and green leafy vegetables R: to promote wound healing Collaborative Interventions: 1. Assisted in wound dressing with Mupirocin (bactroban) once a day R: to keep the wound are clean and dry 2. Administered Ciprofloxacin 500 mg/tab once a day by mouth R: promotes breakage of double-stranded DNA in susceptible organisms and inhibits DNA gyrase, which is essential in reproduction of bacterial DNA. Independent Intervention: 1) Monitored vital signs. R: Alteration in vital signs could indicate pain. 2) Frequently assessed pain scale. R: To rule out development of complications. 3) Provided comfort measures such as assuming patient position (semi-Fowler’s position) of comfort. R: To provide non- pharmacological pain management. 4) Encouraged adequate rest periods. R: To prevent fatigue. remained dry, intact and presence of blood on the edge was noted. 4/30 and 5/2 /08 After 30 minutes of nursing intervention, patient’s dressing was clean, dry and intact. Wound is dry and no purulent discharges noted. Desired Outcome: Within 30 mins. of nurse-client interaction, the patient will be able to demonstrate methods that provide relief, report that pain is relieved and controlled, and pain scale is reduced. Actual Outcome:
  • 36. April 30, 2008 13. Bowel Incontinence related to self-care deficit: inefficient toileting, general decline in muscle tone secondary to increasing age as manifested by inability to delay defecation, fecal staining on clothing, and inability to recognize urge to defecate. SB: Fecal Incontinence describes the involuntary passage of stoolfrom the rectum. Factors that influence fecal continence include the ability of the rectum to sense and accommodate the stool,the amount and consistency ofstool, the integrity of the anal sphincter and musculature, and rectal motility. It can result from neurologic disorders such as diabetic neuropathy,or advancing age. Patients may have minor soiling, occasional urgency,and loss of control. (Smeltzer, Bare, Textbook of Medical-Surgical Nursing, 11th edition, Lippincott Williams and Wilkins, 2008, page 1236) 5) Taught how to do deep breathing exercise and stressed to perform it every time pain occurs. R: To promote relaxation. 6) Encouraged expression of feelings. R: Helpful in establishing individualized treatment needs 7) Taught diversional activities like watching television. R: to divert attention from pain Collaborative: 1. Administered Paracetamol 500mg/itab 1tablet as needed R: for fever and pain Independent Intervention: 1) Obtained a history of condition including date of onset,and significant findings of present condition. R: To provide a baseline data for future comparisons. 2) Determined ability to participate in activities or level of mobility. R: To assess patient’s degree of fatigue. 3) Provided environment conducive for rest and sleep. R: To relieve fatigue. 4) Assisted with self-care needs. R: To limit occurrence of 04/30/08 After 30 mins. of nursing interventions, pain was still noted with a verbalization of “sakit gamay” 5/2/08 After 2 days of nursing interventions, the patient still reported pain with a verbalization of “sakit kung tumban nako, sakit kaayo pero ako lang antuson” Desired Outcome: Within 30 minutes nursing intervention, patient will be able to perform ADLs and display improved ability to
  • 37. April 30, 2008 14, Impaired dentition related to poor oral hygiene and lack of knowledge regarding dental health and aging process as manifested by presence of dental cavities, yellow-colored teeth, 6 lower and 4 upper teeth Scientific Basis: Healthy teeth must be conscientiously and effectively cleaned on a daily basis. The normal movement of the muscles of mastication and the normal floe of saliva aid gently in keeping the teeth clean. Because many ill patients do not eat adequate amounts of foods, they produce less saliva, which in turn reduces the natural cleaning process of the teeth. (Medical – Surgical Nursing by Brunner & Suddarth’s p. 810.) Tooth enamel tends to wear away with age, making the teeth vulnerable to damage and decay. Periodontal disease,however, is the major cause of tooth loss. Periodontal disease is more likely to occur in people with fatigue. 5) Scheduled activities according to client’s ability. R: To maximize participation. 6) Instructed SO to maintain a quiet environment conducive for rest and sleep. R: temperature and level of humidity are known to affect exhaustion 7) Instructed SO to minimize number of visitors in the room or to schedule visits. R: to provide a calm and quiet environment 8) Encouraged SO to let the patient eat foods high in iron such as liver, green leafy vegetables, fish, beans, nuts, eggs, raisins. Collaborative Intervention: 1) Administered O2 @ 4L/min via nasal cannula R: to facilitate breathing and promote ease in respiration. Independent Interventions: 1. Assessed emotional and psychologic factors affecting the current situation such as stress R: to note any changes in emotional status 2. Evaluated current limitations or degree of participate in desired activities. Actual Outcome: 4/28-30/08 After 30 minutes of nursing intervention, patient still appeared weak and lethargic, needed assistance in perfoming ADL’s and decreased activity was still noted. 5/2/08 After 30 minutes of nursing intervention , patient demonstrated improvement in muscle strength from poor ROM to average weakness. She was able to sit on bed with little assistance and interactive with the health care provider. Patient’s HGB and HCT level are still low with 3.74 m/uL, 31.3% respectively
  • 38. poor oral hygiene, smoker and poor nutrition. (Merck Manual of Medical 2nd ed. p.602) deficit in the light of usual status R: provides comparative data 3. Established rapport with patient and S.O. R: To foster trust between the nurse, the patient & S.O 4. Collaborated with the SO of the client in caring for and assisting the client. R: Enhances coordination and continuity of care, optimizing outcomes 5. Planned care with rest periods between activities R: to reduce fatigue 6. Promoted comfort measures R: to enhance ability to participate in activities 7. Provided positive reinforcement when client complies to nursing interventions R: Encourages continuation of efforts. 8. Taught S.O safety concerns such as raising of siderails at all times, keeping away sharp objects R: to prevent injuries 9. Encouraged S.O to stay at patient’s bedside at all times R: To ensure safety and attend patient’s needs Independent Interventions: 1. Assessed emotional and behavioural responses to Desired Outcome: After 8 hrs of nursing interventions, patient will be able to perform self-care activities such as dressing bathing, toileting, feeding and grooming, within the level of her own ability and demonstrate techniques to meet self-care needs. Actual Outcome: 4/28-30/08 After 8 hrs of nursing interventions, the patient still needed assistance of the care provider and SO in performing ADL’s such as dressing, bathing, toileting, feeding, and grooming. 5/2/08
  • 39. problems of immobility. R: Feelings of frustrations and powerlessness may impede attainment of goals. 2. Determined functional level of classification. R: Assess the functional ability. 3. Positioned safely on bed and raised side rails. R: To promote safety. 4. Assisted with the activities of ADL like transferring from bed to bedside commode. R: prevent complications. 5. Assisted in ambulation R: to promote wellness 6. Promoted SO participation in patient care. R: Enhances coordination and continuity of care. 7. Assisted in positioning patient every 2hrs. R: To prevent pressure sores and promote comfort. 8. Supported affected body part with a pillow. R: To maintain position of function and reduce risk of pressure sores. 9. Promoted adequate rest periods. R: To reduce fatigue 10. Assisted in performing active assistive ROM exercises to the patient. R: To stimulate peripheral circulation. After 8 hrs of nursing interventions, patient was able to stand up from bed to bedside commode with assistance for defecation and urination. She was still in need of assistance in performing her ADL’s. Desired Outcome: Within 8 hours of nursing interventions, patient will be able to demonstrate progressive changes in her mobility as tolerated, and at the same time SO will be able to provide the necessary needs of the patient such as changing position and transferring from bed to bedside commode for
  • 40. Independent Interventions: 1. Assessed age. R: to evaluate degree of risk in the individual situation. 2. Assessed client’s cognitive status. R: Affects ability to perceive own limitations and risk for falling. 3. Assessed mood, behaviour, and personality styles. R: Individual’s temperament and typical behaviour can affect attitude towards safety issues. 4. Provided rails, pillows and chair at sides of patient’s bed. R: to prevent from falls 5. Visited frequently R: to promote patient safety 6. Discussed to SO the need for constant supervision R: to maintain patient’s safety Collaborative Interventions 1. Administered Gabapentin (Reinin/Nevrontin) 100mg/cap 1capsule twice a day by mouth R: treatment for tremors; depresses abnormal neuronal changes in the CNS Independent Interventions 1. Noted times of incontinent occurrence. R: Provides baseline data. toileting Actual Outcomes: 4/28-30 and 5/2/08 After 8 hours of nursing interventions, patient cannot change position and ambulate without assistance Desired Outcome: Within 8 hours of nursing intervention, the patient will be safe and free from injury and patient’s SO will verbalize understanding of the
  • 41. 2. Palpated abdomen. R: to determine presence of distention, masses,and tenderness. 3. Auscultated bowel sounds, noting locations and characteristics. R: To note presence, location, characteristics of bowel sounds. 4. Observed for abdominal distention if bowel sounds are decreased. R: Loss of peristalsis paralyzes the bowel, creating bowel distention. 5. Recorded frequencies, characteristics, and amount of stool. R: Identifies degree of impairment/ dysfunction and level of assistance required. 6. Encouraged SO to record times at which incontinence occurs. R: To note relationship to meals, activity, and client’s behavior. 7. Determined presence of impaction. R: Early intervention is necessary to effectively treat constipation or retained stool and reduce risk of complications. 8. Taught to lean forward on commode. safety measures being taught by the HC provider. Actual Outcome: 04/28/07 Patient was free from injury and SO expressed understanding of the importance of safety measures as verbalized by “naa man jud permi kuyog si mama, bantayan nako permi si mama” 04/29-30/07 Patient was free from injury. There were no signs of local infection such as swelling, redness, purulent discharges noted on left foot; slight tremor was noted on upper extremities. 05/02/08 Patient was free from injury. Patient’s wound is dry and covered properly with a clean gauze. A tremor on the upper extremities was very noticeable.
  • 42. R: To increase intra- abdominal pressure during defecation. 9. Encouraged fruit juices such as apple and pineapple juice. R: Improves consistency of stool for transit through the bowel. 10 Encouraged activity within individual ability and up in bedside commode as tolerated. R: Improves appetite and muscle tone, enhancing GI motility. 8. Restricted intake of grapefruit juice and caffeinated beverages such as tea, coffee, and chocolates. R: Diuretic effect can reduce fluid available in the bowel, increasing risk of dry/hard formed stool. 9. Provided skin care. R: loss of sphincter control potentiates risk of skin irritation/ breakdown. Independent Intervention: 1) Noted presence or absence of teeth and ascertain its significance in terms of nutritional needs. R: to assess causative or contributing factors 2) Evaluated current status of Desired Outcome Within 30 mins. of student nurse-patient interaction, the patient will re- establish satisfactory bowel elimination pattern. Actual Outcome 04/30 After 30 mins of nursing intervention, the patient defecated on her bed. 05/2 After 30 mins of nursing intervention, patient felt the urge to defecate. She was able to control it and satisfactorily defecated in the bedside commode
  • 43. dental hygiene and oral health R: to assess causative or contributing factors 3) Discussed the importance of having dental check –up R: to minimize oral or dental tissue damage 4) Discussed the importance of having good dental hygiene. R: to increase patient’s awareness on dental care. 5) Instructed to use warm saline gargle. R: to promote good oral hygiene. Desired Outcome: Within the 30 mins. of nursing intervention, SO and patient will be able to demonstrate effective dental hygiene skills and gain knowledge on the importance and benefits of having a good oral hygiene. Actual Outcome: 04/30/08
  • 44. After 30 mins. of nursing intervention, SO and client was able to understand and gain knowledge of health teachings given to SO by nodding her head and verbalizing “o sige, salamat kaayo” Patient also showed understanding by nodding her head. 05/2/08 After 30 mins. of nursing intervention, patient’s teeth is still yellow in color; presence of cavities were noted.