Case Presentation

BSN3-B2
Barroga, Christine
Cacay, Kristine Denisse A.
Gavina,Ydynn
Malpaya, Mary Grace T.
Menez, Melissa
Narnola, Dana Aira F.
Seberias, Nellie Marie G.
Villaluz, Julienne Selina G.
Nunales, Kevin P.
Tubera, Christian Marco
Nursing Health History
Personal Data
 Ms. TP is 28 years old, born on July 16,
1983 and lives in Bulacan with her parents
and youngest siblings. She is single and a
Roman Catholic. She works as a Manager
in a call center company. She is the
second among the siblings. She was
admitted last June 26,2012 at 10:00pm.
The source of this information was from
Ms. TP. The interview was conducted last
June 29,2012 9:00am in the morning.
Chief Complaint
 “Nagdilim yung paningin ko tapos
bumaksak na ko ” as verbalized by the
client
 “Nabagok yung ulo ko ung bumaksak ako
tapos may tumulo ng dugo galing sa ulo
ko” as verbalized by the client
History of Present Illness
 The client experienced dizziness and
body weakness while she was inside the
MRT. She passed out and bump her head
on the floor at the Ortigas station.
Past Medical History
 The client had a fever and chicken pox
when she was a child. She rarely
experienced cough and cold. She was
diagnosed having Bronchial Asthma in
2008. She had undergone removal of cyst
(Lumpectomy) in her left breast.
 Family Health History

August 19,
1999 60
February 26,
1952

33 28 24
September 17, July 16, October 1,
1987 1983 1987
Interpretation
 There is no Heredofamilial disease
present in the family. The patient’s father
died because of cardiac arrest in August
19, 1999. The patient was diagnosed of
having Bronchial Asthma last 2008.
LEGENDS:

-- Male -- Cardiac Arrest

-- Female -- Bronchial Asthma

-- Patient
Social History
 The client’s work starts at night and end
in the morning. After her work, she just
sleeps all morning. She rarely go out with
her friend because of her work schedule.
REVIEW OF SYSTEM

Person’s
Gordon
Approach
A. PSYCHOLOGICAL
I. Self perception – Self concept pattern
 The client described herself as a hardworking,
kind and jolly person. She has a medium body
frame
II. Role relationship pattern
 TP is 28 years old, single and still lives with her
parents and younger siblings. She’s the second
among the three siblings. She works as a
Manager in a call center company. She doesn’t
like having cough and colds because it triggers
her Bronchial Asthma.
III. Sexually and Reproductive Pattern
 The client is single and not sexually active. She had her first
monthly period (menarche) when she was 13 years old.
IV. Cognitive Perceptual Pattern
 She has no hearing difficulty and she uses glasses that has
220 grade both of the lens. When she has fever, colds and
cough she doesn’t usually take medicine she only uses
water therapy. The client uses simple Tagalog and English
words when communicating. She asked questions when she
doesn’t understand some of the medical terms that we
used. (Lumpectomy, Cyst and etc.)
V. Coping Stress Tolerance
 She usually talk with her mother whenever she had a
problem. When she has colds and cough she doesn’t usually
take medicine. She relieves it by drinking a lot of water. She
rarely drink medicine to relieves pain.
VI. Value Belief Pattern
 She is a Roman Catholic. She is a member of “Singles
for Christ”. She has a bible beside her Bed.
B. ELIMINATION
 The client defecates every other day and
urinates minimum of four times a day. She
drinks a lot of water everyday to relieve
cough and cold. She doesn’t usually take
medicine to relieve sickness.
C. Rest and Activity
I. Activity Exercise Pattern
 The client takes a bath everyday. Her work start
at the night and ends in the morning. She just
sleep and take a rest in the morning.
II. Sleep Rest Pattern
 She usually sleeps in the morning because her
work starts in the evening.
D. SAFE ENVIRONMENT
 The client has no allergy to any kinds of
foods but she is allergic to mefenamic
acid. The client verbalized that their
surrounding is noisy.
E. OXYGENATION
 The client doesn’t like dust, cough and
colds because it triggers her Bronchial
Asthma. Nails are pink and smooth. Has
moist lips. No obstructions of nasal
passages. The client has regular breathing
pattern.
F. NUTRITION
 The client’s favorite food is Fried chicken.
She doesn’t like to eat vegetbles such as
kalabasa, sitaw and okra. She drinks 4 glass
size of tumbler. She drinks a lot of water
at work. She takes vitamins everyday and
eats a lot of foods.
PHYSICAL ASSESSMENT
General Appearance
◦ Patient has a medium frame body built with
an upright posture and smooth rythmic gait.
She is well groomed and appropriately
dressed. Has no body odor nor presence of
any physical deformities. Her height is 5’6 and
weighs 50 kg. Her vital signs are as follows: PR
of 75 bpm, RR of 18 cpm and BP of 120/80.
Mental Status
 The patient is in conscious state. She is
oriented to time, place, and person. She is
cooperative and she uses simple words in
communicating.
Skin
 Skin is in normal racial tone. Cold in
temperature. With dry and smooth skin
texture. Skin is elastic and mobile. There
are no lesions. Hair is evenly distributed.
Nails
 Nail plate shape is convex 160º. No
presence of clubbing. Nail condition is
smooth. Nail bed is pink in color. Capillary
refill within 3 seconds.
Head and Face
 Skull is proportionate to the body size.
Hair is evenly distributed, thick and is
shiny. There are no infestations found or
seen. Face and facial movement are both
symmetrical. Pain felt on the lower left
occipital region of the head. There is a
bump on the client’s forehead that was
caused by her fall. The wound is stitched
and has a length of 3cm.
Eyes
 Eye condition is straight normal. Thin hair
distribution on both eyebrows. Eyelids
have effective closure. Eyeballs are
symmetric. Bulbar and Palpebral
conjunctiva is clear and white in color.
Pupils are equal in size. Has a brisk
reaction to light and accomodation. She
uses glasses with 220 grade on both of
the lens.
Ears
 Auricle is in normal racial tone. It is
symmetric, elastic and non-tender. Pinna
recoils when folded. External ear canals
with some cerumen upon inspection. No
lesions or inflammations found. Responds
to normal voice.
Nose
 Nose is in normal racial tone with septum
in the midline. Mucosa is pink in color.
Both are patent. Nasal cabity is moist.
Sinuses are non-tender.
Mouth
 Lips are pink in color, same with the color
of the mucosa. Tongue is in midline. Pink
in color, rough and is movable. Gums are
pink in color and with complete set of
teeth.
Pharynx
 The uvula is in midline. Mucosa is pink in
color. Tonsils are not inflamed and gag
reflex is present.
Neck
 Neck muscles are equal in size. Lymph
nodes are non-palpable and not tender.
Trachea is in midline.
Breast and Axilla
 This part was not assessed but the client
verbalized that she undergone
lumpectomy on her left breast and no
masses and nodules present. She also
vebalized that she didn’t feel any kind of
tenderness or discomfort on her breasts.
Chest and Lungs
 Chest shape is AP to lateral with a ratio
of 1:2. The measurements are: 28cm and
14cm. Lung expansion on the anterior and
posterior are both symmetrical. Breathing
pattern is regular.
Abdomen
 Skin integrity is in normal racial tone with
flat contour and symmetry. Bowel sounds
are within the normal range.
Upper and Lower Extremities
 Joints are in full range of motion.There
are no present deformities on both upper
and lower extremities. Peripheral pulses
(Brachial and Radial Pulses) are strong.
No masses and tenderness felt upon
palpation.
Laboratory Tests
 CBC, PC
DATE: June 26, 2012
SPECIMEN: Blood

PURPOSE:
A complete blood count (CBC) is a series of
tests used to evaluate the composition and
concentration of the cellular components of blood.
It consists of the following tests: red blood cell
(RBC) count, white blood cell (WBC) count, and
platelet count; measurement of hemoglobin and
mean red cell volume; classification of white blood
cells (WBC differential); and calculation
of hematocrit and red blood cell indices.
 TESTS RESULTS REFERENCE VALUE
Hemoglobin 12.7 12.0-16.0 g/l
Hematocrit 38.9 38-47 %
RBC 4.74 4.0-6.0 10^6/ul
Mean Corpuscular 26.8 26-34 pg
Hemoglobin
Mean Corpuscular Volume 82.1 80-100 fl
Mean Corpuscular 32.6 31-37 g/dl
HGB.CONC.
WBC 8.25 4.5-11.0 10^3/ul
Neutrophils 85.1 50-70 %
Lymphocytes 6.2 20-40 %
Monocytes 8.4 0-7 %
Eosinophil 0.1 0.0-5.0 %
Basophils 0.2 0.0-1.0 %
RDW RBC Distribution Width 14.3 %
Platelet 225 150-400 10^3/ul
Adequate Platelet
INTERPRETATION:

The neutrophil result is high means there is tissue trauma.

FUNCTIONS:
Neutrophils
 protect the host against pyogenic infections.
Lymphocytes
 They are specialized white blood cells, leukocytes, that become
active during an immune response of the body.
Monocytes
 replenish resident macrophages and dendritic cells under normal
states,
 and in response to inflammation signals, monocytes can move
quickly (approx. 8-12 hours) to sites of infection in the tissues and
divide/differentiate into macrophages and dendritic cells to elicit an
immune response.
CT SCAN SECTION
DATE: June 26, 2012
Head Plain
PURPOSE:
A head or brain CT examines the
various structures of the brain to look for a
mass, stroke, area of bleeding, or
blood vessel abnormality. It is also
sometimes used to look at the skull.
 Multiple Plain CT images of the head were
obtained.
The brain parenchyma is unremarkable with
no evident focal mass lesions or abnormal
classifications, likewise, no acute intracerebral
hemorrhage, acute or chronic infarcts are
seen. The gray matter interface is normal.
The cerebral sulci, sylvian fissures and basal
cisterns are not unusual.
There is no evident extra axial fluid collection
or blood
The ventricles are normal in size, shape and
position.
The midline structure are undisplaced.
The sella turcica is not enlarged the pincal
region and posterior fossa are unremarkable.
The orbits, paranasal sinuses, petromastoids
and bony caluarium are not unusual.
Bone window shows no evident cranial vault
fracture
IMPRESSION:

Normal pain CT scan study of the head

negative for cranial vault fracture.
 ELECTROENCE
PHALOGRAPHY
LABORATORY RESULT
DATE: June 28, 2012
Clinical Data: Loss of Consciousness
PURPOSE:
The EEG, also known as a brain wave test,
is a key tool in the diagnosis and management of
epilepsy and other seizure disorders.
EEG Findings:

The background activity during wakefulness

with eyes closed consists of 10-40 uV 8-9 Hz
alpha reactive to eye opening and seen mostly
posteriorly.
Sleep was not recorded.
Photic stimulation and hyperventilation were
unremarkable.
INTERPRETATION:

This is a normal EEG recording of

wakefulness.
Anatomy and Physiology
Frontal Lobe

Prefrontal area – intellectual function and

personalty
Premotor cortex – skilled movements
Motor cortex – voluntary movements
Broca’s area – speech(expression)

Parietal Lobe
Somatosensory area – sensation (e.g. touch,
pain)
Occipital Lobe
Visual cortex – vision

Temporal Lobe
Auditory cortex – hearing
Olfactory cortex – smell
Wernicke’s area – comprehension of speech
memory
Pathophysiology
History of black out spells

Dizziness and body weakness

(Started inside the mrt train)

Collapse
( Patient collapse as soon as she went out of the train shuttle)

Tissue damage
( She fell unconscious and bump her head that resulted to a laceration
about 3cm long in the lower left occipital region of the head )

Bleeding

Pain is present in the occipital part of the head

List of Prioritization
 Nursing diagnosis
Acute pain related to
laceration of skin in the
lower left side of the
occipital part as evidenced
by pain scale of 7/10.
Impaired skin integrity
related to laceration as
evidenced by
3cm.laceration or cut in the
lower left side of the
occipital part.
Risk for infection related to
wound of skin in the posterior
left side of the head due to
unexpected fall
Rank Justification
This is the 1st prioritized prob
1 because, pain is consider as th
vital sign. And it is an actual p
that needs an immediate nurs
intervention to relieve its disc
and pain.
This is the 2nd prioritized pro
2 because, it needs intervention
promote healing process . An
as the first line of defense in t
body.
This is the last prioritized problem b
3 the patient is at risk even though it’s
actual problem, infection may occur
of entry will not given an appropriat
intervention, and it may cause to ser
actual problem
Subjective: Acute pain History of black Discharge -Accept client’s -pain is DO:
“Medyo masakit related to out spells Outcome: description of subjective Upon discharge
pa yung sugat laceration as After 2 days of pain experience and the client was
ko”, as evidenced by Dizziness and nursing -Monitor skin cannot be felt by able to:
verbalized by pain scale of body weakness intervention the color, temp., and others a.Report pain
the client. 7/10 (Started inside client will be VS -which are was relieved or
Objective: the mrt train) able to: -Provide usually altered controlled
-laceration on a.Report pain is comfort in acute b.Decrease in
the left lower Collapse relief or measures like: --for safety pain scale from
occipital part of ( Patient controlled after -raise the -to relax muscle 7/10 to 5/10
the head collapse as soon 2 days side rails of the -to prevent outcome
-pain scale of as she went out b.Decrease in bed pressure on the achieved
7/10 of the train pain scale from -cold affected part STO:
-facial grimace shuttle) 7/10 to 5/10 compress After 2 hours of
upon palpation Short term -avoid lying nursing
on the affected Tissue damage outcome: on bed using left intervention the
part ( She fell After 2 hours of side client was able
-guarding unconscious and nursing to verbalized
position at the bump her head intervention the non
head part that resulted to a client will be pharmacological
laceration about able to verbalize methods that
3cm long in the non provide relief
lower left pharmacological
occipital region methods that
of the head ) provide relief

Bleeding
Pain is present
in the occipital
part of the head
Nursing Care Plan #2
ASSESSMENT DIAGNOSIS SCI.EXPLANATION PLANNING INTERVENTION IMPLEMENTATION EVALUATION
SUBJECTIVE CUES; Dizziness DISCHARGE INDEPENDENT: >first line defense DISCHARGE
“may sugat ako sa Impaired skin OUTCOME; >provide meticulous against nosocomial OUTCOME;
bandang baba ng integrity related to After 2 days of or aseptic care, infection.. Upon discharge, the
ulo ko dahil sa lacerataion as nx.intervention, the maintain good hand pt. was able to
pagkakabagsak ko evidenced by 3cm Black out patient will be able washing tech. >displayed
sa sahig”as laceration or cut in to; >clean skin surface >to prevent increase improvement in
verbalized by the the posterior left >verbalize with diluted of pathogens in the wound healing as
patient’s mother side of his head achievement of hydrogen peroxide site.. evidenced by intact
pt.fell on the floor wound healing. solution. >for fast wound skin and minimized
>display >apply appropriate healind and to meet presence of wound.
OBJECTIVE CUES; improvement in dressings for e.g. needs of the client. Fully achieved
wound healing as dressing and gel. STO; After 2 hoursof
>guarding outermost layer of evidenced by intact >instruct to avoid >may increased pain nursing intervention,
movement upon the skin breaks skin and minimized putting pressure in and may delayed the patient was able to
inspecting bleeding occurs presence of wound the affected area. wound healing . maintained cleanliness
SHORT TERM >instruct her to >minimize further and not show signs of
>3cm laceration or OUTCOME; avoid positioning at skin trauma thus any infections.
cut in the damage skin or After 2 hoursof left side of her head promoting wound .
posterior left side presence of nursing intervention, healing. Fully ACHIEVED
of his head as laceration(3cm) the patient will be
verbalized by the able to;
patient. >maintain
cleanliness and not
>facial griamce show signs of any
upon palpation. infections.
reference
.
Drug Study #1
Drug Classification Dose, route Mechanism of Side effects Contra- Nursing
and indication and frequency action indication responsibility

Generic: Classification: 300mg Through the Nausea, Renal and Before:

paracetamol Analgesic q4 produce drowsiness, hepatic failure explain the
IV analgesia by headache and effect and
Brand: Indication: blocking pain stomach possible side
Aeknil Prevention of impulses by irritation effects of the
febrile inhibiting medication to
convulsion, synthesis of the patient
headache prostaglandin
CNS that During:
synthesize administer
pain receptor the
to stimulation medication
very slow
through IV

After: watch
out for
possible side
effects.
 Drug Study #2
Drug Classificatio Dose, Mechanis Contraind Side Nursing
Name n and Route m of ication Effects Responsib
Indication and action ility
Freq.
Generic 1 gm -Fleeting -Watchout for
hypotensive
name: -CNS Citicholine Any allergy discrete effects
stimulant, BID increases or hypotensio -Monitor pt.
Citicholine Peripheral blood flow hypersensit n effect, neurologic
Vasolidators, PO and O2 ivity to the increased status
-Store
Cerebral consumptio drug, parasympat medicine away
Brand activators, n in the hypertonia hetic from heat and
name: Neurotropics brain. It is of the affects, low direct light
-Take
also parasympat blood Citicholine on
Zynapse -Citicoline is involved in hetic pressure, time
indicated in the nevous itching or -Teach pt on
cranial biosynthesi system. hives, chest how to take
the drug
traumatism. s action. tightness,
ingling in
mouth and
throat.
Narrative Evaluation
On the second day of our duty, the client’s IVF was
removed and the pain on the injured site was
decrease but still she is complaining of dizziness. It
can be the effect of the trauma on her head. The
client was still on the Diet as tolerated. The client
must continue her home medications as ordered
by her physician.
M.E.T.H.O.D
Medications – the client’s medication are (citicholine)
BID PO (aeknil) 300 mg q4 IV when she was in the
hospital. It was given to her according to the order of
her physician. She must continue her some oral
medications.
Exercise – the client must have a regular exercise even
though she was at home to help her body to recover
from her injury. Simple exercises like flexion and
extension or as can tolerated by the client but avoid
exercises that can cause trauma on her head.
Treatment – while on the hospital the client has her
continuous laboratory exams and diagnostic procedure
and continuing her medications also. When the client
was discharge she must continue her medications and
must have a follow up check up on her physician.
Health Teaching- the must continue her medications
ordered by her physician
-Encourage the client to have a complete bed rest
- teach the client to avoid activities that can cause
trauma or injury to the head
- instruct client to ensure her safety to prevent her
self from having an injury.
- the client must have a follow up check up
Out Patient Department – advised the client to take her
home medications prescribed by her physician. Must
have a follow up check up and continue the health
teachings. Follow on the doctor’s order to her.
Diet – the client’s diet was still Diet as tolerated (DAT).
Foods like meat, fish, chicken, vegetable and fruits.
THE END