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CASE STUDY on
OBJECTIVES
General Objectives:
Be capable enough to acquire knowledge about
PATIENTS PROFILE
PATIENTS PROFILE
Service: Name: Age: Male Medical Ward Mr. BJ 65 years old Occupation: Farmer Chief Complain: Difficulty of Breathing Admission Date: September 1, 2012 Attending physician: Dr. Glenn Isip Date of Discharge: September 6, 2012 Length of stay: 5 days Admitting Diagnosis:
Civil Status:
Religion: Nationality:
Separated
Roman Catholic Filipino
Educational Level:
Elementary Graduate
Cardiomegaly, Severe
MEDICAL HISTORY
wife also told that Mr. JB has swelling at both legs. There
is no other complaint that Mr. JB and wife had been mentioning or experiencing.
Vital Signs:
T: 35.3 C
P: 130 BPM R: 20 BPM
Wt: 58kg
Ht: 58
Surgeries: None
Accidents: None Allergies: None
because of Hepatitis.
Lifestyle
Mr. BJ is now 65 years old, due to difficulty of breathing he was not able to perform his daily activity such as exercise and different household chores, he also stop smoking and drinking of alcoholic beverages, eats food like vegetables, fruits, rice and sometimes meat.
CEPHALO-CAUDAL ASSESSMENT
CEPHALO-CAUDAL ASSESSMENT
HEAD/SKULL
is proportional to the size of the body, round, with prominences in the frontal and the occipital area, has dizziness is white, clean and free from masses, lumps and scar, nits, dandruff and any lesions is white and some are black in color and thinning, hair strands are fine and evenly distributed is round-shaped, symmetrical, and wrinkles are present, no involuntary muscle movements
SCALP
HAIR
FACE
CEPHALO-CAUDAL ASSESSMENT
EYES
are parallel and evenly placed, symmetrical, nonprotruding, both eyes are brown and clear, able to move in all direction, able to see/read, Pupils are Equal, Round and Reactive to Light and Accommodation, pale conjunctiva
EARS
NOSE
CEPHALO-CAUDAL ASSESSMENT
MOUTH LIPS
GUMS
TEETH TONGUE UVULA
CEPHALO-CAUDAL ASSESSMENT
NECK
is proportional to the size of the body and head, symmetrical and straight, no palpable lumps, masses, or areas of tenderness, free movable without difficulty, symmetrical and able to resist force, has distended neck vein chest contour is symmetrical, spine is slightly bent forward, chest wall moves symmetrically during respiration - no lumps, masses, areas of tenderness, sides of the thorax expand symmetrically - wheezing sounds heard at both lungs
CEPHALO-CAUDAL ASSESSMENT
ABDOMEN - no scar, color is uniform, symmetrical movements caused by respiration, and color is the same as the surrounding skin - percussion is dull at the livers lower boarder - soft abdomen, no lumps or masses - tenderness in the lower abdomen, guarding behavior HEART
MUSCUSKELETAL
muscle weakness
CEPHALO-CAUDAL ASSESSMENT
UPPER EXTREMITIES ARM
PALM NAILS
skin color is Tan, symmetrical, thin of hairs, there are visible veins, fingers are symmetrical warm, moist and there is loss of elasticity, there are no areas of tenderness pallor and warm convex curvature, smooth texture, pale nail beds and it takes more than 3 seconds before it turns back to its original color
CEPHALO-CAUDAL ASSESSMENT
LOWER EXTREMITIES LEGS
skin is tan, dry, absence of hair, length symmetrical, there is presence of edema on feet with a scale of 3+ (deep pitting, indentation remains for a short time, leg looks swollen), warm and poor muscle tone five toes in each foot, sole have rough surface, nail beds are pale
TOES
Findings: Markedly enlarged cardiac shadow, partial densities at both hilar area and left lower lung field, minimal acceleration of costophrenic markings. Impressions: 1. Cardiomegaly, Severe 2. Chronic Bronchitis with Bibasal Pneumonia
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
Modifiable Factors
smoking
stress
History of Hypertension MYOCARDIAL DYSFUNCTION
over-exercise
alcohol abuse
Non-modifiable Factors
age
heredity
PATHOPHYSIOLOGY
MYOCARDIAL DYSFUNCTION decreased CO decreased systemic BP decreased tissue perfusion
LSCHF
RAAS stimulation
Activation of Baroreceptor
PULMONARY EDEMA
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
Activation of Baroreceptor
PATHOPHYSIOLOGY
LSCHF
decreased myocardial contractility RV Signs & Symptoms: JVD Fatigue Pitting Edema Weight gain S3 Sound
Increased RA pressure
RSCHF
ASSESSMENT/CUES
SUBJECTIVE: (none) OBJECTIVE:
Decreased cardiac output may be related to altered myocardial contractility /inotropic changes.
Modifiable factors such as prolonged smoking and alcoholism Myocardial dysfunction Decreased myocardial contractility Decreased cardiac output
PLANNING
SHORT TERM:
decreased CO
1. Administer supplemental
oxygen as indicated.
prescribed.
-treatment for atrial
fibrillation
EVALUATION
SHORT TERM: After 8 hours of interventions, the patients pulse rate decreases from 130bpm to 93bpm, and a BP of 120/90 from 90/70mmHg. -goal met.
LONG TERM:
Goal partially met
ASSESSMENT/CUES
Subjective: Minsan, nahihirapan akong huminga, as verbalized by the pt. Objective: Patient manifested: -(+) DOB AEB RR= 20 CPM with pale conjunctiva and nail beds -productive cough -wheezing
PLANNING
After 8 hours of nursing interventions, the patient will be able to demonstrate improvement in gas exchange AEB a decrease in respiratory rate from 20 cpm to 16 cpm
nail bed
-to assess if theres a presence of peripheral cyanosis. 5. Promote adequate rest periods -rest will prevent fatigue and decrease oxygen demands for metabolic demands
EVALUATION
After 8 hours of nursing intervention the
patients respiratory rate decreases from 20 cpm
to 18cpm.
-goal met.
ASSESSMENT/CUES
Subjective:(none) Objective:
PLANNING
Short Term:
weights.
-Body weight is a sensitive indicator of fluid balance
excess.
DEPENDENT:
1. Administer diuretics (Furosemide) as
ordered.
-To decrease fluid overload
EVALUATION
Short Term: Pt. verbalized understanding of causative factors and demonstrate behaviors to resolve excess fluid volume.
Long Term:
Pt demonstrated adequate fluid balance AEB output equal
ASSESSMENT/CUES
SUBJECTIVE: Masanit ang tiyan ko sa parte ng gitna, as verbalized by the pt. OBJECTIVE:
PLANNING
EVALUATION
After 8 hours of nursing intervention, the patient verbalized alleviation of pain, pain scale of 3/10.
ASSESSMENT/CUES
SUBJECTIVE:
-restlessness
NDx: Risk for falls related to inadequate cerebral perfusion AEB dizziness.
PLANNING
After 8 hours of nursing intervention the patient will be prevented from injury and the patient will verbalize absence of dizziness.
EVALUATION
After 8 hours of nursing intervention, the patient was free from injury.
DRUG STUDY
DISCHARGE PLAN
MEDICATION
Advice/instruct the client to continue medication that are prescribed by the physician and their actions.
Instruct
the
patient
or
the
significant
others
for
any
observable alterations on the patient condition. Emphasize to the client the side effects of the different
medications to be taken.
Reinforce importance of medication regimen Discuss medications frequency, action,contraindication, doses and adverse reactions.
EXERCISE
Instruct the patient to perform leg exercise as tolerated such as walking to facilitate mobilization on lower extremities.
THERAPY
Instruct the patient to continue medication. Also, activities of daily living and selfto encourage
important
maintenance of hygiene. Explain cautiously the different side effect of some drugs to be taken.
HEALTH TEACHING
Encourage the patient to eat foods rich in
vitamins and minerals/ nutritious food
OUT-PATIENT CARE
Instruct the client to come back for follow-up
the medication.
DIET
Advised the patient that a low-sodium diet Advise client to limit how much fluid intake. Remember: things like ice cream, Jell-O, or ice
such as
immunity components.
SPIRITUAL COUNSELING
Encourage the patient learn to responsibility for mental, and spiritual accept their own physical, emotional, healing.
activities
Make God as the center of life
THANK YOU!