Marian School of Nursing and Midwifery
In Partial Fulfillment of the Requirements In Curative and Rehabilitative Nursing (NCM 104)
A Case Presentation
EAC BSN IV – Section 27 Group C
Magat, Federico Jr. O. Magtira, Anna Riza F. Marquez, Shanelle Erika M. Mercado, Jenilyn L. Moncayo, Michelle B. Navarro, Lovely Naden C. Nomos, Jesse O. Paglicawan, Mc Richard V. Paler, Carmela Ruah C.
November 29, 2008
We, the third year Nursing students of EMILIO AGUINALDO COLLEGE in Manila, Section 27 have prepared a clinical study utilizing the NURSING PROCESS. This is case of C.S.O. a 91 year old woman. She belongs to a very simple and large family of extended type. She was admitted at OSPITAL NG MUNTINLUPA last 20th of November 2008 due to body malaise. Upon admission the patient was diagnosed with: Hypertension T/C CAP S/P Cardiovascular Accident last 2001 with residual. She went through different laboratory procedures (CBG, CBC, BUN, Urea, Na, Potassium, Urinalysis). But after a series of treatment and medical attention given to CSO, she died a day after her admission.
II . Patient’s Data
III. Nursing Health History
A. History of present illness: 6 days prior to admission (+) onset of cough nonproductive with on and off fever, patient was given carbocysteine which prompted temporarily relief. Two days PTC, patient was unable to speak, in respiratory distress. Persistence prompted consultation. 2 days prior to admission Patient is unable to speak and in respiratory distress. Persistence
B. Past medical history The patient had a previous mild stroke, she was admitted to Binan Doctors in an out patient department last 2001 and taken prescribed medicines. (Vidastat 20 mg, Pletaal 50mg)
The patient has a history of heart disease, she has no history of cancer, tuberculosis, bleeding, alcoholism and mental disorder. However, the patient is a known
C. Medical history The patient is positive to hypertension, had a previous stroke (2001) With residue. She has no maintenance medication. D. Family Medical History The patient has a family with the history of hypertension.
E. Gordon’s Functional Pattern
My client’s past perception about health is the act of appreciating what God has given you and at the same time a feeling of being good and free from illness. . Wellness for him is the act of doing and enjoying things by simply making the most of it, an activity of performing an action with a strong and healthy body condition with the absence of illness. My client’s present perception about health is very significant. For her, health is not only feeling good physically but as well as emotionally. Her feelings and emotions affect the whole personality as a human. The client’s general health is poor; She is currently experiencing non productive cough, body weakness and difficulty of breathing. She also encountered different illnesses in the past these are Mild stroke and hypertension. She Exercises every morning through walking and jogging in order to keep healthy and strong. She eats pork and fish more frequently than vegetables. There’s no such accidents that the
Nutritional and Metabolic Pattern
Before, our patient really loves to eat Pork and fish rather than vegetables. She eats three meals per day. She doesn’t skip to take her breakfast. She prefers to drink juice rather than water (4-5 glasses a day). She takes vitamin c to have a good resistance against diseases and microorganisms that are pathogenic. In terms of her weight and height measurements: she gains 20 lbs for a total of 130 lbs. and 2 inches for a total of 5’5’’. She eats 3 times a day. Now, right after the admission the patient experiencing poor nutritional pattern. She couldn’t eat anymore due to difficulty in swallowing (dysphagia).
Before, our patient eliminates body waste twice a day and urinates four times a day. She used laxatives once when she experienced difficulty in elimination. Their toilet facilities, garbage disposal, pet waste disposal are all in good condition. Now, the patient has a less urination than normal ( oliguria ) and an abnormal elimination pattern.
Activity Exercise Pattern Before, our client was very active and she exercises every morning as a part of her everyday routine to keep and maintain her body organs functional and to excrete all the waste products out of the body. Now, our client couldn’t perform an exercise due to hypertension as manifested by body weakness, fatigue and body malaise. She has a very minimal movement. He has passive leisure activities.
Perceived Ability (Code for Level) For: Feeding: 0 Dressing:III Cooking: III Bathing: III Grooming: III Shopping: III Toileting: III General Mobility:II Bed Mobility: 0 Home Maintenance: III Laundry:0 Transportation:0 Managing Money:II
The patient posture is in upright position. All body parts are complete. The patients range of motion ability needs assistance due to body weakness and numbness. The muscle is slightly firm that she couldn’t pick a pencil but can hold it in a longer time. Hes pulse Rate is 83 beats per minute, Respiration rate is 19 breaths per minute, Blood pressure is 130/90 mmHg. The patient has a poor hygienic appearance, poor grooming and energy level.
Sleep-rest pattern Before admission the patient has a normal sleep pattern from 7-8 hours of sleep. Now, our patient has an abnormal sleep pattern ( maximum of 2 hours a day ) due to Difficulty of breathing, high blood pressure and fatigue. Cognitive perceptual pattern Before admission the patient has normal visions of 20/20 and even hearing ability. She has the ability to perform things in proper. Now, our client is experiencing problem on her eyes due to cataract but the hearing ability remains normal. The big decision that his family made was the separation of his children from them, but it was easily resolved through praying and with a strong faith. Her family use Filipino language as their medium of speaking sometimes they use English to practice the international
Self-perception Self concept pattern
There are times that my client feels good to his family when they show some care to one another. The general mood of the family is the act of being happy because all of them speaks well and can easily interact or correlate with others. The general mood state of the family is 1. They are very educated and very careful of what they are saying. The family is
My client’s family relationship to one another is good and has a great bond/chemistry. The income is sufficient to sustain each and everyone. Once a month there is an open conversation between the family to unite everyone and to be informed about the family members’ condition.
Sexuality reproductive pattern
My client is already committed and they’re living a life with happiness and contentment. They are very satisfied with their relationship. They do encounter problem most of the time due to stress after work but that problem is not really complicated, they just easily resolve it. They do use of the contraceptives as their part of family planning. For them having a great number of family members is one of the big problems that most of the family is currently encountering. Having a great number of family leads to a financial problem due to the inability to afford the needs of the children included the
Coping stress tolerance pattern
Our patient was admitted due to Hypertension, asthma and t/c CAP and prayer is the best way to make things possible. If problem comes her way she manages it through praying and with the help of the family members.
Values-beliefs pattern Our client is a Christian who believes in just only one God who created the whole world. She goes to church every Sunday to attend the mass and thank God for all the blessings he has given.
V. PHYSICAL ASSESSMENT (Head to Toe Assessment)
VI. Patterns of Functioning
VII. Laboratory Tests
VIII. Pathophysiology of Hypertension
IX. DRUG STUDY
X. NURSING CARE PLAN