Case Presentation Template 2010 (2)

7/29/2019 Case Presentation Template 2010 (2)

http://slidepdf.com/reader/full/case-presentation-template-2010-2 1/9

LEVEL 2 . NCM 102 . 2ND SEM SY 2010-2011 P a g e | 1

Level 2

CASE PRESENTATION2nd Semester SY 2009-2010

I. Statement of Objectives

A. General Objectives

This case analysis aims to increase the understanding and knowledge of student nurses onhow to care for patients with (SPECIFY CASE) effectively and efficiently.

B. Specific Objectives

Specifically, this case analysis aims to :1. define (SPECIFY CASE) and its effects to the body as a whole;2. illustrate the pathophysiology of (SPECIFY CASE) and in relation to the signs and symptoms

specifically observed in the client;

3. describe and identify the common signs and symptoms of (SPECIFY CASE);4. discuss the medical and surgical interventions for the management of (SPECIFY CASE);5. formulate appropriate nursing care plans suited for the client based on the assessment

findings;6. identify care measures to be given to the patient and family to promote continuity of care

and independence after discharge.

II. Client’s Profile

This portion provides general information about the client.!!! ALERT !!! Anonimity should at all times be observed.

All data presented should not be linked with the identity of the client - unlesswritten and informed consent has been obtained to present identifyinginformation.

Name : Cobain, KurtAge : 19 years oldBirth date : January 27, 1990Sex : MaleEthnic Background : TagalogCivil Status : SingleAddress : #09 High St., Euphoric Hills, Sublime CityReligion : Roman CatholicOccupation : Nursing student

Admitting Diagnosis : Spontaneous PneumothoraxFinal/Principal Diagnosis : Spontaneous PneumothoraxAdmitting Physician : Dr. HouseDate and Time Admitted : April 05, 2009 at 2:00 am

III. Chief Complaint

This presents the main complaint/s of the client, the reason consultation was sought and hence,admitted.

Dyspnea and Sharp Chest Pains

IV. Present History of Illness

Narrative form. This is a brief account of when the client’s condition started, how it developed, upto the time of admission. Initial signs and symptoms are described in line with duration,

domain/localization, progression, character and how it has affected the physiological function of the client. Any interventions made by the client to address the illness are to be described (e.g.

home remedies, medications, consultations) and whether these were effective or not.

The client’s condition started 3 days PTA, when the patient, while simply doing his homework,felt a sudden sharp chest pain. Pain rate was with the severity of 8/10. It was not radiating to otherparts of the body but was accompanied by difficulty of breathing, weakness, shortness of breath,and sudden hacking cough.

A few minutes after the said incident, the patient verbalized that all of the symptomsmentioned slightly improved and was tolerable and only rest was promoted. No medications weretaken nor were consultations done during the incident. 2 days PTA, he was not feeling anythingand verbalized that he was alright until




1 day PTA, the patient has the same manifestation but now the difficulty of breathing was sosevere that the patient decided to seek consult and subsequently admitted in this institution.

V. Past History of Illness

Narrative form. This is a brief account of when the client’s previous illnesses, hospital admissions

and other medical treatments.

The client had no history of accidents and or trauma, only minor illnesses, such as cough, coldsand fever and were remedied with over the counter medications such as bioflu and water therapywith rest. The client however, was admitted last January 2009 at Sublime Medical Hospital due tothe same problem and it was the first time he was diagnosed to have spontaneous pneumothorax.He received medical interventions such as medications for pain and for inflammation and wasdischarged home after 5 days of hospitalization. The patient has unrecalled immunization statusand with no history of prolonged case of use of medications such as aspirin or NSAIDs. He alsoverbalized that he did not have known allergies for foods or medications.

VI. Family Health History

Narrative form. This portion describes the presence of any hereditary disorders/familial-tendency illnesses experienced by the client or any member of the the client’s family.

The client claims to have familial history of Hypertension, Coronary Artery Disease and Cancer

on his mother’s family. Health problems such as Asthma, kidney diseases, diabetes, or mental illness

was verbalized to be absent. No present illness is currently experienced by any member of the

family.

VII. Developmental History

Narrative form. This portion describes significant patterns of the client’s behavior in line with hiscurrent stage of development.

The client is the last son out of the other 5 siblings, which are composed of 4 males and a

female. He is a 19 year old teenager with the task of developing his Identity according to Erik Erikson’s

Developmental theory. He has verbalized no problems with self image and concept and reveals the

desire to achieve his goals in his studies especially in maintaining his place in the dean’s list and

hopefully graduating with honors or having a place in the Local Nursing Licensure examination. He

also noted no difficulty in interacting with people despite his silent nature. He tends to observe most

of the time but also recognized a great number of friends with whom he shared his childhood with.

He also loves music. His passion is seen in his ability to play the guitar with ease and is now learning

how to play the piano.

VIII. Social and Environmental History

Narrative form. As expressed in the sample below.

The client is non-smoker and non-alcoholic beverage drinker. No verbalized vices were

identified. However, he is constantly exposed to noxious fumes from outside air pollution and from

second hand smokers. He lives in a rented apartment together with his three other cousins near the

main highway where jitneys frequently pass. He commutes daily using the public utility jitneys for

his transport to school.

The house where they stay is made up of semi-permanent and permanent materials such as

wood and cement. Privacy is maintained with the 4 separate rooms present. Water used daily is

being supplied by the city water district while the source of drinking water is the water refilling

stations nearby.

Client also verbalized that he did not have any direct contact to harmful chemicals nor has

prepared any chemotherapeutic drugs. As a nursing student however, he is able to care for various

patients with having different respiratory health problems such as tuberculosis, pneumonia and

cough. The community exposure they had as a part of the Clinical RLE allows them to travel to

different areas where he experiences changes in the weather and differences in altitude.

The client belongs to a family with two licensed nurses, hence, the value of maintaining a

healthy lifestyle is promoted. The client with his family visits the local hospital from health problemsunresolved by home remedies and rest. The client after experiencing the same sudden painimmediately went to the hospital to confirm the initial findings he had when he was admitted inSublime City. As a family that belongs to the middle class, access to health care facilities andinterventions is not much of a problem. IX. Lifestyle and Health Practices

Narrative form. As expressed in the sample below.




As a nursing student, he is aware of the potential health threats associated with lifestylerelated vices like cancer for smoking and liver cirrhosis for alcoholic beverage drinking. He ensuresthat he receives adequate nutrients by allowing himself to eat three complete meals in a day withsnacks included specially during his duty times. Food is prepared at home together with his cousinsor is bought in fast-food chains. He prefers pasta dishes and pizza. Fluid and electrolyte intake is atotal of 2 – 3 liters a day coming from fruit juices, carbonated beverages, water and milk. Formaintenance he takes Vitamin C for supplement.

X. Health Assessment

This portion presents assessments performed as seen in the example below.

A. General Survey

The client was received awake, lying on bed with a moderate high back rest elevation.Client with ongoing IVF’s of D5LRS I L x 30 gtts per minute and a Tramadol drip (tramal)300 mg in D5W 250 cc x 24 hours infusing well on the left arm and with oxygen inhalationat 2-3 LPM/ via the nasal cannula. He is connected to a three way bottle system chestdrainage with the first bottle having 300cc bloody discharge. Suction control is applied andthere is bubbling noted in the third bottle.

Client appears weak, needs assistance when assuming activities of daily living like toiletingand feeding or in changing positions. He wears a neat gown, hygiene is fair. Client isconversant speech is well formulated, oriented to the self and others around him,able to determine the time and date and is aware that he stays in a private room for 3 daysnow.

Client is an ectomorph. He verbalized that he is 5’6” tall and weighs 51 kilograms.

B. Head to Toe Assessment

1. Head Normocephalic, hair evenly distributed, oiliness and flaking noted, noareas of pain or tenderness during palpation

2. Eyes Able to distinguish colors, (+) for astigmatism, verbalized difficulty toidentify objects 6 feet away, wears corrective lenses, sclera is anicteric,pupils are equally round, reactive to light and accommodation, EOM isintact, able to follow penlight with gaze, no detectable oscillations,

mucous membranes are moist and light pink3. Ears Able to understand and hear spoken language correctly, with minimal

cerumen build – up in the ear canal, sliver and intact tympanicmembrane

4. Nose andsinuses

Nose is patent, septum is located midline, no flaring noted, able todistinguish the scent of alcohol and perfume, no episodes of epistaxisduring the shift, sinuses are not tender on palpation

5. Mouth Complete set of adult teeth, pearly white in color, and no mal alignedtooth, had braces for 1 year and a half year. No dental caries noted.Oral mucosa is moist and pinkish, no lesions noted, tonsils are notinflamed, Grade 1 bilaterally present, uvula is located midline

6. Neck ROM intact, able to change direction of head slowly but with withoutcomplaints of pain, carotid pulse are bilaterally symmetrical, full andstrong pulses, 2+, jugular vein is not distended, superficial cervical

lymph nodes are palpable but non tender. Thyroid is located midline, noenlargement noted, trachea is located midline7. Chest Shape of the chest is elliptical, asymmetrical chest wall expansion

noted, with respiratory excursion best appreciated on the left side of thethorax, decreased tactile fremitus in the right lung area, decreasedbreath sounds in the right, no crackles, no wheeze, no stridor,production of hollow drum like sounds in percussion of the right sideand resonant sound appreciated on the left. Client with an Axillarythoracotomy, dressing intact and dry, chest tube draining to a bloodydischarge 300 cc in amount. With limited movement on the rightshoulder. Client verbalized, “mahina daw ung lungs ko, spontaneousrupture of the bleb, kaya may pneumothorax ako” “Masakit tlaga ungsugat, parang 8/10 din, pati ata sa loob masakit talaga, ditto langnaman sya sa may incision, parang may tumutusok kaya binigyan nilaako ng analgesic, ngayon, ayos ng konte pero may pain pa din at 6 na

cguro ung scale nya out of 10”. Client is observed to guard area andgrimaces when a painful stimulus is felt. Diaphoresis noted, hands arecool to touch. Maintains the supine position with head of bed elevatedto a moderate high back rest

8. Cardiac Adynamic pericardium; normal rate, regular rhythm, PMI at 50 ICS LMCL,no murmur noted, no visible pulsations in the precordium, palpableapical pulse

9. Breast (-) for gynecomastia, skin color is similar with the rest of the body,nipple is dark colored, no discharges




10. Abdomen Flat, with normoactive bowels sounds heard in all the quadrants, soft,no direct tenderness or rebound tenderness upon palpation, tympanitic,no organomegaly.

11. Genitals Patient verbalized that he had been inserted with a catheter when hewas in the OR. No complaints of dysuria or urinary retention orincontinence post operatively

12. Musculoskeletal muscle strength at the right side is 4/5 while the rest of extremities are

5/5.No visible tremors noted, no complaints of pain

13. Integumentary

XI. Diagnostics

This shows all diagnostic procedures performed with the client. Tabular form. Content of the tablemust follow the format below.

DiagnosticProcedure

Description of the Procedure

Significance/Purpose of theProcedure

Date of Procedure

Findings & Implications

Chest X-ray Chest radiography

is the first

investigation

performed to

assess

pneumothorax

because it is

simple,

inexpensive, rapid,

and noninvasive;

however, it is much

less sensitive than

chest CT indetecting a small

pneumothorax,

blebs, and bullae.

It is used to

determine the

severity of the

patients

pneumothorax and

to determine the

progress of his

medical and surgical

management.

April 20,2009

Follow-up study of the chest taken on

the same day, SIP CIT insertion reveals

a relative partial reduction in the size of

the previously noted right-sided

pneumothorax. There is however no

significant change in the extent and

appearance of the massive atelectasis

of the right lung field. A right sided CTT

is now seen.April 22,2009

Follow-up study of the chest since

6/20/2009 S/p Axillary thoracotomy

shows complete resolution of the

pneumothorax on the right withcomplete re-expansion of the right lung.

A right sided CTT is still seen in SITU. No

other internal change of note.April 26,2009

Follow-up study of the chest since

6/22/09 reveals the presence of

confluent hazy densities at the right

paracardiac areas, presenting a

pneumonic process with consolidation.

There is now a homogenous opacity

with meniscus level seen at the right

lower hemithorax obscuring the right

hemi diaphragm and costrophenic angle

representing fluid.April 26,2009

Follow-up chest study since 6-26-2009reveals minimal clearing of theconfluent hazy densities at the rightparacardiac area. There is however,decrease in the volume of thepreviously noted fluid in the rightHEMITHORAX. A right sided CTT is stillseen in SITU.No other internal change of note.

Ultrasound Abcdeflkjdlj alkdjf Adfjlskdjf jldkjflasd April 29,2009

aljkdhfklashdfa

Pathology Kdljfoijuelasldfjm Dgsdgasdufods April 24,2009

Csalksdjfoi dlfjs;dfsa;fjds

Blood Chem Olkdf djf;olsdojasedl

Sdfdsf;luio April 27,2009

Dsadfeds ldjoldjjw clkdjf dlkdjfld




XII. Comprehensive Pathophysiology

This is a diagrammatic presentation of the course of the disease. Predisposing factors, signs &symptoms, management and nursing diagnoses presented must be in line with actual events that occurred with the client.

PREDISPOSING FACTORS

Exposure to 2nd hand Smoking & Pollution Height (tall person), Male, 19 yearsold

Chemicals (Tar) Gradient of Pleural pressure increasesfrom

lung base to apexBlocks airway passages and degrade

elastic fibers of the lungs

Influx of neutrophils and macrophages Alveoli of lung apex receives theis induced greater distension pressure

Imbalanced enzymes (protease & anti-protease)and antioxidant system

________________Bullae/Blebs Formation______________________ N

Inflammation-induced obstructions of the airway Shearing forces

Increased alveolar pressure

Leakage to the lung interstitium, hilum and pneumomediastinum Rupture of blebs

Increased mediastinal pressure

Rupture of the mediastinal parietal pleura

_______________Pneumothorax____________________

Disequilibrium in the intrapulmonary and intrapleural pressure

Activation of the receptors that monitor Tidal volume affected Changes in the thoracic pressurelung volume

Distortion of movement of airSympathetic stimulation in and out of the lungs

Tachypnea Air flows out of the alveoliinto the Pleural space

Lung collapse during recoil

Dyspnea Sudden, sharp, stabbing pain

Admission to the Hospital---INEFFECTIVE BREATHING PATTERN---

Partial collapse of the affected lung

Impairment of gas conduction Air trapping in the collapsed lung Ruptured bleb andlung collapse

in the lower respiratory airways activate inflammatoryresponse

Decreased tactile fremitus Hyper resonance on percussion Lung assymetry




---------------------IMPAIRED GAS EXCHANGE-------------------

Transudation of fluid and blood from surrounding AxillaryThoracotomy blood vessels of the injured lung

and Bleb Excision

-------PAIN RELATED TO TISSUE TRAUMA-------

Pleural Effusion

Transudate accumulation in the pleural space

Further restriction of lung expansion Collapse of alveoli Disequilibrium in pulmonary andpleural pressures

Increased respiratory difficulty Bleeding Surgical Incision and Insertion of CTT

Stasis of pulmonary sections Decreased Hct and Hgb Tissue trauma andinjury

Growth of microorganisms Decreased oxygen carrying Pain on the incision sitecapacity of the lungs

---RISK FOR INFECTION--- ---IMPAIRED MOBILITY------ACTIVITY INTOLERANCE---

XIII. Treatment/Management

This shows all treatments, including medical procedures, performed with the client. Tabular form.Content of the table must follow the format below.

A. Drugs

NameClassificatio

nDosage

Mechanism of ActionDosage

Nursing Implication Significance

Generic: CefotaximeNa

Brand: Zefocent

Cephalosporin1 gram IV every

12 hours

Inhibits bacterial cell wallsynthesis by binding to

one or more of thepenicillin-bindingproteins (PBPs) which inturn inhibits the finaltranspeptidation step of peptidoglycan synthesisin bacterial cell walls,thus inhibiting cell wallbiosynthesis. Bacteriaeventually lyse due toongoing activity of cellwall autolytic enzymes(autolysins and mureinhydrolases) while cellwall assembly is arrested

Asses drug allergies, hepatic andcardiac functions, and other

laboratory test.Be sure to obtain thoroughpatient health history includingimmune statusAssess for potential druginteractionIt is essential to obtain culturesfrom appropriate sites beforestarting antibiotic therapyPatient should be instructed totake the medications asprescribedAssess for signs and symptomsof super infection: fever, cough,lethargy or unusual dischargeFor safety reasons, check thename of the medication carefullybecause there are many soundalike or have familiar spellingAssess patient for any redness,swelling, burning, or pain atinjection/infusion siteAssess patient for nausea,vomiting, abdominal distention,and bowel sounds before andafter administration.Observe for signs and symptomsof anaphylaxis during first doseMay cause drowsiness.Advise patient to Reportunresolved or persistentdiarrhea; opportunistic infection(vaginal itching or drainage,

sores in mouth, blood in stool orurine, easy bleeding or bruising,unusual fever or chills); orrespiratory difficult

For the treatmentof the patients

nosocomialinfection, or to bespecific, for thetreatment of hishospital acquiredpneumonia

Generic: CinnarizineBrand:Stugeron®[Forte cap]

AntivertigoDrugs,PeripheralVasodilators &CerebralActivators

Cinnarizine inhibitscontractions of vascularsmooth muscle cells byblocking calcium

Assess patient for nausea,vomiting and caution patient fordizziness and sedation mayoccur.Assess patient for blurred vision,difficult

y in micturition, dysuria,

To reduce ortreat the patientfeeling of dizziness andvertigo




1 tab now (75mg)

channels. In addition tothis direct calciumantagonism, cinnarizinedecreases the contractileactivity of vasoactivesubstances eg,norepinephrine andserotonin, by blockingreceptor-operatedcalcium channels.Blockade of the cellularinflux of calcium istissue-selective andresults in anti-vasoconstrictorproperties without effecton blood pressure andheart rate.

dryness of mouth and tightnessof chest.Patients should not operatehazardous machinery or drivemotor vehicles or performpotentially hazardous taskswhere loss of concentration maylead to accidents.

Always have analgesic antidoteor antagonist : naloxone

B. IV Fluids

Name Classification

Component/s Use & Effects Significance

C. Surgeries

Procedure Description & Indication Nursing CareThoracotomy the process of making of a

surgical incision into the chestwall which allowed for the study

of the condition of the lungs andremoval of part of a lung. Theclient had undergone an Axillarythoracotomy. This method isused by a majority of thoracicsurgeons for all pulmonaryresections. Its major indication isnow for pneumothorax surgery,allowing easily apical resectionand pleurectomy with excellentlong-term results

Pleurodesis a procedure aimed at makingadhesions between the visceraland parietal pleura, obliteratingthe potential pleural spaceindicated for conditions such as

pneumothoraxPleurodesis isachieved by putting one of anynumber of chemicals (sclerosingagents or sclerosants) into thepleural space. The sclerosantirritates the pleurae which resultsin inflammation (pleuritis) andcauses the pleurae to sticktogether. The patient is given anarcotic pain reliever andlidocaine, a local pain killer, isadded to the sclerosant. A varietyof different chemicals are used assclerosing agents. There is no onesclerosant that is more effectiveor safer than the others.

The patient should keep the wound from the chest tube clean anddry until it heals. Also, the patient should watch for signs of woundinfection such as redness, swelling, and/or drainage, and be alertto symptoms indicating that the effusion recurred.

Chest Tube

Drainage

procedure made to place a

flexible, hollows drainage tube

into the chest in order to remove

an abnormal collection of air or

fluid from the pleural space.

The client was attached to a three

way bottle system with the first

The chest tube typically remains secure and in place until imagingstudies such as X rays show that air or fluid has been removedfrom the pleural cavity.Nurses must also note for such complications like:

bleeding from an injured intercostal artery (running from theaorta)accidental injury to the heart, arteries, or lung resulting fromthe chest tube insertiona local or generalized infection from the procedurepersistent or unexplained air leaks in the tubethe tube can be dislodged or inserted incorrectly

http://www.answers.com/topic/inflammation


http://www.answers.com/topic/narcotic

http://www.answers.com/topic/lidocaine

http://www.answers.com/topic/sclerosant


http://www.answers.com/topic/swelling


http://www.answers.com/topic/narcotic

http://www.answers.com/topic/lidocaine







bottle as the drainage, the

second as the water seal and the

third bottle connected to a

suction control

insertion of chest tube can cause open or tensionpneumothorax

XIV. Nursing Care Plans

A. Prioritization of Problems1. List of Problems

This portion lists the health problems according to priority (No. 1 having the highest priority).

Health Problems are stated as Nursing Diagnoses using the Basic 3-Part Statement : PES Format

- Problem Statement + Etiology + Signs and Symptoms- Three parts are joined together by “related to” or “associated with” and “as manifested by” or

“as evidenced by” - Ex: Self-Esteem Disturbance related to rejection by husband as manifested by hypersensitivity tocriticism, stating "I don't know if I can manage by myself", and rejecting positive feedback - Variations to the PES format in order to make the problem statement more descriptive

(e.g. adding "Secondary to") is acceptable as long as the part following “secondary to” is adisease process

(Ex: High-Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary toDiabetes)

Problems should comprise AT LEAST 3 Actual Problems and 1 Potential Problem ranked in order of priority.

2. Basis of Prioritization

This portion presents the basis of how the health problems were prioritized. Prioritization should alsobe discussed.

B. Nursing Care Plans

The Care Plans for the Nursing Diagnoses shall be presented here.The format discussed during the Orientation shall be followed.

XV. List of References

This portion cites all books, journals and other references that were used as shown in the examplebelow

American Lung Association. (2000). Asthma statistics. [On-line.] Available: http://lungusa.org/data.

Babu K.S., Salvi S.S. (2000). Aspirin and asthma. Chest 118, 1470– 1476.

Busse W.W., Lemanske R.F. (2001Asthma. New England Journal of Medicine 344, 350–362.

Chan-Yeung M., Malo J. (1995). Occupational asthma. New England Journal of Medicine 333, 107–112.

Chestnut M.S., Prendergast T.J. (2002). Lung. In Tierney L.M., McPhee S.J., Papadakis M.A. (Eds.),Current medical diagnosis and treatment (41st ed., pp. 350–355). New York: Lange Medical Books/McGraw-Hill.

Cotran R.S., Kumar V., Collins T. (1999). Robbins pathologic basis of disease (6th ed., p. 713). : W.B.Saunders.

Dubuske D.M. (1994). Asthma: Diagnosis and management of nocturnal symptoms. ComprehensiveTherapy 20, 628–639.

Gilliland F.D., Berhane K., McConnell R., et al. (2000). Maternal smoking during pregnancy,environmental tobacco smoke exposureand childhood lung function. Thorax 55, 271–276.

Light R.W. (1995). Diseases of the pleura, mediastinum, chest wall, and diaphragm. In George R.B.,Light R.W.,

Matthay M.A., et al. Eds.), Chest medicine (3rd ed., pp. 501–520). Baltimore: Williams& Wilkins.

McFadden E.R., Gilbert I.A. (1994). Exercise-induced asthma. NewEngland Journal of Medicine 330,1362–1366.




National Asthma Education and Prevention Program. (1997,2002). Expert Panel report 2: Guidelines for the diagnosis and management ofasthma, and Guidelines for the diagnosis and management of asthma—Update on selected topics 2002. Bethesda, MD: National Institutes of Health, National Heart,Lung, and Blood Institute. Available: http://www.nhlbi.nih.gov/guidelines/asthma.

Romero S. (2000). Nontraumatic chylothorax. Current Opinion in Pulmonary Medicine 6, 287–291.

Sahn S.A., Heffner J.E. (2000). Spontaneous pneumothorax. New England Journal of Medicine 342, 868–874.

Sly M. (2000). Allergic disorders. In Behrman R.E., Kliegman R.M., Jenson H.B. (Eds.), Nelson textbook of pediatrics (16th ed., pp. 664–685). Philadelphia: W.B. Saunders.

Tan K.S., McFarlane L.C., Lipworth B.J. (1997). Loss of normal cyclical B2 adrenoreceptor regulation andincreased premenstrual responsiveness to adenosine monophosphate in stable female asthmaticpatients.Thorax 52, 608–611.

Young S., LeSouef P.N., Geelhoed G.C., et al. (1991). The influence ofa family history of asthma andparental smoking on airway responsiveness in early infancy. New England Journal of Medicine324,1168–1173.

Case Presentation Template 2010 (2)

Documents

Transcript of Case Presentation Template 2010 (2)