Professional Documents
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CASE
STUDY
HELLO GOOD MORNING STUDENT
NURSES
General objective
After 3-4 hours of case presentation, the student nurses will be able to
acquire knowledge about the health and condition of the patient, enhance
the skills in improving and identifying the problems and elicit positive
attitude to the co student nurse as well as towards other people.
Specific objective
• Acquire knowledge and familiarization of each disease.
• Determine the signs and symptoms of the particular diseases.
• Review the anatomy and physiology of the affected parts of the
diseases.
• Interpret laboratory and diagnostic studies.
• Analyze and understand the pathophysiology each disease.
• Integrate all drugs being used for patient’s treatment.
• Present nursing care plan that identifies the patient’s needs be able to
professionally formulate nursing interventions.
COVID 19 ,COMMUNICATED
ACQUIRED PNEUMONIA, CVD
INFRACT, TYPE 2 DIABETES MELLITUS
CONTROLLED
4
Biographical Data
Patient L.R.A., 70 years old, male, the status is
married, Roman Catholic , Filipino Citizen. The Pt’s.
address is from Pac naan , Mandaue and was born
on August 17, 1949 was admitted to the hospital on
July 29, 2020 with a complaint of change in
sensorium and LBM ( Loose bowel movement) and
was put in the IM department under by Dr.
Fernandez .
01 Vital Statics
4
01
4
In 2020, Cerebrovascular diseases were the third leading cause which accounted for
64.10 thousand deaths(10.5% share) of the total. Deaths due to diabetes mellitus (39.72 thousand or 6.5% share),
which ranked fourth in 2020, had an annual increase of 14.9 percent. Meanwhile, deaths due to pneumonia,
which recorded 34.25 thousand cases (5.6% share) in 2020, posted a -45.4 percent decrease from 62.72 thousand cases (10.1%
share) in 2019, making it the fifth leading cause of death for the year.
Cerebrovascular Disease
From 2009 to 2019, stroke remains the second leading cause of death and one of the top
five leading causes of disability in the Philippines. The true stroke prevalence is uncertain, but
reported estimates vary between 0.9% (2005) to 2.6% (2017) of the population. Based on types
of stroke, seven out of 10 cases are diagnosed as ischemic while the other three are considered
hemorrhagic. Thirty six percent (36%) of the total stroke deaths are not attended by any medical personnel.
01 Diabetes Mellitus
According department of health update Diabetes is the 6th leading cause
of death among Filipinos based on the data from the 2013 Philippine
Health Statistics, and over 6 million Filipinos are diagnosed to have
diabetes, as declared by the Philippine Center for Diabetes Education
Foundation in 2016. 4
PSA (Philippine Statistics Authority)
Philippine Statistics Authority data showed that deaths due to diabetes mellitus ranked fourth in 2020 at
37,265, after heart diseases (99,680), cancer (62,289), and cerebrovascular diseases (59,736) , and there
is increased by 7.8 percent from the 2019 tally. “Type 2 diabetes makes up about 85 percent of patients
with diabetes. These patients have multiple risk factors. Some are smokers, some are hypertensive, some
have cholesterol problems,
Reference: (Cudis 2021)
01
Communicated Acquired Pneumonia
refers to an acute infection of the pulmonary parenchyma acquired outside of the hospital.
In the Philippines, 57,809 pneumonia deaths were reported in 2016, nearly 10 percent of 582,183
registered deaths in 2016. This made pneumonia the 3rd top killer behind ischemic heart disease and
cancer. A number of things can cause pneumonia to include bacteria, viruses and other infectious agents.
Risk factor
4
Older age - The risk of CAP rises with age. The annual incidence of hospitalization for CAP among adults
≥65 years old is approximately 2000 per 100,000. This figure is approximately three times higher than the
general population and indicates that 2 percent of the older adult population will be hospitalized for CAP
annually
Smoking and alcohol overuse – Smoking, alcohol overuse (eg, >80 g/day), and opioid use are key
modifiable behavioral risk factors for CAP.
Chronic comorbidities - The comorbidity that places patients at highest risk for CAP hospitalization is chronic
obstructive pulmonary disease (COPD), with an annual incidence of 5832 per 100,000.
Viral respiratory tract infection - Viral respiratory tract infections can lead to primary viral pneumonias and
also predispose to secondary bacterial pneumonia.
Impaired airway protection - Conditions that increase risk of macro aspiration of stomach contents and/or
micro aspiration of upper airway secretions predispose to CAP, such as alteration in consciousness
01
Other lifestyle factors - Other factors that have been associated with an increased risk of CAP include
crowded living conditions (eg, prisons, homeless shelters), residence in low-income settings, and exposure to
environmental toxins
4
COVID 19 ( CORONA VIRUS 19 )
01
4
Department of health update of the cases in COVID 19 (CORONA VIRUS) on September 2021 nationwide
update there are 2,470,175 total cases, with active case of 165,092, recovered 2,267.678 and death of
37,045. On central Visayas (Cebu and Cebu City) update there are 79,140 total cases with active case of
3,236, recovered 72,967 and death is 2,937 .
DEFINITION OF
DISEASE
Signs and Symptoms
Covid 19 •
•
Fever or chills
Cough
• Shortness of breath or difficulty breathing
• Fatigue
Coronavirus disease (COVID-19) is an infectious • Muscle or body aches
disease caused by a newly discovered • Headache
coronavirus. Most people who fall sick with • New loss of taste or smell
COVID-19 will experience mild to moderate • Sore throat
symptoms and recover without special treatment. • Congestion or runny nose
• Nausea or vomiting
The virus that causes COVID-19 is mainly • Diarrhea
transmitted through droplets generated when an
infected person coughs, sneezes, or exhales.
These droplets are too heavy to hang in the air, Assessment
and quickly fall on floors or surfaces. You can be • Travel history
infected by breathing in the virus if you are within • Physical examination
• Health history
close proximity of someone who has COVID-19, • Vital signs monitoring
or by touching a contaminated surface and then
your eyes, nose or mouth.
CVD INFARCT Signs and Symptoms
• Dizziness, nausea, or vomiting
• Unusually severe headache
A cerebral infarction is an area of necrotic tissue
• Confusion,
in the brain resulting from a blockage or
• disorientation or memory loss
narrowing in the arteries supplying blood and
• Numbness, weakness in an arm, leg or the
oxygen to the brain. The restricted oxygen due to
face,
the restricted blood supply causes an ischemic
• especially on one side
stroke that can result in an infarction if the blood
• Abnormal or slurred speech
flow is not restored within a relatively short period
• Difficulty with comprehension
of time. The blockage can be due to a thrombus,
• Loss of vision or difficulty seeing
an embolus or an atheromatous stenosis of one
• Loss of balance, coordination or the ability to
or more arteries. Which arteries are problematic
• walk
will determine which areas of the brain are
affected (infarcted). These varying infarcts will
produce different symptoms and outcomes.
About one third will prove fatal.
TYPE 2 DIABETES MELLITUS Signs and Symptoms
• Increased thirst
Type 2 diabetes is a chronic disease. It is • Frequent urination
characterized by high levels of sugar in the • Increased hunger
blood. Type 2 diabetes is also called type 2 • Unintended weight loss
diabetes mellitus and adult-onset diabetes. That's • Fatigue
because it used to start almost always in middle- • Blurred vision
and late-adulthood. However, more and more • Slow-healing sores
children and teens are developing this condition. • Frequent infections
Type 2 diabetes is much more common than type • Areas of darkened skin, usually in the armpits
1 diabetes, and is really a different disease. But it and
shares with type 1 diabetes high blood sugar • neck
levels, and the complications of high blood sugar.
Type 2 diabetes occurs when your body's cells
resist the normal effect of insulin, which is to
drive glucose in the blood into the inside of the
cells. This condition is called insulin resistance.
As a result, glucose starts to build up in the
blood.
COMMUNICATED
Signs and Symptoms
• Shortness of breath
ACQUIRED PNUEMONIA • Coughing
• Heavy sputum
Community-acquired pneumonia (CAP) is defined as • Fever And chills
pneumonia that is acquired outside the hospital. The
• Chest pain that is worse when you
most commonly identified pathogens are
Streptococcus pneumoniae, Haemophilus influenzae, breathe or cough
atypical bacteria (i.e. Chlamydia pneumoniae, • Nausea and vomiting (less common)
Mycoplasma pneumoniae, Legionella species), and
viruses. Symptoms and signs are fever, cough,
sputum production, pleuritic chest pain, dyspnea,
tachypnea, and tachycardia. Diagnosis is based on
clinical presentation and chest x-ray. Treatment is
with empirically chosen antibiotics. Prognosis is
excellent for relatively young or healthy patients, but
many pneumonias, especially when caused by S.
pneumoniae, Legionella, Staphylococcus aureus, or
influenza virus, are serious or even fatal in older,
sicker patients.
ANATOMY AND PHYSIOLOGY
EYES BRAIN
This is the ringed one. It’s a gas Neptune is the fourth-largest
giant, composed mostly of planet in our Solar System and
hydrogen and helium the farthest from the Sun
LUNGS BONE
Despite being red, Mars is a cold Mercury is the closest planet to
place. The planet is full of iron the Sun and the smallest one in
oxide dust our Solar System
LIVER KIDNEY
Jupiter is a gas giant and the Venus has a beautiful name and
biggest planet in our Solar is the second planet from the
System Sun. It’s terribly hot
ANATOMY OF THE LUNGS
FUNTIONS:
Larynx- serves to protect the lower airways, facilitates respiration, and plays a key role in
phonation.
Trachea- Commonly called the windpipe, is the main airway to the lungs. It divides into the right
and left bronchi at the level of the fifth thoracic vertebra, channeling air to the right or left lung.
R.U.L- The lung tissue of this lobe is responsible for most of the gas exchange in the right lung
during calm, shallow breathing.
Carina-A ridge at the base of the trachea (windpipe) that separates the openings of the right and left
main bronchi (the large air passages that lead from the trachea to the lungs).
R.P.B- Carries air to your right lung.
L.P.B- Carries air to your left lung.
Bronchiole- Their function is to further warm, moisten, and clean the inspired air and distribute it to
the gas-exchanging zone of the lung.
FUNCTIONS:
Frontal lobe- Important for voluntary movement, expressive language and for managing higher level
executive functions.
Parietal lobe- Is vital for sensory perception and integration, including the management of taste, hearing,
sight, touch, and smell.
Temporal lobe- They are most commonly associated with processing auditory information and with the
encoding of memory.
Occipital lobe- It is associated with visuospatial processing, distance and depth perception, color
determination, object and face recognition, and memory formation.
Cerebellum-It helps with the coordination and movement related to motor skills,
especially involving the hands and feet. It also helps maintain posture, balance, and
equilibrium.
Pons- works together with the medulla oblongata to serve an especially critical role in
generating the respiratory rhythm of breathing.
Medulla-It plays an essential role in passing messages between your spinal cord and
brain.
Spinal cord-Is the pathway for messages sent by the brain to the body and from the
body to the brain.
Normal Function of Pancreas
PANCREAS an exocrine function that helps in digestion and
an endocrine function that regulates blood sugar.
Parts of Pancreas
Head: The head of the pancreas is, as the name implies,
the widest portion of the organ.A small portion of the
organ that joins with the superior mesenteric vein. This
section also has a bile duct, which plays a role in
digestion.
Activation of S protein
RNA released
Polyproteins are
translated from the RNA
genome
Replication/ transaction
Occurs via protein cleavage
Release of histamine
Release of histamine
Fluid shifting
Fluid shifting
Impaired gas
Impaired gas exhange
exhange
Respiratory
Alkalosis)
PATIENT MEDICAL HISTORY
VENUS
MERCURY
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REVIEW OF
SYSTEMS
MARS SATURN
Despite being red, Mars is a cold Saturn is the ringed one. It’s a
Mercury is the closest place. The planet is full of iron gas giant, composed mostly of
oxide dust hydrogen and helium
planet to the Sun, but does
its name have anything to
do with the liquid metal?
JUPITER VENUS
Jupiter is a gas giant and the Venus has a beautiful name and
biggest planet in our Solar is the second planet from the
System Sun. It’s terribly hot
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REVIEW OF
SYSTEMS
STEP 2 STEP 4
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RESULTS
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PREVALENCE EVOLUTION
200,000,000
BIG NUMBER
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DISCUSSION
DR. RICHARD ROE
“Jupiter is a gas giant and the
biggest planet in our Solar
System. It’s the fourth-brightest DR. LEWIS
DR. JENNA MORGAN object in the sky” PATTERSON
“Despite being red, Mars is a “Mercury is the closest planet to
cold place, not hot. It’s full of the Sun and the smallest one in
iron oxide dust, which gives the our Solar System. It’s only a bit
planet its reddish cast” larger than our Moon”
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DISCUSSION
SUMMARY
Mercury is the closest planet to the Sun and the POINT 1
smallest one in the Solar System—it’s only a Mercury is the closest planet to the Sun and the smallest one
bit larger than our Moon. The planet’s name in the Solar System—it’s only a bit larger than our Moon.
has nothing to do with the liquid metal, since it
was named after the Roman messenger god,
Mercury POINT 2
Venus has a beautiful name and is the second planet from the
Sun. It’s terribly hot and its atmosphere is extremely
poisonous
POINT 3
Saturn is a gas giant, composed mostly of hydrogen and
helium. It’s named after the Roman god of wealth and
agriculture
COMPARISON
PATIENT 1 PATIENT 2 PATIENT 3
SYMPTOM 2 NO NO YES
SYMPTOM 3 YES NO NO
JUPITER MARS
Jupiter is the biggest planet in our Despite being red, Mars is a cold
Solar System and the fourth- place. The planet is full of iron
brightest object in the sky oxide dust
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TREATMENT
VENUS
Venus has a beautiful name and is the second
planet from the Sun. It’s hotter than Mercury
and its atmosphere is poisonous
MARS
Despite being red, Mars is a cold place, not
hot. It’s full of iron oxide dust, which gives
the planet its reddish cast
JUPITER
Jupiter is a gas giant and the biggest planet in
our Solar System. It’s also the fourth-
brightest object in the sky
PATIENT MONITORING
MERCURY
MARS VENUS
8%
24%
68%
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CONTRAINDICATIONS
Mercury is the closest planet to ● Here you can describe a reason to stop the
the Sun and the smallest one in treatment
the Solar System—it’s only a ● Here you can describe a reason to stop the
bit larger than our Moon
treatment
● Here you can describe a reason to stop the
treatment
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INDICATIONS
MARS SATURN
Despite being red, Saturn is the ringed
Mars is a cold one. It’s a gas
place, not hot. It’s giant, composed
MERCURY full of iron oxide VENUS mostly of hydrogen
dust and helium
Mercury is the Venus has a
closest planet to beautiful name and
the Sun and the is the second planet
smallest one in our from the Sun
Solar System
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CASE TIMELINE
JUPITER SUN
Jupiter is the biggest The Sun is the star at the
planet in our Solar center of the Solar
System System
MERCURY SATURN
Mercury is the smallest Saturn is composed
planet in our Solar mostly of hydrogen and
System helium
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CONCLUSIONS
Mercury is the closest planet to the Sun and the
smallest one in the Solar System—it’s only a
bit larger than our Moon. The planet’s name
has nothing to do with the liquid metal since it
was named after the Roman messenger god,
Mercury
LINDA JOHN
SPENCER SMITH
MARTIN
MOE
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