Beruflich Dokumente
Kultur Dokumente
Name of Student _________Section B_________________________ Clinical Instructor _Sir Rambe Ramel Jr.___________________
Area of Assignment Medicine ward (Male senior citizen ward) Date Submitted __July 12, 2012_________________________
NURSING ASSESSMENT I
PATIENT’S PROFILE
Name Patient X______ Address Lacob, Dalipuga, Iligan City Age 76 years old
Sex male Religion Roman Catholic Civil Status Widow Occupation farmer
HEALTH HABITS
A. CHIEF COMPLAINTS
Difficulty of Breathing
B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and
vocational responsibilities, affected diagnoses}.
Present condition started 15 days prior to admission; patient experienced an onset of cough, productive with yellowish phlegm, associated with dysphagia, difficulty opening the
mouth, difficulty speaking due to lockjaw which later associated with difficulty breathing, until patient seek consultation to Mindanao Sanitarium Hospital, and was subsequently
admitted, patient was diagnosed with Tetanus, nosocomial infection, S/P Tracheostomy & stage II hypertension, then he was referred after 14 days to GregorioT. Lluch Memorial
hospital or GTLMH.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth
and developmental history, nutrition- for pedia)
Patient has no history of infectious disease or major illness, he was hospitalized before at Mindanao Sanitarium Hospital due to cough in 2002 and he had an operation performed
on his eye to remove cataract in 1988, he has no major illness, no known allergies, and he was taking multivitamins which cannot be recall by the SO.
1. Present Illness
N/A
2. Hospital Environment
N/A
E. SUMMARY OF INTERACTION
The interaction with the so and the patient was a very challenging one, the patient was unable to talk, he can only respond or answer to the student-nurse by nodding his head, so all if
not, most of the information were from the SO, the So was so cooperative and was really willing to provide the answers to the student-nurse’s question, she was very cooperative in answering
the questions asked by the student-nurse, thought there is a language barrier the Student-nurse was able to get the necessary information from the SO and the patient as well. In general the
interaction was a very informative one.
REVIEW OF SYSTEMS
Respiration 40 cpm
Blood Pressure
110/70 mmHg
The patient is generally weak, conscious but not oriented to time, place and person. Patient is lying on the bed
most of the time and is wearing white pajamas that cover his extremities. Patient skin was dry with some
rashes noted. There are many tattoos on his body, he looks old with white hair and with not firm skin, Facial
1.GENERAL
grimace noted when moving extremities even if it’s just too little movement. Poor grooming noted. With
tracheoostomy inserted and nasogastric tube.
H- head is normocephalic, with lesion noted, px hair become white due to aging. Patient had no previous head
injury, hair is not combed. Presence of scars noted, some dandruffs noted.
E- Eyes are symmetric in shape, pale palpebral conjunctiva, pupils are equally round and not reactive to light
and accommodation, patience could not able to follow 6 cardinal gaze, he is not wearing any eye glasses or
any eye wear. And with Presence of lesions and discharges.
2. HEENT E- ears are symmetric in shape on both sides, and in line with outer canthus of eyes, no lesions noted , no ear
ache reported, small cerumen formation was inspected during inspection, and with no presence of swelling
N-patient’s nose was inserted with naso gastric tube, (-) discharges and secretion. Patient’s ability to smell
and distinguish odor were not assessed.
T- throat was inserted tracheostomy to facilitated easy expulsion of secretion, patient cannot masticate foods
and suffering from dysphagia.
Patient skin is dry, no hair noted on the skin of the extremities just tiny hairs, patient skin is warm to touch,
hair of the head is white-black in color,
Patient nails are not cut and dirty
Edema presence on the lower extremities
3. INTEGUMENTARY
Patient had freckles noted on the face.
RR 4O with adventious breath sound(crackles) heard upon auscultation, patient experience cough and difficulty of breathing,
4. RESPIRATORY Equal chest expansion and crackles breath sound heard upon auscultation, no deformities in chest, patient sometimes is tachypnic.
Pulse palpated on both hands with the same rate, Pulse rate is 99bpm with strong palpable pulse appreciated at both hands, BP 120/80mmhq.
5. CARDIOVASCULAR Pulse pressure of 40 mmHg, capillary refill of 2 seconds, temporal was not heard upon auscultation, Patient had a hypertension stage 2
Patient was on a “Full Adult diet”, he only consume foods prepared by the hospital, he has lesions on his oral mucosa, due to lockjaw, patient’s
6. DIGESTIVE oral mucosa is dry because it is always expose to air, no denture was observed, patient’s teeth are yellow in color with some brown portion noted,
since patient can’t move he was in a diaper , no abdominal mass was palpated, Abdomen is flat and soft, patient’s stool is usually yellow to brown
in color, and is semi-formed to watery in texture.
Patient generally weak, Patient is not ambulatory, patient was not able to move,
Patient is lying on bed at all times,
8. MUSCULOSKELETAL Muscle strength of 1/5 on the upper and lower extremities,
(+) muscle spasm
Patient is awake but not oriented to time, place, and person.
9. NERVOUS Some of the 5 senses are still functioning while other are not assessed due to the condition of the patient
EYES: unable to follow 6 cardinal gaze but patient gaze at his SO whenever the SO touches his
EARS: patient respond to verbal question by nodding head
NOSE: not assesses
TASTE: unable to masticate food, not assessed
SKIN: warm to touch, patient stares at the SO and SN whenever they touch him.
Weight and height are not taken
No history of goiter.
10. ENDOCRINE No enlargement of thyroid
Skin is slightly warm to touch; no eyeball protrusion skin color is no yellowish but is brown in complexion.
DRUG STUDY
BRAND NAME GENERIC Prescribed and Mechanism
NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration
B: Cipro P: 2oo mg IVTT q 12 hours Inhibits bacterial DNA Indicated for treating Contraindicated in Headache, dizziness, Check culture and
synthesis, mainly by infections like UTI, patients with known insomnia, depression, sensitivity reports
G: Ciprofloxacin R: 400 mg IVTT q 12 hours blocking DNA gyrase; allergy to any fever, rash, to ensure that
respiratory tract infection,
bactericidal fluoroquinolone and in photosensitivity this is the drug of
C: Antibacterial and skin infections that
pregnant or lactating choice for the
(Fluoroquinolone) are caused by susceptible women and cautions patient.
strains of gram-negative should be used in the
bacteria including E. coli, presence of renal Monitor renal
K. pneumoniae, P. dysfunction function tests
aeruginosa, group D. before initiating
therapy to
streptococci etc.
appropriately
arrange for
dosage reduction
if necessary
Be aware of drug-
interactions, to
avoid decreasing
drug’s effects.
Long-term
therapy nay result
in overgrowth of
organisms
resistant to
ciprofloxacin
.
Mucolytic agent in
Decreases viscosity of adjunctive treatment of
B: Acetadote P: 600 mg in 1\2 glass of secretions, promoting Hypersensitivity to drug Headache, hypotension,
acute and chronic hypertension, chest
water\NGT OD @ HS secretion removal through
G Acetylcysteine coughing, postural bronchopulmonary tightnss
R: drainage and mechanical disease like pneumonia
C: Mucolytic, Instruct patient to
means. In acetaminophen
acetaminophen antidote: report worsening
overdose, maintainsand
restores hepatic cough, and other
glutathione, needed to respiratory
inactivate toxic symptoms
metabolites
:
NURSING ASSESSMENT II
DAY 1 DAY 2
2.NUTRITIONAL- METABOLIC
The patient has no diet restriction, The patient’s diet is “Full Adult Diet”, The patient’s diet is “Full Adult Diet”, The patient’s diet is “Full Adult Diet”,
a. Typical intake(food, fluid) he just eat what he wants, and he is he only consume foods (Ensure) he only consume foods (Ensure) he only consume foods (Ensure)
fond of fruits and vegetables, he prepared by the hospital, he is being prepared by the hospital, he is being prepared by the hospital, he is being
b. Diet
eats a lot of rice, he is also fond of fed via NGT or nasogastric tube fed via NGT or nasogastric tube fed via NGT or nasogastric tube
c. Diet restrictions eating meat such as chicken, pork because patient has difficulty because patient has difficulty because patient has difficulty
and cow meat swallowing, due to lockjaw. swallowing, due to lockjaw. swallowing, due to lockjaw.
d. Weight (Weight was not taken) (Weight was not taken) (Weight was not taken) (Weight was not taken)
Patient was taking multivitamins Patient was given medication via Patient was given medication via Patient was given medication via
e. Medications/supplement which can’t be recalled by the SO. NGT, and the medication is NGT, and the medication is NGT, and the medication is
food sucralfate. sucralfate. sucralfate
3. ELIMINATION The patient usually urinate three to
four times a day, usually the color of The patient had a urine at 300 mL; The patient had a urine output of The patient had a urine output of
the urine according to the SO is urine is amber in color and is 200 mL; urine is amber in color and 500 mL; urine is amber in color and
a. Urine (frequency, color, amber in color and is transparent. transparent. is transparent. is transparent.
transparency) The patient usually defecates one to
two times a day, and the waste or The patient has not defecated The patient has not defecated The patient has defecated once
stool is usually yellow to brown in during the shift. during the shift. during the shift, the stool is slightly
b. Bowel (frequency, color, color, sometimes the stool is quite watery and yellow and brown in
consistency) watery but most of the time it is color.
formed.
4. EGO INTEGRITY The patient was a very active 76
year old man, he is a very caring
a. Perception of self grandfather according to the SO, The patient perception of self was The patient perception of self was The patient smiles when ever his SO
and when every time he is sad, he not assesses because patient can’t not assesses because patient can’t jokes around or asks him funny
b. Coping Mechanism talk. Though it can be seen that he’s talk. Though it can be seen that he’s things. His family members are
just plays with his grandchildren or
drink with his friends. The patient is sad and having hard time due to his sad and having hard time due to his acting as his support system since
c. Support System
also supported by his family condition and his family members condition and his family members his wife is gone. He is starting to
d. Mood/Affect members such as his children, are acting as his support system are acting as his support system have brighter facial expression.
nieces, nephews and grandchildren since his wife is gone. since his wife is gone.
5. NEURO-SENSORY
Patient is mentally capable, there Patient is lethargic, he only respond Patient is awake but drowsiness Patient is awake and respond to
a. Mental state were no visible abnormalities to painful or sudden touch by the noted. verbal stimuli (questions) by
reported or discovered according to SO, nodding, he also respond to visual
stimuli (hand movement) assesses
the SO.
b. Condition of five senses: The sense of touch, sight, and by asking patient if he has seen a
According to the SO, before Senses were not assessed hearing are functioning he responds hand, then patient respond by
(sight, hearing, smell, taste, to touch, movement of hand (sight) nodding means yes, the patient also
hospitalization the patient has no
and voice of the SO and the student- respond to touch, because he always
touch) impairment in five senses reported nurse. have facial grimace whenever SO
or discovered, so all five senses are Smell and taste were not assessed suddenly move a limb of the patient.
functioning
6. OXYGENATION
a. Vital signs
7. PAIN-COMFORT The patient shows facial grimace The patient shows facial grimace
According to the SO the patient The patient shows facial grimace whenever the SO suddenly move a whenever the SO suddenly move a
a. Pain (location, onset,
usually experience headache and whenever the SO suddenly move a limb of the patient. limb of the patient.
character, intensity, duration,
muscle aches. It is usually alleviated limb of the patient.
associated symptoms,
by sleeping or taking mefenamic Pain is alleviated through Pain is alleviated through
aggravation)
acid or paracetamol Pain is alleviated through touch(gentle tapping) of the touch(gentle tapping) of the
touch(gentle tapping) of the patient’s daughter. patient’s daughter.
patient’s daughter.
b. Comfort
Medication taken by the patient
measures/Alleviation
were multivitamins, mefenamic ND Medications:
Paracetamol.
c. Medications
The patient is confined on his bed The patient is confined on his bed
8. HYGIENE AND ACTIVITIES The patient usually wake up early to The patient is confined on his bed due to his present condition, he due to his present condition, he
OF DAILY LIVING work or visit his relatives around the due to his present condition, he spends most of his time on bed, he spends most of his time on bed, he
town, then goes back home in the spends most of his time on bed, he spends most of his time sleeping or spends most of his time sleeping or
evening, he takes a bath once a day, spends most of his time sleeping or resting. resting.
and changes clothes every day too, resting. The SN provided afternoon care and The SN provided afternoon care,
he is the one attending to his The personal hygiene of the patient helped the patient change clothes. while the SO helped the patient
hygiene, he usually sleep early in the is performed and maintained by the change clothes.
evening, according to the SO the patient’s SO, the SO helps the
patient spends too much time patient change clothes.
grooming before going outside their
house.
9. SEXUALITY
DIFF. COUNT:
Neutro 0.78 0.55-0.65 Above: acute infection
Monitor pts condition and and
assess further aggravation of
infection
Promote proper handwashing and
proper disposal of waste
Lympho 0.15 0.25-0.40
Below: immunodeficiency
Have respiratory precautions in
handling pt.
Keep pt. away from other pts with
Eosino 0.05 0.01-0.05 infection
Within normal range
Platelet count 563 140-440x1012/L
Above: injury
Observe for signs of bleeding
Encourage adequate nutrition and
fluid intake
BLOOD CHEMISTRY
DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED
COMPUTATION:
= 25 hours
SUMMARY OF MEDICATION
DATE MEDICATIONS- dosage, frequency, route Remarks
July 3-6, 2012 Ciprofloxacin 2oo mg IVTT q 12 hours GIVEN, Taken and Tolerated
July 3-5, 2012 Meropenem 500 mg IVTT q 8 hours GIVEN, Taken and Tolerated
July 3-6,2012 Sodium chloride 1 g 2 tabs PO TID GIVEN, Taken and Tolerated
July 3-6,2012 Acetaminophen 300mg 1 amp q 4 hours prn GIVEN, Taken and Tolerated
July 3-6,2012 Acetylcysteine 600 mg in 1\2 glass of water\NGT OD @ HS GIVEN, Taken and Tolerated
Amikacin 300mg IVTT q 8 hours ANST(-) ___(revised) GIVEN, Taken and Tolerated
July 3-4,2012
Levofloxacin 500mg tab OD GIVEN, Taken and Tolerated
July 3-6,2012
Amikacin 1amp IVTT q 8 hours ANST(-) GIVEN, Taken and Tolerated
July 4-6,2012
Paracetamol 300mg IVTT q 4h (PRN for fever) GIVEN, Taken and Tolerated
July 3-6,2012
Ipratropium bromide + albuterol SO4 GIVEN, Taken and Tolerated
July 3-6,2012
Clonidine 75mg ~ tab q 8h GIVEN, Taken and Tolerated
July 3-6,2012
Baclofen 10mg ~tab BID GIVEN, Taken and Tolerated
July 3-6,2012
Domperidon ~ tab TID GIVEN, Taken and Tolerated
July 3-6,2012
Sucralfate ~ gm q 6h per NGT GIVEN, Taken and Tolerated
July 3-6,2012
Muperocin BID GIVEN, Taken and Tolerated
July 3-6,2012
Azithromycin 500mg tab OD per NGT GIVEN, Taken and Tolerated
July 3-6,2012
Ranitidine 50mg IVTT q 8h GIVEN, Taken and Tolerated
ANATOMY AND PHYSIOLOGY
The respiratory system is an intricate arrangement of spaces and passageways that conduct
Air from outside the body into the lungs and finally into the blood as well as expelling waste
gases. This system is responsible for the mechanical process called breathing with the average
adult breathing about 12 to 20 times per minute.
Alveoli
Are tiny sacks that are enveloped in a network of capillaries.
Nostrils/Nasal Cavities
During inhalation, air the nostrils and passes into the nasal cavities where foreign bodies
are removed, the air is heated and moisture before it is brought further in the body.
Sinuses
Are small cavities that are lined with mucous membrane within the bones of the skull.
Pharynx/Throat
Carries food and liquid into the digestive tract and air in the respiratory tract.
Larynx/Voice Box
Located between pharynx and trachea. It is the location of adam’s apple, which is the
Thyroid gland and houses the vocal cords.
Trachea/ Wind Pipe
Is a tube that extends from the lower edge of the larynx to the upper part of the chest
And conducts air between the larynx and lungs.
Lungs
Organ which the gases takes place. At the lungs, the bronchi subdivide becoming
smaller as they branch through the lung tissue, until they reach the air sacks called
alveoli.
Bronchi
The trachea divides into two parts called bronchi which enters the lungs.
Bronchioles
During subsequent development, the three primary brain vesicles develop into five secondary brain vesicles. The names of these vesicles and the major adult structures that
develop from the vesicles follow (see Table 1):
The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia).
The diencephalon generates the thalamus, hypothalamus, and pineal gland.
The mesencephalon generates the midbrain portion of the brainstem.
The metencephalon generates the pons portion of the brainstem and the cerebellum.
The myelencephalon generates the medulla oblongata portion of the brainstem.
The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part of the brain, the
cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions:
o A gyrus (plural, gyri) is an elevated ridge.
The deeper fissures divide the cerebrum into five lobes (see Figure 1; most lobes are named after bordering skull bones): the frontal lobe, the parietal lobe, the temporal
lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain.
A cross section of the cerebrum shows three distinct layers of nervous tissue (see the list below and Figure 2):
o The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control of skeletal muscles occur
here. These activities are grouped into motor areas, sensory areas, and association areas.
o The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres (association fibers), connect gyri
within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association
fibers that forms a nerve tract that connects the two cerebral hemispheres.
o Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major regions in the basal ganglia—the caudate
nuclei, the putamen, and the globus pallidus—are involved in relaying and modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm
swinging while walking, for example, is controlled here.
The diencephalon connects the cerebrum to the brainstem. It consists of the following major regions:
o The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve impulses are sorted and grouped here before
being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and sensitivity to temperature, are also evaluated here.
o The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological clock (sleep-wake cycles).
o The hypothalamus regulates numerous important body activities. It controls the autonomic nervous system and regulates emotion, behavior, hunger, thirst, body
temperature, and the biological clock. It also produces two hormones (antidiuretic hormone or ADH, and oxytocin) and various releasing hormones that control
hormone production in the anterior pituitary gland.
The following structures are either included or associated with the hypothalamus:
o The mammillary bodies relay information related to eating, such as chewing and swallowing.
o The infundibulum connects the pituitary gland to the hypothalamus.
o The optic chiasma passes between the hypothalamus and the pituitary gland. Here, portions of the optic nerve from each eye cross over to the cerebral hemisphere
on the opposite side.
The brainstem connects the diencephalon to the spinal cord. The brainstem resembles the spinal cord in that both consist of white matter fiber tracts surrounding a core of
gray matter. The brainstem consists of the following four regions, all of which provide connections between various parts of the brain and between the brain and the spinal
cord. (Some prominent structures of the brainstem regions are listed in Table 2 and illustrated in Figure 3, which also illustrates the relationship of the cranial nerves to the
brainstem.)
Anatomy and physiology of urinary system
The urinary system comprises the kidneys, ureters, bladder, and urethra. A thorough understanding of the urinary system is necessary for assessing individuals with acute or
chronic urinary dysfunction and implementing appropriate nursing care.
Anatomy of the Upper and Lower Urinary Tracts The urinary system—the structures of which precisely maintain the internal chemical environment of the body—perform various
excretory, regulatory, and secretory functions.
The kidneys are a pair of brownish-red structures located retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen from the 12th thoracic
vertebra to the 3rd lumbar vertebra in the adult
An adult kidney weighs 120 to 170 g (about 4.5 oz) and is 12 (about 4.5 inches) long, 6 cm wide, and 2.5 cm thick. The kidneys are well protected by the ribs, muscles, Gerota’s fascia,
perirenal fat, and the renal capsule, which surround each kidney.
The kidney consists of two distinct regions: Renal Parenchyma Renal Pelvis
The renal parenchyma is divided into the cortex and the medulla. The cortex contains the glomeruli, proximal and distal tubules, and cortical collecting ducts and their adjacent
peritubular capillaries. The medulla resembles conical pyramids. The pyramids are situated with the base facing the concave surface of the kidney and the apex facing the hilum, or pelvis
Renal Parenchyma
The hilum, or pelvis, is the concave portion of the kidney through which the renal artery enters and the renal vein exits. The renal artery (arising from the abdominal aorta) divides into
smaller and smaller vessels, eventually forming the afferent arteriole. Renal Pelvis
The afferent arteriole branches to form the glomerulus , which is the capillary bed responsible for glomerular filtration. Blood leaves the glomerulus through the efferent arteriole and
flows back to the inferior vena cava through a network of capillaries and veins. Renal Pelvis
Each kidney contains about 1 million nephrons, the functional units of the kidney. Each kidney is capable of providing adequate renal function if the opposite kidney is damaged or
becomes nonfunctional. Nephrons
The nephron consists of a glomerulus containing afferent and efferent arterioles, Bowman’s capsule, proximal tubule, loop of Henle, distal tubule, and collecting ducts. Collecting ducts
converge into papillae, which empty into the minor calices, which drain into three major calices that open directly into the renal pelvis. Nephrons
Nephrons are struturally divided into two types: cortical and juxtamedullary.
The glomerular membrane normally allows filtration of fluid and small molecules yet limits passage of larger molecules, such as blood cells and albumin. Kidney function begins to
decrease at a rate of approximately 1% each year beginning at approximately age 30.
The glomerulus is composed of three filtering layers: the capillary endothelium, the basement membrane, and the epithelium.
Kidneys • Urine formation • Excretion of waste products • Regulation of electrolytes • Regulation of acid–base balance • Control of water balance • Control of blood pressure • Renal
clearance • Regulation of red blood cell production • Synthesis of vitamin D to active form • Secretion of prostaglandins
Ureters Urine, which is formed within the nephrons, flows into the ureter, a long fibromuscular tube that connects each kidney to the bladder. The ureters are narrow, muscular
tubes, each 24 to 30 cm long, that originate at the lower portion of the renal pelvis and terminate in the trigone of the bladder wall.
There are three narrowed areas of each ureter: ureteropelvic junction ureteral segment ureterovesical junction
The angling of the ureterovesical junction is the primary means of providing antegrade, or downward, movement of urine, also referred to as efflux of urine. This angling prevents
vesicoureteral reflux, which is the retrograde, or backward, movement of urine from the bladder, up the ureter, toward the kidney. ureterovesical junction
The angling of the ureterovesical junction is the primary means of providing antegrade, or downward, movement of urine, also referred to as efflux of urine. This angling prevents
vesicoureteral reflux, which is the retrograde, or backward, movement of urine from the bladder, up the ureter, toward the kidney. ureterovesical junction
During voiding ( micturition), increased intravesical pressure keeps the ureterovesical junction closed and keeps urine within the ureters. As soon as micturition is completed,
intravesical pressure returns to its normal low baseline value, allowing efflux of urine to resume. Therefore, the only time that the bladder is completely empty is in the last seconds of
micturition before efflux of urine resumes.
The angling of the ureterovesical junction is the primary means of providing antegrade, or downward, movement of urine, also referred to as efflux of urine. This angling prevents
vesicoureteral reflux, which is the retrograde, or backward, movement of urine from the bladder, up the ureter, toward the kidney. ureterovesical junction
The left ureter is slightly shorter than the right” Did Y OU k now ?
The lining of the ureters is made up of transitional cell epithelium called urothelium. As in the bladder, the urothelium prevents reabsorption of urine. The movement of urine
from the renal pelves through the ureters into the bladder is facilitated by peristaltic waves (occurring about one to five times per minute) from contraction of the smooth muscle in the
ureter wall (Walsh, Retik, Vaughan & Wein, 1998).
Ureters functions as tubes that actively convey urine from the kidneys to the bladder.
The urinary bladder is a muscular, hollow sac located just behind the pubic bone. The bladder is characterized by its central, hollow area called the vesicle, which has two inlets
(the ureters) and one outlet (the urethrovesical junction), which is surrounded by the bladder neck.
Adult bladder capacity is about 300 to 600 mL of urine. In infancy, the bladder is found within the abdomen. In adolescence and through adulthood, the bladder assumes its position in
the true pelvis.
The wall of the bladder comprises four layers: adventitia detrusor lamina propria urothelium
The urothelium layer is specialized, transitional cell epithelium, containing a membrane that is impermeable to water. The urothelium prevents the reabsorption of urine stored in the
bladder urothelium
The bladder neck contains bundles of involuntary smooth muscle that form a portion of the urethral sphincter known as the internal sphincter. The portion of the sphincteric mechanism
that is under voluntary control is the external urinary sphincter at the anterior urethra, the segment most distal from the bladder (Walsh et al., 1998).
The urinary bladder functions as a muscular sac that expands as urine is produced by the kidneys to allow storage of urine until voiding is convenient.
The urethra arises from the base of the bladder: In the male, it passes through the penis; in the female, it opens just anterior to the vagina. In the male, the prostate gland, which lies
just below the bladder neck, surrounds the urethra posteriorly and laterally.
The urethra is a muscular tube that drains urine from the body; it is 3–4 cm long in females, but closer to 20 cm in males.
The cardiovascular system is a continuation of that oxygenation process. The heart pumps blood through a closed system of blood vessels in order to bring oxygen and other nutrients to the cells
throughout the body.
In part I of the cardiovascular system we will gain an understanding of the various parts of this system and then put these organs together to gain an understanding of how blood is circulated
through the body.
The heart
Blood vessels including arteries, capillaries, and veins
Blood
The Heart
The heart is a muscular organ made up of involuntary striated muscle tissue. It is located in the thoracic cavity in between the lungs and just above the diaphragm. It is covered in protective
membranes called the pericardium. Besides forming a protective layer, these membranes also secrete a fluid that helps to reduce friction as tissues rub together during heart contractions.
The next layer of the heart is a thick layer of cardiac muscle tissue called the myocardium. It is the contraction of the myocardium that creates the force necessary to pump blood through the
body.
Attached to the outer surface of the myocardium is the epicardium. This membrane consists of blood vessels that nourish the heart.
Blood Supply
The heart is supplied blood through the coronary arteries, which come off of the aortic artery. Blockage of the coronary artery is what causes a heart attack.
There are four chambers in the heart. The two upper chambers are called the atria. They receive blood from the veins. The two lower chambers are the ventricles. Blood is pumped from the
ventricles to the arteries and to the rest of the body. The heart consists of two pumps. The left atrium and left ventricle is the left pump. The right atrium and the right ventricle is the right pump.
There is no opening between the atria or between the ventricles. Instead, there are valves in between the atria and the corresponding ventricles.
There are two types of valves located in the heart: the atrioventricular valves and the semilunar valves. The atrioventricular valves are located between each atrium and its corresponding
ventricle. These valves allow blood to flow from the atrium to the ventricle without allowing any blood to flow backwards from the ventricle to the atrium. The two atrioventricular valves are the
tricuspid valve and the mitral valve.
Semilunar valves are located in the arteries that carry blood from the ventricles to the rest of the body. The two semilunar valves are called the pulmonary semilunar valve and the aortic
semilunar valve.
The sound we associate with the heartbeat is actually the closing of the heart valves. “Lub-dub” is the sound often used to describe the sound of the heartbeat. The first sound, “lub”, is the sound
of the atrioventricular valves closing. The second sound, “dub”, is the sound of the semilunar valves. If any of the heart valves are not working correctly then another sound might be heard. This
is referred to as a heart murmur.
Blood vessels
There are three main types of blood vessels. Arteries, capillaries, and veins form a system of tubes that carry blood to and from the heart. The blood vessels form an incredible network of tubes
throughout the body. An adult has as many of 100,000 miles of blood vessels in their body.
Arteries
These large blood vessels are made of a thick muscular layer to withstand higher blood pressure. They carry blood from the heart to the capillaries.
Capillaries
Capillaries form a vast network of very small vessels that enable the exchange of materials between blood and the tissue cells. The term capillary bed refers to a network of capillaries that supply
blood to an organ.
Veins
Veins return blood from the capillaries back to the heart. They are made up of a relatively thin muscular layer and contain internal valves to keep the blood from ever flowing backwards. About
60% of the blood volume is located in the veins at any given time.
Blood Flow
Deoxygenated blood from the body flows from the superior and inferior vena cava veins to the right atrium. This blood is pumped to the right ventricle and then proceeds to the pulmonary trunk
where it is oxygenated by the act of inhalation. This newly oxygenated blood then flows through pulmonary veins to the left atrium and is pumped to the left ventricle to continue to the aorta and
the rest of the body. These are referred to as the pulmonary and systemic circuits.
Assists deoxygenated blood from the right ventricle to the lungs and then
Pulmonary Circuit assists newly oxygenated blood from the lungs to the left atrium. (This is the
flow of blood between the heart and lungs.)
Assists oxygenated blood to all parts of the body (except the lungs) and then
Systemic Circuit returns deoxygenated blood to the right atrium. (This is the flow of blood
from the heart to the rest of the body.)
PATHOPHYSIOLOGY
>Work (Farming)
Vegetative Spore
Cell Lysis
Tetanolysin Tetanospasmin
Release of biochemical mediators of inflammatory response Blood vessels Lymphatics Neural Pathy
Inflammatory response Endocellar damage Depress immune system Blocks the release of inhibitory transmitters
Aspiration of oral secretions Rapid firing of impulses Fixed smile & elevated Lock Jaw
Eyebrows Failure to speak Chest wall muscle Diaphragm
or cry
Pneumonia Asphyxiation
Hypoxemia
Death
MEDICAL MANAGEMENT
IDEAL
2. Bed rest with a nonstimulating environment ( dimlight, reduced noise, and stable temperature)
5. Sedatives
6. Breathing support with oxygen, a breathing tube, and breathing tube and a breathing machine
2. Sputum specimen for culture and sensitivity should be obtained prior to initiating antibiotic therapy
3. Antiviral agents
5. Bronchodilators
6. Mucolytic agents
7. Expectorants
9. Pneumococcal vaccine
Diet: Adequate Hydration
1. Diuretic
3. Alpha1-receptor blockers
8. Direct vasodilators
1. Aminoglycosides
ACTUAL
Hematology
Differential count
Blood chemistry
June 29, 2012
Hematology
Differential count
July 3-4,2012
Lactulose 30 cc OD @ HS
Muperocin BID
July 4-6,2012
July 4, 2012
July 5,2012
IDEAL:
ACTUAL:
Infection control
Proper diet
Proper hygiene
SURGICAL MANAGEMENT
IDEAL
1. Thoracotomy - standard surgery for pneumonia. It requires general anesthesia and an incision to open the chest and view the lungs.
No surgical management
3. Malignant otitis requires for bowel necrosis, perforation, obstruction, or abscess drainage
-is an intraocular procedure in which 1- to -4 mm incisions are made at the pans plana
ACTUAL
TRACHEOSTOMY- a surgical procedure in which an opening is made into the trachea.
DISCHARGE PLAN
CONDITION UPON DISCHARGE Must be well _________ Nature: Home per request ( ) Discharge against medical advice ( )
Encourage SO not to forget to let patient take medications at right time, dosage, and route and always check for
expiration.
1. MEDICATIONS Encourage SO to keep drugs at dry, cool place.
Encourage SO not to double dose if forgotten to take medications on scheduled time.
Encourage SO to let the patient eat before taking the medications to lessen GI irritation, unless otherwise
prescribed.
Encourage SO to help monitor the medications taken.
Encourage SO to exercise the body parts of the patient.
Encourage SO to raise and elevate the legs of the patient when lying on bed to promote venous blood return.
2. EXERCISE Encourage SO to provide passive ROM.
Encourage SO to reposition patient every two hours to prevent bed sores.
Encourage adequate periods of rest and sleep to prevent fatigue.
Encourage SO to let the patient eat healthy foods such as vegetables and fruits to promote faster recovery.
Encourage increased intake of fluid to promote hydration.
3. DIET Encourage SO to follow recommended diet for the patient.
Teach SO about the importance of Infection Control such as proper hand washing.
Teach SO about the importance of practicing proper hygiene.
4. HEALTH TEACHING Provide demonstration on deep breathing exercises.
Discuss the proper way of coughing and the DO’s and DON’T’s when coughing.
S: “laayan man ko magbantay, Risk for injury r/t presence of Within my 8 hours of nursing Monitor v/s To obtain baseline
gapahangin ko sahay sa disease process, care, the patient’s data
gawas”, as verbalized by the neuromuscular impairment, environment will be modified Provide bedside care to promote comfort
SO. secondary to tetanus as indicated to enhance Monitor and regulate IVF to prevent cardiac
safety and free of injury. and fluid overload
O: 3:00pm, received patient Assess patient’s muscle to identify risk for
lying in bed in a supine strength falls
position, uncoscious, with #8
D5 0.3 NaCl, 400 cc level left, Encourage SO to to enhance
regulated @ 10 gtts/min, participate commitment to plan
hooked @ the right arm, FBC
teach SO to control the patient’s with tetanus
is @50cc level and also with
environment such as are irritable, it may
tracheostomy insertion
dimming or turning off stimulate seizure
connected with oxygen with
lights
flow rate of 1.5L/min.
teach SO to control the patient’s with tetanus
With initial v/s: are irritable, it may
environment such as
T-37.5 degree Celsius stimulate seizure
reducing the noise
P- 100bpm
production
R- 30 cpm
BP- 120/80 mmHg ask SO to stay at patient’s to prevent possible
Patient is side at all times injuries
unconscious
Patient’s watcher is make sure that the side to prevent falls
not always at the rails are up
patient’s bedside
discuss to SO the fatigue, anger,
noted
importance of monitoring irritability can
Restlessness noted
of condition or emotions contribute to
Lock-jaw noted occurrence of injury
NURSING CARE PLAN
S: “murag ga lisud siya pag Ineffective breathing pattern Within my 8 hours of nursing Monitor v/s To obtain baseline
ginhawa”, as verbalized by r/t presence of disease care, I will be able to identify data
the SO. process, neuromuscular factors that affects patients Provide bedside care to promote comfort
impairment, secondary to breathing pattern Monitor and regulate IVF
O: 3:00pm, received patient to prevent cardiac
tetanus and fluid overload
lying in bed in a supine Auscultate chest to evaluate presence
position, uncoscious, with #8 or character of breath
D5 0.3 NaCl, 400 cc level left, sounds and
regulated @ 10 gtts/min, secretions
hooked @ the right arm, FBC
is @50cc level and also with Evaluate cough
tracheostomy insertion to indicate possible
connected with oxygen with Assess for obstruction
flow rate of 1.5L/min. concomitant pain or that may restrict
discomfort respiratory effort
With initial v/s:
T-37.5 degree Celsius Encourage to promote proper
P- 100bpm positioning breathing
R- 30 cpm
Stress importance of
BP- 120/80 mmHg
good posture to SO to facilitate deeper
DOB noted respiratory effort
Modify environment to prevent
Tachypnea noted (noise reduction, irritability
dimming of light)
Cough noted
Encourage adequate to prevent fatigue
Grunting noted rest periods