presentation lion heart

8/14/2019 Presentation Lion Heart

1/40

Marian School of Nursing and

Midwifery


2/40

In Partial Fulfillment of theIn Partial Fulfillment of the

RequirementsRequirementsInIn

Curative and Rehabilitative NursingCurative and Rehabilitative Nursing

(NCM 104)(NCM 104)


3/40

A Case PresentationA Case Presentation

EAC BSN IV Section 27 Group CEAC BSN IV Section 27 Group C

Magat, Federico Jr. O.Magat, Federico Jr. O. Magtira, Anna Riza F.Magtira, Anna Riza F. Marquez, Shanelle Erika M.Marquez, Shanelle Erika M. Mercado, Jenilyn L.Mercado, Jenilyn L. Moncayo, Michelle B.Moncayo, Michelle B. Navarro, Lovely Naden C.Navarro, Lovely Naden C.

Nomos, Jesse O.Nomos, Jesse O. Paglicawan, Mc Richard V.Paglicawan, Mc Richard V. Paler, Carmela Ruah C.Paler, Carmela Ruah C.

November 29, 2008


4/40

I. INTRODUCTIONI. INTRODUCTIONWe, the third year Nursing students of EMILIOWe, the third year Nursing students of EMILIO

AGUINALDO COLLEGE in Manila, Section 27 haveAGUINALDO COLLEGE in Manila, Section 27 haveprepared a clinical study utilizing the NURSINGprepared a clinical study utilizing the NURSINGPROCESS.PROCESS.

This is case of C.S.O. a 91 year old woman. She belongsThis is case of C.S.O. a 91 year old woman. She belongs

to a very simple and large family of extended type.to a very simple and large family of extended type.She was admitted at OSPITAL NG MUNTINLUPA lastShe was admitted at OSPITAL NG MUNTINLUPA last20th of November 2008 due to body malaise.20th of November 2008 due to body malaise.

Upon admission the patient was diagnosed with:Upon admission the patient was diagnosed with: HypertensionHypertension T/C CAPT/C CAP S/P Cardiovascular Accident last 2001 with residual.S/P Cardiovascular Accident last 2001 with residual.

She went through different laboratory procedures (CBG,She went through different laboratory procedures (CBG,CBC, BUN, Urea, Na, Potassium, Urinalysis). But after aCBC, BUN, Urea, Na, Potassium, Urinalysis). But after aseries of treatment and medical attention given toseries of treatment and medical attention given toCSO she died a da after her admission.


5/40


6/40

III. Nursing HealthIII. Nursing Health

HistoryHistoryA. History of present illness:A. History of present illness: 6 days prior to admission6 days prior to admission (+) onset of cough nonproductive with on(+) onset of cough nonproductive with on

and off fever, patient was givenand off fever, patient was givencarbocysteine which promptedcarbocysteine which promptedtemporarily relief. Two days PTC, patienttemporarily relief. Two days PTC, patientwas unable to speak, in respiratorywas unable to speak, in respiratory

distress. Persistence prompteddistress. Persistence promptedconsultation.consultation. 2 days prior to admission2 days prior to admission Patient is unable to speak and inPatient is unable to speak and in

respiratory distress. Persistencerespiratory distress. Persistence


7/40

B. Past medical historyB. Past medical history

The patient had a previous mild stroke,The patient had a previous mild stroke,she was admitted to Binan Doctors in anshe was admitted to Binan Doctors in an

out patient department last 2001 andout patient department last 2001 and

taken prescribed medicines. (Vidastat 20taken prescribed medicines. (Vidastat 20

mg, Pletaal 50mg)mg, Pletaal 50mg)

The patient has a history of heartThe patient has a history of heart

disease, she has no history of cancer,disease, she has no history of cancer,tuberculosis, bleeding, alcoholism andtuberculosis, bleeding, alcoholism and

mental disorder.mental disorder.

However, the atient is a knownHowever, the atient is a known


8/40

C. Medical historyC. Medical history

The patient is positive toThe patient is positive to

hypertension, had a previous strokehypertension, had a previous stroke

(2001)(2001)

With residue. She has noWith residue. She has no

maintenance medication.maintenance medication.

D. Family Medical HistoryD. Family Medical History

The patient has a family with theThe patient has a family with the

history of hypertension.history of hypertension.


9/40

E. Gordons Functional PatternE. Gordons Functional PatternHealth perceptionHealth perception

My clients past perception about health is the act ofMy clients past perception about health is the act ofappreciating what God has given you and at the sameappreciating what God has given you and at the sametime a feeling of being good and free from illness. .time a feeling of being good and free from illness. .Wellness for him is the act of doing and enjoyingWellness for him is the act of doing and enjoyingthings by simply making the most of it, an activity ofthings by simply making the most of it, an activity ofperforming an action with a strong and healthy bodyperforming an action with a strong and healthy body

condition with the absence of illness.condition with the absence of illness. My clients present perception about health is veryMy clients present perception about health is very

significant. For her, health is not only feeling goodsignificant. For her, health is not only feeling goodphysically but as well as emotionally. Her feelings andphysically but as well as emotionally. Her feelings andemotions affect the whole personality as a human.emotions affect the whole personality as a human.

The clients general health is poor; She is currentlyThe clients general health is poor; She is currentlyexperiencing non productive cough, body weaknessexperiencing non productive cough, body weaknessand difficulty of breathing. She also encounteredand difficulty of breathing. She also encountereddifferent illnesses in the past these are Mild strokedifferent illnesses in the past these are Mild strokeand hypertension. She Exercises every morningand hypertension. She Exercises every morningthrough walking and jogging in order to keep healthythrough walking and jogging in order to keep healthy

and strong. She eats pork and fish more frequentlyand strong. She eats pork and fish more frequentlythan vegetables. Theres no such accidents that thethan vegetables. Theres no such accidents that the


10/40

Nutritional and Metabolic PatternNutritional and Metabolic Pattern

Before, our patient really loves to eatBefore, our patient really loves to eatPork and fish rather than vegetables. ShePork and fish rather than vegetables. Sheeats three meals per day. She doesnt skipeats three meals per day. She doesnt skipto take her breakfast. She prefers to drinkto take her breakfast. She prefers to drink

juice rather than water (4-5 glasses a day).juice rather than water (4-5 glasses a day).

She takes vitamin c to have a goodShe takes vitamin c to have a goodresistance against diseases andresistance against diseases andmicroorganisms that are pathogenic. Inmicroorganisms that are pathogenic. Interms of her weight and heightterms of her weight and heightmeasurements: she gains 20 lbs for a totalmeasurements: she gains 20 lbs for a totalof 130 lbs. and 2 inches for a total of 55.of 130 lbs. and 2 inches for a total of 55.She eats 3 times a day.She eats 3 times a day.

Now, right after the admission the patientNow, right after the admission the patientexperiencing poor nutritional pattern. Sheexperiencing poor nutritional pattern. She

couldnt eat anymore due to difficulty incouldnt eat anymore due to difficulty inswallowin d s ha ia .swallowin d s ha ia .


11/40

Elimination patternElimination pattern

Before, our patient eliminatesBefore, our patient eliminatesbody waste twice a day and urinatesbody waste twice a day and urinatesfour times a day. She used laxativesfour times a day. She used laxativesonce when she experienced difficultyonce when she experienced difficultyin elimination. Their toilet facilities,in elimination. Their toilet facilities,garbage disposal, pet waste disposalgarbage disposal, pet waste disposal

are all in good condition.are all in good condition. Now, the patient has a lessNow, the patient has a less

urination than normal ( oliguria ) andurination than normal ( oliguria ) andan abnormal elimination pattern.an abnormal elimination pattern.


12/40

Activity Exercise PatternActivity Exercise Pattern

Before, our client was very activeBefore, our client was very active

and she exercises every morning asand she exercises every morning asa part of her everyday routine toa part of her everyday routine to

keep and maintain her body organskeep and maintain her body organs

functional and to excrete all thefunctional and to excrete all thewaste products out of the body.waste products out of the body.

Now, our client couldnt perform anNow, our client couldnt perform an

exercise due to hypertension asexercise due to hypertension asmanifested by body weakness,manifested by body weakness,

fatigue and body malaise. She has afatigue and body malaise. She has a

very minimal movement. He hasvery minimal movement. He has

passive leisure activities.passive leisure activities.


13/40

Perceived Ability (Code for Level) For:Perceived Ability (Code for Level) For: Feeding: 0Feeding: 0 Dressing:IIIDressing:III Cooking: IIICooking: III

Bathing: IIIBathing: III Grooming: IIIGrooming: III Shopping: IIIShopping: III Toileting: IIIToileting: III General Mobility:IIGeneral Mobility:II

Bed Mobility: 0Bed Mobility: 0 Home Maintenance: IIIHome Maintenance: III Laundry:0Laundry:0 Transportation:0Transportation:0 Managing Money:IIManaging Money:II

The patient posture is in upright position. All body partsThe patient posture is in upright position. All body partsare complete. The patients range of motion ability needsare complete. The patients range of motion ability needsassistance due to body weakness and numbness. Theassistance due to body weakness and numbness. Themuscle is slightly firm that she couldnt pick a pencil butmuscle is slightly firm that she couldnt pick a pencil butcan hold it in a longer time. Hes pulse Rate is 83 beats percan hold it in a longer time. Hes pulse Rate is 83 beats perminute, Respiration rate is 19 breaths per minute, Bloodminute, Respiration rate is 19 breaths per minute, Blood

pressure is 130/90 mmHg. The patient has a poor hygienicpressure is 130/90 mmHg. The patient has a poor hygienicappearance, poor grooming and energy level.appearance, poor grooming and energy level.

Sl


14/40

Sleep-rest patternSleep-rest pattern Before admission the patient has a normalBefore admission the patient has a normal

sleep pattern from 7-8 hours of sleep.sleep pattern from 7-8 hours of sleep. Now, our patient has an abnormal sleep patternNow, our patient has an abnormal sleep pattern

( maximum of 2 hours a day ) due to Difficulty of( maximum of 2 hours a day ) due to Difficulty ofbreathing, high blood pressure and fatigue.breathing, high blood pressure and fatigue.

Cognitive perceptual patternCognitive perceptual pattern

Before admission the patient has normal visionsBefore admission the patient has normal visionsof 20/20 and even hearing ability. She has theof 20/20 and even hearing ability. She has theability to perform things in proper.ability to perform things in proper.

Now, our client is experiencing problem on herNow, our client is experiencing problem on hereyes due to cataract but the hearing abilityeyes due to cataract but the hearing abilityremains normal. The big decision that his familyremains normal. The big decision that his familymade was the separation of his children frommade was the separation of his children fromthem, but it was easily resolved through prayingthem, but it was easily resolved through prayingand with a strong faith. Her family use Filipinoand with a strong faith. Her family use Filipinolanguage as their medium of speaking sometimeslanguage as their medium of speaking sometimesthey use English to practice the internationalthey use English to practice the international


15/40

Self-perception Self conceptSelf-perception Self concept

patternpattern

There are times that my clientThere are times that my clientfeels good to his family when theyfeels good to his family when they

show some care to one another. Theshow some care to one another. Thegeneral mood of the family is the actgeneral mood of the family is the actof being happy because all of themof being happy because all of them

speaks well and can easily interact orspeaks well and can easily interact orcorrelate with others. The generalcorrelate with others. The generalmood state of the family is 1. Theymood state of the family is 1. Theyare very educated and very carefulare very educated and very careful

of what they are saying. The family isof what they are saying. The family is


16/40

Role-relationship patternsRole-relationship patterns

My clients family relationship toMy clients family relationship to

one another is good and has a greatone another is good and has a great

bond/chemistry. The income isbond/chemistry. The income is

sufficient to sustain each andsufficient to sustain each and

everyone. Once a month there is aneveryone. Once a month there is an

open conversation between theopen conversation between the

family to unite everyone and to befamily to unite everyone and to beinformed about the family membersinformed about the family members

condition.condition.


17/40

Sexuality reproductive patternSexuality reproductive pattern

My client is already committed andMy client is already committed andtheyre living a life with happiness andtheyre living a life with happiness andcontentment. They are very satisfied withcontentment. They are very satisfied withtheir relationship. They do encountertheir relationship. They do encounter

problem most of the time due to stressproblem most of the time due to stressafter work but that problem is not reallyafter work but that problem is not reallycomplicated, they just easily resolve it.complicated, they just easily resolve it.

They do use of the contraceptives as theirThey do use of the contraceptives as theirpart of family planning. For them having apart of family planning. For them having a

great number of family members is one ofgreat number of family members is one ofthe big problems that most of the family isthe big problems that most of the family iscurrently encountering. Having a greatcurrently encountering. Having a greatnumber of family leads to a financialnumber of family leads to a financialproblem due to the inability to afford theproblem due to the inability to afford the

needs of the children included theneeds of the children included the


18/40

Coping stress tolerance patternCoping stress tolerance pattern

Our patient was admitted due toOur patient was admitted due toHypertension, asthma and t/c CAP andHypertension, asthma and t/c CAP andprayer is the best way to make thingsprayer is the best way to make thingspossible. If problem comes her way shepossible. If problem comes her way she

manages it through praying and with themanages it through praying and with thehelp of the family members.help of the family members.

Values-beliefs patternValues-beliefs pattern Our client is a Christian who believes inOur client is a Christian who believes in

just only one God who created the wholejust only one God who created the wholeworld. She goes to church every Sunday toworld. She goes to church every Sunday toattend the mass and thank God for all theattend the mass and thank God for all theblessings he has given.blessings he has given.


19/40

V. PHYSICAL ASSESSMENTV. PHYSICAL ASSESSMENT(Head to Toe Assessment)(Head to Toe Assessment)


20/40


21/40


22/40

VI. Patterns of Functioning


23/40


24/40


25/40

VII. Laboratory TestsVII. Laboratory Tests


26/40

VIII. Pathophysiology ofVIII. Pathophysiology ofHypertensionHypertension


27/40


28/40

IX. DRUG STUDYIX. DRUG STUDY


29/40


30/40


31/40


32/40


33/40


34/40

X. NURSING CARE PLANX. NURSING CARE PLAN


35/40


36/40


37/40


38/40


39/40


40/40

Thank You!Thank You!

www.nursingdepartment.blogspot.comwww.nursingdepartment.blogspot.com
http://www.nursingdepartment.blogspot.com/http://www.nursingdepartment.blogspot.com/http://www.nursingdepartment.blogspot.com/

presentation lion heart

Documents