Grand Case Presentation Repaired)

8/4/2019 Grand Case Presentation Repaired)

1/45

PAMANTASAN NG LUNGSOD NG PASIG

Alcalde Jose Street, Kapasigan, Pasig CityCOLLEGE OF NURSING

GRAND CASE STUDY:


2/45

INTRODUCTION

I.OBJECTIVES

A. GENERAL OBJECTIVEWithin our group case study, we would be able to develop and evaluate

clinical assessment to effectively manage the patient through determiningsignificant signs and symptoms, history and main etiology of the disease and

by doing so, allowing us to gain more knowledge and learn new skills. We willalso be able to improve our patient-centered way of caring for clients havingsame disease condition thereby developing therapeutic use of self.

Specific Objectives:

To know the risk factors that would contribute to the causation of the disease

To determine the physiologic changes undergone by the patient with regards to

the condition. To recognize the health history of the patient as basis for evaluating the

disease condition.

To be familiar of the medical and surgical procedures being done to the patient

To formulate appropriate nursing intervention and effective care plan in thecourse study

To acquire beneficial knowledge that may improve the students foundation in

relation to the disease

Every 53 seconds someone experiences a stroke; a stroke is an interruption of


3/45

that the circulation in the skin is compromised by the pressure, particularly over abony prominence.

Bed sores also known as decubitus or pressure ulcers. It is an ischemicnecrosis and ulceration of tissues overlying a bony prominence which has beensubjected to prolonged pressure against an external object like a bed conditioncontinues to present a major health care problem not only for hospitalized olderadults but for other immobilized individuals. The condition results to impaired skinintegrity related to unrelieved, prolonged pressure. The predictions and prevention ofpressure ulcers is therefore is one of the priorities in the health care field. Theprevalence ofpressure ulcers ranges from 3 to 11 percent in hospitalized elderlypatients. For nurses and other caregivers who work with elderly patients, identifyingrisk for developing pressure ulcers, treating ulcers, and reducing their negative

effects is a significant element of comprehensive and holistic care. By exercisinganalytic and assessment skills and by taking simple steps to reposition bedriddenelderly patients, nurses can provide the kind of care that significantly enhances skinintegrity even among patients who are bedridden for lengthy periods of time.

REASONFORCHOOSINGTHISCASE

Case study is very important in Nursing; it provides us vast knowledge on thecases of patients. We interview the patient to know their health history, we study thelaboratory result and physically assess them to be able to know the right nursing andmedical management. With case studies, we can also evaluate the effectiveness andquality of health care services provided to the patient.

Choosing this case, to consider sepsis secondary to Decibitus Ulcer, amongother cases really catches our attention due to clinical signs of decubitus ulcer which

occurred in the patient, there are some complications also related to the diseasesdiagnosed almost a year ago and our group wanted to give care for her to lessen therisk of developing more pressure ulcer, furthermore the client is not able to move onher own and needs full assistance. Elderly people need someone who has care for
http://www.lotsofessays.com/essay_search/pressure_ulcer.htmlhttp://www.lotsofessays.com/essay_search/pressure_ulcer.html


4/45


5/45

ANATOMY

Pressure Ulcer

NERVOUS SYSTEM

The skin is the body's largest organ, covering the entire body. In addition to serving as a protective shieldagainst heat, light, injury, and infection, the skin also:

PARTS OF THE SKINEpidermisThe epidermis is the outer layer of skin. The thickness of the epidermis varies in different types of skin. It is

the thinnest on the eyelids at .05 mm and the thickest on the palms and soles at 1.5 mm.The epidermis contains 5 layers: stratum basale, stratum spinosum, stratum granulosum, stratum licidum,stratum corneum

The bottom layer, the stratum basale, has cells that are shaped like columns. In this layer the cells divide andpush already formed cells into higher layers. As the cells move into the higher layers, they flatten andeventually die.The top layer of the epidermis, the stratum corneum, is made of dead, flat skin cells that shed about every 2weeks.

DermisThe dermis also varies in thickness depending on the location of the skin. It is .3 mm on the eyelid and 3.0mm on the back. The dermis is composed of three types of ti ssue that are present throughout - not in layers.

Specialized Dermal CellsThe dermis contains many specialized cells and structures. The hair follicles are situated here wi th the erector pili muscle that attaches to each follicle.

Sebaceous (oil) glands and apocrine (scent) glands are associated with the folli cle. This layer also contains eccrine (sweat) glands, but they are not associated with hair follicles.

Blood vessels and nerves course through this layer. The nerves transmit sensations of pain, itch, andtemperature.

There are also specialized nerve cells called Meissner's and Vater-Pacini corpuscles that transmit thesensations of touch and pressure.

Subcutaneous TissueThe subcutaneous tissue is a layer of fat and connective tissue that houses larger blood vessels and nerves.This layer is important is the regulation of temperature of the skin itself and the body. The size of this layervaries throughout the body and from person to person.

Skin performs the following functions:

1. Protection: an anatomical barrier from pathogens and damage between the internal andexternal environment in bodily defense; Langerhans cells in the skin are part of the adaptive immunesystem.

2. Sensation: contains a variety of nerve endings that react to heat and cold, touch, pressure,vibration, and tissue injury; see somatosensory system andhaptics.

3. Heat regulation: the skin contains a blood supply far greater than its requirements whichallows precise control of energy loss by radiation, convection and conduction. Dilated blood vesselsincrease perfusion and heatloss, while constricted vessels greatly reduce cutaneous blood flow andconserve heat.

4. Control of evaporation: the skin provides a relatively dry and semi-impermeable barrier tofluid loss. Loss of this function contributes to the massive fluid loss inburns.

5. Aesthetics and communication: others see our skin and can assess our mood, physicalstate and attractiveness.

6. Stora e and s nthesis: acts as a stora e center for li ids and water, as well as a means of

HOW BRAIN CONTROLS MOVEMENT

All the information is compiled by the brain in a central area of the brain, called

the striatum, which controls many aspects of bodily motion. The striatum workswith other areas of the brain, including a part called the substantia nigra, tosend out the commands for balance and coordination. These commands gofrom the brain to the spinal cord through nerve networks to the muscles thatwill then help you to move

The entire nervous system is made up of individual units called nerve cells.Nerve cells serve as a "communication network" within your body. Tocommunicate with each other, nerve cells use a variety of chemicalmessengers called neurotransmitters. Neurotransmitters carry messagesbetween nerve cells by crossing the space between cells, called the synapse

Neurotransmitters also allow the nervous system to communicate with thebody's muscles and translate thought into motion. One especially importantmessenger is dopamine, which is manufactured in the substantia nigra.Dopamine is crucial to human movement and is the neurotransmitter thathelps transmit messages to the striatum that both initiate and control yourmovement and balance. These dopamine messages make sure that muscleswork smoothly, under precise control, and without unwanted movement.

When a dopamine message is needed, a nerve cell that produces dopaminegathers packets within itself filled with dopamine particles. These packets

carrying the dopamine move to the end of the nerve cell, open a "window," andrelease the dopamine particles into the synapse. The dopamine particles flowacross the synapse and fit into special pockets on the outside of theneighboring, or receiving, nerve cell. The receiving cell is now stimulated tosend on the message, so it gathers its own packets of dopamine and passesalong the message to the next nerve cell in the same way.After the receiving cell has been stimulated to pass along the message, thepockets then release the dopamine back into the synapse. To fine-tunecoordination of movement, these "used" dopamine particles, along with anyexcess dopamine that did not originally fit into a pocket on the receiving cell,are broken down by a chemical in the synapse called MAO-B. This is an

important step in the precise control of muscle movement. Too much or toolittle dopamine can disrupt the normal balance between the dopamine systemand another neurotransmitter system, and interfere with smooth, continuousmovement.
http://en.wikipedia.org/wiki/Adaptive_immune_systemhttp://en.wikipedia.org/wiki/Adaptive_immune_systemhttp://en.wiktionary.org/wiki/sensationhttp://en.wiktionary.org/wiki/sensationhttp://en.wikipedia.org/wiki/Thermoreceptorhttp://en.wikipedia.org/wiki/Somatosensory_systemhttp://en.wikipedia.org/wiki/Hapticshttp://en.wikipedia.org/wiki/Hapticshttp://en.wikipedia.org/wiki/Hapticshttp://en.wikipedia.org/wiki/Burn_(injury)http://en.wikipedia.org/wiki/Burn_(injury)http://en.wikipedia.org/wiki/Adaptive_immune_systemhttp://en.wikipedia.org/wiki/Adaptive_immune_systemhttp://en.wiktionary.org/wiki/sensationhttp://en.wikipedia.org/wiki/Thermoreceptorhttp://en.wikipedia.org/wiki/Adaptive_immune_systemhttp://en.wikipedia.org/wiki/Adaptive_immune_systemhttp://en.wiktionary.org/wiki/sensationhttp://en.wikipedia.org/wiki/Thermoreceptorhttp://en.wikipedia.org/wiki/Somatosensory_systemhttp://en.wikipedia.org/wiki/Hapticshttp://en.wikipedia.org/wiki/Burn_(injury)


6/45

ENDOCRINE SYSTEM


7/45

CIRCULATORY SYSTEM

Insulin is a hormone produced by the pancreas (a gland thatreleases a digestive juice into the intestine). The pancreas iscomposed of acinar cells, which produce digestive enzymes, andthe islet cells of Langerhans, which produce hormones.

What Insulin Does

Four hormones are produced by the Langerhans islet cells. Insulinis produced in the B cells, glucagon in the A cells, somatostatin inthe D cells, and pancreatic polypeptide in the F cells. Insulinpromotes anabolism (building up of tissues) and inhibits catabolism(breaking down of tissues) in muscle, liver, and fat cells. Itincreases the rate of synthesis (blending) of glycogen, fatty acids,and proteins. Lack of insulin causes diabetes mellitus (a diseasecharacterized by excess sugar in the blood and other body fluids).Insulin's most important feature is its ability to increase the rate ofglucose (a crystalline sugar) absorption by cells. Glucose is themost efficient fuel used by and found in almost all cells. Insulin

causes a decreased concentration of glucose in the blood andcauses the cells to store glycogen (a starchlike substance), mostlyin the liver. It also promotes the entry of other sugars and aminoacids into the muscle and fat cells. Insulin is therefore responsiblefor promoting fat storage in fat cells and for the total quantity ofprotein in the body.

Insulin ProductionInsulin production is stimulated by high levels of glucose andinhibited (limited) by lower levels of glucose. Insulin regulatesglucose with glucagon. Glucagon catabolizes (changes into a

product of simpler composition) glycogen to glucose and alsoraises the blood sugar. Glucagon can be given to increase theblood sugar when intravenous (by needle) glucose cannot begiven. Glucagon takes about twenty minutes to raise the blood

All cells in the body need to have oxygen and nutrients, and they need their wastesremoved. These are the main roles of the circulatory system. The heart, blood and bloodvessels work together to service the cells of the body. Using the network of arteries,veins and capillaries, blood ferries carbon dioxide to the lungs (for exhalation) and picks

up oxygen. From the small intestine, the blood gathers food nutrients and delivers themto every cell.

BloodBlood consists of:

Red blood cells - to carry oxygen White blood cells - that make up part of the immune system Platelets - needed for clotting Plasma - blood cells, nutrients and wastes float in this liquid.

The heartThe heart pumps the blood around the body. It sits inside the chest, in front of the lungsand slightly to the left side. The heart is actually a double pump made up of fourchambers. The contractions of the chambers make the sound of heart beats.

The right side of the heartThe right upper chamber (atrium or auricle) takes in deoxygenated blood that is loadedwith carbon dioxide. The blood is squeezed down into the right lower chamber (ventricle)and taken by an artery to the lungs where the carbon dioxide is replaced with oxygen.

The left side of the heartThe oxygenated blood travels back to the heart, this time entering the left upperchamber (atrium or auricle). It is pumped into the left lower chamber (ventricle) and theninto an artery. The blood starts its journey around the body once more.

Arteries

Oxygenated blood is pumped from the heart along arteries, which are muscular. Arteriesdivide like tree branches until they are slender. The largest artery is the aorta, whichconnects to the heart and picks up oxygenated blood from the left ventricle. The onlyartery that picks up deoxygenated blood is the pulmonary artery, which runs betweenthe heart and lungs.

CapillariesThe arteries eventually divide down into the smallest blood vessel, the capillary.Capillaries are so small that blood cells can only move through them one at a time.Oxygen and food nutrients pass from these capillaries to the cells. Capillaries are alsoconnected to veins, so wastes from the cells can be transferred to the blood.

Veins

Veins have one-way valves instead of muscles, to stop blood from running back thewrong way. Generally, veins carry deoxygenated blood from the body to the heart, whereit can be sent to the lungs. The exception is the network of pulmonary veins, which takeoxygenated blood from the lungs to the heart.


8/45


9/45

Heart has difficultypumping the blood

Increaseperipheral

resistance against

arterial wall

Increase bloodpressure:

BP = 150/80mmHg

Poorcirculation

The WBCs inthe blood,which arevital in the

healingprocess, areunable to do

their job

Damage to the cell'smembrane may in turn

cause the release of morefree radicals

Leukocytes mayalso build up insmall capillaries

Further decreased inblood supply to tissues

Destruction on skinintegrity

Formation ofwound

Worsening ofwound and getting

infected

Obstructionleading to

moreischemia

Cells andtissues

die

(+) woundat sacral

areaapproximately 2.5 wideand 1 deep

at the

center

Producesfoul-

smellingdrainage

Continuedactivation of the

inflammatorymediators

Increasedbody

temperature4/29/11

Temp: 38.2STAGE IVFull thickness loss

of skin andsubcutaneous tissue

and extension intomuscle

Invasion andproliferation of

microorganismin the

bloodstream

Ulceration enlargesextending deep into

the fascia, andmuscle

Ulcerationleft heel

(S2)Rednessright heel

(S1)

Sepsis

Causes formationof

thrombus/plaques

Travels into theblood vessels

HEART BRAIN

Causingobstruction in the

blood flow

CVA

MI F

A B C

M2

M4

M2 M3

M2

Inadequate blood

supply inthe hearttissues

Hypoxia

CHEST

PAIN

M8

inc WBC. incneutron, dec.

lympho(4-28-2011)

IncreaseTrop1

(4-28-2011)

Increase CK(4-28-2011)

M1 Clopidogrel 75 mg OD through NGTM2 Metronidazole 500mg IV q12M3 - Ampicillin/Sulbactam 750mg TIVq12M4 - Paracetamol 300mg TIV q4M5 - Humulin 70/30

30 u pre-breakfast20 u pre-dinner

M6 Fenofibrate 100mg/tab OD through

NGTM7 Sinemet 1tab OD through NGTM8 ISMN 60g/tab tab q HS

MEDICATIONS

Knowledge deficitabout proper

Mngt.

Poor woundhealing

Soiled linens, poor self

care

Poor wound care


10/45A


11/45

THEORETICAL FRAMEWORK

Dorothea Orems Self Care Deficit Model

Self care theory is based on four related concepts : (1) Self care defined as theactivities an individual performs independently to maintain personal well being; (2)Selfcare agency that refers to individuals ability to perform self care activities;(3) Selfcare requisites which known as measures or action taken to provide self care and;(4)Therapeutic self care demands that refers to activities required to meet existing

self care requisites.

A patient with previous stroke, decubitus ulcer, diabetes mellitus and Parkinsonsdisease, there is a lack of self care of the client which results to formation of bedsoresand immobility. Patients performance of self care includes active range of motion toprevent contractures and effective wound care for the bedsores, appropriate dietmodification for management of blood sugar and determining its effect on certainmedications the client takes.

For the self care agency, the patients significant others provides necessary careand needs of patient during hospitalization like providing the necessary needs such asmedications and toiletries. Due to the presence of illness, the client cannot follow thetherapeutic regimen effectively as well as perform necessary self care managementshe needs.

For self care requisites ,due to the left sided weakness from previous stroke theclient is unable to participate in effective self care activities especially active andpassive range of motion, turning herself side to side and ambulating herself; presenceof decubitus ulcer at her sacral area prevent her from ambulating herself and


12/45

NURSING HEALTH HISTORY

BIOGRAPHIC DATA

1. Name: Patient M

2. Address: Pasig City

3. Age: 64 y/o4. Gender: Female

5. Marital Status: Married

6. Occupation: Former Lotto Operator

7. Religion: Catholic

8. Source of medical care: Daughter and SSS

9. Birthday: May 19, 1946

10. Birthplace: Pasig City

11.Admitting diagnosis: T/C Sepsis secondary to Decubitus Ulcer, DM type

II, HCVD

12.Attending Physician: Dr. Marquez ; Dr. Gardon ; Dr. Lim ; Dr. Ramos

CHIEF COMPLAINT

Lumalaki na kasi yung bedsore niya eh, hindi na namin makontrol yungpaglaki kaya dinala na namin siya dito sa ospital, as verbalized by the clients


13/45

the center. There was also a pressure ulcer present at her left heel with ameasurement of 1 inch wide.

B. Past History

Patient M has a previous hospitalization at Lourdes hospital last January2010 because of her accident causing her fracture and she also suffered fromstroke that causing her left sided weakness. The present hospitalization was hersecond hospitalization. She was also diagnosed of Type II Diabetes Mellitus andwas a known hypertensive since she was on her late 50s. Before the incident,she was observed to be irritable, restless and manifests slowed movements byher husband. He stated that her wife became wayward and does whatever she

likes. They were surprised when she was diagnosed of Parkinsons disease whenshe was admitted at Lourdes hospital because of her fracture. She also had amaintenance medication of Amlodipine for her hypertension. She uses Sinemet(Carbidopa and Levodopa) for her Parkinsons disease and started using it a yearago. To manage her Diabetes, she first used Oral Hypoglycemic Agents and justonly started using Insulin (Humulin N 70% and Humulin R 30% ; 30 units in AMand 20 units in PM) 2 years ago because OHA cant control anymore her bloodsugar. She first used silver sulfadiazine ointment for the management of herpressure ulcer but they discontinue using it because they observed that usingthis ointment doesnt help relieving the said pressure ulcer so they shifted topovidone iodine and perceived that it was more effective. They used triplesolution for the pressure ulcer at her ankle but didnt use it to her pressure ulcerat the back. She has no known allergies to any foods and drugs.

C. Family History of illness

MotherFather

DECEASED

Diabetes MellitusHypertension

DECEASED

Liver CancerHypertension


14/45

PAIN ASSESSMENT

Since Patient M became verbally unresponsive 2 weeks prior to admission,

she wasnt able to report or communicate any kind of pain or discomfort.According to her significant other, she completely opens her eyes whenever theytry to stretch her flexed extremities. The stretching of her extremities can be theone causing her discomfort and even pain. Since the client is verballyunresponsive, the client wasnt able to rate her pain or discomfort.

FUNCTIONAL HEALTH PATTERNS

1. Health Perception & Health Management PatternThe clients general health is obviously disturbed because of the presence

of her illness and because of the physical changes that are happening at themoment, especially the formation of the unwanted pressure ulcers. Hersignificant other helps in managing her health on the hospital by cooperatingwith the nurses and doctors and also by doing what they are saying. Accordingto her significant other, the client was an occasional alcohol drinker on her latetwentys up to her 40s. The specific quantity or the number of bottles that theclient can consume was not accurately known by the significant other. He juststated that the client totally stopped drinking when she developed Diabetes andshe realized that she was old enough, that taking care of her body at this goldenage of her life was the vital part. Her significant other also stated that Patient M

never smoked or consumed cigarette on her entire life. The client was fond ofhaving regular check ups with her doctor, especially on the management of herDiabetes, Parkinsons disease and pressure ulcer. She also uses a glucometer tomonitor her blood sugar. She gets blood sugar twice a day, one in the morning


15/45

oral medications that she intake was crushed and given in between her feeding.According to her husband, there is no change on her physical appearance sincethe client got hospitalized. She first had an IVF of D5W 500cc for 16 hours. Thenit was changed to PNSS IL x 12 hours last May 1 - 2, 2011 because she

underwent blood transfusion. Then it was again shifted into D5W 500cc x 16hours hooked at her left hand.

3. Elimination PatternBefore hospitalization, the client wears medium diaper for her urination

and defecation. According to her husband, he changes the soiled diaper of thepatient 3 4 times a day. 2 out of the 4 diapers were fully soaked with yellowishurine. Her husband also noticed that ants was seen He also states that the

patient usually defecates twice, one in the morning and one in the evening. Herstool was soft, formed and brownish in color. Since the client was verballyunresponsive, we werent able to identify whether there is presence of anydifficulty and discomfort in urinating and defecating.

Presently on her hospitalization, she was inserted with a foley catheterattached to a urine bag. She eliminates urine at least 1550cc per day. Her urineis yellow in color. She still wears diaper and defecates at least once a day, stillwith soft, formed and brownish stool. But last May 3 5, 2011, the clientexperienced watery, yellow-brown stool with at least 4 5 times a day.

4. Activity & Exercise Pattern

Before hospitalization, the client was already partially dependent andpartially immobile for more than a year. She was able to move and sit, but ofcourse with the assistance of her significant other. The only time that Patient Mwas to do the best way of doing Range of Motion exercises passively is when her

physical therapist will visit her. This was also her very form of exercise. Whenher husband was just the only one who will take care of her, Patient M wasrather just be on bed or just be placed on a wheelchair. She prefers usingwheelchair because she had a hard time using crutches. She also had a left


16/45

Feeding: 0 Bed Mobility: 2 Grooming: 2Bathing: 2 Dressing: 2Toileting: 2 General Mobility: 3

During hospitalization:Feeding: 3 Bed Mobility: 2 Grooming: 2Bathing: 2 Dressing: 2Toileting: 2 General Mobility: 2

5. Sleep & Rest Pattern

Before hospitalization, the clients sleep pattern was usually 7 hours.

According to her husband, she sleeps very well and doesnt have the need totake any sleep medications. Her sleep is continuous and usually wakes up early.She always does daytime naps. She always does watching television, but mostof the time, she was asleep.

Presently, her husband noted that she still sleeps most of the time, dayand night. She usually sleeps for at least 8 9 hours. She also often wakes upintermittently. She just wakes up whenever she will be fed, when changing hersoiled clothes and diapers and sometimes, when someone is visiting her.

6. Cognitive-Perceptual Pattern

The client has no hearing and visual difficulty before and during thehospitalization. He doesnt wear any hearing aids or eye glasses. According toher husband, he thinks that Patient M cannot remember him anymore. She is notresponsive to him unlike to her other family members. She observed that Patient

M smiles at them.7. Self - perception & Self-concept Pattern

According to her husband, prior to hospitalization, Patient M doesnt share


17/45

Presently, Patient Ms relationship with her husband was really strong. Hewas always on the side of his wife no matter what happen. He even also statedto us that, masama magpapalit palit ng asawa, kahit anong mangyari, di kosiya iiwan.

9. Sexuality - Reproductive Pattern

Because of his hospitalization, his sexual life was obviously not a priorityfor her. She has no history of STDs. She also got menopausal at the age of 45.According to Erik Eriksons psychosocial developmental task, she is under theGenerativity vs. Stagnation stage, at this stage, it is vital for her to sharesomething for others and be productive. We can see that she can be under

stagnation she lacks productivity which can result to her dissatisfaction in life.

10. Coping Stress Tolerance Pattern

According to her significant other, he cant say whether Patient M is understressed or not. Since she doesnt usually share her thoughts, he doesnt haveany idea what causes her wifes stress. According to him, Di ko kasi talaganapapansin yun eh, madalas lang naman kasi nakahiga lang siya.

Since she was verbally unresponsive, she wasnt able to report any thingsor events that make her stressed. But obviously she was stressed of her presentcondition.

11. Value Belief Pattern

The client is a Catholic. According to her significant other, they always pray

together and never forget the Almighty God even before hospitalization. Prior tohospitalization, they dont really go to church because it is difficult for Patient M togo outdoors and often refuses to.Her husband said that the management andinterventions that are done to her are acceptable and doesnt offend any of their


18/45

PHYSICAL EXAMINATION

PRE-PHYSICAL EXAMMay 5, 2011

I. Vital Signs:Temperature: 36.2CPulse Rate: 78 bpmRespiratory rate: 22 cpmBP: 150/80mmHg

II. General Appearance

GCS 8 (E:4 V:1 M:3) Sleeping at bed

On MHBR

Tired and weak looking

Decorticated

(+) left sided weakness

(+) muscle rigidity

III. Skin Dry

Light brown in color

(+) pressure ulcer at thelumbosacral area with ameasurement of 2.5 inches wideand 1 inch deep at the center

(+) pressure ulcer at the left

heel measuring 1 inch wide

IV. Eyes

Anicteric sclera

(+) white curd like exudate

Coated tongue

(+) tartar on teeth

Yellowish teeth

VIII. Neck

No palpable lymph nodes

IX. Chest and Lungs

1:2 AP Ratio

(-) retractions

(-) cough

(-) wheezes

(-) fremitus

(+) crackles at the baseof the left lung

X. Heart

Precordim AP

No murmurs

XI. Abdomen

Soft, flabby abdomen NABS

XII. Genitals


19/45

(+) pressure ulcer at leftheel measuringapproximately 1 inch wide

Cold and clammy

No edema

POST-PHYSICAL EXAM


20/45

LABORATORY STUDIES

SECTION OF HEMATOLOGYApril 28, 2011

TEST INDICATION NORMAL VALUE RESULT INTERPRETATION

Hemoglobin

This test is used toevaluate blood disorders,

possible reaction toinflammation and

infections.

120.0-160.0 g/L95.0LOW May indicate anemia or

nutritional deficiency.Hematocrit 0.40-0.54 g/L 0.29LOW

Platelet Count150.0-400.0 x 10

g/L372 Normal

WBC 4.50-11.0 x 10 g/L26.8HIGH

May indicate presence ofinfection.

Neutrophils 0.35-0.65 g/L0.98HIGH

Lymphocytes 0.20-0.40 g/L0.02LOW

Prothrombin Time This is done to measurehow long it takes blood to

clot and to check forbleeding problems.

10.0-14.0 sec 11.4Normal result indicates ability

of the liver to synthesizeclotting factors.

Active PartialThromboplastin Time

27.70-34.10 sec 33.7

(Cardiac Markers)

Troponin IThis is used for early

diagnosis of MI.


21/45

SECTION OF CLINICAL CHEMISTRYApril 28, 2011

TEST INDICATION NORMAL VALUE RESULT INTERPRETATION(Protein & Protein Metabolites)

CreatinineThis is done to determine any

renal problems.

53-132.5 mmol/L 131 Normal

Urea 2.5-7.1 mmol/L11.9HIGH

May indicate possible renalproblem.

(Electrolytes)

PotassiumThis is done to determineelectrolyte and acid-base

imbalances.

3.6-5 mmol/L 3.6 Normal

Sodium 137-145 mmol/L132LOW

Low result due to her maintenanceof sinemet. It reduces sodium

levels.(Cardiac Markers)

CKUse to diagnose acute MI andrisk stratification for unstable

angina

30-135 U/L900

HIGHIndicates possible myocardial

infarction.

CK-MB 0-16 U/L < 1 Normal

SECTION OF BLOOD CHEMISTRYApril 29, 2011


Glucose This is done to determinethe amount of glucose

and uric acid in the bloodthat affects the present

condition.

3.61-5.83 mmol/L 3.62 Normal

Uric Acid 149-446 mmol/L559HIGH

May indicates possible goutthat is why the patient is

taking allopurinol.

(Lipids)

TriglyceridesThis is done to determinethe amount of lipidcomponents in the bloodthat affects the present

condition.

0-2.26 mmol/L2.57HIGH

An increased value is possiblydue to her increase intake offood high in carbohydrates and

sugar (hotcake).

HDL 1-1.6 mmol/L0.3

LOWMay indicates poorly controlled

diabetes mellitus.LDL 0-3.36 mmol/L 0.98 Normal

Cholesterol 0-5.2 mmol/L 2.5 Normal


22/45

SECTION OF CLINICAL CHEMISTRYApril 29, 2011

TEST INDICATION NORMAL VALUE RESULT INTERPRETATION(Protein & Protein Metabolites)

CreatinineThis is done to determine any

renal problems.

53-132.5 mmol/L 91 Normal

Urea 2.5-7.1 mmol/L8.1

HIGHMay indicate possible renal

problem.

(Liver Function Test)

ASTThis is done to determine anymalfunction in the liver. AST

may also release after injury ordeath of cells.

14-36 U/L110

HIGH

Indicates tissue damage as aresult of decubitus ulcer (bed

sore).May also indicate liver damage.

ALT 9-52 U/L82

HIGHMay indicate possible liver

damage.

SECTION OF MICROBIOLOGY

May 1, 2011

Specimen and BloodNo growth after 24.7 hours of incubation

SECTION OF CLINICAL CHEMISTRYMay 3, 2011


HbA1cThis is done to determine howwell blood glucose levels have

been controlled during the prior3 to 4 months.

6.6-8.8 % 8.69 % Normal


23/45

DRUG STUDY

DRUGS CLASSIFICATIONand MECHANISM

OF ACTION

INDICATION ADVERSE EFFECTS CONTRAINDICATION

NURSINGMANAGEMENT

Generic:LactuloseBrand Name:Duphalac

Lilac

30cc qHSthrough NGT

Laxatives. Cause aninflux of fluid in theintestinal tract byincreasing the

osmotic pressurewithin the intestinallumen. Bacterialmetabolism of thedrug to lactate andother acids whichare only partiallyabsorbed in thedistal ileum andcolon augments theosmotic effects of

-heart disease-liver damage

GI-abdominal discomfortassoc. with flatulenceand intestinal cramps

-nausea-vomiting-diarrhea on prolongeduse

-Patient who requirelow lactose diet.-Galactosemia ordissacharide

deficiency-intestinalobstruction

-Assess mentalcondition (clearingconfusion,restlessness,

irritability)-Monitor possibleadverse reaction.-Monitor Input andOutput


24/45

lactulose. Thedistention of thecolon due toincreased fluidenhances intestinalmotility andsecretion. Decreasein the lumenal pH

(due to bacterialmetabolism) furtherincrease motilityand secretion. Italso lowersintestinal absorptionof ammoniapresumably due toinc. utilization ofammonia byintestinal bacteria

Generic:ClopidogrelBrandName:Plavix

75 mg ODthrough NGT

Anticoagulant/AntiplateletThrombolytic.BlocksADP receptors,which preventfibrinogen binding atthat site andthereby reduce thepossibility of plateletadhesion andaggregation

-Reduction ofatheroscleroticevents-MI

GI-GI bleeding-GI disturbances-DiarrheaSKIN-purpura-bruising-hematoma-rash-pruritusEENT-EpistaxisURINARY-hematuriaOPTHA-eye bleedingCNS-intracranial bleeding

-Hypersensitivity-severe liverimpairement-pregnancy andlactation-active pathologicalbleeding

-Assess forsymptoms ofstroke/ MI duringtreatment-monitor signs ofbleeding-monitor liverfunction test.

Generic: H2-Receptor -prevent ulcer GI -Hypersensitivity Use caution in


25/45

RanitidineBrandName:Zantac

50mg TIV q8

Antagonist. Inhibitshistamine at H2receptor site in thegastric parietal cells,which inhibitsgastric acidsecretion.

(NPO) -abdominal discomfort-nausea-vomiting-constipation-pancreatitis-hepatocellular effectsCARDIO-Cardiac arrhythmias

-bradycardiaCNS-headache-somnolence-fatigue-dizziness-hallucinations-depression-insomniaHEMATO-agrunulocytosis-aplastic anemia-thrombocytopenia-granulocytopeniaGENERAL-hypersensitivityreaction.

-history of acuteporphyria.-long term therapy

presence of renal rhepaticimpairment;monitor for sideeffects; instructpatient not to takeany newmedications

without consultingthe physician.

Generic:MetronidazoleBrandName:Zolvex

500mg IV q12ANST

Antiprotozoal.Direct-actingamebicide/trichomonacide. It binds tobacterial andprotozoal DNA tocause loss of helicalstructure, strandbreakage, inhibitionof nucleic acidsynthesis and celldeath

-infections in theintra-abdominal,skin and skinstructure-bacterialsepticemia

GI-anorexia-GI disturbances-nausea-less freq. vomiting-diarrheaEENT-dry mouth-furred tongue-unpleasant metallictaste-watery eyes if appliednear to the eyesCNS-convulsive seizure

-blood dyscrasias-active CNS dse-hypersensitivity toimidazole-TB-1st tri of pregnancy-lactation

-obtain baselineinfo on pxsinfection-obtain C&S beforebeginning drugtherapy-assess for allergicreaction-monitor forpossible druginduced interaction-monitor renalfunction-assess forovergrowth of


26/45

-headache-dizziness-psychiatric disorderSKIN-rash-pruritus-transient redness-mild dryness

-burning-skin irritationURINARY-darkening of the urineHEMATO-leukopeniaGENERAL-weakness

infection-monitor bowelpattern

GENERIC:Ampicillin/SulbactamBRANDNAME:Unasyn

750mg TIVq12 ANST

Penicillins.Belonging tothe penicillin groupof beta-lactamantibiotics,ampicillin is able topenetrate Gram-positive andsome Gram-negative bacteria. Itdiffers frompenicillin only by thepresence ofan amino group.That amino grouphelps the drugpenetrate the outermembrane of gram-negative bacteria.Ampicillin acts as acompetitive inhibitorof theenzyme transpeptid

This combinationmedication isused to treat awide variety ofbacterialinfections. It isknown as apenicillin-typeantibiotic. Itworks by stoppingthe growth ofbacteria. Thisantibiotic treatsonly bacterialinfections. It willnot work for viralinfections.

GI-diarrhea that is wateryor bloody- nausea-vomiting-stomach pain-bloatingCNS-fever- headacheEENT-sore throat-black, or "hairy" tonguethrush (white patches orinside your mouth orthroat)SKIN-severe blistering,peeling-red skin rash

GENERAL-chills

-hypersensitivityreactions to any ofthe penicillins.

-Determineprevioushypersensitivityreactions topenicillins,cephalosporins,and other allergensprior to therapy.-Lab tests: BaselineC&S tests prior toinitiation oftherapy; start drugpending results.-Report promptlyunexplainedbleeding (epistaxis,ecchymoses)-Monitor patientcarefully during thefirst 30 min afterinitiation of IVtherapy for signs ofhypersensitivity
http://en.wikipedia.org/wiki/Penicillinhttp://en.wikipedia.org/wiki/Gram-positivehttp://en.wikipedia.org/wiki/Gram-positivehttp://en.wikipedia.org/wiki/Gram-negativehttp://en.wikipedia.org/wiki/Gram-negativehttp://en.wikipedia.org/wiki/Aminohttp://en.wikipedia.org/wiki/DD-transpeptidasehttp://en.wikipedia.org/wiki/Penicillinhttp://en.wikipedia.org/wiki/Gram-positivehttp://en.wikipedia.org/wiki/Gram-positivehttp://en.wikipedia.org/wiki/Gram-negativehttp://en.wikipedia.org/wiki/Gram-negativehttp://en.wikipedia.org/wiki/Aminohttp://en.wikipedia.org/wiki/DD-transpeptidase


27/45

ase, which isneeded by bacteriato make their cellwalls. It inhibits thethird and final stageof bacterial cell wallsynthesis in binaryfission, which

ultimately leads tocell lysis

-body aches-flu symptoms

and anaphylactoidreaction. Seriousanaphylactoidreactions requireimmediate use ofemergency drugsand airway mngt.-Observe for and

report symptoms ofsuperinfections-Monitor I&O ratioand pattern. Reportdysuria, urineretention, andhematuria.

GENERIC:ParacetamolBRANDNAME:BiogesicTempra300mg TIV q4

Antipyretic/Analgesic. Decreases feverby inhibiting theeffects of pyrogenson the hypothalamicheat regulatingcenters and by ahypothalamic actionleading to sweatingand vasodilataion.Relieves pain byinhibitingprostaglandinsynthesis at the CNSbut does not haveanti-inflammatoryaction because of itsminimal effect onperipheralprostaglandinsymthesis.

-Decrease fever-Mild to moderatepain

GI-N/V-abd. Pain- hepatotoxicity-hepatic seizureCNS-drowsiness-stimulation-drowsiness-delirium-comaSKIN-rash-urticaria-jaundiceHEMATO-leukopenia-neutropenia-hemolytic anemia-thrombocytopenia-pancytopeniaURINARY-renal failureGENERAL-hypersensitivity

-Hypersensitivity-Intolerance totartrazine, alcohol,table sugar,saccharin

-Assess for fever orpain-assess allergicreaction-assesshepatotoxicity-monitor liver orrenal functions-check I&O
http://en.wikipedia.org/wiki/DD-transpeptidasehttp://en.wikipedia.org/wiki/Cell_wallhttp://en.wikipedia.org/wiki/Cell_wallhttp://en.wikipedia.org/wiki/Binary_fissionhttp://en.wikipedia.org/wiki/Binary_fissionhttp://en.wikipedia.org/wiki/Lysishttp://en.wikipedia.org/wiki/DD-transpeptidasehttp://en.wikipedia.org/wiki/Cell_wallhttp://en.wikipedia.org/wiki/Cell_wallhttp://en.wikipedia.org/wiki/Binary_fissionhttp://en.wikipedia.org/wiki/Binary_fissionhttp://en.wikipedia.org/wiki/Lysis


28/45

-cyanosisGENERIC:AllopurinolBRANDNAME:Elavil

100mg/tab

OD throughNGT

Uricosurics. Inhibitsxanthine oxidase, anenzyme involved inthe synthesis of uricacid withoutdisrupting thebiosynthesis of

essential purine.Results in dec. uricacid level.

-gout-hyperuricemia

GI-abd. Pain-dyspepsia-diarrhea-gastritis-N/V-hepatic necrosis

-elevated liver enzyme-hepatitis-hepatomegalyCNS-drowsiness-gen. seizure-headache-nueritisSKIN-alopecia-ecchymosis-skin rash-cho;estatic jaundiceHEMATO-leukocytosis-leucopenia-thromocytopenia

Contraindicated topatients who havehypersensitivity todrug

-Monitor uric acidlevel-Tell patient toreport any unusualreactions from thedrug

GENERIC:Insulin,humanisophane susp& insulinrecombinantBRANDNAME:Humulin70/30

30 u pre-breakfast20 u pre-

Intermediate-actingInsulins. Decreasesblood glucose; bytransport of glucoseinto cells and theconversion ofglucose to glycogenindirectly increasesblood pyruvate andlactate, decreasesphosphate andpottassium

Management oftype 2 DM whichcannot becontrolled by diet,exercise or weightreduction alone

MUSCULO-lipodystrophyENDO-insulin resistance-hypoglycemiaGENERAL-allergic reactions

-hypoglycemia-insulinoma-hypersensitivityreactions-diabetic coma

-monitor FBS-monitor urineketones-monitor bodyweight-assess forhypoglycemicreaction-observe inj. Sitefor s/sx of localhypersensitivity-assess forhyperglycemia


29/45

dinner

GENERIC:Fenofibrate

BRANDNAME:Nubrex

100mg/tabOD throughNGT

Fibric AcidDerivative. It is a

fibric acid derivativewhose lipidmodifying effectsreported in humansare mediated viaactivation ofperoxisomeproliferator-activated receptortype alpha (PPAR).Through activation

of PPAR fenofibrateinc. the lipolysis andelimi -nation ofatherogenictriglyceride-richparticles fromplasma byactivatinglipoproteinlipase and reducingproduction ofapoprotein CIII.Activation of PPARalso induces an inc.in the synthesis ofapoproteins AI andAII, which leads to areduction in VLDLand LDL containingapoprotein B and aninc.in the high-

-hypertriglyceridae

mia

GI-Digestive, gastric or

intestinal disorders-abdominal pain-nausea-vomiting-diarrhea-flatulenceSkin-Rashes-Pruritus-urticaria orphotosensitivity

reactions.

-pregnancy orlactation

-liver insufficiency-presence ofgallstones-renal insufficiency-hypersensitive tofenofibrate and/orexcipients, knownphotoallergy orphototoxic reactionduring treatmentwith fibrates or

ketoprofen.

-monitor BP-monitor

electrolytes, bloodstudies-assess hydrationstatus-assess nutrition-monitor bowelpattern
http://en.wikipedia.org/wiki/Peroxisome_proliferator-activated_receptor_alphahttp://en.wikipedia.org/wiki/Peroxisome_proliferator-activated_receptor_alphahttp://en.wikipedia.org/wiki/Peroxisome_proliferator-activated_receptor_alphahttp://en.wikipedia.org/wiki/Peroxisome_proliferator-activated_receptor_alphahttp://en.wikipedia.org/wiki/Lipoprotein_lipasehttp://en.wikipedia.org/wiki/Lipoprotein_lipasehttp://en.wikipedia.org/wiki/High-density_lipoproteinhttp://en.wikipedia.org/wiki/Peroxisome_proliferator-activated_receptor_alphahttp://en.wikipedia.org/wiki/Peroxisome_proliferator-activated_receptor_alphahttp://en.wikipedia.org/wiki/Peroxisome_proliferator-activated_receptor_alphahttp://en.wikipedia.org/wiki/Lipoprotein_lipasehttp://en.wikipedia.org/wiki/Lipoprotein_lipasehttp://en.wikipedia.org/wiki/High-density_lipoprotein


30/45

densitylipoprotein fraction(HDL) containingapoprotein AI andAII. In addition,through modulationof the synthesis andcatabolism of VLDL

fractions,fenofibrateincreases the LDLclearance and dec.small and denseLDL, the levels ofwhich are elev. inthe atherogeniclipoproteinphenotype, acommon d/o in pts

at risk for coronaryheart disease.

GENERIC:Levodopa/CarbidopaBRANDNAME:Sinemet

1tab ODthrough NGT

Antiparkinsonism.Levodopa isconvertedto dopamine via theaction of a naturallyoccurring enzyme called DOPAdecarboxylase. Thisoccurs both in theperipheralcirculation and inthe central nervoussystem afterlevodopa hascrossed the bloodbrain barrier.Activation of centraldopamine receptorsimproves the

Treatment ofsymptoms ofidiopathicParkinson disease(paralysisagitans),postencephaliticparkinsonism andsymptomaticparkinsonismassociated withcarbon monoxideand manganesepoisoning.

CARDIO-Cardiac irregularities-palpitations-hypertension-phlebitis-orthostatic hypotension-MI-palpitation-syncope.CNS-Paranoid-delusions-psychotic episodes-depression-suicidal ideation-dementia-convulsions-hallucinations-dizziness

-Narrow-angleglaucoma-undiagnosed skinlesions or priorhistory of suspectedmelanoma-concurrent use ofor within 2 wk ofMAOIs.
http://en.wikipedia.org/wiki/High-density_lipoproteinhttp://en.wikipedia.org/wiki/High-density_lipoproteinhttp://en.wikipedia.org/wiki/Dopaminehttp://en.wikipedia.org/wiki/Enzymehttp://en.wikipedia.org/wiki/DOPA_decarboxylasehttp://en.wikipedia.org/wiki/DOPA_decarboxylasehttp://en.wikipedia.org/wiki/Central_nervous_systemhttp://en.wikipedia.org/wiki/Central_nervous_systemhttp://en.wikipedia.org/wiki/Blood_brain_barrierhttp://en.wikipedia.org/wiki/Blood_brain_barrierhttp://en.wikipedia.org/wiki/High-density_lipoproteinhttp://en.wikipedia.org/wiki/High-density_lipoproteinhttp://en.wikipedia.org/wiki/Dopaminehttp://en.wikipedia.org/wiki/Enzymehttp://en.wikipedia.org/wiki/DOPA_decarboxylasehttp://en.wikipedia.org/wiki/DOPA_decarboxylasehttp://en.wikipedia.org/wiki/Central_nervous_systemhttp://en.wikipedia.org/wiki/Central_nervous_systemhttp://en.wikipedia.org/wiki/Blood_brain_barrierhttp://en.wikipedia.org/wiki/Blood_brain_barrier


31/45

symptoms ofParkinson's Disease,however, activationof peripheraldopamine receptorscauses nausea andvomiting. For thisreason levodopa is

usually administeredin combination witha DOPAdecarboxylaseinhibitor (DDCI), inthis case carbidopa,which is very polar(and charged atphysiologic pH) andcannot cross theblood brain barrier,

however preventsperipheralconversion oflevodopa todopamine andthereby reduces theunwanted peripheralside-effects oflevodopa. Use ofcarbidopa alsoincreases thequantity of levodopain the bloodstreamthat is available toenter the brain.

-choreiform-dystonic and otherinvoluntary movements-fatigue-malaise-bradykinetic episodes(ie, on-off phenomenon)-confusion

-headache-increased libido-insomnia-paresthesia.EENTDiplopia-blurred vision.GI-Nausea-anorexia-vomiting

-GI distress-epigastric pain-GI bleeding-dry mouth-duodenal ulcer-constipation-diarrhea.-Elevated LFT results-hepatotoxicityGENITO-Dark urine-urinary retention-urinary incontinence-priapism-UTI-urinary frequency.HEMATO-Hemolytic andnonhemolytic anemia-thrombocytopenia-leukopenia
http://en.wikipedia.org/wiki/DOPA_decarboxylase_inhibitorhttp://en.wikipedia.org/wiki/DOPA_decarboxylase_inhibitorhttp://en.wikipedia.org/wiki/DOPA_decarboxylase_inhibitorhttp://en.wikipedia.org/wiki/DOPA_decarboxylase_inhibitorhttp://en.wikipedia.org/wiki/DOPA_decarboxylase_inhibitorhttp://en.wikipedia.org/wiki/DOPA_decarboxylase_inhibitor


32/45

-agranulocytosis..HYPERSENSITIVITY-Angioedema-bullous lesions(including pemphigus-like reactions)-pruritus-urticaria.

MUSCULO-Back pain-muscle cramps-shoulder pain.RESPI-Dyspnea-upper respiratory tractinfection.GENERAL-Flushing-chest pain

-increased sweating-dark sweat

GENERIC:LiversilymarinBRANDNAME:Carsil

1 tab TIDaftermealsthrough NGT

Supplement.Theanti-hepatotoxiceffect of Silymarin isassociated with thecompetitiveinteraction with thereceptors of therelevant toxins inthe hepatocytemembrane, and witha more generalaction of protectivenature (Vogel 1975).The biflavonoids areassumed to possessa vitamin-C-sparingeffect. They have ananti-inflammatoryaction and improve

-hepatic injurydue to DM

GI-Occasional laxativeeffects-Abdominal bloating-diarrhea-flatulence-loss of appetite-anorexia-nausea-stomach upset.

-Hypersensitivity-pregnancy-lactation

-monitor foradverse reaction-monitor liverfunction


33/45

the synthesis ofproteins andglycoproteins, aswell as theperoxidation oflipids in the liver.Clinically, the aboveeffects are

translated intoimproved signs andsymptoms, andlowered values ofthe transaminases,g-globulines andblood bilirubin.

GENERIC:IsosorbideMononitrateBRAND

NAME:Cardismo

60g/tab tabq HS

Organic nitrites.Similar to othernitrites and organicnitrates, Isosorbide

Mononitrate isconverted to nitricoxide (NO), anactive intermediatecompound whichactivates theenzyme guanylatecyclase (Atrialnatriuretic peptidereceptor A). Thisstimulates thesynthesis of cyclicguanosine 3',5'-monophosphate(cGMP) which thenactivates a series ofprotein kinase-dependentphosphorylations inthe smooth musclecells, eventually

-angina pectoris CNS-Throbbing headache-dizziness-postural hypotension

SKINFlushingCARDIO-tachycardia (butparadoxical bradycardiahas occurred).

CARDIO-Hypotensiveconditions-hypovolaemia

-hypertrophicobstructivecardiomyopathy-aortic stenosis-cardiac tamponade-constrictivepericarditis-mitral stenosisHEMATO-marked anaemiaCNS-head trauma-cerebralHaemorrhageEENT-closed-angleglaucoma

-Headache may bea marker for drugactivity; do not tryto avoid by altering

treatmentschedule; aspirin oracetaminophenmay be used forrelief-Dissolve SL tabletsunder tongue; donot crush, chew, orswallow-Do not crushchewable tabletsbeforeadministering-Avoid alcohol-Make changes inposition slowly toprevent fainting


34/45

resulting in thedephosphorylationof the myosin lightchain of the smoothmuscle fiber. Thesubsequent releaseof calcium ionsresults in the

relaxation of thesmooth muscle cellsand vasodilation.

NURSING CARE PLAN

ASSESSMENT DIAGNOSI PLANNING INTERVENTION EVALUATION


35/45

ASSESSMENT DIAGNOSIS

PLANNING INTERVENTION EVALUATION

SUBJECTIVE:S.O. states: Bed ridden na kasisiya sa bahay pa lang. Taposnagkaroon ng bed sore at yungbedsore niya yung dahilan ngpagkaospital niya.Nadulas kasi siya sa banyo lastyear, tapos naoperahan. Simulanoon hindi na siyanakakalakad.S.O said that she has history ofCVA and diagnosed ofParkinsons disease andDiabetes Mellitus

OBJECTIVE:

Generalized body weaknessespecially on Left side

Unable to move extremities Motor response: (+) flexionof extremities = 3/5

Patient cant move in bedindependently

VS: BP:150/80 mmHgPR:98 bpmRR:25 cpmTemp:36.2C

(+) wound at lumbosacralarea approximately 2.5wide and 1 deep at the

center (+) wound at left heel

approximately 1 wide

(+) blood tinge on wounddressing

(+) foul odor from thewound

Decrease Hgb level: 95 g/L

Decrease Hct level: .29

CBG: 321 g/dL

Post BT of 1 u PRBC and S/F

2 u PRBC; Blood type: A+ Doctors order: For

debridement once CPcleared

Impaired skinintegrity

related todecreased

peripheralcirculation

secondary toprolonged bed

rest asevidenced by

wound atsacral area

approximately2.5 wide and1 deep at the

center andwound at left

ankleapproximately

1 wide

GOAL:After 3 m0nths ofnursing intervention,the client will be ableto display timelyhealing of bed sore.

After 4 days of nursingintervention:

1. The client willbe able to preventrecurrence of newbed sore.

2. The client willbe able to displayimprovement in thehealing of herwound.

OBJECTIVES:After 8 hours of nursingintervention:

1. The client willmaintain skinintegrity of otherbody parts.

2. The significantother will be able toidentify at least 3ways how toprevent recurrenceof bed sore andprevent infection.

INDEPENDENT:

Monitor VS especially Tempand assess wound for anysigns of infection.

Assess other body parts to

determine any newoccurrence of bed sore.

Measure size of wounddaily to determine if thewound is worsening.

Perform wound care andchange dressingaccordingly.

Perform/Teach S.O aboutthe following:

Turn patient side to sideq 2

Put pillows on areas ofhigh pressure

Changelinens/diapers/clothingaccordingly.

Maintain skin dry andfree from moisture.

Provide passive ROM

Encourage use of eggmattress

COLLABORATIVE:

Review CBC result and CBGand facilitate BT: 2 u PRBCproperly typed and crossmatched.

Follow up/assist in wounddebridement.

Give medications asprescribed by physician.

After 8 hours of nursingintervention:

1. The client had thefollowing VS:BP: 160/80 mmHgPR: 80 bpmRR: 21 cpmTemp: 36.8 CCBG: 235 g/dL

2. The client maintainedskin integrity of otherbody parts.

3. The significant otherwas able to identify atleast 3 ways how toprevent recurrence ofbed sore and preventinfection.

After 4 days of nursingintervention:

1. The client was able toprevent recurrence ofnew bed sore.

2. The client was able todisplay improvementin the healing of herwound:Wound at sacral areaapproximately 2.5wide and 1 deep atthe centerWound at left ankleapproximately .5wide


36/45


37/45

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE:

S.O said that she hashistory of CVA last 2010and diagnosed ofParkinsons disease andhistory of hip dislocation

S.O. states: Simula nungnadulas siya atnaoperahan hindi na siyanakakapaglakad, walasiyang saklay pero maywheelchair siya sabahay.

OBJECTIVE:

Generalized bodyweakness especially onLeft side

Unable to move anddecortication ofextremities

(+) hand tremors

Muscle rigidity

Client is fully dependenton S.O and does notparticipate in activities

Observed assistance

from significant otherwhile doing ADLs.

Feeding: 4Bathing: 4Bed mobility:

4Dressing: 4Grooming: 4General

mobility: 4

(+) wound at sacral area

approximately 2.5 wideand 1 deep at the center

(+) wound at left heelapproximately 1 wide

Impairedphysicalmobility

(Level IV)related to

generalized

bodyweakness

especially onleft side and

history ofhip

dislocation

GOAL:After 2 m0nths ofnursing intervention,the client will be ableto resume heractivities of daily living

prior to admission.

After 4 days of nursingintervention, the clientwill be able to at leastincrease strength ofher extremities.

OBJECTIVES:After 8 hours ofnursing intervention:

1. The client and S.Owill be abledemonstratetechniques thatenable resumptionof activities andprevention of injury.

2. The client will beable to maintainposition and

function of skinintegrity of otherbody parts andprevent worseningof bed sore.

INDEPENDENT:

Measure size ofwound daily to determineif the wound is worsening.

Assess other bodyparts to determine anynew occurrence of bedsore.

Support body partswith high risk ofdeveloping bed sores withpillows.

Provide and teachclient about safety

measures such askeeping the side railsraised.

Assist client inactivities of daily livingsuch as in feeding andbathing.

Provide passive ROM.

Provide wound care,change dressing and turnside to side q 2.

COLLABORATIVE:

Encourage client tocontinue consultation withphysical therapist.


After 8 hours ofnursing intervention:1. The client and S.O

will be abledemonstratetechniques that

enable resumptionof activities andprevention ofinjury.

2. The client will beable to maintainposition andfunction of skinintegrity of otherbody parts andprevent worsening

of bed sore.

After 4 days ofnursing intervention,the client was able toat least increasestrength of herextremities.


38/45

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE:

S.O states: Mamayapwede bang linisannatin ung loob ng bibigkasi parang may putiputi na yung loob ngbibig.

OBJECTIVE:

On NPO since admitted

(4/27/11) With NGT at right

nostril with 1,600 kcalof Nutren into 6equal feeding

Patient unable to speak

(+) Dry lips

(+) Cracking lips

(+) Desquamation oflips

(+) white curd likeexudate

Coated tongue

(+) tartar on teeth

Yellowish teeth

Impaired oral

mucusmembranerelated to

prolongedNPO more

than 24 hours

GOAL:

After 4 days of nursingintervention, the clientwill be able to restoreand maintain integrity oforal mucosa.

OBJECTIVES:


1. The client will beable to demonstratea decrease insymptoms noted indefiningcharacteristics.

2. The S.O will be ableto identify at leastone specificintervention to

promote healthy oralmucosa.

INDEPENDENT:

Routinelyinspect oral cavityand throat forinflammation.

Provide routinelymouth care.

Lubricate lipsand provide

commerciallyprepared orallubricant solution.

Wet lips asnecessary todecrease thirst andprevent dry andcracking lips.

Provide gummassage and assist

S.O in tonguebrushing with cottontip applicators.

Teach significantother about properoral hygiene to client.

After 8 hours of nursing

intervention:

1. The client hadthe following:

Dryness, crackingof lips anddesquamation waslessened

White curd likeexudate waslessened

Tartar on teethwas lessened

2. The S.O will beable to identify atleast one specificintervention topromote healthy oralmucosa.


39/45


40/45

ASSESSMENT DIAGNOSIS

PLANNING INTERVENTION EVALUATION

SUBJECTIVE:

S.O states: Tignan moyung kamay niya nurse, ok

lang ba na parangnamumutla yan tsakamalamig kasi.

S.O said she was dignosedof DM

OBJECTIVE:

LOC: Obtunded (opens eyeto loud voice and seemsunaware of theenvironment.

Unable to speak

GCS: 8/15 (E:4;V:1;M:3)

VS: BP:150/80 mmHgPR:98 bpmRR:52 cpmTemp:36.2C

With O2 inhalation via NC@ 4lpm

(+) weakness ofextremities

Capillary refill >2 seconds

Weak pulses

Cold clammy skin ER O2 sat: 90%

Pale hands and feet

(+) wound at sacral areaapproximately 2.5 wideand 1 deep at the center

(+) wound at left heelapproximately 1 wide

Decrease Hgb level: 95 g/L

Decrease Hct level: .29

CBG: 321 g/dL

Increase BUN 8.1 mmol/L ABO typing: A+

Post BT of 1 u PRBC S/F 2 uof PRBC

Ineffectivetissue

perfusion

related todecrease

hemoglobinconcentration

in blood

GOAL:

After 4 days of nursing

intervention, the clientwill be able to improveor increase tissueperfusion as evidencedby improvement in thedefining characteristics.

OBJECTIVES:


1. The clientwill be able todemonstrate withassistancebehaviors thathelp improvecirculation.

2. The S.Owill be able toparticipate in theplan of care to

improve patientsbody circulation.

INDEPENDENT:

Monitor VS for

baseline data.

Assess for mentalstatus, perform NVSas necessary.

Monitor O2 saturationand capillary refill.

Maintain O2inhalation via NC at 4lpm.

Provide passive ROM.

Turn patient side toside every 2 hours.

COLLABORATIVE:

Encourage client tocontinue consultationwith physical therapist.

Facilitate 2 u of PRBCproperly typed and crossmatched when blood isavailable.

Facilitate repeat CBC asordered by physician.



1. The client had

the following:BP: 160/80 mmHgPR: 80 bpmRR: 21 cpmTemp: 36.8 CCBG: 235 g/dLCapillary refill > 2 secs

2. The client wasable to demonstrate withassistance behaviors thathelp improve circulation.

3. The S.O was ableto participate in the planof care to improvepatients body circulation.

After 4 days of nursingintervention, the client was ableto improve or increase tissueperfusion as evidenced by:


41/45


42/45

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION

EVALUATION

SUBJECTIVE:

S.O states: Sabe ni Dr.Marquez, lalagyan dawng butas dito sa maystomach kasi daw bakamapunta yung gatas sabaga niya. Pero hindikami papayag kasimahirap ng butasan pauli, baka lalong lumala.Yung sugat nga sa likod

di gumaling galingtapos dadagdagan pa.

OBJECTIVE:

On NPO since admitted(4/27/11)

With NGT at right

nostril with 1,600 kcal

of Nutren into 6

equal feeding

Decreased cough and

gag reflex

Impaired swallowing

Unable to move in bed

independently

Unable to move

extremities

(+) crackles

Risk foraspiration

related to NGTinsertion

GOAL:

After 4 days of nursingintervention, the clientwill be able to preventaspiration.

OBJECTIVES:

After 8 hours ofnursing intervention:

1.The S.O will beable to identify atleast 1 way howto preventaspiration.

2.The client willbe able tomaintainplacement of NGTtubing.

INDEPENDENT:

Assess forabdominaldistention.

Checkplacement oftube prior tofeeding.

Elevate

head of the bedat least 30 priorto feeding.Maintain head ofthe bed elevatedat least 30minutes afterfeeding.

Note forstomach

residual. If >100 mL do notfeed the client.

Maintainpatient on NPO.

Alwaysassess fullnesswhen feeding,do not continue

feeding if nottolerated bypatient.

After 4 days of nursingintervention, the client will be

able to prevent aspiration asevidence by:


1. The S.O was able toidentify at least 1 wayhow to preventaspiration.

2. The client was able tomaintain placement ofNGT tubing.


43/45

CLINICAL PATHWAY

Patients Name: Marcelo, Potenciana Admission Date: April 28, 2011Diagnosis: t/c Sepsis secondary to Decubitus Ulcer, DM Type II, HCVD in failure

04/28/111st day

04/29/112nd day

04/30/113rdday


44/45

ASSESSMENT Emergency Room (3:45am)

Vital signs:oBP 90/60mmHgoTemp. 36.70c

oPR 105bpm

oRR 20cpm

GCS 10 (E-4 V-1 M-5)

O2 saturation 90% (+) Body malaise

Lethargic

Unresponsive with blank stare

Anicteric sclera but slightly palepalpebra

Inability to speak

Tachycardic

(+) Crackles at left base lung

(+) ulcer on sacral areaoGrade 2-3

(+) Bipedal edema

Shy pulse, CRT: >2secs

Phil Health Ward (FMW)

Vital Signso BP 110/60mmHgo RR 23cpmo PR 100bpm

oTemp 37.90c

GCS 11 (E-4,V-1,M-6)

Awake Lethargic

Generalized weakness

With ongoing D5W 500cc x 16 @left hand (250cc level)

With O2 via nasal cannula at 4 lpm

Febrile

(-) DOB



o Temp 37.30c

GCS 9 (E-4,V-1,M-4) 8:00amGCS 8 (E-4,V-1,M-3) 12:00n

CBG 221mg/dL (6:00am)CBG 385mg/dL (12:00n)

Lethargic

Awake

Generalized weakness

With ongoing D5W 500cc x 16 @left hand (350cc level)

With O2 via nasal cannula at 4 lpm

(-) DOB

(+) difficulty in swallowing andunable to eat

LABORATORYPROCEDURES

Emergency Room

For the following laboratorystudies:

CXR-PA

Lumbo-Sacral X-Ray

CBC with PC , PT, APTT

Na, K, Crea

ABO typing

Trop I UA

Blood GS/CS

NOTE:

CXR-PA (not done)

Lumbo-Sacral X-Ray (not done)

CBC with PC, PT, APTTo Hemoglobin 95g/L (low)o Hematocrit 0.29 g/L(low)o Platelet 372 x 10g/L(normal)

o WBC 26.8 x 10g/L (high)o Neutrophils 0.98 g/L(high)o Lymphocytes 0.02 g/L(low)o PT 11.4secs(normal)


For the following laboratorystudies:

HBA1C

Lipid profile

2D echo with doppler

Still for the following laboratory

studies: CXR-PA

Lumbo-Sacral X-Ray

UA

Blood GS/CS

NOTE:

Lipid profileo Glucose 3.62 mmol/L (normal)o Urea 8.1 mmol/L (high)o Creatinine 91 mmol/L (normal)o

Cholesterol 2.5 mmol/L(normal)o Triglycerides 2.57 mmol/L

(high)o HDL 0.3 mmol/L (low)


Still for the following laboratorystudies:

CXR-PA

Lumbo-Sacral X-Ray

UA

Blood GS/CS

HBA1C

2D echo with Doppler

Variance

Financial Problem

Unavailability within hospitalfacility

05/04/117th day

05/05/118th day


45/45

ASSESSMENT Phil Health Ward (FMW)


o Temp 37.80c

GCS 8 (E-4,V-1,M-3)

Lethargic, Awake Blank stare

Febrile

CBG 356 mg/dL(6am)

With ongoing D5W 500cc x 16 @ left hand (150cclevel)

Hooked to O2 via nasal cannula at 4 lpm

(-) DOB

(+) Crackles

(+) LBM (yellow brown watery stools, 5x BM)



o Temp 37.40c

GCS 8 (E-4,V-1,M-3)

Lethargic, Awake Blank stare

CBG 359 mg/dL(6am)

With ongoing D5W 500cc x 16 @ left hand(250cc level)

Hooked to O2 via nasal cannula at 4 lpm

(-) DOB

(+) Crackles

LABORATORY

PROCEDURES

Phil Health Ward

Still for the following laboratory studies:

CXR-PA (for results)

UA (for results)

2D echo with Doppler (done and for results)

Lumbo-Sacral X-Ray

For the following laboratory study:

Fecalysis

Variance

Financial Problem Unavailability within hospital facility

Phil Health Ward

Still for the following laboratory studies:

CXR-PA (for results)

UA (for results)

2D echo with Doppler (for results)

Fecalysis (for results)

Lumbo-Sacral X-Ray

Variance

Financial Problem

Unavailability within hospital facility

MEDICATIONS Phil Health Ward (FSXW)

Continue medications ordered:

Amlodipine 10mg OD

Metronidazole500mg TIV q 8

Ampi-Sulbactam 750mg TIV q 8

Ranitidine 50mg TIV q 8

Clopidogrel 75mg/tab 1 tab OD

Lactulose 30cc q HS Sinemet 1tab OD

Phil Health Ward (FSXW)

Continue medications ordered:

Amlodipine 5mg OD

Metronidazole500mg TIV q 8

Ampi-Sulbactam 750mg TIV q 8

Ranitidine 50mg TIV q 8

Clopidogrel 75mg/tab 1 tab OD

Lactulose 30cc per orem OD Sinemet 1tab OD

Grand Case Presentation Repaired)

Documents

Transcript of Grand Case Presentation Repaired)