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CASE PRESENTATION – NEURO
Submitted by: BSN 136/ Group 142 AMATA, Angeli Grace I. POBRERO, Mary Greyzel E. QUEBRAL, Alf Carlo S. REYES, Daryl M. RUSTIA, Jhonnavie Q. SABINO, Vangil R. SALCEDO, Hannah Joy J. SANTOS, Carlisse Caye P. SUBA, Marlon C. TABIRARA, Nicolo Paulo L. TAN, Richard G. TAYSON, Leah Marie C.
Submitted to: Ma’am Sheila Paragua, RN, MAN
September 24, 2010
I. Biographic Data
chicken pox and mumps during childhood. He also had 3 episodes of vomiting of previously ingested food. Catapres and Furosemide. The client has no known allergies in foods and other medications. The client remembers that he had the anti-hepatitis B vaccine. Nursing History A. right basal ganglia II. He notes that his sister has Diabetes Mellitus. Psychological Health • Coping Patterns . the client was diagnosed with SP/ CVA Infarction at Malvar Hospital. He was having shortness of breath. the client was diagnosed SP/ Myocardial Infarction at FEU-NRMF but was also discharged as soon as his condition improved. His usual BP was always noted to be 160/100 mmHg and his highest BP was noted to be 240/120 mmHg. Family History The client’s family has a prevalent history of hypertensions and heart problems on both sides. slurring of speech and left-sided body weakness. Quezon City Birth date: 5-May-1954 Marital Status: Married Gender: Male Age: 56 years old Religion: Roman Catholic Occupation: Security Guard (formerly 10 years ago) Admission Date / Time: Aug. At 2004. approximately about 2 cups in amount while on their way to the hospital. There were no complications noted. Payatas. dizziness. Past Health History The client claims that he has had measles. Present Health History The client was first found lying on the floor in supine position. Upon arriving at FEU-NRMF’s ER.Name: Mr. shortness of breath. At 2008. 23. Patterns of Functioning A. JCM Address: Ilang-Ilang Ext. Before the current hospitalization. headache. Calciblock. lab tests were done and he was admitted to Station 5B. Other than those mentioned they have no other hereditary diseases. the client remembers taking medications such as Neoblock.. C. He had received unrecalled medications and was discharged as soon as his conditions improved. Room 506-J. It was here that he was noted to be hypertensive for 30 years. The client has no known accidents. III. 2010 Room #: 506-J Chief Complaint: headache. B. body weakness Admitting Diagnosis: Intra-cerebral Hemorrhage.
he spends more time with his family. friends and relatives. and is oriented to time and place. • Interaction The client describes himself as a very sociable person.1835) Analysis: As he is still recovering from the Intra-cerebral Hemorrhage. His/her speech must be clear and coherent. But probably. alert. he wants his family to gather together and talk things over and solve it. • Self-Concept The client sees himself right now as an aging but a happy man. writing and reading. trust others and enter into mutual and interdependent relationships. (Medical-Surgical Nursing by Smeltzer and Bare. • Cognitive The client’s highest educational attainment level is that of high school graduate. clear and relevant. When the client experiences a family problem. Right now that they have grown up. He also acknowledges that God is there to help them solve their problems.855) Analysis: The client faces his problems head on. He was fond of hanging out with his peers and friends in his 30’s. the client might have had trouble doing certain functions. He is very close to his wife and children. Right now though. The client also doesn’t have any problems in speaking. natural. . he used to be a very strict disciplinarian to his sons when they were still kids. They communicate well with each other and seldom have arguments. he thinks of a way to solve his problems by himself. Interpretation: A healthy person can relate to others and intimately receive gratification from social and personal roles. (Principles and Practice of Psychiatric Nursing 8th Edition by Stuart and Laraia. p. he tries to understand them a bit more. Interpretation: Coping mechanism are used to decrease stress. sue to his ailing health. 307) Analysis: The client is a sociable person.The client said that when he encounters problems. Also. and responsive. The patient’s thought content should be spontaneous. His reasons for not able to pursue a college course were because of financial reasons. he seems to be closer to his family right now. Many coping behaviors are learned based on one’s family. but also with the help of his significant others. Then on. When he had his own problems. p. (Fundamentals of Nursing by Taylor p. he needs someone to talk to and listen to him and he will feel better. the patient’s affect or external manifestations of mood should be natural and even. past experiences and socio-cultural influences and expectation. Interpretation: A patient with proper mental status has a good appearance and behavior. As a father. he would just ask for a piece of advice from her family.
They move distinctively.1844) Analysis: Despite his current hospitalization. (Fundamentals of Nursing by Taylor et al. Carol. Fundamentals of Nursing. (Medical-Surgical Nursing by Smeltzer and Bare. Emotional support from family members allows open expression of feelings and helps meet love and belonging needs. p.Interpretation: People with self. 5th Edition. the client is still a happy person and tries to see things positively • Family Coping The client currently lives with his wife and three sons under one house.al. they would have a family meeting and discuss it all together. food) they feel sad or anxious & when people satisfy a need.) Analysis: The client and his family cope with the problems easily by discussing and solving their problems as a family. 2005 pg. When he gets angry he just stays silent and later on he will be okay. Interpretation: Family can provide the social support necessary to help the patient manage and adapt to stress. Sadness on the other hand is a feeling of displeasure which can be triggered by real or imagined wrongs. whereas those with negative self-concept find to exhibit poorer self-knowledge. Facial muscles are very responsive to emotions. Facial movements reflect the intensity of experience too. arouse relatively strong emotions. Several situations would arouse several feelings like when people are deprived of something (money. even when observers see no signs of emotion on the face. physical measurement suggest. the client is still a happy person and tries to see things positively. less realistic perceptions and expectations and lower self-esteem. Moreover. He expresses his feelings to his family or friends by giving good service to them and having quality time with them especially his family. 82) Analysis: Despite his current hospitalization. . (Taylor.concept usually have greater and more diversified self-knowledge. Simply thinking happy or sad thoughts moves facial muscles in patterns ways. more realistic perceptions and expectations and higher self-esteem. He says that when problems arise. • Emotional The patient’s usual mood is happy. Happy people emphasize the positive in what they see & remember. they feel happy. Like for an example. Experience. et. happiness of a person may reflect a tendency toward optimism rather than over all satisfaction with life. love. Interpretation: An individual’s affect (mood or feeling tone) can affect thinking ability.
Interpretation: People are becoming increasingly aware of their environment and how it affects their health and level of wellness.g. producer smokes w/c pollutes air). But he notes that the water they use is purified and their garbage is collected daily. Pollution can naturally (e. Vol.253) Analysis: The environment. He says that their previous home was a much better place. Pollution of the water. 2-bedroom home has poor ventilation. air. Interpretation: Lifestyle refers to a person’s general way of living. (Fundamental of nursing by Kozier. Right now. He usually has the volume loud in order not to hear the noise from outside his house. and these are often transmitted from parents to children. Each culture has ideas about health. • Recreation Patterns The client says that his only way of passing time is by watching TV. and soil can affect the support of life. He and his family also enjoy holidays together such as in the Christmas season and the New Year. There would also be occasional brownouts. including living conditions and individual patterns of behaviors that might affect health. He would spend the entire at home watching at home. page 301) Analysis: The clients has a normal way of spending time.B. Safe. Contamination of water supply has negative effects on human consumption. page 178) Analysis: The client and his family have a normal way of a family should have and they do things the same together. their new 1 storey. and copes with health and illness. During mealtimes. client is clearly unsatisfied with his current living . Socio-Cultural Patterns • Cultural Patterns The client stated that they practice a normal day to day activity at home. Interpretation: Culture and social interactions also influence how a person perceives. Poor air quality can lead to increase in asthma and other respiratory problems. road and workplaces are necessary or health maintenance. There is always noise from the outside caused by the neighbours and the vehicles that pass by the street. (Kozier and Erbs. (Fundamentals of Nursing by Kozier et al. accessible and affordable housing and safe accessible schools. 5th ed. • Environment The client and his family had recently moved to a new neighbourhood 6 months ago.Page. the family would dine together. lightning-caused fires. The quality of water impact the quality of soil used to grow food. experiences. It is always hot inside as there is only one window. 1.
Religious teachings vis-à-vis health helps to present a meaningful philosophy and system of practices within a system of social controls having specific values. He states that praying is important for him because this is the only way you can communicate and lay your burden to God. C. He also adds that his sons do not join him as they attend separate organizations such as the Singles for Christ or Youth for Christ. He would also go to his church and attend mass with his wife.• Economic Until ten years ago. He also believes that being positive in everything makes worse things become better in the end. and there is evidence that a lower status is associated with increased risks of some diseases. and obey his parents. . Spiritual Pattern • Religious Beliefs and Practices The client is a very devout Roman Catholic. the client had once worked as a security officer. Interpretation: Socio-economic status has been shown to have a major impact on health. Interpretation: Religion may be considered a system of beliefs. He believes in angels which God sent to every child to serve as their guide. 2006) Analysis: The client depends on his family for their source of income. • Values and Valuing The client said that the value that his parents had been inculcated in him is that he must learn to respect the elders. But due to his health condition. Illness is sometimes seen as the punishment for the violation of religious codes and morals. and ethics. These are related to health in that adherence to a religious code is conducive to spiritual harmony. The family’s current source of income is that from his wife’s savings who worked abroad and only came back recently. His sons also contribute by working in part-time jobs. (BBC news. Religion gives a person a frame of reference and a perspective with which to organize information. He makes sure that these values are passed down to his children. he had to quit working and leave it to his wife and sons to take care of the finances. norms. 209 -210. (p. He would actively join in church activities. His faith is what still keeps him positive about himself. mortality and life span. Kozier 7th edition) Analysis: The client is a very religious person. practices and ethical values about divine or superhuman powers or powers worshipped as the creator(s) and ruler(s) of the universe.
Interpretation: An individual is not born with values. Taylor. 1246) Elimination The client would frequently urinate at least 6 times a day. 3-4 servings of food groups. After the removal of the NGT. p. (Fundamentals of Nursing. Impaired mobility may limit the . and 2-3 servings of meat. the client is very particular with values. fish and beans group. values are formed during a lifetime from information from the environment. (Fundamentals of Nursing by Taylor. family. cheese group. IV. Cereals. rather. 3-5 servings of vegetable groups. Activities of Daily Living Before Hospitalization Nutrition The client eats 3 times a day. rice and pasta. p. Interpretation and Analysis The normal food intake or regular food intake basing in the Recommended Dietary Allowance or RDA stated that 6-11 servings of Bread. and culture. The client still frequently urinates many times a day Spinal cord and head injuries can decrease the sensory stimulation for defecation. 2-3 servings of milk. poultry. He says that is due to his many maintenance medications.91) Analysis: As a father and still the head of the family. his appetite was the same as before hospitalization. The client was fond of eating salty foods. the client previously had NGT. yogurt. fish and vegetables and would usually have 2 and ½ cups of rice per meal During Hospitalization Upon admission.
page 18) Sleep and Rest The client says he cannot sleep well during the night because of his problem with urination and bloated sides. (Fundamentals of Nursing by Kozier pg. 74) Substance Use The substances the client uses are the medications as ordered by physician. (Kozier and Erb’s. usually up to 8 hours a day. Due to his immobility. Black. (Medical-Surgical Nursing. Vol II. He says he tries to be comfortable by sleeping with 3 pillows. Vol. Volume I.client’s ability to respond to the urge to defecate. II. (Kozier and Erb’s. p. The normal frequency of exercise is three times per week and the duration is 30 minutes. A therapist would come and visit to teach and help the client do 2-3 exercises per day. (Kozier & Erb 8th ed. The client can now sleep well. He also drinks alcohol when there is an occasion. the client can only take a bath every other day. page 1164) . Smoking is directly linked to many forms of cancer. heart disease and hypertension. Ill or people in pain may not have the motivation or energy to attend to hygiene. Sleep is a basic human need. the client would take a bath 4. The client is a 20pack per year smoker. page 1327) Exercise The client would always do occasional stretching exercises. usually stretching ones. 1065) Hygiene Because he is always at home most time.6 times a day. it is a universal biological process common to all people.
0 – 1.69 mmol/L 26. Laboratory and Diagnostic Examination Results Date Procedure Norms Result Interpretation and Analysis CHEST X-RAY Pulmonary vascular congestion/ edema Left ventricular cardiomegaly Left pleural effusion CBC RBC: 5.25 HDL: 167 LDL: 34.0 – 5.16 Eosino: 0.90 .54 VLDL: 85.VI.17 mmol/L Triglycerides: 0.47 Lympho: 0.8 CREA: 147 mg/dl CBG: 5.90 Blood Chemistry 1.22 x 1012/L Hgb: 15.02 Total Cholesterol: 0.30 Hct: 0.
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