June 2019

Demographic Profile

Name: Patient M Occupation: Batchoy Cook

Age: 55 years old Civil status: Widow

Sex: Female Educational attainment: High school

Graduate

Nationality: Filipino Religion: Roman Catholic

Spouse Name: Margallo, Gener Occupation: N/A

Address: Balamban, Cebu

Admitting Diagnoses: T/C Spinal Metastasis

Patient’s complaint: Lower back pain

Nursing Clinical Abstract

The patient is admitted to the hospital due to her lower back pain. According to her, 5
months prior, Patient fall down from jeepney around 7pm in LIloan and got injured in
the left thigh and pelvic area since patient tolerated the condition. No consultation
and no self meds taken. 1 month prior, pt had pain in the lumbar and pelvic area and
then there was an excessive sharp pain felt. She called her sibling and she told her
what she is feeling right at that moment and with no hesitant, her sister brought her
right away to VSMMC to be checked upon by health care personnel and she got
admitted at that moment as well.
Nursing History

1 History of Present Illness

Mrs. V is weak and had an elevated blood pressure, felt pain from her lumbar area,
she is having a sharp pain and numbness in her extremities as well.

2. Past Health History

According to Mrs. V, she never had been admitted to the hospital due to having a
disease except when she delivered CS to her two daughter at the hospital. Her
health is always in a good condition because she is more of a health conscious
person and is living a healthy lifestyle

3. Immunization Status

Mrs. V cannot remembers her childhood days.

4. Family Health History

Mrs. V stated that on her mother side, they are mostly hypertensive and she doesn’t
remember of any diseases on her father side.

5. Allergies

Mrs. V doesn’t have any known allergies on medication but has an allergy on
seafood, specifically on octopus.

Gordon’s Typology of Functional Health Pattern

1. Health –Perception/health-Management Pattern

The patient described her usual health before to be fair and body is strong but now
she considered it to be poor and weak. This is because of the limited movements
she felt, the inability to walk or stand and difficulty in moving the extremities due to
the fracture of her lumbar are. Before the admission, the patient eats more foods rich
in fats, sugar or glucose and cholesterol in their meals and she drinks plenty of water
every day. During the patient’s hospitalization, her diet was changed to low fat and
low cholesterol diet. The patient’s attending physician encourages her to take more
of calcium and Vitamin D in order for her bones to become stronger. The patient is
non-smoker and non-alcoholic drinker and she has no known allergies.

2. Nutritional/Metabolic Pattern
The patient’s usual food intake before the hospitalization includes fish, meat,
vegetables, fruits, chicken and especially foods rich in fats, sugar/glucose and
cholesterol. She consumes more than 8 glasses of water a day. Her maintenance
meds is Centrum. Now the patient was advised by her attending physician to restrict
foods that can aggravate her condition. The patient was also encourage to take more
of Calcium and Vitamin D in order for her bones to become stronger. The patient
doesn’t smoke or drink alcoholic beverages, has no known allergies. There is a
change in her appetite now; she often eats a little only each meal.

3. Elimination Pattern

Before, the patient can freely go to the C.R. to void or defecate but now that she’s
hospitalized she was advised to wear diaper for her to have difficulty in standing and
walking. There is no burning sensation during urination and her stool is brownish
formed stool.

4. Activity/exercise Pattern

Functional Level Classification Findings/Assessment

1. Perceived ability for bed motility 2
2. Perceived ability for general mobility 3
3. Perceived ability for dressing 2
4. Perceived ability for bathing 3
5. Perceived ability for grooming 0
6. Perceived ability for toileting 3
7. Perceived ability for home 3
maintenance
8. Perceived ability for shopping 3
9. Perceived ability for cooking 3
Legend:
0= complete independent
1= requires use of equipment or device
2= requires help from another person for assistance, supervision, or teaching
3= requires help from another person and equipment or device
4= complete dependence

The patient before hospitalized wakes up early in the morning for her to have fine
walking around their house as her exercise. She usually guided her grandsons and
granddaughters, but now, she’s just on bed lying assisted

5. Sleep and Rest Pattern

Before the hospitalization, the patient usually sleeps late at night at around 10
o’clock pm and wakes up early in the morning at 6 o’clock am with an hour of sleep
of 8 hours. Now, she usually sleeps early at night (8-9 o’clock pm) and wakes up at
around 7 o’clock am with an hour of sleep of 10 hours. The patient usually stays in
bed and read newspapers sometimes, she can’t take a nap and sleep because of
the pain.

6. Cognitive/Perceptual Pattern.

The patient before, can hear, smell, taste and feel well and correctly but the patient
cannot read her newspaper without her eyeglasses just the same as now. She
speaks slowly English, Tagalog and Bisaya languages as of now but before she
speaks fluently all of those languages. She easily communicates, understands
questions, instructions and be able to follow and answer them correctly.

7. Self -perception/ Self-concept Pattern.

The patient’s most concern about right now is her health. The patient wants to stay
at the hospital until she improves. The patient never loses the support of her children
even if they were not there physically and also her nurses. Through this, she maybe
able to cope up easily from her unhealthy condition. The treatment, managements,
medications and all out care rendered by the hospital to the patient assured her for
the improvement of her condition.

8. Role- Relationship Pattern.

The patient understands more on English and Bisaya languages but a little only in
Tagalog language. The patient was living all by herself with her private nurses but
sometimes, her grandchildren will come over to visit her. She never uses the support
of her children even if they were away from their mother they always make sure that
their mother is safe and secure. The patient can easily communicate, cooperate,
listen and follow instructions easily.

9. Sexuality/ Reproductive Pattern.

The patient’s husband just recently died. Now, the patient does not allow anyone to
see her getting undressed, changing diaper, changing clothes because she believes
that as a woman, it should be keep as private.

10. Coping/Stress Tolerance Pattern.

The patient usually makes her decision as for now since her children were busy in
their work ab, but they make sure they never forget to support and help their mother
recover from illness. Sometimes, the patient usually shares her concerns to her
private nurses and of course also to the student nurses. She usually reads
newspaper for her to be more relaxed.

11. Values/Belief Pattern.

The patient find source strength and hope with God and her loved ones. God is very
much important to the patient. Before, she usually goes to church together with her
other children. They were not involved in any religious organizations or practices.
The patient knows how to pray and praise God for all the nice things he had given.

Vital signs / Measurable cues / Anthropometric Data

Parameter Normal Actual Analysis and

Value Findings Interpretation

BP 120/80 120/80 Normal

Pulse Rate 60-100 82 bpm Normal

Respiration Rate 12-20 28 bpm Increased RR

Temperature 36-37 38.2 Normal

Physical Assessment

AREA TECHNIQUES NORMAL ACTUAL

ASSESSED USED FINDINGS FINDINGS

SKIN:

Color inspection light to deep brown Light to deep

brown

Texture palpation rough, presence of rough,

hair presence of
hair

Skin turgor palpation skin springs back Skin springs

immediately when back slowly
pinched when pinched-
about 4
seconds

Temperature palpation uniform within Uniform within

normal range normal range

presence of palpation no edema Edema noted

edema

presence of palpation some birth marks, Lesions noted

skin lesion some flat and at the skin
raised moles

Wound inspection No wound Wounds in the

lower back

HAIR:

Color inspection brown or black Black

distribution inspection evenly distributed evenly

distributed

hair thickness inspection either very little or Great number

and thinness great deal of body of body and
and scalp hair scalp hair

thick or thin hair

texture and palpation smooth and silky Rough and dry
oiliness

NAIL:

Color Inspection Pinkish Pinkish

Shape and Inspection and Smooth, convex in Smooth,

texture palpation curvature, long convex in
curvature, long

Thickness Inspection Extremely thin Extremely thin

Capillary refill Performed Prompt return of Returns

blanched test pink or usual color immediately

HEAD:

Size, shape Inspection Rounded Rounded

and symmetry (normocephalic)sy (normocephalic
mmetric, with ) symmetric
frontal, parietal with frontal,
and occipital parietal and
prominences occipital
prominences

Head Inspection and 35-45 cm 38 cm

circumference palpation

Presence of Inspection Smooth, uniform in Smooth,

mass or consistency, uniform in
nodules absence of consistency,
nodules and mass. absence of
nodules and
mass.

Head inspection Can lift head Can’t lift head

movement slightly and turn slightly and
them from side to turn them from
side side to side

EYES:

Eyebrows: hair Inspection Hair evenly Hair evenly

distribution and distributed, skin distributed, skin
alignment intact, eyebrows intact,
symmetrically eyebrows
 aligned symmetrically
aligned

Eyelashes: inspection Equally distributed, Equally

evenness of curled slightly distributed,
distribution and outward. curled slightly
direction of curl outward.

Conjuctiva and Inspection Bulbar Conjunctiva Bulbar

sclera is clear with tiny conjunctiva is
capillaries visible, clear with tiny
Palpebral capillaries
conjunctiva is pink, visible,
no discharge, Palpebral
sclera is white conjunctiva is
pink, no
discharge,
sclera is white

Response to Inspection Illuminated pupils Illuminated

light constrict pupils constrict

Ability to read inspection Able to read news Cannot able to

newsprint print read newsprint
materials

NOSE:

Symmetry, Inspection Symmetrical, Symmetrical

shape and straight and and uniform in
color uniform in color color

Occurrence of Inspection Pink mucosa, no Pink mucosa,

redness, discharge and no discharge
swelling and swelling free of and swelling
discharge lesion free of lesion

Facial sinus Palpation No tenderness No tenderness

MOUTH:

Lips:

Symmetry, Inspection and Symmetry of Symmetry of

color, palpation contour uniform contour uniform
tenderness pink color, soft, pink color, soft,
 moist, smooth moist, smooth
texture texture

Gums:

Color and Inspection Pink, moist and Red and not

moisture firm moist

Teeth:

Number Inspection Complete teeth- Incomplete- 17

32 number of teeth number of
teeth

Smell Inspection No foul odor Mild foul odor

EARS:

Auricles: Inspection Color is same as Color is same

the color of the as the color of
Color, face, symmetrical the face,
symmetry of auricles align in symmetrical
size and the outer canthus auricles align in
position of the eyes the outer
canthus of the
eyes

Texture, Palpation Mobile, firm, no Mobile, firm, no

elasticity and tenderness, pinna tenderness,
areas of recoils after it is pinna recoils
tenderness folded after it is folded

NECK:

Appearance inspection Short and mobile Short and

and movement mobile

THORAX:

Color Inspection Light to deep Brown

brown

Chest shape Inspection Rounded Rounded

Respiratory Inspection 16-20breaths per 30 breaths/min

pattern minute

Breath sound Auscultation Vesicular, Wheezing

broncho-vesicular sounds
and bronchial

HEART:

Cardiac rate auscultation 60-100 bpm 84 bpm

and rhythm

ABDOMEN:

Contour Inspection Rounded Rounded

Bowel sound auscultation High pitched High pitched

irregular gurgles, irregular
hyperactive gurgles,
hyperactive

UPPER &
LOWER
EXTREMITIES
:

size inspection Equal in size Equal in size

Strength and inspection Can flex and Cannot flex

tone extend arms and and extend
legs arms and legs

Mobility Inspection mobile Imobile

 Drug Study

DRUG DOSAGE & MECHANISM OF INDICATION CONTRAINDICATION ADVERSE NURSING

DESCRIPTION FREQUENCY ACTION EFFECT RESPONSIBILITY

Pregabalin 70 mg BID Pregabalin binds to Neuropathic pain Contraindicated in Dizziness,  Tell the patient that he
calcium channels or patients with renal drowsiness, dry can experience mood
nerves and may impairment, elderly mouth, edema or behavior changes,
modify the release patients, angioedema, (accumulation of depression, anxiety,
of neurotransmitter depression, CNS fluid), blurred insomnia, or if you
(chemical that depressant use, vision, weight gain, feel agitated, hostile,
nerves use to alcohol use, and reduced blood restless, hyperactive
communicate with abrupt withdrawal. platelet unit and
each other. increased blood  Monitor blood drug
level, CBC and liver
creatinine kinase
Reducing function test results
levels. during the long-term
communication
or high-dose therapy,
between nerves
as ordered
may contribute to
pregabalin’s effect  Do not give lyrica if
of pain and the patient is allergic
seizures. to pregabalin

 Store at the room

temperature away
from moisture, light
and heat.

 TRAMADOL  50mg IVTT  Binds to mu-  Moderate to  Decreased  Nausea,  Assess type, location,
q 8hrs opioid receptors. moderately function of the vomiting, and intensity of pain
severe pain adrenal gland, sweating and before and 2-3 hr (peak)
 Inhibits reuptake symptoms from constipation. after administration. •
of serotonin and alcohol withdrawal,
norepinephrine depression, lower  Drowsiness is  Assess bowel function
in the CNS seizure threshold, reported, routinely.
asthma, although it is
 less of an issue  Assess previous
decreased lung
than for analgesic history.
function, stomach Tramadol is not
or intestine nonsynthetic
opioids. recommended for
blockage, toxic patients dependent on
amount of  Patients opioids or who have
narcotics in the prescribed previously received
body tramadol for opioids for more than 1
general pain wk; may cause opioid
relief with or withdrawal symptoms.
without other
agents have  Monitor patient for
reported seizures. May occur
withdrawal within recommended
symptoms dose range..
including  Overdose may cause
uncontrollable respiratory depression
nervous and seizures.
tremors,
muscle  Encourage patient to
contracture, cough and breathe
and 'thrashing' deeply every 2 hr to
in bed (similar prevent atelactasis and
to restless leg pneumonial
syndrome.
Laboratory/Diagnostic Study

Result Normal Value Rationale

Hemoglobin 135 g/dL 135-180 g/dL Normal

Hemoglobin 135 g/dL 135-180 g/dL Normal

RBC count 4.36 x 10¹²/L 4.7-6.1 x 10¹²/L Decrease due to

bleeding

Platelet count 3.21 x 10/L 150-400 x 10/L Normal

WBC count 16.0 x 10/L 5-10 x 10/L Increase due to

inflammatory
process

Lymphocyte 0.23 .20-.40 Normal

Platelet 387 150,000-450,000 Normal

Diagnosis Procedure Normal Value Result

Differential Count

 Neutrophil 40-70 % 67

 Basophil 0-1 % 0

 Eosinophil 0-5 % 4

 Monocyte 0-8% 09

 Lymphocytes 20-40% 20

Serum

 Potassium 3.6-5 4.7

6.7-1.5 6.6
 Creatinine
8.4-10.2 8.2
 Calcium
3.3-5.5 2.9
 Protein
2 2.9
 Albumen
6.8 5.8
 Globulin
65-110 145
 Total Protein
8-35 u/mL 20
 GCT(50gms)
65-110 118
 PBS
2.5-7.5 4.4mg/dL
 Uric acid
2.3-9.5 6.31 min.-sec.
 Bleeding time-sim
5-15 10.41 min.-sec.
 Clotting time
10-13 13.8 sec.
 Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis

Subjective: Impaired physical Goal: 1. Continually 1. Evaluates status Within the duration
mobility related to asses motor of individual of duty, the patient
“dili kaayo ko neuromuscular Within the 8 hours of function by situation (motor- was able maintain
kalihok lihok” asverbali nursing intervention, requesting sensory
impairment position of function
zed by the patient. the patient will patient to impairment may
perform certain be mixed and/ or and skin integrity as
Definition: maintain position of evidenced by
Objectives: actions. not clear) for a
function and skin absence of foot
Limitation in specific level of
 Decreased integrity as injury, affecting drops, contractures
independent, evidenced by
muscle 2. Provide means type and choice
purposeful absence of foot to summon
control/strength of intervention.
physical drops, contractures help.
 Limited ROM movement of the 2. Enables patient
body or of one or Objectives: to have sense of
 Inability to more extremities. 3. Assist in range control, and
1. Patient will of motion reduces fear of
purposefully
perform exercises on all being left alone.
more within the extremities and
physical
physical joints, using 3. Enhances
activity
environment slow, smooth circulation,
independently movements. restores or
 Inability to move or within
maintains
purposefully limits of muscle tone and
within physical disease. 4. Plan activities to joint mobility,
provide and prevent
environment,
2. Patient will uninterrupted disuse
including bed rest periods.
demonstrate contractures and
mobility, Encourage
measures to muscle atrophy.
transfers, and involvement
increase
ambulation within individual 4. Prevents fatigue,
mobility tolerance or
 Inability to 3. Patient will ability. allowing
perform action demonstrate 5. Reposition opportunity for
as instructed the use of periodically maximal efforts
even when or participations
adaptive
 Reluctance to sitting in chair. by patient.
devices to Teach patient
attempt increase how to use 5. Reduces
movement mobility weight-shifting pressure areas,
techniques. promotes
6. Encourage peripheral
verbalization of circulation.
feelings.
6. Open expression
allows client to
7. Inspect the skin deal with
daily. Observe feelings and
for pressure begin problem
areas, and solving.
provide
meticulous skin 7. Altered
care. circulation, loss
of sensation,
and paralysis
8. Consult with potentiate
physical or pressure sore
occupational formation.
therapist.
8. Helpful in
planning and
implementing
individualized
exercise
program and
 identifying or
developing
assistive devices
to maintain
function
enhance mobility
and
independence.

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Elevated body Goal: 1. Provide tepid 1. Enhances heat After 8 hours of
“Gihilantan mana siya”, temperature sponge bath. loss by comprehensive
as verbalized by the related to the After 8 hours of evaporation & nursing
S.O. comprehensive 2. Assess fluid conduction.
infectious process intervention, the
nursing intervention, loss & facilitate 2. Increases
Objective: evidenced by oral intake. metabolic rate & patient was able
chills noted the patient temperature will
 Skin warm to touch diaphoresis.
temperature will lower down to
with a temperature 3. Promote bed 3. Reduces body
Definition: lower down to rest. heat production. normal levels:
of 38.1°C
 ↑RR: 28cpm normal levels: 4. Dissipates heat by
Body temperature
 ↑HR:82 bpm 4. Provide cool convection.
elevated above Objectives: circulating air
 Weakness
normal range. using a fan.
observed
 Dry mucous 1. Patient will 5. Assist patient in
membranes maintain body changing into 5. Increases comfort.
Flushed Skin touch dry clothing.
temperature 6. Provide oral 6. Prevents herpetic
below 38° C hygiene. lesions of the
- body malaise 2. Patient will be mouth.
free of 7. Monitor vital
- poor appetite dehydration signs.
3. Patient will 8. Perform tepid 7. Notes progress &
- chills noted maintain vital sponge bath changes of
signs at 9. Apply cold wet condition.
normal levels compress if 8. Vaporization of
4. Patient will be necessary water relieves heat
alert and 10. Remove some from the surface of
responsive blankets and the skin
clothes which 9. To help normalize
are not body temperature
necessary 10. To provide air
11. Advise to wear movement, to
loose and augment heat loss.
comfortable 11. To be more
clothes comfortable

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Activity Goals: 1. Evaluated 1. To provide Within the duration

intolerance r/t clients actual comparative of duty, the patient
“Dali rako kapoyon neuromuscular Within the 8 hours of and perceive baseline and was able to
maong matulog nlang nursing intervention, limitations/ provide
impairment demonstrate a
ko” the patient will degree of deficit information
in light of usual about needed decrease in
Definition: demonstrate a physiologic sign of
status education/
decrease in intolerance.
Insufficient intervention
Objective: physiologic sign of regarding
physiologic or intolerance. 2. Noted client’s
 Needs psychological Objectives: report of quality of life
assistance in energy to endure weakness,
repositioning or complete  Patient will fatigue, pain
and difficulty 2. Symptoms may
required or exhibit results of/or
 Inability to do accomplishing
his ADL’s desired daily his task. contribute to
tolerance
activities. 3. Ascertained intolerance of
 Generalized during
ability to move activity
weakness physical about and
 Deconditioned activity as degree of
assistance 3. To determined
state evidenced by necessary use current status
a normal of equipment and needs
 Sedentary
associated with
lifestyle fluctuation of participation in
 Lack of vital signs 4. Encouraged needed desired
expression of activities.
motivation during 4. To assist the
feelings
 Prolonged bed physical contributing to client to deal
his condition with
rest activity.
contributing
 Insufficient  Patient will factors and
sleep identify manage
activities within
 Imposed activity factors that individual limits
restriction aggravate act
5. Assist with
ivity activities and 5. To protect from
intolerance. provide/ monitor injury
clients use of
 Patient will assistive
report devices
6. Promote
the ability to
comfort
 perform measures and
provide relief of
required pain 6. To enhanced
activities of the ability to
participate in
daily living. 7. Repositioning activities
 Patient will every 2 hours
verbalize and 7. To prevent
use energy- 8. Made bedsore and to
repositioning maintain body
conservation
schedule and alignment all
techniques. post at bedside the time.
and educated 8. To prevent
the patient’s bedsore and to
S.O in proper promote
turning the circulation.
patient
 Pathophysiology

Predisposing factors: Predisposing factors:

1. Gender 1. Prostate cancer
2. Age 2. Brain cancer
3. Surgery
4. Hypercalcaemia
5. Biphosphonate
6. Multiple Myeloma
7. Neurofibromatosis

Blood flows into the extradural, subdural or subarachnoid spaces of

the spinal cord.

Spinal cord vasculature

Nerve fibers swell and integrate

Blood circulation to the gray matter of the spinal cord isimpaired

Compression of nerve roots results in arm or leg pain along with

1. Ischemia
weakness
2. Hypoxia
Difficulty urinating and defecation
3. Edema
Loss of sensation in affected limbs
4. Hemorrha
gic lesion Compression of spinal cord

Gait abnormalities or varying degrees of paralysis,

Deformities of the back due to collapse of the affected vertebrae

 Worksheet C (Health Teaching Plan)

Teaching Strategies Learning Content Time Duration Resources Evaluation

Objective

Review or discuss Lecture Some coping strategies Materials: Understand the coping
the coping include: strategies including the
strategies to the Laptop with SO.
 Meditation and
client. relaxation techniques downloaded videos
Abdominal 1 hours
breathing  Time to yourself
 Physical activity
exercise,
 Reading Speaker and
Calming music,
 Friendship projector
Yoga
 Humor
 Hobbies
 Spirituality
Demonstration  Pets Visual aids with
and return  Sleeping pictures related to
demonstration.  Nutrition coping strategies.

Negative coping strategies:

 Drugs
  Excessive alcohol
use
 Self-mutilation
 Ignoring or storing
hurt feelings
 Sedative
 Stimulants
 Excessive working
 Avoiding problems
 Denial
(www.mhww.org/
strategies.html)