This document discusses traumatic brain injury (TBI). It defines TBI and describes the types of brain injuries including concussion, contusion, epidural hematoma, subdural hematoma, and diffuse axonal injury. It lists common causes of TBI such as motor vehicle accidents and falls. It then provides objectives for gaining knowledge on handling patients with brain injuries and skull fractures through a case presentation.
This document provides an overview of health assessment for nursing students. It discusses the objectives of health assessment, which include surveillance of health status, periodic assessment, and increasing client participation in health care. It also covers the nursing process, which is used to organize health assessment data. The major steps of health assessment are described as collecting subjective and objective data through patient interviews and physical examinations. Specific techniques for interviews, such as using open-ended questions, are outlined. The document also lists the components of a complete health history.
Nursing management client with Increased intracranial pressure ( ICP)ANILKUMAR BR
The rigid cranial vault contains brain tissue (1,400 g), blood (75 ml), and CSF (75 ml)
The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP.
ICP is usually measured in the lateral ventricles; normal ICP is 10 to 20 mm hg.
The Monro-kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others.
Increased ICP is a syndrome that affects many patients with acute neurologic conditions.
This is because pathologic conditions alter the relationship between intracranial volume and pressure.
Although an elevated ICP is most commonly associated with head injury, it also may be seen as a secondary effect in other conditions, such as brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies.
Standardized nursing language powerpointZulie Dorsan
Standardized Nursing Language refers to approved vocabularies used to describe nursing care related to diagnosis, interventions, and outcomes. This ensures consistent communication among nurses globally. Popular standardized languages include NANDA (nursing diagnoses), NIC (interventions), and NOC (outcomes). Using standardized language enhances data collection and evaluation of nursing care outcomes, and improves communication between healthcare professionals by facilitating consistent documentation and patient-centered care.
Dynamics of communication health and development for submissionYnneb Reine Manginsay
This document provides an overview of key concepts in community organizing including:
1. Definitions of a healthy community, characteristics of communities, and components of communities.
2. The basic community organizing process including entry, social investigation, problem identification, planning, core group formation, and organization development.
3. Principles of community organizing such as people being motivated by self-interest and tactics being within community experience.
4. Phases of community organizing including preparatory, organizational, education and training, and intersectoral collaboration phases.
5. Elements of community organizing like power, relationship building, leadership development, and political education.
So in summary, the document outlines foundational concepts and
This document discusses the key concepts of community health nursing (CHN). It defines CHN as applying nursing skills, public health, and social assistance through organized community efforts to promote health, prevent disease, and ensure access to healthcare. The goals of CHN are to raise the health levels of communities by empowering them to cope with health threats and maximize wellness. CHN is a generalist field that addresses individuals, families, populations and communities across all ages and levels of healthcare.
The document provides an overview of health education, including definitions, aims, principles, approaches, methods, and practices. It defines health education as any combination of learning experiences designed to help individuals and communities improve their health. The key principles of health education discussed are credibility, interest, participation, motivation, comprehension, reinforcement, learning by doing, known to unknown, setting an example, good human relations, feedback, and using community leaders. The common approaches covered are regulatory, service, educational, and primary health care. Audio-visual aids and various methods of communication are also mentioned as practices of health education.
This nursing care plan addresses an ineffective breathing pattern in a patient. It identifies the patient's problem as an ineffective breathing pattern related to contributing factors. Short term goals are for the patient to feel rested, perform diaphragmatic breathing, and demonstrate maximum lung expansion within 2 days. The long term goal is for the patient to maintain an effective breathing pattern and normal breathing during activities of daily living within 2 weeks. The plan outlines assessments, interventions, and health teachings to address the patient's breathing issues.
it contains information about the important measurements , the vital signs, head, eyes, ears, nose , mouth and throat, neck, chest, breast and abdomen of a newborn. You'll find the normal and the abnormal findings on each category.
This document provides an overview of health assessment for nursing students. It discusses the objectives of health assessment, which include surveillance of health status, periodic assessment, and increasing client participation in health care. It also covers the nursing process, which is used to organize health assessment data. The major steps of health assessment are described as collecting subjective and objective data through patient interviews and physical examinations. Specific techniques for interviews, such as using open-ended questions, are outlined. The document also lists the components of a complete health history.
Nursing management client with Increased intracranial pressure ( ICP)ANILKUMAR BR
The rigid cranial vault contains brain tissue (1,400 g), blood (75 ml), and CSF (75 ml)
The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP.
ICP is usually measured in the lateral ventricles; normal ICP is 10 to 20 mm hg.
The Monro-kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others.
Increased ICP is a syndrome that affects many patients with acute neurologic conditions.
This is because pathologic conditions alter the relationship between intracranial volume and pressure.
Although an elevated ICP is most commonly associated with head injury, it also may be seen as a secondary effect in other conditions, such as brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies.
Standardized nursing language powerpointZulie Dorsan
Standardized Nursing Language refers to approved vocabularies used to describe nursing care related to diagnosis, interventions, and outcomes. This ensures consistent communication among nurses globally. Popular standardized languages include NANDA (nursing diagnoses), NIC (interventions), and NOC (outcomes). Using standardized language enhances data collection and evaluation of nursing care outcomes, and improves communication between healthcare professionals by facilitating consistent documentation and patient-centered care.
Dynamics of communication health and development for submissionYnneb Reine Manginsay
This document provides an overview of key concepts in community organizing including:
1. Definitions of a healthy community, characteristics of communities, and components of communities.
2. The basic community organizing process including entry, social investigation, problem identification, planning, core group formation, and organization development.
3. Principles of community organizing such as people being motivated by self-interest and tactics being within community experience.
4. Phases of community organizing including preparatory, organizational, education and training, and intersectoral collaboration phases.
5. Elements of community organizing like power, relationship building, leadership development, and political education.
So in summary, the document outlines foundational concepts and
This document discusses the key concepts of community health nursing (CHN). It defines CHN as applying nursing skills, public health, and social assistance through organized community efforts to promote health, prevent disease, and ensure access to healthcare. The goals of CHN are to raise the health levels of communities by empowering them to cope with health threats and maximize wellness. CHN is a generalist field that addresses individuals, families, populations and communities across all ages and levels of healthcare.
The document provides an overview of health education, including definitions, aims, principles, approaches, methods, and practices. It defines health education as any combination of learning experiences designed to help individuals and communities improve their health. The key principles of health education discussed are credibility, interest, participation, motivation, comprehension, reinforcement, learning by doing, known to unknown, setting an example, good human relations, feedback, and using community leaders. The common approaches covered are regulatory, service, educational, and primary health care. Audio-visual aids and various methods of communication are also mentioned as practices of health education.
This nursing care plan addresses an ineffective breathing pattern in a patient. It identifies the patient's problem as an ineffective breathing pattern related to contributing factors. Short term goals are for the patient to feel rested, perform diaphragmatic breathing, and demonstrate maximum lung expansion within 2 days. The long term goal is for the patient to maintain an effective breathing pattern and normal breathing during activities of daily living within 2 weeks. The plan outlines assessments, interventions, and health teachings to address the patient's breathing issues.
it contains information about the important measurements , the vital signs, head, eyes, ears, nose , mouth and throat, neck, chest, breast and abdomen of a newborn. You'll find the normal and the abnormal findings on each category.
The patient was experiencing dizziness and had high blood pressure. The nurse assessed the patient and found their blood pressure to be elevated at 180/110. The nurse diagnosed the patient with hypertension and explained to the patient that it is a condition where blood pressure is abnormally high, putting them at risk for health problems like heart disease. The nurse's plan was to educate the patient on hypertension, identify lifestyle factors that could be contributing to it, and ensure the patient understands the importance of following their treatment plan and making healthy changes.
The nursing care plan addresses a patient complaining of dizziness. It assesses the patient's risk for hypertension due to lack of disease knowledge. The diagnosis is risk for hypertension. The plan includes defining hypertension and its treatment regimen to the patient, identifying modifiable risk factors like diet and stress, and suggesting lifestyle changes to control blood pressure such as rest, exercise, and limiting sodium and caffeine. The rationale is to educate the patient and decrease risk of end-organ damage from long-term high blood pressure. The evaluation will assess the patient's understanding after interventions.
Oxygen therapy
Definition:
Oxygen is a colorless, odorless, tasteless gas that is essential for the body to function properly and to survive.
Oxygen therapy is a treatment that delivers oxygen gas to breathe. The oxygen therapy is received from tubes resting in nose, a face mask, or a tube placed n your trachea, or windpipe. This treatment increases the amount of oxygen in lungs to receive and deliver to blood.
What is meaning of O2 therapy
Oxygen therapy is the administration of oxygen at a concentration of pressure greater than that found in the environmental atmosphere
The air that we breathe contain approximately 21% oxygen
the heart relies on oxygen to pump blood.
Purpose
Oxygen therapy is a key treatment in respiratory care.
The purpose is to increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury.
What are the signs that a person needs oxygen
shortness of breath.
headache.
restlessness.
dizziness.
rapid breathing.
chest pain.
confusion.
high blood pressure.
Contd…..
Pulmonary hypertension
Acute myocardial infarction (heart attack)
Short-term therapy, such as post-anesthesia recovery
Oxygen may also be used to treat chronic lung disease patients during exercise .
Methods of oxygen administration:
1- Nasal cannula
Face mask
The simple Oxygen mask
The partial rebreather mask:
The non rebreather mask:
The venturi mask:
The partial rebreather mask:
The mask is have with a reservoir bag must romaine inflated during both inspiration & expiration
It collection of the first parts of the patients' exhaled air.
It is used to deliver oxygen concentrations up to 80%.
The non rebreather mask
This mask provides the highest concentration of
oxygen (95-100%) at a flow rate6-15 L/min.
It is similar to the partial rebreather mask
except two one-way valves prevent conservation of exhaled air.
The bag is an oxygen reservoir
Venturi mask
It is high flow concentration of oxygen.
Oxygen from 40 - 50%
At liters flow of 4 to 15 L/min.
T-piece
Used on end of ET tube when weaning from ventilator
Provides accurate FIO2
Provides good humidity
Documentation:
Date and time oxygen started.
Method of delivery.
Oxygen concentration and flow rate.
Patient observation.
Add oronasal care to the nursing care plan
O2 DELIVERY DEVICES
Assessment on Skin, Hair & Nails / HEENTTim Bersabe
The document discusses assessment of the integumentary system. It describes inspecting the skin, hair, nails and scalp using visualization, palpation and smell. Abnormalities in color, temperature, moisture, texture, turgor and lesions should be noted. The skin reveals the need for nursing interventions like moisturizing dry skin or ensuring adequate hydration and nutrition. A thorough assessment is important for early detection of conditions like pressure ulcers or skin cancers.
The EINC initiative of the Philippine Department of Health- Non Communicable Diseases Prevention and Control-Family Health Office (DOH-NCDPC-FHO) and DOH Center for Health Promotions (NCHP), supported by the Joint Programme on Maternal and Neonatal Health (JPMNH), and being funded by AusAID, was piloted in 11 hospitals in the Philippines, and has yielded favorable results.
The recommended EINC practices during the intrapartum period include continuous maternal support by having a companion of choice during labor and delivery, freedom of movement during labor, monitoring progress of labor using the partograph, non-drug pain relief before offering labor anesthesia, position of choice during labor and delivery, spontaneous pushing in a semi-upright position, non-routine episiotomy, and active management of the third stage of labor (AMTSL).
For newborns, four core steps were recommended in a time bound sequence. A social marketing handle, “The First Embrace,” accompanied the initiative for practice change among health workers.
Steam inhalation involves inhaling warm, moist air to relieve symptoms of respiratory inflammation and congestion. It works by loosening secretions, relaxing muscles to reduce coughing, and moistening irritated airways. To perform steam inhalation, boil water and add medication like Vicks vaporub. Direct the steam into a tent made from an umbrella and sheet covering the patient, or have them sit near the boiling water. Treatment lasts 30 minutes to an hour twice a day. Burn risks and drafts should be avoided, and extra care taken with children.
The nursing care plan addresses Mr. JRB's presenting issues of ineffective airway clearance due to productive cough, ineffective breathing pattern due to retained secretions, and ineffective thermoregulation manifested by an elevated temperature of 38.5°C. The plan involves monitoring respiration and breath sounds, encouraging increased fluid intake and chest physiotherapy to loosen secretions, and promoting surface cooling to address the fever. The goals are for the patient to expectorate secretions, maintain clear airway, and reduce temperature.
This document provides an overview of nursing codes of ethics, including their purpose and history. It discusses the International Council of Nurses, which was established in 1899 and has been a pioneer in developing nursing ethics codes. The first nursing ethics book was written in 1900. Nursing codes outline ethical standards and guidelines for nurses, inform the public of nursing standards, and provide direction for self-regulation. The document reviews the Code of Ethics for Filipino Nurses and the American Nurses Association Code of Ethics, noting updates made in 2001.
The document discusses health teaching in nursing. It outlines three major purposes of health teaching: promoting health, preventing illness, and coping with illness/disability. It describes the assessment required to define a client's learning needs, which involves collecting general data and assessing health beliefs, cultural factors, and learning style. Finally, it discusses factors that facilitate learning, types of learning domains, and principles for effective teaching and learning.
The nursing process is a systematic method for planning and providing nursing care to patients. It involves five interrelated phases: assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first phase and involves collecting subjective and objective data about the patient's health status through various techniques like inspection, palpation, percussion, and auscultation. The data is then organized, validated, and documented to form the patient's database which provides the basis for determining the patient's diagnoses, developing a care plan, and evaluating outcomes.
This document discusses the history, philosophy, and principles of child health nursing. It outlines the evolution of pediatric nursing from ancient practices of child rearing to modern specialized nursing care. Key developments include the establishment of the first pediatric hospital in 1855, the inclusion of pediatric nursing education in 1917, and research in the mid-20th century highlighting the importance of family-centered care. The history of pediatric nursing in India incorporated it as a course in nursing programs from the 1950s onward.
The document discusses perception, coordination, brain anatomy, cranial nerves, levels of consciousness, neurological assessment of older adults, the Glasgow Coma Scale, and common neurological diagnostic tests. It provides nursing implications for several diagnostic tests including MRI, CT scan, EEG, and lumbar puncture. Critical thinking questions assess ability to apply knowledge of the Glasgow Coma Scale.
The document discusses different methods for calculating intravenous fluid rates. It provides formulas for calculating flow rates based on volume over time for infusion pumps, and drop rates based on volume over time and drop factor for manual regulation. An example is shown for each method. It also includes a table for calculating daily fluid maintenance requirements based on a patient's weight.
Community health nursing involves promoting health, preventing disease, and managing factors affecting health at the community level. It aims to raise the overall health status of populations. A community is defined as a group of people living in a specific geographical area with common characteristics or interests. Community health nursing utilizes the nursing process to provide care to individuals, families, population groups, and communities. It combines public health science with nursing skills and social assistance. The community is considered the patient, with the family as the unit of care.
The document discusses assessing vital signs including body temperature, pulse rate, respiratory rate, and blood pressure. It provides details on:
- The purposes and importance of vital sign assessment
- Factors that can affect each vital sign reading
- Proper technique for measuring each vital sign, including sites of measurement and positioning
- Normal ranges and clinical significance of abnormal readings
Acute appendicitis (AA) is considered as one of the most common causes of surgical emergencies worldwide (1). The gold standard treatment for AA is Appendectomy (2). About 6% of the population during their lifetime, will suffer from acute appendicitis
COPAR (Community Organizing Participatory Action Research) is an approach to community development that aims to transform apathetic communities into active, participatory communities through collective action. It is a sustained process of raising awareness, identifying community needs and objectives, taking action to address immediate issues, and developing cooperative attitudes. The COPAR process involves progressive cycles of action, reflection on outcomes, and further informed action. It is participatory, group-centered, and biased towards empowering the poor and marginalized.
The document provides 12 triage scenarios with patient details and suggested triage scores. For each scenario, the triage score and brief rationale is given, focusing on airway, breathing, circulation, risk of deterioration, and urgency of treatment. Triage scores range from 1 to 5, with 1 indicating treatment is needed immediately and 5 being non-urgent. The scenarios cover a range of medical conditions and injuries seen in emergency departments.
This document discusses oxygenation and factors that can impact it. It covers the structures and processes involved in respiration and oxygen transport. Key points include the role of the respiratory and cardiovascular systems in gas exchange and oxygen transport, factors that can disrupt oxygen balance like diseases and lifestyle, signs of inadequate oxygenation, common tests to evaluate oxygen status like ABGs and chest x-rays, and nursing responsibilities related to promoting optimal respiratory and cardiovascular function.
Here is a prioritized list of the patient's problems:
1. Constipation r/t obstruction
2. Acute Pain r/t obstruction
3. Acute pain r/t surgical incision
4. Altered comfort secondary to pain
5. Fatigue r/t post-operative experience
6. Impaired Skin Integrity r/t surgery
7. Altered Health Maintenance r/t choice of health practices
8. Health-Seeking Behavior r/t concern for health status
9. High Risk for Injury r/t developmental age
10. Readiness for enhanced ability to eliminate waste products r/t post-operative experience
This document describes Gordon's 11 Functional Health Patterns, which are used to organize client health data. The patterns include health perception/management, nutritional-metabolic, elimination, activity-exercise, cognitive-perceptual, sleep-rest, self-perception, role-relationship, sexuality-reproductive, coping/stress tolerance, and values-beliefs. Each pattern describes an area of client health and provides examples of related data that would be assessed.
The patient was experiencing dizziness and had high blood pressure. The nurse assessed the patient and found their blood pressure to be elevated at 180/110. The nurse diagnosed the patient with hypertension and explained to the patient that it is a condition where blood pressure is abnormally high, putting them at risk for health problems like heart disease. The nurse's plan was to educate the patient on hypertension, identify lifestyle factors that could be contributing to it, and ensure the patient understands the importance of following their treatment plan and making healthy changes.
The nursing care plan addresses a patient complaining of dizziness. It assesses the patient's risk for hypertension due to lack of disease knowledge. The diagnosis is risk for hypertension. The plan includes defining hypertension and its treatment regimen to the patient, identifying modifiable risk factors like diet and stress, and suggesting lifestyle changes to control blood pressure such as rest, exercise, and limiting sodium and caffeine. The rationale is to educate the patient and decrease risk of end-organ damage from long-term high blood pressure. The evaluation will assess the patient's understanding after interventions.
Oxygen therapy
Definition:
Oxygen is a colorless, odorless, tasteless gas that is essential for the body to function properly and to survive.
Oxygen therapy is a treatment that delivers oxygen gas to breathe. The oxygen therapy is received from tubes resting in nose, a face mask, or a tube placed n your trachea, or windpipe. This treatment increases the amount of oxygen in lungs to receive and deliver to blood.
What is meaning of O2 therapy
Oxygen therapy is the administration of oxygen at a concentration of pressure greater than that found in the environmental atmosphere
The air that we breathe contain approximately 21% oxygen
the heart relies on oxygen to pump blood.
Purpose
Oxygen therapy is a key treatment in respiratory care.
The purpose is to increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury.
What are the signs that a person needs oxygen
shortness of breath.
headache.
restlessness.
dizziness.
rapid breathing.
chest pain.
confusion.
high blood pressure.
Contd…..
Pulmonary hypertension
Acute myocardial infarction (heart attack)
Short-term therapy, such as post-anesthesia recovery
Oxygen may also be used to treat chronic lung disease patients during exercise .
Methods of oxygen administration:
1- Nasal cannula
Face mask
The simple Oxygen mask
The partial rebreather mask:
The non rebreather mask:
The venturi mask:
The partial rebreather mask:
The mask is have with a reservoir bag must romaine inflated during both inspiration & expiration
It collection of the first parts of the patients' exhaled air.
It is used to deliver oxygen concentrations up to 80%.
The non rebreather mask
This mask provides the highest concentration of
oxygen (95-100%) at a flow rate6-15 L/min.
It is similar to the partial rebreather mask
except two one-way valves prevent conservation of exhaled air.
The bag is an oxygen reservoir
Venturi mask
It is high flow concentration of oxygen.
Oxygen from 40 - 50%
At liters flow of 4 to 15 L/min.
T-piece
Used on end of ET tube when weaning from ventilator
Provides accurate FIO2
Provides good humidity
Documentation:
Date and time oxygen started.
Method of delivery.
Oxygen concentration and flow rate.
Patient observation.
Add oronasal care to the nursing care plan
O2 DELIVERY DEVICES
Assessment on Skin, Hair & Nails / HEENTTim Bersabe
The document discusses assessment of the integumentary system. It describes inspecting the skin, hair, nails and scalp using visualization, palpation and smell. Abnormalities in color, temperature, moisture, texture, turgor and lesions should be noted. The skin reveals the need for nursing interventions like moisturizing dry skin or ensuring adequate hydration and nutrition. A thorough assessment is important for early detection of conditions like pressure ulcers or skin cancers.
The EINC initiative of the Philippine Department of Health- Non Communicable Diseases Prevention and Control-Family Health Office (DOH-NCDPC-FHO) and DOH Center for Health Promotions (NCHP), supported by the Joint Programme on Maternal and Neonatal Health (JPMNH), and being funded by AusAID, was piloted in 11 hospitals in the Philippines, and has yielded favorable results.
The recommended EINC practices during the intrapartum period include continuous maternal support by having a companion of choice during labor and delivery, freedom of movement during labor, monitoring progress of labor using the partograph, non-drug pain relief before offering labor anesthesia, position of choice during labor and delivery, spontaneous pushing in a semi-upright position, non-routine episiotomy, and active management of the third stage of labor (AMTSL).
For newborns, four core steps were recommended in a time bound sequence. A social marketing handle, “The First Embrace,” accompanied the initiative for practice change among health workers.
Steam inhalation involves inhaling warm, moist air to relieve symptoms of respiratory inflammation and congestion. It works by loosening secretions, relaxing muscles to reduce coughing, and moistening irritated airways. To perform steam inhalation, boil water and add medication like Vicks vaporub. Direct the steam into a tent made from an umbrella and sheet covering the patient, or have them sit near the boiling water. Treatment lasts 30 minutes to an hour twice a day. Burn risks and drafts should be avoided, and extra care taken with children.
The nursing care plan addresses Mr. JRB's presenting issues of ineffective airway clearance due to productive cough, ineffective breathing pattern due to retained secretions, and ineffective thermoregulation manifested by an elevated temperature of 38.5°C. The plan involves monitoring respiration and breath sounds, encouraging increased fluid intake and chest physiotherapy to loosen secretions, and promoting surface cooling to address the fever. The goals are for the patient to expectorate secretions, maintain clear airway, and reduce temperature.
This document provides an overview of nursing codes of ethics, including their purpose and history. It discusses the International Council of Nurses, which was established in 1899 and has been a pioneer in developing nursing ethics codes. The first nursing ethics book was written in 1900. Nursing codes outline ethical standards and guidelines for nurses, inform the public of nursing standards, and provide direction for self-regulation. The document reviews the Code of Ethics for Filipino Nurses and the American Nurses Association Code of Ethics, noting updates made in 2001.
The document discusses health teaching in nursing. It outlines three major purposes of health teaching: promoting health, preventing illness, and coping with illness/disability. It describes the assessment required to define a client's learning needs, which involves collecting general data and assessing health beliefs, cultural factors, and learning style. Finally, it discusses factors that facilitate learning, types of learning domains, and principles for effective teaching and learning.
The nursing process is a systematic method for planning and providing nursing care to patients. It involves five interrelated phases: assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first phase and involves collecting subjective and objective data about the patient's health status through various techniques like inspection, palpation, percussion, and auscultation. The data is then organized, validated, and documented to form the patient's database which provides the basis for determining the patient's diagnoses, developing a care plan, and evaluating outcomes.
This document discusses the history, philosophy, and principles of child health nursing. It outlines the evolution of pediatric nursing from ancient practices of child rearing to modern specialized nursing care. Key developments include the establishment of the first pediatric hospital in 1855, the inclusion of pediatric nursing education in 1917, and research in the mid-20th century highlighting the importance of family-centered care. The history of pediatric nursing in India incorporated it as a course in nursing programs from the 1950s onward.
The document discusses perception, coordination, brain anatomy, cranial nerves, levels of consciousness, neurological assessment of older adults, the Glasgow Coma Scale, and common neurological diagnostic tests. It provides nursing implications for several diagnostic tests including MRI, CT scan, EEG, and lumbar puncture. Critical thinking questions assess ability to apply knowledge of the Glasgow Coma Scale.
The document discusses different methods for calculating intravenous fluid rates. It provides formulas for calculating flow rates based on volume over time for infusion pumps, and drop rates based on volume over time and drop factor for manual regulation. An example is shown for each method. It also includes a table for calculating daily fluid maintenance requirements based on a patient's weight.
Community health nursing involves promoting health, preventing disease, and managing factors affecting health at the community level. It aims to raise the overall health status of populations. A community is defined as a group of people living in a specific geographical area with common characteristics or interests. Community health nursing utilizes the nursing process to provide care to individuals, families, population groups, and communities. It combines public health science with nursing skills and social assistance. The community is considered the patient, with the family as the unit of care.
The document discusses assessing vital signs including body temperature, pulse rate, respiratory rate, and blood pressure. It provides details on:
- The purposes and importance of vital sign assessment
- Factors that can affect each vital sign reading
- Proper technique for measuring each vital sign, including sites of measurement and positioning
- Normal ranges and clinical significance of abnormal readings
Acute appendicitis (AA) is considered as one of the most common causes of surgical emergencies worldwide (1). The gold standard treatment for AA is Appendectomy (2). About 6% of the population during their lifetime, will suffer from acute appendicitis
COPAR (Community Organizing Participatory Action Research) is an approach to community development that aims to transform apathetic communities into active, participatory communities through collective action. It is a sustained process of raising awareness, identifying community needs and objectives, taking action to address immediate issues, and developing cooperative attitudes. The COPAR process involves progressive cycles of action, reflection on outcomes, and further informed action. It is participatory, group-centered, and biased towards empowering the poor and marginalized.
The document provides 12 triage scenarios with patient details and suggested triage scores. For each scenario, the triage score and brief rationale is given, focusing on airway, breathing, circulation, risk of deterioration, and urgency of treatment. Triage scores range from 1 to 5, with 1 indicating treatment is needed immediately and 5 being non-urgent. The scenarios cover a range of medical conditions and injuries seen in emergency departments.
This document discusses oxygenation and factors that can impact it. It covers the structures and processes involved in respiration and oxygen transport. Key points include the role of the respiratory and cardiovascular systems in gas exchange and oxygen transport, factors that can disrupt oxygen balance like diseases and lifestyle, signs of inadequate oxygenation, common tests to evaluate oxygen status like ABGs and chest x-rays, and nursing responsibilities related to promoting optimal respiratory and cardiovascular function.
Here is a prioritized list of the patient's problems:
1. Constipation r/t obstruction
2. Acute Pain r/t obstruction
3. Acute pain r/t surgical incision
4. Altered comfort secondary to pain
5. Fatigue r/t post-operative experience
6. Impaired Skin Integrity r/t surgery
7. Altered Health Maintenance r/t choice of health practices
8. Health-Seeking Behavior r/t concern for health status
9. High Risk for Injury r/t developmental age
10. Readiness for enhanced ability to eliminate waste products r/t post-operative experience
This document describes Gordon's 11 Functional Health Patterns, which are used to organize client health data. The patterns include health perception/management, nutritional-metabolic, elimination, activity-exercise, cognitive-perceptual, sleep-rest, self-perception, role-relationship, sexuality-reproductive, coping/stress tolerance, and values-beliefs. Each pattern describes an area of client health and provides examples of related data that would be assessed.
The document provides a nursing history for a 64-year-old male patient who was admitted to the hospital for left-sided body weakness. It details his personal history, medical history, family history, and assessments of his functional health patterns. The patient lives with his daughter and has a history of smoking and hypertension. Since his admission, he requires assistance with activities of daily living and has prolonged sleep periods. His relationship with his daughter remains strong and supportive.
Med-Surg Case Presentation german measlesVan Macabio
1. The patient presented with fever, rashes and cough and was suspected of having Rubella. Her vital signs and physical exam were normal except for the presence of red rashes on her skin.
2. A history and physical assessment was conducted where it was found that the patient had no significant medical history and her symptoms started 1 week prior with cough.
3. The patient's condition was being managed supportively as there is no specific treatment for Rubella.
The document describes a patient's activities of daily living before and during hospitalization. It discusses the patient's health perceptions, nutritional patterns, elimination patterns, activity levels, sleep patterns, cognitive functioning, self-concept, family roles, stress coping mechanisms, sexual history, and religious beliefs. The patient viewed himself as healthy but able to work, but now in the hospital feels less healthy. His routines have changed in the hospital, including following the hospital diet and engaging in limited physical activity. He is oriented but experiences confusion during seizure attacks. He views hospitalization positively and is well-supported by his family.
1) A 7-year-old male child presented with a severe head injury after falling 4 stories, with an initial normal CT scan but gradually rising intracranial pressure.
2) The patient underwent an emergency decompressive craniectomy due to refractory elevated ICP, which improved his condition and he was successfully extubated on the third postoperative day.
3) An audit of over 2000 head injury patients at this trauma center over 18 months found that 53% had severe injuries, with an overall mortality of 22%, rising to 36% for severe injuries.
Nursing Case Study of a Patient with Severe Traumatic Brain Injuryrubielis
This details the critical care nurse's role in caring for a patient with severe traumatic brain injury, managing ICP and brain oxygenation. Ties in closely with Orem's self-care deficit theory for nursing.
This document provides an overview of the management of head injuries. It defines head injury as damage to the head from impact and classifies injuries as closed or open, diffuse or focal. The pathophysiology section explains how small increases in intracranial volume can raise pressure dramatically. Presentation may include altered consciousness, bleeding, seizures or vomiting. Investigations include CT scans to detect fractures or bleeds. Treatment focuses on preventing secondary injuries like hypoxia, controlling pressure, and maintaining perfusion and nutrition. Follow-up is needed as some patients with mild injuries may later develop complications.
This document discusses functional assessments used in nursing, including Gordon's Functional Health Patterns, the Katz Index of Independence, and the Barthel Index. It provides details on Gordon's 11 categories for assessing health and human function, which include health perception and management, nutrition, elimination, activity, sleep, cognition, self-perception, roles/relationships, sexuality, coping, and values/beliefs.
Marjorie Gordon proposed 11 functional health patterns as a standardized approach to comprehensive nursing data collection. The patterns include health perception, nutrition, elimination, sleep, roles and relationships, sexuality, coping, and values. For each pattern, the nurse collects subjective and objective data to identify health issues and needs. Functional health patterns provide a systematic framework to assess all aspects of a person's health.
Management of head injury involves thorough assessment using the Glasgow Coma Scale and imaging like CT scan to determine severity and guide treatment. Minor injuries may only require observation, while moderate and severe injuries require interventions to prevent complications like raised intracranial pressure. Treatments aim to maintain oxygenation, ventilation, blood pressure and avoid seizures, fever and coagulopathy which can worsen outcomes. Surgical evacuation is considered for certain skull fractures and hemorrhages based on size, mass effect and neurological status. Long term risks include seizures, cranial nerve injuries and syndrome of inappropriate antidiuretic hormone.
The document provides information about a 89-year-old female patient, Mrs. Torralba, who was admitted to the hospital due to a fracture of the right femoral neck. She fell two days prior and experienced pain and limited movement in her right hip. Diagnostic tests revealed decreased hemoglobin and hematocrit levels, indicating anemia. Her prothrombin time was increased, suggesting a deficiency in clotting factors. All other lab results were normal. The patient has a history of breast cancer, diabetes, and osteoporosis, putting her at high risk for fractures from falls.
A 48-year-old Hispanic male was admitted to the emergency room for left ankle pain and swelling. He has a history of IV drug use, hepatitis C, and other health issues. Since admission, he has undergone surgery to drain infection from his ankle joint. He has been treated with antibiotics and pain medication. The patient remains concerned about his recovery and living situation upon discharge.
This nursing care plan outlines the assessment data, expected outcomes, nursing diagnosis, and implementation strategies for a client experiencing depression. The client presents with symptoms including suicidal thoughts, slowed mental processes, disordered thoughts, feelings of despair and worthlessness, and sleep disturbances. The nursing diagnosis is ineffective coping. Expected immediate outcomes are for the client to be free from self-harm, engage in reality-based interactions, and be oriented. Stabilization outcomes include expressing feelings directly and being free from psychotic symptoms. Community outcomes are medication compliance if prescribed, increased ability to cope with stress, and identifying a support system. Nursing interventions include providing a safe environment, continually assessing suicide risk, closely observing the client during medication changes or behavioral changes,
This document provides information about a case study on a 30-year-old female patient who was admitted to the hospital for postpartum hypertension. It includes her medical history, physical assessment findings, laboratory results, nursing diagnoses of postpartum hypertension and urinary tract infection. Her hemoglobin, hematocrit and urine tests showed abnormalities consistent with her conditions. The case study aims to improve nursing students' skills and knowledge in caring for patients with pregnancy-induced complications.
Mohamed Anwer Naleef, I am Nurse at Hemas Hospital,
This is about care of patient with Cirrhosis Disease Condition. As a Nurse three days my Nursing Process, observation, Nursing care Plan, Nursing Care and Help to patient manage and adjust the disease condition. Because the Cirrhosis is majority of male patients are facing the srilanka due to Alcohol. Even developing countries people also facing this problem due to uncontrolled Alcohol Consumption.
In my Case Studies, I briefly explained about Liver Alcoholic Cirrhosis, Treatment Complaience , medical management, Nursing Care, Nursing assessment, Nursing diagnosis, Nursing Planning, Nursing Intervention, Health Education for a Patient when patient Discharge.
The history of emergency nursing began with male Catholic monks providing care to the sick during the Dark Ages. Nursing later evolved and was formalized through various wars and crises which demonstrated the need for organized medical care on the battlefield and beyond. Key figures like Florence Nightingale and developments like specialized nursing schools and programs helped establish emergency nursing as a respected profession. Wars of the 20th century, like World Wars I and II, further advanced the skills and roles of emergency nurses and helped define the modern emergency department structure and staffing model still used today.
The document discusses road accidents in India and methods to reduce them using Six Sigma methodologies. It notes that road accidents have significantly increased in India in recent decades. Various statistics about road accidents from 2002-2011 are presented, showing increases in total accidents, deaths, and injuries over that period. Major causes of road accidents discussed include speeding, drunken driving, distractions, and ignoring traffic lights. Reducing these unsafe behaviors through improved safety measures and traffic management could help lower India's high rate of road accident deaths and injuries.
A 16-year-old boy was admitted to the hospital after a traffic accident where he fell from a motorcycle. He reported pain in his left thigh. Examination found deformity, hematoma, and swelling of the left femur region with tenderness. X-rays showed a closed fracture of the middle third of the left femur. He was diagnosed and treated with open reduction internal fixation surgery.
This case presentation summarizes a 14-year-old male patient admitted with dengue fever. Dengue fever is an infectious disease caused by a virus transmitted by mosquitoes. The patient presented with fever, joint and muscle pain. On examination, he had a flushed face and skin that was warm to touch. Laboratory tests were not performed. The patient was treated with rest, hydration and antipyretics. His symptoms improved over a few days and he was discharged with instructions on follow up care.
Comprehensive SOAP ExemplarPurpose To demonstrate what each sLynellBull52
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over the counter Ibuprofen 200mg -2 PO as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstrating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.
Lifestyle:
She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness starte ...
1. T.Z.S.H is a 1 year and 2 month old female admitted to the hospital complaining of severe cough, fever, and runny nose for two days.
2. Her immunizations are up to date and her development appears normal for her age. She enjoys playing with dolls and watching TV.
3. On examination, she appears well but has wheezing and a runny nose. Her vital signs and physical exam are otherwise normal. She is diagnosed with bronchitis.
This document discusses neurology and provides definitions of neurological conditions like dystonia, myoclonus, and opisthotonos. It then summarizes the purpose and scope of the journal Neurology, noting that it aims to advance the field by presenting new basic and clinical research with an emphasis on knowledge that will influence clinical neurology practice. It also notes that the number of neurologists in India is inadequate relative to the large population, and that neurological cases are often handled by internal medicine specialists instead. The document ends by outlining techniques for examining neurological patients, including aspects of inspection, assessment of tone and strength, and eliciting a history.
This document provides demographic and clinical information for a 21-year-old male patient presenting with abdominal pain, nausea, vomiting and fever. It includes the patient's medical history, family history, social situation, and results of a physical examination. Specifically, it notes the patient's history of appendectomy and intestinal surgery, current symptoms of 10 weeks duration, vital signs, and findings from a review of systems examining the integumentary and hair/head systems. The patient has a history of malnutrition and appears weak with visible veins and pale nails. The physical examination found normal skin and hair aside from dry, scaly skin.
This document provides a clinical summary for a 65-year-old male patient named A.M.R., including his biographic data, history of present illness, past medical history, familial history, and physical assessment findings. It also describes his psychological and interaction patterns. The physical assessment revealed increased blood pressure, dehydration, difficulty voiding, and edema. His past medical history was unremarkable except for a family history of hypertension. Psychologically, he copes well with problems through communication and has good social interactions and relationships. The document concludes with a nursing care plan for the patient.
Comprehensive SOAP ExemplarPurpose To demonstrate what each sec.docxdonnajames55
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise.
Patient Initials: _______
Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over-the-counter Ibuprofen 200mg -2 PO as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet, on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstruating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood.
Lifestyle:
She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.
Review of Systems:
General: + fatigue .
The document describes several medical cases and procedures. A 54-year-old patient is seen for CLL in remission. Susan Oster is admitted with septicemia, respiratory failure, and acute hepatic failure due to septicemia. An operative report describes a diagnostic thoracentesis and pleural biopsies performed on Mara Bell Lee to investigate an undiagnosed pleural effusion.
Comprehensive SOAP ExemplarPurpose To demonstrate what each sec.docxmaxinesmith73660
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise.
Patient Initials: _______
Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over-the-counter Ibuprofen 200mg -2 PO as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet, on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstruating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood.
Lifestyle:
She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.
Review of Systems:
General: + fatigue .
Cranial nerves history and examination Prof Vinod PatelVinod0901
The document provides guidance on examining the cranial nerves, including introducing the aims and objectives of cranial nerve examination, presenting a clinical case of COVID-19 presenting with Bell's palsy, and providing instructions on taking a relevant history and specifically examining cranial nerves I-VI. The goal is for medical students to learn how to recognize common neurological symptoms, conduct a comprehensive cranial nerve exam, and understand how conditions like COVID-19 can initially present with neurological manifestations.
Miss Vaishnavi Santosh Mankape, a 12-year-old female, presented with fever, drowsiness, headache, weakness, irritability, and seizures for the past year. On examination, she had an altered mental status with a GCS score of 8 and abnormal motor function. Investigations showed abnormal CT scan and MRI brain images as well as abnormal CSF analysis. She was diagnosed with encephalitis and nursing diagnoses included increased body temperature related to infection, ineffective tissue perfusion related to increased intracranial pressure, risk for injury related to seizures, impaired physical mobility related to neuromuscular damage, and imbalanced nutrition related to anorexia and fatigue.
This document provides information about neonatal tetanus. It begins by defining tetanus as a neurological disease caused by Clostridium tetani bacteria. Neonatal tetanus is most common in developing countries and transmitted through wounds from unclean umbilical cords or delivery practices. Symptoms include muscle rigidity, spasms, and lockjaw. Treatment focuses on wound cleaning, antitoxins, and supportive care like sedation and feeding until the toxins are metabolized. Prevention emphasizes immunizing mothers during pregnancy and cleaning deliveries. Prognosis depends on supportive care quality, with fatality rates around 60% for neonates.
SubjectiveChief complaint headaches and blurriness of visi.docxpicklesvalery
Subjective:
Chief complaint: headaches and blurriness of vision on the right side
History of present illness: the patient is 67 years old Caucasian female, she complains of having had headaches for 2 weeks now. The pain is located in the right temporal area. She describes the pain as 8-10/10, sharp, constant, interferes with her sleep, she states that nothing aggravates it, not even the bright lights or high sounds, but she gets a little relief by taking Ibuprofen 800 mg. She stated that she has been having some blurriness in the right eye, while her left eye is fine. She also complains of pain in her jaw and tongue while chewing food. Her appetite has been low, and lost about 5 pounds in the last 2 weeks. She noticed low grade fever as well. She also reported ringing sounds in the right ear. She denies any nausea or vomiting. She denied having similar headaches in the past. The patient denies complaining of nasal or postnasal drainage.
PMH: past medical history is significant for Hypertension, type II diabetes mellitus, asthma, and degenerative arthritis of the knees.
PSH: hysterectomy
Medications: Lisinopril 10 mg PO QD
Metformin 500 mg PO BID.
Proair HFA 2 puffs PRN.
Ibuprofen 800 mg TID
Multivitamins
By comparing the medications that the patient is taking with Beers criteria, they all looked appropriate to be used in elderly patients.
Family Hx:
Father: HTN, diabetes, and stroke.
Mother: HTN, Diabetes, and breast cancer at the age of 72.
Social Hx: the patient never smoked tobacco products.
ETOH: social drinker
Illicit substances: denies ever using illicit drugs.
Allergies: penicillin.
Review of systems:
Constitutional: the patient complains of fever, fatigue, anorexia, and weight loss.
Head: the patient denies complaining dizziness or lightheadedness.
Eyes: blurriness in the right eye.
Ears: the patient reports tinnitus- right ear, but denies complaining of ear pain or ear discharge
Nose: the patient denies any nasal bleeding, discharge or obstruction
Mouth: the patient reports painful chewing, she denies gingival bleeding, having mouth sores, or having dental difficulties
Throat: no sore throat
Cardiovascular: the patient denies complaining of Chest pain, palpitations, or swelling in the legs.
Respiratory: the patient denies any wheezing, shortness of breath or coughing.
Gastrointestinal: the patient denies any nausea, vomiting, GERD, epigastric pain, diarrhea, constipation, having black stools, or blood in stool.
Genitourinary: the patient denies any dysuria, polyuria, or visible hematuria
Musculoskeletal: bilateral knee pain.
Integumentary (Skin): the patient denies having any skin rash or skin discolorations.
Neurological: the patient denies complaining of tingling or numbness in any extremity; there is no history of seizures, stroke, syncope, or memory changes.
Psychiatric: the patient denies complaining of depression, or anxiety, denies complaining of hallucinations.
Endocrine: the pat ...
This document provides a case study on a 35-year old male patient diagnosed with schizophrenia. It includes an assessment of the patient's personal information, medical history, family history, and physical and mental health assessments. Key findings are that the patient does not cooperate during interviews and does not recall or provide information about his present illness, past health history, or other questions. The document also provides background information on schizophrenia, including typical clinical manifestations, diagnostic tests, and treatment options including medication and nursing interventions to promote patient safety, socialization and differentiation.
A 76-year-old man was admitted to the hospital emergency room experiencing loss of consciousness, fever, fatigue, dilated pupils, facial paralysis, shortness of breath, and rapid breathing due to a second cerebrovascular accident (CVA or stroke). He had a history of diabetes, hypertension, amputations due to diabetic foot complications, and a previous CVA. A CT scan showed multiple cerebral infarctions and brain atrophy. The man was treated with IV fluids and medications. Nursing care focused on preventing vomiting, reducing anxiety, and promoting nutrition.
This document contains medical information about a 18-year-old male patient named Ismailov Asgar who presented with lower back pain and headaches. His chief complaints included pain in the lumbar region and headaches in the frontal area. His past medical history included osteochondrosis of the lumbar region and chronic maxillary sinusitis. A physical exam found pain and muscle rigidity in the lumbar area. Laboratory tests showed normal results except for an elevated erythrocyte sedimentation rate. The provisional diagnosis was chronic lumbar osteochondrosis with exacerbation, lower back pain, chronic vertebral syndrome, and chronic maxillary sinusitis.
1. INTRODUCTION:
Traumatic Brain Injury (TBI) is a leading cause of death and
disability in the U.S. The national head injury foundation defines TBI
as a traumatic insult to the brain capable of causing physical,
intellectual, emotional, social and vocational changes.
Head injury known as traumatic brain injury, is the disruption
of normal brain function due to trauma (blunt or penetrating
injury).Neurologic deficits result from shearing of white matter,
ischemia and mass effect from the hemorrhage, and cerebral edema
of surrounding brain tissue.
TYPES OF BRAIN INJURIES:
1) Concussion = involves jarring of head without tissue injury.
Temporary loss of neurologic function lasting for a few minutes
to hours.
2) Contusion = involves structural damage. The patient becomes
unconscious for hours.
3) Epidural hematoma = blood collects in the epidural space
between skull and dura matter. Usually due to laceration of the
middle meningeal artery, symptoms develop rapidly.
4) Subdural hematoma = a collection of blood between the dura
and the arachnoid mater caused by trauma. This is usually due
to tear of dural sinuses or dural venous vessels, symptoms
usually develop slowly.
5) Diffuse axonal injury = is a brain injury in which a high speed
acceleration-deceleration injury, typically associated with
motor vehicle crashes, causes widespread disruption of axons
in the white matter.
2. Risk Factors:
>adults age 15-30
>being over the age of 75
>male to female ratio of 3:1
Causes:
>motor vehicle accidents
>increased blood alcohol levels
>falls
>sports injuries
>occupational injuries
>assaults
>gunshot wounds
3. GENERAL OBJECTIVES:
After our case presentation, we will be able to gain
knowledge, skills and attitudes on how to handle patient
with brain injury and fracture of the skull.
SPECIFIC OBJECTIVES:
After 1 hour of case presentation, we will be able to:
1. Deal patient with brain injury.
2. Care patient with neurologic disorders.
3. Provide spiritual care to the patient.
4. Provide emotional support to the patient.
5.Render different nursing interventions.
4. ASSESSMENT
A.) PATIENT’S HISTORY
• PATIENT’S PROFILE
NAME: Patient X
AGE: 30 years old
Sex: Male
Nationality: Filipino
Religion: Christian
Date of Birth: October 10, 1980
Address: Marfa, Maguikay, Mandaue City
Occupation: Production worker
Date of Admission: February 27, 2011
Time of Admission: 11:40 p.m
Case number: 122677
Ward: Neuro-surgery
Bed number: Male 2
Admitting Diagnosis: 1.) Diffuse axonal injury
2.) Fx, closed depressed (R)
frontal with contusion Hematoma
Physician: Dr. Sasing
Chief Complaint: Loss of consciousness and vomiting
Operation Performed: Debridement and suturing (L)
rd th
hand 3 -5 digits
5. • HISTORY OF PRESENT ILNESS
A case of Patient X, 30 years old, male, single, Filipino from
Marfa, MAGUIKAY, Mandaue City, admitted for the first time via
ambulance (EMERGENCY RESCUE UNIT FOUNDATION) due to
collisions of vehicles resulting to the loss of his consciousness.
• PAST HEALTH HISTORY
No previous hospitalization. Family background shows a
history of hypertension.
• VITAL SIGNS
Temperature= 36.8 degrees Celsius
Respiratory Rate= 16 cycles per minute
Pulse Rate= 70 beats per minute
Blood Pressure= 130/90 mmHg
1) GENOGRAM LEGEND:
FEMALE
MALE
PATIENT
DECEASED
6. HYPERTEENSIV
E
PATERNAL SIDE MATERNAL SIDE
B.) GORDON’S 11 FUNCTIONAL HEALTH
PATTERN
7. 1. ) HEALTH PERCEPTION-HEALTH MANAGEMENT
PATTERN
Patient is a 30 years old, male and single. He cannot describe
thoroughly about his condition due to his unconsciousness.
2) NUTRITIONAL-METABOLIC PATTERN
Before:
Patient has complete meals (breakfast, lunch, and
dinner) and has usual fluid intake of 8-10 glasses/day.
Now:
He’s on blenderized feeding with 1600kcal/meal and has
parenteral intake of PNSS running at 30gtts/min. He consumed
300cc after the end of the shift. Later, the doctor ordered him
on NPO (Nothing per Orem) status for further observation. The
patient gained weight over short period of time due to excess
fluid volume in the body as evidenced by edema of the face and
hands.
3) ELIMINATION PATTERN
BLADDER:
Before:
He can void 5x a day without any pain felt.
Now:
He wears diaper that is fully soaked weighing
800gms (800ml) after the end of the shift.
BOWEL:
Before:
He can defecate once a day with a formed stool.
Now:
8. He was not able to defecate since the day he was
admitted, February 27, 2011.
4) ACTIVITY-EXERCISE PATTERN
Before:
He is working at San Miguel Corporation as a
production worker. He works 8hours/day and sometimes
he also works over a long period of time.
Now:
He is on the bed over a long period of time.
5) SLEEP-REST PATTERN
Before:
He has a good sleep-wake cycle. He usually sleeps
at 9pm and wakes up at 6am due to his job.
Now:
He has sleep pattern disturbance due to pain on his
eyes as evidenced by restlessness.
6) COGNITIVE-PERCEPTUAL PATTERN
Before:
He graduated at Asian College of Technology with a
Bachelor of Science in Computer Science. According to
the significant others, he has no deficit in his sensory
perception (hearing and sight) and he’s able to read and
write.
Now:
He is experiencing eye problem. He cannot
spontaneously open his eyes due to periorbital swelling
and cannot talk.
9. 7) SELF-PERCEPTION PATTERN
According to the significant others, the patient is a good
brother and son. He is not an alcoholic and smoker. He is
very dedicated to his work as a production worker. He
doesn’t have any previous history of hospitalization.
8) ROLE-RELATIONSHIP PATTERN
COMMUNICATION:
Before:
According to the significant others, before his
speech is clear and he can speak English and Tagalog
language.
Now:
He is incoherent and unable to communicate. He
just nods when his family members talk to him.
RELATIONSHIP:
He is currently residing at Maguikay, Mandaue City
with his sister for easy access to his workplace. He
assists his family with their finances.
9) SEXUALITY-SEXUAL FUNCTIONING
According to the significant others, he is in a relationship
with his 3 months girlfriend.
10)COPING-STRESS MANAGEMENT PATTERN
According to the significant others, that whenever he has
a problem, he shares it to his family members inorder to
solve it.
11) VALUE-BELIEF SYSTEM
According to the significant others, patient is a Catholic
but due to the influence by his eldest brother, he was
10. converted into Christian and has been baptized. But,
every Sunday, he attends mass at the Catholic Church.
C.) REVIEW OF SYSTEMS
1.) INTEGUMENTARY SYSTEM
a. SKIN: Light brown complexion, good skin turgor,
edema of the hands and periorbital regions, multiple
abrasions noted, 36.8 degrees Celsius skin
temperature.
b. HAIR: Short curly hair
c. SCALP: Clean and no dandruff
d. NAIL: Nails turn to pink tones when performing
Capillary Refill test at 1-2 seconds.
2.) HEAD AND NECK
a. HEAD: bulging head
b. FACE: multiple abrasions and edema noted
c. NECK: no presence of lumps
d. LYMPH NODES: non tender, can be palpated
3.) EYES: Periorbital swelling on both eyes with hematoma
noted, unable to open his eyes when giving command.
4.) EARS
a. RIGHT: with blood
b. LEFT: with blood and pus
Noted during the inspection of the EENT (Eyes, Ears,
Nose, and Throat) doctor.
5.) NOSE: With Nasogastric tubing inserted and Oxygen
inhalation at 4L/min via nasal prong.
11. 6.) SINUSES: No inflammation noted
7.) MOUTH AND OROPHARYNX
a. LIPS: Pale, dry, cracked
b. BUCCAL MUCOSA: Moist
c. GUMS: Moist and pinkish
d. TEETH: 32 white teeth with no dentures
e. TONGUE: Moist and pale, no lesions noted.
f. SOFT PALATE: Pinkish and moist
g. HARD PALATE: Moist and whitish in color
h. TONSILS: No inflammation
8.) RESPIRATORY SYSTEM
a. INSPECTION: He is not using his accessory
muscles to assist breathing, with oxygen inhalation at
4L/min via nasal cannula, respiratory rate=16cycles
per minute.
b. PALPATION: non tender
c. PERCUSSION: (+) resonance
d. AUSCULTATION: normal breath sounds heard
(bronchovesicular sound)
9.) CARDIOVASCULAR SYSTEM
a. INSPECTION: (-)palpitations
b. PALPATION: presence of visible pulsations, pulse
rate=70beats/minute
c. PERCUSSION: (+)resonance
12. d. AUSCULTATION: Blood Pressure=130/90mmHg
PULSE SITES:
Temporal: 78bpm Popliteal: 79bpm
Carotid: 80bpm Doralis pedis: 65bpm
Brachial: 75bpm Posterior tibial: 70bpm
Radial: 70bpm Femoral: 73bpm
10.) BREAST
a. INSPECTION: No lesions noted
b. PALPATION: No mass and pain noted upon
palpation.
11.) ABDOMEN
a. INSPECTION: Free of lesions and rashes, pale,
umbilicus is midline at lateral line, noted abdominal
movement during respiratory movements.
b. AUSCULTATION:
c. PERCUSSSION: (+)tympanic sound
d. PALPATION: Free of swellings and masses
12.) GENITO-URINARY REPRODUCTIVE SYSTEM:
No Foley Bag Catheter attached, with diaper weighing
800mL after the end of the shift.
13.) ANUS AND RECTUM: unable to assessed the patient
14.) MUCULOSKELETAL SYSTEM: joints can easily
move.
15.) NEUROLOGIC SYSTEM
GLASGOW COMA SCALE
13. PARAMETERS FINDING SCORE
BEST EYE Spontaneously 4
OPENING To speech 3
RESPONSE To pain 2
(1) No response 1
BEST VERBAL Oriented 5
RESPONSE Confused 4
(3) Incoherent 3
Inappropriate 2
words
No response 1
BEST MOTOR Obeys
RESPONSE command 6
(5) Localizes pain 5
Flexion
withdrawal 4
Abnormal
flexion 3
Abnormal
extension 2
No response 1
TOTAL SCORE: [E1V3M5] =9
DIAGNOSTIC EXAM
HEMATOLOGY
CBC REFERENCE RESULT SIGNIFICANCE
WBC COUNT 4.8-10.8 30.30 Increased:
10^g/L 10^g/L leukemia,
bacterial infection,
14. severe sepsis
HEMOGLOBIN 140-180g/ 143g/L Normal
L
HEMATOCRIT 0.42-0.52 0.43L/L Normal
MCV 80-94 87.00fL Normal
MCH 27-31 28.80pg Normal
RBC COUNT 4.70-6.10 4.98 Normal
10^12/L
MCHC 330-370 333g/L Normal
RDW 11-16 12.70fL Normal
MPV 7.2-11.1 7.60fL Normal
PLATELET 150-400 242.00 Normal
COUNT 10^g/L
DIFFERENTIAL
COUNT
NEUTROPHILS 40-74 86.40% Increased:
acute infections,
trauma or surgery,
leukemia.
malignant disease,
necrosis
LYMPHOCYTES 19-48 6.90% Decreased:
aplastic anemia,
SLE.
MONOCYTES 3-9 4.90% Normal
EOSINOPHILS 0-7 1.30% Normal
BASOPHILS 0-2 0.50% Normal
ANATOMY AND PHYSIOLOGY
15. The nervous system is your body’s decision and communication
center. The central nervous system (CNS) is made of the brain and
the spinal cord and the peripheral nervous system (PNS) is made of
nerves. Together they control every part of your daily life, from
breathing and blinking to helping you memorized facts for a test.
The brain is made of three main parts: the forebrain, midbrain, and
hindbrain. The forebrain consists of the cerebrum, thalamus, and
hypothalamus (part of limbic system). The midbrain consists of the
tectum, and tegmentum. The hindbrain is made of the cerebellum,
pons and medulla. Often the midbrain, pons, and medulla, are
referred to together as the brainstem.
The Cerebrum: The cerebrum or cortex is the largest part of human
brain, associated with higher brain function such as thought and
action. The cerebral cortex is divided into four sections, called
“lobes”: the frontal lobe, parietal lobe, occipital lobe, and temporal
lobe.
• Frontal lobe – associated with reasoning, planning, parts of
speech, movement, emotions, and problem solving.
• Parietal lobe – associated with movement, orientation,
perception of stimuli.
• Occipital lobe – associated with visual processing.
• Temporal lobe – associated with perception and recognition of
auditory stimuli, memory, and speech.
The Cerebellum: The cerebellum, or “little brain”, is similar to the
cerebrum in that it has two hemispheres and has a highly folded
surface or cortex. This structure is associated with regulation and
coordination of movement, posture, and balance.
16. Limbic system: The limbic system, often referred to as the
“emotional brain”, is found buried within the cerebrum. This system,
from a midsagittal view of the human brain.
Brai stem: Underneath the limbic system is the brain stem. T his
structure is responsible for a basic vital life functions such as
breathing, heartbeat, and blood pressure. Scientists say that this is
the “simplest” part of the human brains because animas’ enter
brains, such as reptiles (who appear early scale) resemble our brain
stem.
The brain stem is made of the midbrain, pons, and medulla.
Midbrain
Pons
Medulla
PATHOPHYSIOLOGY
BRAIN INJURY
PREDISPOSING FACTORS CAUSE
>adults age (15-30) >motor vehicle accidents
>over the age of 70 Brain
>living in a high crime area
>male to female ratio 3:1
A blow to the head, even with no break in the skull, can cause
serious and diffuse brain injury.
17. Injury to the axons
Disrupts oligodendroglia and direct mechanical disruption caused by debris
and leakage.
There is immediate vascular response to the injury.
Results in increased capillary permeability to solutes.
COMPLICATIONS
Infections immobility hydrocephalus neurologic deficits SIADH
MANIFESTATIONS:
>Disturbance in level of consciousness
>headache
>vertigo
>agitation
>restlessness
>CSF leakage at ears and nose
>contusions about eyes and ears
18. >pupillary abnormality
>sudden onset of neurologic deficits
DIAGNOSTIC EXAMINATION
>CT scan
>skull x-ray
>complete blood count
>neuropsychological test
Date: March 02, 2011
CT scan
Procedure: Brain (Completion)
Findings:
Follow up study with examination done last February 28, 2011 shows
there is slight interval increase in the size of the contusion hematoma in
the right frontal parenchyma now measuring 2.2 x 1.8 previously 1.8 x 1.5
cm. There is more pronounced perilesional edema noted in the right frontal
lobe and basal ganglia. The frontal horns appear compressed. There is
resolving soft tissue swelling and hematoma in the left frontal scalp.
MEDICAL MANAGEMENT
>Placement of NGT with intubation to prevent aspiration
>Administer antibiotics
SURGICAL MANAGEMENT
>Shunting to relieve persistent fluid build up
>evacuation of intracranial hematomas
>debridement of penetrating wounds
19. >subdural tapping to remove fluid
NURSING MANAGEMENT
>monitor for declining LOC
>elevate the head of bed at 30 degrees as ordered
>turn patient every 2 hours
>monitor potential complications
>provides skin care every 4 hours
SUMMARY OF FINDINGS
DRUG THERAPEUTIC RECORD
NA DOSA CL MECHANIS INDI CONT SID NURSING RESPONSIBLITIES
ME GE AS M OF CATI RA- E
OF SIF ACTON ON EFF
DR IC INDIC ECT
UG AT ATION S
-
IO
N
TR 50mg An Binds with To Alcoh CNS BEFORE:
AM IVTT alg mu- reliev ol :
AD q8 esi receptor e intoxi >Check the medication record.
Dizz
20. OL hrs. c and mode cation ines >performed skin test.
HC inhibits the rate exces s,
L reuptake to sive fati DURING:
of mode use of gue
(UL >monitored the patient every now and then.
norepineph rately centra
TR rine and sever l CV:
AFTER:
AM serotonin, e acting
) Vas
which may pain. analge >urge S.O to notify prescriber about unusualities.
odil
account for sics,
atio
tramadol’s hypno
n
effect. tics
,opiod
s or
other EEN
psych T:
otropi
Dry
c
mo
drugs.
uth
GI:
Con
stip
atio
n,
nau
sea,
vom
itin
g
GU:
Urin
e
rete
ntio
n
SKI
N:
Pru
ritu
s,
ras
21. h
Ery Eye Ant Binds the To Hyper CNS BEFORE:
thr ointm ibi 50s treat sensiti :
om ent to oti ribosomal mild vity to >Check the medication record.
yci both c subunit of to erythr Fev
er, DURING:
n eyes; the 70s mode omyci
QID ribosome rate n or mal
>Instruct S.O not to let the patient to scratch his eye
(er in many skin their aise
yth types of and compo >Report for any reactions.
roc CV:
aerobic soft nents.
in) and tissu Ven
anaerobic e tri-
gram- infect
positive ions cula
bacteria. cause r
This d by
actions S
inhibit, .pyog arrh
enes yth
RNA or mia
dependent Staph s
protein yloco
synthesis ccus EEN
in bacterial aureu T:
cells, s.
causing Hea
them to ring
diet loss
GI:
Diar
rhe
a,
nau
sea,
vom
itin
g
GU:
Vag
22. inal
can
didi
asis
SKI
N:
jau
ndic
e
Chl 1g Ant Produces a To Hyper CNS BEFORE:
ora IVTT ibi bacteriosta treat sensiti :
mp (ANS oti tic effect or bacte vity to >Check the medication record
he T) q6 c susceptible remia chlora Con
fusi >performed skin test.
nic hrs. organisms or mphe
ol by meni nicol on,
DURING:
Na inhibiting ngitis or its feve
protein . compo r >assess the patient for any unusualities.
(ch synthesis, nents.
lor CV: AFTER:
thereby
om preventing Gre >Report to prescriber signs of blood dyscrasias.
yce amino y
tin)
syn
acids from
dro
being
me
transferred
to growing EEN
polypeptid T:
e chains.
Opti
c
neu
ritis
GI:
Diar
rhe
a
,na
use
a,
vom
itin
g
24. NURSING CARE PLAN
DATE CUES/ NURSING SCIENTIFIC EXPECTED NURSING RA
BASIS OUTCOME INTERVENTION
EVIDENCES DIAGNOSIS S
March 5, Subjective: Risk for The client After >Monitor for >O
2011 infection with a skull otorrhea or fra
related to fractures it at rhinorrhea. th
possible high risk for inc
access to the infection po
Objectives: cranial through the lea
contents wound that fro
through a tear may be or
in the dura contaminated >Keep the
by dirt, hair, nasopharynx >W
or other and the external dr
debris. ear clean. Place fac
a piece of sterile mo
SOURCE: cotton in the or
ear, or tape a
Medical-
sterile cotton
Surgical
pad loosely
Nursing,
under the nose;
Vol.2, 3rd ed.
change
By Priscilla
dressings when
Lemone
they become
wet.
>Use aseptic >U
technique at all te
times when re
changing head po
dressings and int
insertion sites. inf
>Test drainage >C
of clear fluid dr
from ear and te
nose for glucose fo
by using a ind
glucose reagent lea
strip, such as CS
Dextrostix.
26. S: Fluid Volume Nursing care After 2 hours >Measure >T
Excess for the client of nursing intake and th
with fluid care output. pa
volume interventions,
O: >Assess vital >H
excess there is
includes decrease of signs and ac
BP=130/90nnH
administering edema. breath sound hy
g
diuretics and every 4hours.
>T
PR=70bpm maintaining
>Turn the sk
fluid
RR=16cpm patient every br
restrictions.
2hours.
Temp=36.8 >O
SOURCE:
degrees Celsius >Provide oral co
Medical- care every cli
Edema of the 2-4hours. an
Surgical
hands and mu
Nursing,
periorbital me
Vol.2, 3rd ed.
regions int
By Priscilla
Lemone re
Skin cool and
flu
pale, dry lips
re
>T
>Elevate head go
of the bead at br
30-45degrees.
>T
>Assess the if
extent of edema de
particularly in ed
the lower
extremities and
periorbital
regions
Self Care After 2hours
The client
Deficit of nursing
needs
care
assistance
interventions,
with dressing,
the significant •
grooming,
others will be
and feeding.
able to
The help
perform daily
needed can
care
range from
activities.
minimal
guidance to
total
dependence.
27. Discharged Planning
Medication
Encouraged the patient
to take the prescribed
medications and follow
instructions of dosage and
28. time intervals as prescribed
by the physician. The
medications are as follows:
Penicillin
Doxycycline 100mg 1
tab BID
Kalium ii tab TID
29. Instructed patient for
following check up after 1
week
Environment
Instructed the patient to
use protective clothing and
boots during getting food
for the animals.
30. Encouraged to clean the
household to prevent
pesticides from circulating
the house
Treatment
Encouraged the patient
to take vitamin C and
31. medications as prescribed
by the physician
Health Teaching
Educated the patient to
increase awareness about
the disease and the
importance of health
maintenance and wearing of
32. protective clothing and foot
wear.
Observable Signs and
Symptoms
Instructed patient if he
noticed signs and
symptoms, immediately
33. refer or report it to the
nearest hospital
Diet
Instructed patient to
always eat nutritious food
like fruits and vegetables
and have a proper diet.
Spiritual
34. Encouraged patient to
always pray to God and
don’t forget to visit his
house every Sunday and
asked guidance
Objectives Methodology
Evaluation
General:
After 8 hours of nursing intervention, the patient will be able to understand and
participate of doing some dependent activities
Specific:
After 30 minutes of nursing interventions the patient will be able to gain knowledge about
the disease
35. Content
• Therapeutic regime
• Protective Clothing
• Mode of Transmission
• Signs and Symptoms
Proper hygiene
Methodology
Demonstration
Taking examples
Health teaching
36. Evaluation
After 8 hours of nursing
intervention the patient
was able to verbalize
knowledge and asked
questions