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R.N. Pelaez Boulevard, Cagayan de Oro City 9000 COLLEGE OF NURSING NCM501106
In Partial Fulfillment of the Requirements In NCM501104 Related Learning Experience
A Case Presentation on
Mr. Roberto Alli, RN, MN
GOLINDANG, Kyle JALAGAT, Kristian Rey LAMELA, April Joel SABELLA, Winset Rose SANCHEZ, Adyth SHORETTE, Jun Mari Thel
Group B3 BSN 106-A February 13, 2012
Liceo De Cagayan University College of Nursing NCM104 A Case Study Mr. A. V. Submitted to Mr. Roberto Alli, RN,MN As Partial Requirement for NCM104 Submitted by Adyth P. Sanchez Name of Student
A. WRITTEN I. Introduction a) Overview of the case b) Objective of the study c) Scope and Limitation of the study II. Health History a) Profile of patient b) Family and personal health history c) History of Present Illness d) Chief Complaint III. Developmental Data IV. Medical Management a) Medical Orders and rationale b) Drug Study V. Pathophysiology with Anatomy and Physiology VI. Nursing Assessment (System Review & Nursing Assessment II) VII. Nursing Management a) Ideal Nursing Management (NCP) b) Actual Nursing Management (SOAPIE) VIII. Referrals and Follow-up IX. Evaluation and Implications X. Documentation a) Documentation of evidence of care for 1 week rotation b) Organization/ Grammar/ Bibliography Total Score Equivalent Grade
5 20 (10) (10) 10 10 30 (10) (20) 5 5 5
TABLE OF CONTENTS
I. Introduction a.) Overview of the Case b.) Objective of the Study c.) Scope and Limitation of the Study II. Health History a.) Profile of Patient b.) Family and Personal Health History c.) History of Present Illness d.) Chief Complaint III. Developmental Data IV. Medical Management a.) Medical Orders Laboratory Results b.) Drug Study V. Pathophysiology with Anatomy and Physiology VI. Nursing Assessment (System Review & Nursing Assessment II) VII. Nursing Management a.) Ideal Nursing Management (NCP) b.) Actual Nursing Management (SOAPIE) VIII. Referrals and Follow-up IX. Evaluation and Implications X. Documentation/ Bibliography
A. Overview of the Case The diverse group of neurologic disorders that make up infectious and autoimmune disorders, cranial and peripheral neuropathies present unique challenges for nursing care. Infectious processes of the nervous system sometimes cause death or permanent dysfunction. Autoimmune disorders usually have a slow, progressive course, requiring the nurse to manage symptoms and facilitate patients’ and families’ understanding of the disease process. Cranial and peripheral nerve disorders may affect the patient’s comfort, functional independence, and self-esteem. The nurse who cares for patients with these disorders must have a clear understanding of the pathologic processes and the clinical outcomes. Some of the issues nurses must help patients and families confront include adaptation to the effects of the disease, potential changes in family dynamics, and, possibly, end-of-life issues. Guillain-Barré syndrome is an autoimmune attack of the peripheral nerve myelin. The result is acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia (inability to execute voluntary movements), hyporeﬂexia, and paresthesias (numbness). In 66% of cases, there is a predisposing event, most often a respiratory or gastrointestinal infection, although vaccination, pregnancy,and surgery have also been identiﬁed as antecedent events (Bella & Chad, 1998). Infection with Campylobacter jejuni (a relatively common gastrointestinal bacterial pathogen) precedes Guillain-Barreé syndrome in a few cases (Ho& Grifﬁn, 1999; Lindenbaum, Kissel& Mendel, 2001). The antecedent event usually occurs 2 weeks before symptoms begin. Weakness usually begins in the legs and progresses upward for about 1 month. Maximum weakness varies but usually includes neuromuscular respiratory failure and bulbar weakness. The duration of the symptoms is variable: complete functional recovery may take up to 2 years (Hickey, 2003). Any residual symptoms are permanent and reﬂect axonal damage from de-myelination. The annual incidence of Guillain-Barré is 0.6 to 1.9 cases per 100,000. Eighty-ﬁve percent of patients recover with minimal residual symptoms. Severe residual deﬁcits occur in up to 10% of patients. Residual deﬁcits are most likely in patients with rapid disease progression, those who require mechanical ventilation, or those 60 years of age or older. Death occurs in 3% to 8% of cases, resulting from respiratory failure, autonomic dysfunction, sepsis, or pulmonary emboli (Bella & Chad, 1998)
B. Objective of the study At the end of 2 days of hospital exposure and continuous care at the Emergency room ofPolymedic General Hospital, the completion of this case study enables the proponent to do the following: Describe and explain what Guillain-Barré syndrome. Review the anatomy and physiology of the organs involved. Identify the risk factors contributing to the occurrence of the disease. Expound on the laboratory and diagnostic procedures done with the patient, their purposes, and specific nursing responsibilities before, during and after the procedure. Enumerat the different medications administered for the disease, their indications, contraindications, side effects, and specific nursing responsibilities. Formulate significant nursing diagnoses, with their significantly related nursing care plans. Render series of nursing interventions for the client’s care Provide and disseminate important information as teachings to the client and the significant others to boost the knowing and understanding of the nature of the said health condition. Improve skills and knowledge as health care providers in the clinical area. C. Scope and Limitation of the Study This study includes the collection of information specifically to the patient’s health condition. The study also includes the assessment of the physiological and psychological status, adequacy of support systems and care given by the family as well as other health care providers. The scope of this study would include: a. Data collected via assessment, interviews with the patient, family members and clinical records. b. Actual and ideal problems for 2 days including the initial assessment and its appropriate nursing intervention that would be applied within her stay in the hospital at PGH c. Developing a plan of care that will reduce identified predicaments and complications. d. Coordinating and delegating interventions within the plan of care to assist the client to reach maximum functional health. e. Further evaluating the effectiveness of nursing interventions that have been rendered to the client. An array of factors influencing the limitations of this study includes: a. Data collected is limited only to assessment and interview to the patient, patient’s chart and nurse on duty. b. The interaction, assessment and care were only limited to a total of 16 hours (2 days clinical duty, 1 day assessment) with actual nursing intervention done. c. The lack of complete family history obtained was due to lack of laboratory examinations or diagnostic examinations.
II. HEALTH HISTORY
A. Patient’s Profile Client’s Name: Birthday: Age: Sex: Civil Status: Height: Weight: Nationality: Religion: Address: Number of Children: Allergy: Occupation: Informant: Patient P. V. March 24, 1937 74 years old Male Married 156 cm 49 kg Filipino Roman Catholic Zone 8 Bulua, Cagayan de Oro City 3 No known food and drug allergies Retired Patient
B. Family and Personal Health History According to the patient, he acquired his high blood on the paternal side but on the maternal side, no history of hypertension and diabetes. During his secondary level, Patient P. V. started to smoke and can consume about 1 pack of cigarette a day and drink 5 bottles of beverages with his friends or occasionally. He was influenced by his High School barkadas to drink and smoke. But he stopped smoking and drinking in the year 2000. He has no known food and drug allergies. He received blood transfusion but could not recall when but according to him there were no reaction at all. C. History of Present Illness This is a case of patient P. V. a 74 year old male, Married with 3 children, residing at Zone 8 Bulua, Cagayan de Oro City with a chief complaint of body weakness. 15 days prior to admission, patient was admitted at Cagayan de Oro Polymedic Medical Plaza due to affected wound sustained during Typhoon Sendong, Patient was admitted for 10 hospital days and was noted to have weakness at lower extremities later progressing to the upper body until patient could not barely move. 2 days prior to admission, patient was discharged but without improvement. D. Chief Complaint - Body weakness Date of Admission: Time of Admission: Admitting Diagnosis: Attending Physician: January 30, 2012 1:41 P.M. To consider Gullain-Barre Syndrome Dr. Phillip Lazo
III. DEVELOPMENTAL DATA
A. Freud’s Psychoanalytic Theory Freud offered dynamic and psychosocial explanations for human behavior. He conceptualized what we call the psychosexual stages of development. Freud believed that there are specific stages in which an individual has a specific need, and if needs are left unfulfilled or over stimulated, according to Freud there are dramatic effects on an individual’s behavior. Freud’s explanation of these developmental stages provided early psychosocial explanations for an individual’s deviance or abnormal behavior. Freud outlined five stages of development: the oral stage, the anal stage, the phallic stage, the latency stage, and the genital stage. Stage Description During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. Where in earlier stages the focus was solely on individual’s needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be wellbalanced, warm and caring. The goal of this stage is to establish a balance between the various life areas. Justification Patient P. V. belongs in this stage. He already had a family and he was able to establish a good relationship with them. He was able to develop a sense of responsibility towards his family and was able to establish balance between the various areas of life.
Genital Stage (13 and Up)
B. Erikson’s Stages of Psychosocial Development The Psychosocial Stages of Development developed by Erikson enumerates eight stages though which healthily developing human should pass from infancy to late adulthood. Erikson considers life as composed of sequence of levels of achievement and each stage indicates a certain task to be achieved. An achievement would mean a healthier personality while failure would also mean that the person will not be able to go to the next level and probably will lead to regression.
Ego Integrity vs. Despair (Seniors, 65 years onwards)
Description This phase occurs during old age and is focused on reflecting back on life. Those who are unsuccessful during this phase will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair. Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets
Justification Patient P. V. belongs to this stage at this point of his life. According to him he doesn’t feel any regret of what his life have been before and during the present. He was able to accept things that had happened over the years.
and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death.
C. Havighurst’s Developmental Task According to Havighurst, learning is fundamental to life and in order to have a deeper insight on growth and development, one must understand it and recognize the premise that human being continues to learn throughout life. Happiness is being achieved when a particular task of a certain age is achieved by the person successfully but if not, failure occurs which is a feeling of unhappiness and disapproval from people surrounding the client. Stage Description Justification Important tasks that needs to be Patient was able to accomplish all Later accomplished during this stage of these tasks. He was already Maturity includes the following: been able to adjust to his (60 years 1. Adjusting to decreasing decreasing strength and health. strength and health He was able to adjust with his old and 2. Adjusting to retirement retirement and the lesser salary over) and reduced income that he can get. He has his own 3. Adjusting to death of friends which also have the same spouse age with him. 4. Establishing relations with one's own age group 5. Meeting social and civic obligations 6. Establishing satisfactory living quarters
IV. MEDICAL MANAGEMENT
January 30, (1:35PM)
2012 *Please admit patient under my service
*Secure consent to care * Soft diet with strict aspiration precaution
- Allows close monitoring of the patient and immediate response during emergencies. - To provide adequate care and to establish legality. - Soft diet contains foods that are soft and easy for you to chew or swallow. Aspiration precaution to prevent airway obstruction. To meet the patient’s metabolic needs. - To check for any abnormalities in the blood and glucose level. - To check if there’s a problem in the urine. - To monitor if there’s a following abnormalities in minerals and kidney. - To know if there’s corresponding arrhythmia or dsyrrhythmia in the heart.
* Laboratory CBC, Hgt U/A
Na, K,SGPT,Crea 12 lead ECG
Chest X-ray PA FBS,uric acid Lipid profile
- To view if there’s a cardiomegaly or lung problem. - To check for the blood sugar and uric acid abnormalities. - A test to check for risk of coronary heart disease. - Antipyretic drug help to treat fever. - Drug reduces blood sugar levels in patients with type 2 DM. - Anti-infective use to kill bacteria. - Products are specifically and scientifically designed to meet the needs of people with abnormal glucose metabolism. - Measures of various physiological statistics and order to assess the most basic body functions. - To refer any abnormalities noted in the patient. - To provide patients nutrition. - Antipyretic drug help to treat fever. - Used to give intravenous fluid to the patients from salt and water deprivation.
* Medication: Paracetamol 500mg 1tab every every 4 hours Sitagliptin (Janvia) 50mg 1 tablet Ceftriaxone initial dose 2gm ANST(-) Glucerna OF 100cc every 3 hours *Monitor vital signs every 4 hours and record
*Please inform AP *Refer accordingly
January 31, 2012
*OF 1200cal/day 1500cc every3 hours *PCM 500mg 1tab every4 hours *Plain Normal Saline Solution 1 liter 40gtts/min
January 31, 2012 ABNORMALITIES: Direct Bilirubin Uric acid Lipid profile HDL Total Bilirubin Fasting blood sugar Hgt157mg/dl 29.25mgs/dl 1.43mgs/dl 116.76mgs/dl 157mg/dl (30.00-85.00) (0.20-1.00) (70.00-90.00) (80-120) 0.87mgs/dl 7.55mgs/dl (0.05-0.30) (3.40-7.00)
Nursing Implication: Hyperuricemia can be caused by the over-production of uric acid in the body or the inability of the kidneys to clear out enough uric acid. Possibly there’s a problem in the bile pigment in the liver of the patient. A low HDL cholesterol level is thought to accelerate the development of atherosclerosis because of impaired reverse cholesterol transport and possibly because of the absence of other protective effects of HDL, such as decreased oxidation
January 31, 2012 URINALYSIS Color: Appearance: Glucose: Protein: Reaction: Specific Gravity: WBC: RBC: Bacteria: RESULT Yellow Turbid negative 2 positive 6.0pH 1.010 20 plenty moderate
of other lipoproteins. And patient FBS is increase possibly patient has DM. Nursing Implication: Turbidity or cloudiness may be caused by excessive cellular material or protein in the urine. There’s a decreased filtration of protein in the nephrons. The lower the pH, the greater the acidity of a solution and becomes increasingly acidic as the amount of sodium and excess acid retained by the body increases. WBC detected due to infection and presence of bacteria. And RBC present if there’s damage in the kidney.
500mg 1 tablet Classification – Antipyretic Indication - for fever Mechanism of Action - Inhibits the synthesis of prostaglandin that may serve as mediator for pain and fever, primarily in the CNS Contraindication - previous hypersensitivity, hepatic disease Side effects - hepatic failure, renal failure, rashes Nursing implication - Advise patient to consult health care professionals if discomfort noted or if fever is not relieved
Classification – Anti-invectives Indication - Skin to skin structure infections and joint infections Mechanism of Action - bind to bacterial cell wall membrane causing cell death Contraindication - hypersensitive, renal impairment Side effects - seizure, diarrhea, nausea, vomiting, jaundice, rashes, super infection Nursing implication - instruct patient to take drugs with meals
Classification – Antidiabetic drug Indication - treatment for increased glucose level in blood Mechanism of Action - competitively inhibit the enzyme dipeptidyl peptidase 4 (DPP-4). This enzyme breaks down the incretins GLP-1 and GIP, gastrointestinal hormones released in response to a meal. By preventing GLP-1 and GIP inactivation, they are able to increase the secretion of insulin and suppress the release of glucagon by the pancreas. This drives blood glucose levels towards normal. As the blood glucose level approaches normal, the amounts of insulin released and glucagon suppressed diminishes, thus tending to prevent an "overshoot" and subsequent low blood sugar (hypoglycemia) which is seen with some other oral hypoglycemic agents. Contraindication - contraindicated in patients with a history of a serious hypersensitivity reaction to sitagliptin, such as anaphylaxis or angioedema. Side effects - common side effects of sitagliptin are upper respiratory tract infection and headache. Sitagliptin also is associated with abdominal pain, nausea and diarrhea. Sitagliptin did not increase the occurrence of hypoglycemia. Nursing implication - Sitagliptin may be taken with or without food. And check the blood glucose level before administer.
V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
Anatomy and Physiology of Autonomic Nervous System
The peripheral nervous system consists of the somatic nervous system (SNS) and the autonomic nervous system (ANS). The SNS consists of motor neurons that stimulate skeletal muscles. In contrast, the ANS consists of motor neurons that control smooth muscles, cardiac muscles, and glands. In addition, the ANS monitors visceral organs and blood vessels with sensory neurons, which provide input information for the CNS. The ANS is further divided into the sympathetic nervous system and the parasympathetic nervous system. Both of these systems can stimulate and inhibit effectors. However, the two systems work in opposition—where one system stimulates an organ, the other inhibits. Working in this fashion, each system prepares the body for a different kind of situation, as follows: The sympathetic nervous system prepares the body for situations requiring alertness or strength, or situations that arouse fear, anger, excitement, or embarrassment (―fight-orflight‖ situations). In these kinds of situations, the sympathetic nervous system stimulates cardiac muscles to increase the heart rate, causes dilation of the bronchioles of the lungs (increasing oxygen intake), and causes dilation of blood vessels that supply the heart and skeletal muscles (increasing blood supply). The adrenal medulla is stimulated to release epinephrine (adrenalin) and norepinephrine (noradrenalin), which in turn increases the metabolic rate of cells and stimulates the liver to release glucose into the blood. Sweat glands are stimulated to produce sweat. In addition, the sympathetic nervous system reduces the activity of various ―tranquil‖ body functions, such as digestion and kidney functioning. The parasympathetic nervous system is active during periods of digestion and rest. It stimulates the production of digestive enzymes and stimulates the processes of digestion, urination, and defecation. It reduces blood pressure and heart and respiratory rates and conserves energy through relaxation and rest. In the SNS, a single motor neuron connects the CNS to its target skeletal muscle. In the ANS, the connection between the CNS and its effector consists of two neurons—the preganglionic neuron and the postganglionic neuron. The synapse between these two neurons lies outside the CNS, in an autonomic ganglion. The axon (preganglionic axon) of a preganglionic neuron enters the ganglion and forms a synapse with the dendrites of the postganglionic neuron. The axon of the postganglionic neuron emerges from the ganglion and travels to the target organ (see Figure 1). There are three kinds of autonomic ganglia: The sympathetic trunk, or chain, contains sympathetic ganglia called paravertebral ganglia. There are two trunks, one on either side of the vertebral column along its entire length. Each trunk consists of ganglia connected by fibers, like a string of beads. The prevertebral (collateral) ganglia also consist of sympathetic ganglia. Preganglionic sympathetic fibers that pass through the sympathetic trunk (without forming a synapse with a postganglionic neuron) synapse here. Prevertebral ganglia lie near the large abdominal arteries, which the preganglionic fibers target. Terminal (intramural) ganglia receive parasympathetic fibers. These ganglia occur near or within the target organ of the respective postganglionic fiber.
Figure 1. The target organs of the different nervous systems.
A comparison of the sympathetic and parasympathetic pathways follows (see Figure 2): Sympathetic nervous system. Cell bodies of the preganglionic neurons occur in the lateral horns of gray matter of the 12 thoracic and first 2 lumbar segments of the spinal cord. (For this reason, the sympathetic system is also called the thoracolumbar division.) Preganglionic fibers leave the spinal cord within spinal nerves through the ventral roots (together with the PNS motor neurons). The preganglionic fibers then branch away from the nerve through white rami (white rami communicantes) that connect with the sympathetic trunk. White rami are white because they contain myelinated fibers. A preganglionic fiber that enters the trunk may synapse in the first ganglion it enters, travel up or down the trunk to synapse with another ganglion, or pass through the trunk and synapse outside the trunk. Postganglionic fibers that originate in ganglia within the sympathetic trunk leave the trunk through gray rami (gray rami communicantes) and return to the spinal nerve, which is followed until it reaches its target organ. Gray rami are gray because they contain unmyelinated fibers. Parasympathetic nervous system. Cell bodies of the preganglionic neurons occur in the gray matter of sacral segments S2–S4 and in the brainstem (with motor neurons of their associated cranial nerves III, VII, IX, and X). (For this reason, the parasympathetic system is also called the craniosacral division, and the fibers arising from this division are called the cranial outflow or the sacral outflow, depending on their origin.) Preganglionic fibers of the cranial outflow accompany the PNS motor neurons of cranial nerves and have terminal ganglia that lie near the target organ. Preganglionic fibers of the sacral outflow accompany the PNS motor neurons of spinal nerves. These nerves emerge through the ventral roots of the spinal cord and have terminal ganglia that lie near the target organ.
Figure 2. A comparison of the sympathetic and parasympathetic pathways.
V. Pathophysiology of Guillain-Barré Syndrome
- is an autoimmune attack of the peripheral nerve myelin. The result is acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia (inability to execute voluntary movements), hyporeﬂexia, and paresthesias (numbness).
Precipitating Factors: •Age •Sex
Predisposing Factors: •Post infection to Campylobacter jejuni •Poor Hygiene •Stress •Diet •Lifestyle
Campylobacter jejuni Enters the body by the use of multifenestrated cells or other mechanisms Innate immune response results in the uptake of the pathogens by immature antigen presenting cells. Migration to the lymphnodes, a mature, diffentiated antigen presenting cell can present in major histocompatibility complex molecules and activate CD4 T cells that recognize antigens from the infectious pathogens. B cells can be activated as well by newly activated Th2 cells. This produces a cell mediated and humoral response against the pathogens. Antibodies will be produced, leading to activation of the complement system and phagocytosis of the bacteria.
Pathogen and host have homologous or identical amino acids sequences, antigens in its capsule shared with nerves.
Molecular mimicry Immune responses directed against the capsular components produce antibodies that cross react with myelin.
Lymphocytes and macrophages circulate in the blood and eventually find myelin. Lymphocytic infiltration of spinal roots and peripheral nerves, followed by macrophages-mediated multifocal stripping of myelin and axonal damage.
Defects on the propagation of electrical nerve impulses, with eventual conduction block. Antibodies will be produced, leading to activation of the complement system and phagocytosis of the bacteria.
Guillain Barre Syndrome
Guillain Barre Syndrome
Sensory changes, paresthesias or numbness in feet and hands.
Acute progressive ascending weakness •Lower limbs •Upper limbs •hyporeflexia
Dull aching pains of lower back , flank, proximal legs.
Cranial nerve involvement, facial droop •Dysarthria •Dysphagia •Difficulty with protruding
If not treated
•Plasma Exchange •Intravenous immune globulin (IVIG) •Physical Therapy and exercise •medication
•Extensive axonal destruction
•Ascending weakness progresses •Weakening of the diaphragm and respiratory muscle. •Respiratory distress syndrome BAD PROGNOSIS
VI. NURSING SYSTEM REVIEW CHART
Name: Patient P. V. Date: Jan. 31, 2012 Temp.: 36.5 C Heart Rate: 80bpm Respiration Rate: 20cpm Height: 156cm Weight: 49 kgs An [X] is placed in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X]. EENT: [X] impaired vision [ ] blind *nearsightedness [ ] pain redden [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf *sunken eyes [ ] burning [ ] edema [ ] lesion teeth [ ] assess eyes ears nose [ ] throat for abnormality [ ] no problem RESP: [ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough *with Foley catheter [ ] bradypnea [ ] shallow [ ] bronchi attached to urobag [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic [ ] assess resp. rate, rhythm, pulse blood [ ] breath sounds, comfort [X] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sounds, rate rhythm, pulse, blood Pressure, circ., fluid retention, comfort [x] no problem *upper right bed GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass sores, 1-1 ½ in [ ] dysphagia [ ] rigidity [ ] pain diameter [ ] assess abdomen, bowel habits, swallowing [ ] bowel sounds, comfort [X] no problem *body weakness GENITO – URINARY AND GYNE [ ] pain [ ] urine [ ] color [ ] vaginal bleeding *body pain 7/10 [ ] hematuria [ ] discharge [ ] nocturia [ ] assess urine frequency, control, color, odor, comfort [ ] gyne bleeding [X] no problem *poor hygiene; NEURO: body odor [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] treamors *poor skin [ ] confused [ ] vision [ ] grip [ ] assess motor, function, sensation, LOC, strength turgor; dry skin [ ] grip, gait, coordination, speech [X] no problem MUSCULOSKELETAL and SKIN: *weight loss [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling *limited [ ] lesion [X] poor turgor [ ] cool [X] wound [ ] flushed movement [ ] atrophy [X]pain [ ]ecchymosis [ ]diaphoretic [ ]moist [X] assess mobility, motion gait, alignment, joint function [ ] skin color, texture, turgor, integrity [ ] no problem *wound
SUBJECTIVE Communication: [ ] hearing loss [X] visual changes [ ] denied
OBJECTIVE [ ] glasses [ ] languages Comments: [ ] contact lens [ ] hearing aide “ hanap-hanap lang gyud akong R L panan-aw.” as verbalized by the patient. Pupil size: 2-3mm [ ] speech difficulties Reaction: pupil equally round and reactive to light and accommodation Comments : Resp. [X] regular [ ] irregular “Ga sigarilyo ko pero sa una ra man to.” Describe: regular breath sounds heard while auscultated as verbalized by the patient R: symmetrical to the left lung. L: symmetrical to the right lung.
Oxygenation: [ ] dyspnea [X] smoking history Since high school [ ] cough [ ] denied Circulation: [ ] chest pain [ ] leg pain [ ] numbness of extremities [x]denied
Comments: “wala man koy problema ana.” As verbalized by the patient
Heart Rhythm [X] regular [ ] irregular Ankle Edema: with bipedal edema Pulse Car. Rad. DP. FEM* R 72 68 72 not obtain L 71 66 71 not obtain Comments Right and left pulses are strong and palpable. [ ] dentures Full Upper Lower   [X] none Partial   W/ Patient  
Nutrition: Diet : Soft diet with strict aspiration precaution. [ ]N V Comments: Character “Nabantayan nko nga nag niwanga [X] recent change in jud ko.” as verbalized by the Patient weight, appetite [ ] swallowing difficulty [ ] denied Elimination: Usual bowel pattern once a day [ ] constipation remedy none Date of Last BM 2/05/12- 7am [ ] Diarrhea character none
[ ] urinary frequency 5 times a day [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foley in place [x] denied
Comments: Patient has an active Bowel sounds.
Bowel sounds: Active Abdominal distention present In defecating. yes [ ] no [X] Urine* (color, consistency odor) Urine color is yellow amber transparent and slightly aromatic.
MGT. of Health & Illness: [X] alcohol [X] denied Can consume 5 bottles with friends in work or drinks occasionally [ ] SBE: N/A Last Pap Smear: N/A LMP: N/A
Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). The patient, as well as his significant others, participates and cooperates with his treatment.
SUBJECTIVE Skin Integrity: [ ] dry [ ] itching [ ] other [x] denied .
Comments: “ wala koy problema sa akong pamanit.” as verbalized by the patient
[X] dry [ ] cold [ ] pale [ ] flushed [ ] warm [ ] moist [ ] cyanotic *rashes, ulcers, decubitus (describe size, location, drainage) Bed sores noted on the upper right, about 1 to 1 ½ in diameter [ ] LOC and orientation the patient is oriented to the place, date and time. Gait: [ ] walker [ ] cane [ ] other [ ] steady [ ] unsteady [ ] sensory and motor losses in face or extremities: No sensory and motor losses in face or extremities. [X] ROM limitations: the patient has limited range of motion [X] facial grimaces [ ] guarding [ ]No other signs of pain . [ ] side rail release from signed (60 + years) N/A Observed non-verbal behavior: the patient was conscious and coherent Person(Phone number): kept confidential
Activity/Safety: [ ] convulsion Comments: [ ] dizziness “Sakit kayo akong lawas tungod dili ko maka [X] limited motion lihok-lihok.” As verbalized by the patient. of joints Limitation in ability to [X] ambulate [X]bathe self [X]other [ ] denied Comfort/Sleep/Awake: [X] pain Comment: (whole body, 7/10) “Sakit gyud akong lawas. Pero maka tulog [ ] nocturia man nuon ko pag gabie,” as verbalized by [ ] sleep difficulties the patient. [ ] denied Coping: Occupation: Retired Member of household: Wife and 3 Children Most supportive person: Daughter
SPECIAL PATIENT INFORMATION (Use lead pencil) Not ordered 110/60 Not ordered Not ordered Date Ordered 1/30/12 Daily weight BP q shift Neuro vs CVP/SG. Reading Date done Not ordered Not ordered Not ordered Not ordered Date Ordered 1/30/12 PT/OT Irradiation Urine test 24-hour Urine Collection Date done 1/31/12
Diagnostic/Laboratory exams CBC, Hgt, U/A, Serum Electrolyte, SGPT, Creatinine Blood Electrolyte Chet X-ray-PA 12 Lead ECG FBS, Uric Acid
IV Fluids/ Blood Plain Normal saline soution 1 liter at 40 drops per minute
VII. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT
CUES Subjective: “wala koy problema sa akong pamanit‖ As verbalized by the patient NURSING DX Impaired skin integrity related to complete bed rest OBJECTIVES At the end of the care patient maintains intact skin as evidence by absence of skin break down >to maintain good skin >maintain good skin care, keeping skin clean and lubricated with lotion as needed >improves skin circulation Objective: >Dry skin >Poor turgor > Bed sores noted >keep bed clothes dry and free of wrinkles, crumbs >provide kinetic therapy or alternating-pressure mattress as indicated >reduces/prevents skin irritation >improves systemic and peripheral circulation and decreases pressure >turn q2h according to a an established turning schedule and reduces pressure time on bony prominence >Bed sores still noted integrity INTERVENTIONS >assess skin integrity, noting color, moisture, texture, and temperature RATIONALE >skin is prone to breakdown especially when the client is complete bedrest EVALUATION Goal not met, because patient always denies his problem with the integrity of his skin. And patient won’t cooperate regarding this matter
CUES Subjective: ―Sakit kayo akong lawas tungod dili ko maka lihoklihok.‖ As verbalized by the patient
NURSING DX Self care deficit related to decreased strength as evidenced by poor personal hygiene
OBJECTIVES At the end of our care client will be able to perform self care activities within level of own ability
INTERVENTIONS >determine current activity level/ physical condition. >assist according to degree of disability, allow as much autonomy as possible
RATIONALE >to develop plan of care for rehabilitation >participation in own care can ease frustration over lose of independences > assisting client reduces fatigue and enhancing participation
EVALUATION Goal partially met, with the help of the significant others patient was able to perform self care activities
>anticipate hygienic needs and calmly assist as necessary with care o nails,
Objectives: >body weakness >limited movement >fatigue >body odor >poor hygiene
skin mouth care, shaving >encourage scheduling activities early in the day or during the time when energy level is best >to decrease to risk of fatigue
>reposition frequently when client is immobile
>reduces pressure on susceptible areas, prevents skin breakdown.
Subjective: ―Sakit kayo akong lawas tungod dili ko maka lihoklihok.‖ As verbalized by the patient
Impaired physical mobility related to
At the end of the care patient
> assess motor strength and reflexes
>checking for level of progression of ascending paralysis >to prevent bed sores
Goal was partially met, able Client to was
muscle weakness maintain optimal as a result of disease process physical mobility, as evidenced by good range of motion >maintain limbs slightly extended and begin a passive range of motion >encourage diet high fiber and adequate fluid intake. >Turn and position q2h as needed
maintain physical good
optimal mobility, range noted of
Good contractures, and maintain function >reduces risk of constipation related to decreased level of activity.
Objectives: >body weakness >limited movement >fatigue
>coordinate and work physical therapist
>to assist in maintaining muscle tone
B. ACTUAL NURSING MANAGEMENT
S O A P I
―Nabantayan nko nga nag niwanga jud ko.‖ as verbalized by the Patient
>decrease appetite >weight loss >soft diet with AP Imbalanced nutrition: less than body requirements related to inadequate food intake as evidence of weight loss
At the end of our care pt. will be able to verbalize understanding of nutritional needs and demonstrate stable weight toward individually expected range >assessed clients ability to swallow -impaired gag reflex affects to client to eat >provided with small frequent feedings -to improve nutritional food intake >encouraged to increase oral fluid intake -to improve hydration >provided with the opportunity to choose food preferences -enhance participation and may promote nutritional needs >recommended with daily monitoring of weight -provides information regarding the effectiveness of dietary plan
E S O A P I
Client was able to verbalize understanding of nutritional needs.
―Sakit kayo akong lawas tungod dili ko maka lihoklihok.‖ As verbalized by the patient
>bodyweakness >limited movement >fatigue Impaired physical mobility related to muscle
weakness as a result of disease process
At the end of our care patient maintain optimal physical mobility, as evidenced by good range of motion
> assessed motor strength and reflexes -checking for level of progression of ascending paralysis >Turned and positioned q2h -to prevent bed sores >maintained limbs slightly extended and begin a passive range of motion - to prevent contractures, and maintain function >encouraged diet high fiber and adequate fluid intake -reduces risk of constipation related to decreased level of activity.
Client was able to maintain optimal physical mobility
S O A P I
―Sakit kayo akong lawas tungod dili ko maka lihoklihok.‖ As verbalized by the patient
>pain scale of 7/10 > guarding sign >limited movement Acute pain related to alteration in muscle tone
At the end of 15 min the patient will be able to verbalize relief of pain
>encouraged client to assume position for comfort -to relieve muscle fatigue and discomfort >encouraged to do the deep breathing exercise -to reduce/ relieve pain >provided with back rub -reduces pain alteration of sensory neurons, muscle relaxation. >assisted with ROM exercises -to reduce muscle joint stiffness
patient was able to verbalize pain.
REFERRALS AND FOLLOW-UP (DISCHARGE PLAN)
As referrals, parents should contact physician for immediate management of the condition if any unusualities occurs. The patient was instructed to have follow-up check up with her physician in the exact day at the exact time of schedule, usually one week after discharge, even if he already feels better. Follow-up is needed to check the patient as well as possible side effects of certain treatments and drugs. Continued care also is needed to minimize problems related to immobility, neurogenic bowel and bladder, and pain. Early involvement of allied health staff is recommended. Early recognition and treatment of GBS also may be important in the long-term prognosis, especially in the patient with poor clinical prognostic signs, such as older age, a rapidly progressing course, and antecedent diarrhea. Patient was advised for compliance of medications prescribed to him by the doctor.
EVALUATION AND IMPLICATION
Our assessment for two successive days showed that my patient’s status became stable and had improved the patient’s view towards promoting health. We had established rapport and harmonious communication during the whole course of the study, reviewed patient’s chart and had carried out doctor’s orders. Moreover, I had understood the Anatomy, Physiology and Pathophysiology of the disease condition of the patient which is Guillain-Barre Syndrome. We had identified Patient’s Clinical Manifestations as basis for the Actual and Ideal Nursing Care Plans and had intervened identified problems through patient-based nursing care. As nursing student, the knowledge that we had gained during the 2 days assessing and caring of the patient had enhanced our understanding about the patient’s condition. This exposure had helped us improved and developed our interpersonal relationship to people whom we worked with.
Amy Karch(2009).Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins. Black, Joyce et. Al(2009). Medical-Surgical Nursing Clinical Management for Positive Outcomes(8th edition). Volume 1. Singapore: Elsevier Pte Ltd. Kozier, Barbara et. Al(2004).Fundamentals of Nursing, Concepts, Process and Practice (4th edition). Philippines: Pearson Education South Asia Pte Ltd.
Kozier, Barbara et. Al(2008). Fundamentals of Nursing(8th edition).Volume 1. Philadelphia: Pearson Education South Asia Pte Ltd. Smeltzer, Suzanne et. Al(2008).Textbook of Medical-Surgical Nursing(11th edition). Volume 1. Philadelphia: Lippincott Williams & Wilkins. Internet: www.scribd.com www.google.com www.wikipedia.com
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