CAMARINES SUR POLYTECHNIC COLLEGES Nabua, Camarines Sur COLLEGE OF HEALTH CARE TECHNOLOGY Second Semester, s/y 2011-2012

COMPETENCY APPRAISAL-FUNDA/HEALTH ASSESSMENT Worksheet # 1

NURSING CASE STUDY

1. Identify the assessment data from the case study presented. PATIENT DATA: Name: Mr. Stoop Age: 95 years old Sex: Male Date of Admission: November 23, 2002 Place of Admission: Orange County Hospital (lying on the floor, confused, and soaked in urine) Diagnosis: Acute Cerebral Vascular Accident Assessment Data: Subjective data: confused depressed body weakness dysphagia; at times aphagia gaze preference to the left urinary incontinence

Objective data: BP- 143/86 HR- 84 RR-20 T- 95 degrees F O2 saturation- 95% Slight left facial droop Slurred speech noted Wheezes at the left lung lower lobe noted (-) pedal pulses Skin warm and dry to touch Few abrasions on left arm noted WBC elevated Mildly dehydrated

MRI Scan results: Bilateral acute infarcts Atrophy and chronic ischemic changes noted

DG swallow function tests: Frank Tracheal Aspiration (thin liquid, nectar, thick liquid and honey thick consistency and vallecular pooling) = congestion Laboratory Findings: Low potassium level= 3.1 mEq/L Low lymphocyte count= 3% Low monocyte count= 0% Low ABS monocyte count= 0% High WBC count= 2.42 k/uL RDW high count= 15.3% Neutrophil count elevated= 97% High ADS grnulocytes= 23.5% RBC low level= 23.5K/uL

(November 25, 2002) CO2 level high= 33mEq/L WBC count high= 17.2K/uL High RDW= 15% Low Hgb= 11.1g/dL Low Hct level= 33.5% Low RBC level= 3.86%

2. List down the nursing problems that can be identified using the Gordons 11 Functional Health Patterns a. Ineffective Tissue Perfusion b. Risk for Aspirations c. Impaired Physical Mobility d. Impaired Swallowing e. Impaired Gas Exchange f. Urinary Incontinence g. Risk for Contractures h. Impaired Skin Integrity i. j. Self-Care Deficit Risk for Injury

k. Imbalanced Nutrition Less than Body Requirements l. Impaired Verbal Communication

m. Disturbed Thought Process n. Disturbed Sensory Perception

3. Prioritize the result # 2. Risk for Aspirations is listed here because of its importance in maintaining airway and oxygenation. Outcomes: the client will have reduced risk of aspirations as evidenced by easily managing the saliva, no choking or coughing while eating, no fever, and no crackles or rhonchi. Interventions: assess the client for clinical manifestations of aspiration, such as fever, dyspnea, crackles, and rhonchi, confusion and decreased PaO2 in arterial blood gases. Use caution in feeding the client, either orally or enterally. If the client is receiving enteral feeding, add food coloring to the tube feeding to assist with identifying aspiration via suctioned aspirate. Monitor chest x-ray results, and report findings of pulmonary infiltrate. 4. Make (4) nursing care plan. CSPC format. (another pages)

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