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13 AREAS OF ASSESSMENT
Medical History: Has history of high blood pressure and high cholesterol. Sedentary lifestyle. Heavy
smoker. Absence of all other major illnesses noted.
Family History: No siblings. Father is a heavy smoker and has had two strokes in the past three
years. Mother suffers from obesity. Grandparents died of old age and not of a major illness. No other
major illness noted.
Social History: No heavy drinking. Smokes 2-3 packs of light cigarettes daily. Sedentary lifestyle.
Lives in apartment alone. Works full time as sales executive for Sears Department Store.
Physical assessment: High blood pressure of 130/95. High cholesterol. Overweight (height is 5,11 @
275lbs. Pulse is 95bpm. Temperature is 98.8 C. Respiratory rate is 18. Patient is somewhat confused
and suffers from blurred vision, slurred speech and loss of balance.
Physical Examination
Use of the Stethoscope. The most important diagnostic tool for pneumonia is the
stethoscope. Sounds in the chest that may indicate pneumonia include:
Rales, a bubbling or crackling sound. Rales on one side of the chest or that are
heard while the patient is lying down strongly suggest pneumonia.
Rhonchi, abnormal rumblings indicating that there is sputum in the large
airways.
A dull thud. The physician will use a test called percussion, in which the chest
is tapped lightly. A dull thud, instead of a hollow drum-like sound, indicates
certain conditions that suggest pneumonia. These conditions include
consolidation (in which the lung becomes firm and inelastic) and pleural
effusion (fluid build-up in the space between the lungs and the lining around it).
Patient lives in an extended type of family; her fathers mother is residing in
thefamilys
house
Unit No:
Location:
Informant: patient, who is reliable, and old CPMC chart.
Chief Complaint: This is the 3
rd
CPMC admission for this 83 year old woman with a long history of
hypertension who presented with the chief complaint of substernal toothache like
chest pain of 12 hours
duration.
History of Present Illness: Ms J. K. is an 83 year old retired nurse with a long history
of hypertension that
was previously well controlled on diuretic therapy. She was first admitted to CPMC
in 1995 when she
presented with a complaint of intermittent midsternal chest pain.
electrocardiogram at that time
Her
showed first degree atrioventricular block, and a chest X-ray showed mild pulmonary
congestion, with
cardiomegaly.
Myocardial infarction
electrocardiographic and cardiac enzyme
was
ruled
out
by
the
lack
of
abnormalities. Patient was discharged after a brief stay on a regimen of enalapril, and
lasix, and digoxin,
for presumed congestive heart failure. Since then she has been followed closely by her
cardiologist.
Aside from hypertension and her postmenopausal state, the patient denies other
coronary artery disease risk
factors, such as diabetes, cigarette smoking, hypercholesterolemia or family history
for heart disease. Since
her previous admission, she describes a stable two pillow orthopnea, dyspnea on
exertion after walking two
blocks, and a mild chronic ankle edema which is worse on prolonged standing. She
denies syncope,
paroxysmal nocturnal dyspnea, or recent chest pains.
She was well until 11pm on the night prior to admission when she noted the onset of
aching pain under
her breast bone while sitting, watching television.
heavy and toothache
like. It was not noted to radiate, nor increase with exertion. She denied nausea,
vomiting, diaphoresis,
palpitations, dizziness, or loss of consciousness. She took 2 tablespoon of antacid
without relief, but did
manage to fall sleep. In the morning she awoke free of pain, however upon walking
to the bathroom, the
pain returned with increased severity. At this time she called her daughter, who gave
her an aspirin and
brought her immediately to the emergency room.
presentation showed sinus
Her electrocardiogram on
tachycardia at 110, with marked ST elevation in leads I, AVL, V4-V6 and occasional
ventricular
paroxysmal contractions.
cardiac medications, and
workup. All the questions were discussed in this regard. The patient understood aggressive
plan of care.
Read
more: http://www.umm.edu/patiented/articles/how_pneumonia_diagnosed_000064_6.
htm#ixzz26jeZWTqW
Soapie
1.
Antral gastritis
Subjective
>
Reports of pain
Objective
>
Assessment
>
episgastric Pain
Planning
>
>
>
>
Promote comfort
Monitor vital signs
Monitor urine discharge
Assess pain, noting location, intensity (scale of 0 to
10). Characteristics and duration
Promotes muscle relaxation
Prevent complication
Advise him on his diet
Help patient deal with psychosocial concerns
Promote information on BPH and possible
complications
Reinforce importance of medical follow-up for at least
6 months to 1 year, including rectal examination and
urinalysis
>
>
>
>
>
>
Intervention
>
>
>
>
>
>
Evaluation
>
>
>
Pain/discomfort relieved
Complications prevented/minimized
Patient promised that he will go to the hospital and
have himself be checked up
GENERAL EVALUATION
After conducting this case study, we were able to appreciate more the essence of utilizing the nursing
process in the care and management of our patient. It was indeed a tough job on conducting this
study, yet, it gave us a big impact regarding ow useful it is in our chosen profession. Nursing really
demands a tender loving care attitude. It demands patience and is calling that cannot be merely taken
for granted.
Moreover, this case study taught us to stand on our own by not depending on others just to make this.
This provide us, the studenst, a big learning regarding onhow well we take care of our patients in the
real clinical setting. Most of all, thi s study teaches the students to provide clients care more efficiently
and competitively to achieve an effective and quality nursing care.
Good adherence to health care teachings provided to our client and parents
became the reason of meeting our family centered objectives.
Before any nursing intervention, we made it a point that we were able tounderstand the disease
itself and its proper management. Rendering healtht e a c h i n g i s o n e o f t h e
i m p o r t a n t t o o l s t o h e l p p r o m o t e t h e h e a l t h o f t h e patient. We
established a trusting relationship with the parents especially the mother which
enable us to provide efficient nursing care. A good nurse-patient interaction plays a
vital role in meeting the objectives. This is metthrough creating an
environment of trust in listening to the mother of
thep a t i e n t c o n c e r n a n d b e i n g a v a i l a b l e t o c l i e n t s s i d e . T h i s e n a b l e s
u s t o established rapport and respect needed before the mother of the patient willbe willing to take
part in the learning process.We the student discussed about the disease of the
patient to themother and how it is acquired. Maybe, caused by their environment,
lifestylea n d a l s o h e r e d i t a r y. To p r e v e n t s u c h d i s e a s e , t h e p a r e n t s o r
t h e f a m i l y should clean their surroundings and before handling the baby they must
dohandwashing to prevent spread of microorganism. Most important thing
isfor them to give vitamin C to protect her immune system and the importanceof completing all the
immunizations provided by the Department of
Healthe s p e c i a l l y t h e D P T v a c c i n e w h i c h h e l p s t h e c h i l d t o p r e v e
n t i n h a v i n g pneumonia.Certain health teaching was discussed to the mother
like theimportance of adhering therapeutic management regimens like taking
themedications and knowing its advantages or benefits and the effects
andadhering to proper hygiene like cleaning the breast with water before
thebaby will suck and washing the hands before handling the baby. We
alsoimparted to them knowing the potential complications and how to
initiatea p p r o p r i a t e p r e v e n t i v e o r c o r r e c t i v e a c t i o n . L a s t l y
ACKNOWLEDGEMENT
I wish to thank my groupmate who assisted me in the tiresome work of giving their
comments, observations and criticisms for the improvement of the text.
To our family who encouraged us and for many days tolerated our complete
preoccupation with the making of this paper, we lovingly dedicate this humble opus.
SOAPIE
SS
Ang una gyud nga Gi-TB sa amoa kay akong bana tapos wala ko nakabalobahin ana nga sakit. As
verbalized by the patient.
OO
Lack of information
helps minimize fatigue and promote recovery5.Provided a position of comfort and a quite
environment for the clientduring interaction/discussion. This allows patient to concentrate onwhat
is being discussed.
EE
At the end of 2 hours, client was able to verbalized understanding of
thedisease process, treatment regimen, and preventive measures to reducethe risk of