College of Nursing Allied Health Sciences

Manuel S.
Enverga University Foundation

Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES
COLLEGE OF NURSING ALLIED HEALTH SCIENCES
In partial fulfillment of the requirements for

Related Learning Experience at
NCM 104A Orthopedic Nursing
NURSING CASE STUDY

NEUROFIBROMATOUS TYPE 1; NEUROMUSCULAR SCOLIOSIS
Submitted by:
Placino, Siena Kathleen V.
Submitted to:
Clinical Instructor
Dr. Dario Sumande, RN PhD
Date Submitted:
06/06/19
Manuel S. Enverga University Foundation
Lucena City
GENERAL OBJECTIVES
SPECIFIC OBJECTIVES
I. INTRODUCTION
a. Background
i. Incidence, race, gender, age, ration and proportion
ii. Rationale for choosing the case
iii. Significance of the study
iv. Scope of limitation of study
v. Conceptual Theoretical Theory
vi. Related Literature
II. CLINICAL SUMMARY
a. General Data Profile
b. Chief Complaint
c. Nursing theory
1. History of Present Illness
d. Family History {genogram}
e. Social History – Include theories of growth and development
f. Environment/Living Condition
g. Physical Assessment
h. Patterns of functioning
i. Health Management Pattern
ii. Nutritional/Metabolic
1. Numbers of meal/day
2. Appetite
3. Glass of water/day
4. Height & weight
iii. Elimination
1. Frequency of urination
2. Amount of urine/day
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3. Frequency of BM
4. Consistency of the Feces
5. Amount defecated/day
iv. Activity and Exercise
1. Exercise
2. Fatigability
3. ADL
v. Cognitive/Perceptual
1. Orientation
2. Responsiveness
vi. Roles/Relationship
1. As a son/daughter
2. As a brother/sister
3. As a boyfriend/husband/girlfriend/wife
4. As an employee and co-worker
vii. Self-Perception/Self-Concept
viii. Coping/Stress
ix. Values/Beliefs
i. Course in the ward
j. Laboratory/Diagnostic Exam
k. Impression/Diagnosis
III. CLINICAL DISCUSSION OF THE DISEASE
a. Anatomy and Physiology
b. Pathophysiology
i. Book Based
ii. Client Based
c. Drug Study
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IV. NURSING PROCESS
a. Long Term Objective
b. Prioritized List Nursing Problem
c. Nursing Care Plan
d. Discharge Plan (METHOD)
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General Objective:
The purpose of this study is to enhance and gain knowledge, to develop communication
and nursing skills, to provide privacy and maintain confidentiality of the patient and to apply the
right attitudes of the student nurses in rendering and giving care to the patient with
Neurofibromatosis Type 1, Neuromuscular Scoliosis, its importance and implication.
Specific Objectives:
 Understand the condition of Neurofibromatosis Type 1; Neuromuscular Scoliosis and
associate it with the patient through the introduction of the case.
 To illustrate the Anatomy and Physiology of the affected organ or the part of the body.
 To discuss the pathophysiology of the disease.
 To be clinically aware of the clinical manifestation and its complication.
 To develop an effective skill on how to plan and manage proper care in patient with,
Breast Cancer, Pneumonia.
 To formulate a drug study with regards to the patient’s condition.
 To correlate the laboratory result to its normal value.
 To provide the client nursing care plan and discharge plan to assure client’s total wellness
during his hospitalization up to the time of his hospital discharge.
 To apply right attitude by respect through providing privacy and maintaining client’s
confidentiality.
I. INTRODUCTION
A. Background of the study
a. Incidence, rate, gender, age, ratio and proportion
Neurofibromatosis Type 1
Neurofibromatosis type 1 makes up about 96% of all neurofibromatosis cases. The
prevalence of neurofibromatosis type 1 (NF1) is about 1/3,000. There are no known ethnic
groups in which NF1 does not occur or is unusually common. The prevalence is somewhat
higher in young children than in adults, a difference that probably results at least in part from the
early death of some NF1 patients. NF1 is fully penetrant in adults, but many disease features
increase in frequency or severity with age. . It occurs equally between gender and races. Fifty
percent of patients have a spontaneous mutation, and the other half have an inherited mutation.
Approximately one-half of the cases are familial (inherited). The remainder is the result
of de novo (sporadic) mutations. The de novo mutations occur primarily in paternally derived
chromosomes, and the likelihood of de novo NF1 increases with advanced paternal age. Aside
from the de novo mutations, the disease is characterized to have a genetic transmission of
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autosomal dominant; meaning only one copy of the gene is needed from one parent for the
offspring to be a symptomatic carrier. The reproductive fitness of NF1 patients is reduced by
about one-half. About half of all cases result from new mutations. The estimated rate of new NF1
mutations is unusually high, but the basis for this high mutation rate is not known.
Neuromuscular Scoliosis
Because of the many causes of neuromuscular scoliosis, the incidence is variable (Table
1). The likelihood and severity of the curves tends to increase with the degree of neuromuscular
involvement.
Diagnosis Incidence of Scoliosis
Cerebral palsy (2 limbs involved) 25%
Myelodysplasia (lower lumbar) 60%
Spinal muscle atrophy 67%
Friedreich ataxia 80%
Cerebral palsy (4 limbs involved) 80%
Duchenne muscular dystrophy 90%
Myelodysplasia (thoracic level) 100%
Traumatic paralysis (<10 years) 100%
Table 1. Incidence of Neuromuscular Scoliosis

Scoliosis affects 2-3 percent of the population, or an estimated six to nine million people
in the United States. Scoliosis can develop in infancy or early childhood. However, the primary
age of onset for scoliosis is 10-15 years old, occurring equally among both genders. Females are
eight times more likely to progress to a curve magnitude that requires treatment. Every year,
scoliosis patients make more than 600,000 visits to private physician offices, an estimated 30,000
children are fitted with a brace and 38,000 patients undergo spinal fusion surgery.
b. Rationale for choosing the case
The group decided to choose the case of Neurofibromatosis Type1; Neuromuscular
Scoliosis because not only is this a rare combination of two complex diseases affecting both the
patient’s skeletal , or more specifically, the spinal column, and also the patient’s nervous system,
more specifically the patient’s nerves. We are able to study two body systems that are
chronically affected by the patient’s disease. Another reason that was a factor in choosing the
case was because of the de novo incidence and occurrence of Neurofibromatosis Type 1 in our
patient. Additionally, it was our first time encountering with such a case of cancer that was
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characterized as benign and affecting the nervous and skeletal system. The fact that the patient
and their accompanying family member were very cooperative and open to sharing facts relating
to the client’s disease and medical history also influenced our decision in choosing this case.
c. Significance of the study

The significance of this study is to enhance/gain knowledge, to develop skills and apply
the right attitudes of the student nurses in rendering and giving care to the patient with
Neurofibromatosis Type 1; Neuromuscular Scoliosis, its importance and implication. This study
will serve as guidelines in assessing and providing proper nursing care to patient with the same
problem or disease.
These are other significance of the study that would support the above statement:
1. Understand condition of Neurofibromatosis Type 1; Neuromuscular Scoliosis and
associate it with the patient through the introduction of the case.
2. To know the Nursing history: the Personal data, Health history and Physical
assessment of the patient.
3. Illustrate the anatomy and physiology and pathophysiology of the affected organ or
part of the body.
4. Discuss and determine manifestation and complications.
5. Develop of an effective skill on how to manage a proper care in patient with
Neurofibromatosis Type 1; Neuromuscular Scoliosis.
6. Formulate a drug study with regards to the patient’s condition.
7. Correlate the lab result to its normal value.
8. To provide the client nursing care plan and Discharge plan to assure for client’s total
wellness during his hospitalization up to the time of his hospital discharge
d. Scope of limitation of the study
The study would only focus on Neurofibromatosis Type 1; Neuromuscular Scoliosis
which is indicative to the client’s health condition and its underlying nursing care relevant for the
client within the two- week duty at Philippine Orthopedic Center, Manila, Philippines.
v. Conceptual Theoretical Framework

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THEORETICAL FRAMEWORKS
Self-Care Deficit Nursing Theory of Dorothea Orem
Orem developed the Self-Care Deficit Theory of Nursing, which is composed of three
interrelated theories: (1) the theory of Self-Care, (2) the theory of Self-Care Deficit, and (3) the
theory of Nursing System.
Theory of Self-Care
Self-care is the performance or practice of activities that individuals initiate and perform
on their own behalf to maintain life, health, and well-being.
Self-care agency is a human ability which is “the ability for engaging in self-care.”
Therapeutic self-care demand “totality of self-care actions to be performed for some
duration in order to meet self-care requisites by using various methods and related sets of
operations and actions.”
Three Categories of Self-Care Requisites
Universal self-care requisites- are associated with life processes, maintenance of the
integrity of human structure and functioning, and with general being.
Developmental self-care requisites- are associated with the developmental processes;
derived from a condition or associated with an event (e.g. adjusting to a new job).
Health Deviation self-care requisites- Required in conditions of illness, injury, or
disease; includes seeking medical assistance, learning to live with effects of condition, etc.
Theory of Self-Care Deficit
Self-care deficit is the basic element of Orem’s general theory of nursing because it
delineates when nursing is needed. Nursing is required when adults are incapable of or limited in
their ability to provide continuous effective self-care.
Five methods of helping
1. Acting for or doing for another
2. Guiding and directing
3. Providing physical or psychological support
4. Providing and maintaining an environment that supports personal
development
5. Teaching
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Theory of Nursing System

1. Wholly Compensatory Nursing System
2. Partly Compensatory Nursing System
3. Supportive-Educative System
The wholly compensatory nursing system is selected when the patient cannot or should
not perform any self-care actions. The partly compensatory nursing system is selected when the
patient can perform some, but not all, self-care actions. The supportive-educative nursing system
is selected when the patient can and should perform all self-care actions.
Considering the fact that our patient is diagnosed with a progressive and chronic neuro-
skeletal disease, the patient is in need of intensive nursing care in coordination of effort with
other members of the health team, especially with the physician and physical/occupational
therapist in order to properly symptomatically treat the patient and alleviate self-care deficits
caused by his diagnosis.
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vi. Related Literature
Overview
Neurofibromatosis is a genetic disorder characterized by tumors or neurofibromas that grow in
the nervous system and under the skin. The disease occurs as two distinct types
- neurofibromatosis 1 (NF1) and neurofibromatosis 2 (NF2) - with each type having a unique set
of manifestations. NF1 occurs more commonly, in approximately 1 in 3000 births, whereas NF2
affects roughly 1 in 25,000 individuals.
Children with NF1 frequently develop orthopaedic problems. The two most common are spine
deformities, particularly scoliosis - a curvature of the spine in a sideways or lateral orientation -
and tibial dysplasia, which refers to failure of the tibia (shin bone) to develop appropriately.
Patients with tibial dysplasia may also have a tendency to fracture and to
develop pseudarthrosis, which refers to failure of the fracture to heal properly. Tibial dysplasia
can also result in limb length discrepancy, where one leg is longer than the other. Other children
with NF1 may develop overgrowth of a limb without any underlying bony abnormalities; in
these cases, the underlying problem is soft tissue overgrowth.
In contrast to NF1, NF2 is associated with “acoustic neuromas” that may affect hearing and
balance and frequently do not have any orthopaedic manifestations of their disease. As a result,
this interview will focus on issues related only to NF1.
Etiology
Mutations in the NF1 gene cause neurofibromatosis type 1.
 The NF1 gene provides instructions for making a protein called neurofibromin. This

protein is produced in many cells, including nerve cells and specialized cells surrounding
nerve. Neurofibromin acts as a tumor suppressor, which means that it keeps cells from
growing and dividing too rapidly or in an uncontrolled way.
 Mutations in the NF1 gene lead to the production of a nonfunctional version of
neurofibromin that cannot regulate cell growth and division. As a result, tumors such as
neurofibromas can form along nerves throughout the body. It is unclear how mutations in
the NF1 gene lead to the other features of neurofibromatosis type 1, such as café-au-lait
spots and learning disabilities.
Inheritance Pattern
Neurofibromatosis type 1 is considered to have an autosomal dominant pattern of inheritance.
People with this condition are born with one mutated copy of the NF1gene in each cell. In about
half of cases, the altered gene is inherited from an affected parent. The remaining cases result
from new mutations in the NF1gene and occur in people with no history of the disorder in their
Unlike most other autosomal dominant conditions, in which one altered copy of a gene in each
cell is sufficient to cause the disorder, two copies of the NF1 gene must be altered to trigger
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tumor formation in neurofibromatosis type 1. A mutation in the second copy of the NF1 gene
occurs during a person's lifetime in specialized cells surrounding nerves. Almost everyone who
is born with one NF1mutation acquires a second mutation in many cells and develops the tumors
characteristic of neurofibromatosis type 1.
 NF1. The NF1 gene is located on chromosome 17. This gene produces a protein called
neurofibromin that helps regulate cell growth. The mutated gene causes a loss of
neurofibromin, which allows cells to grow uncontrolled.
 NF2. The NF2 gene is located on chromosome 22, and produces a protein called merlin
(also called schwannomin), which suppresses tumors. The mutated gene causes a loss of
merlin, leading to uncontrolled cell growth.
Clinical Manifestations
Neurofibromatosis 1
Neurofibromatosis 1 (NF1) usually appears in childhood. Signs are often noticeable at birth or
shortly afterward, and almost always by age 10. Signs and symptoms are often mild to moderate,
but can vary in severity.
Signs and symptoms include:
 Flat, light brown spots on the skin (cafe au lait spots). These harmless spots are
common in many people. Having more than six cafe au lait spots is a strong indication of
NF1. They are usually present at birth or appear during the first years of life. After early
childhood, new spots stop appearing.
 Freckling in the armpits or groin area. Freckling usually appears by ages 3 to 5.
Freckles are smaller than cafe au lait spots and tend to occur in clusters in skin folds.
 Tiny bumps on the iris of the eye (Lisch nodules). These harmless nodules can't easily
be seen and don't affect vision.
 Soft, pea-sized bumps on or under the skin (neurofibromas). These benign tumors
usually develop in or under the skin, but can also grow inside the body. Sometimes, a
growth will involve multiple nerves (plexiform neurofibroma). Plexiform neurofibromas,
when located on the face, can cause disfigurement. Neurofibromas may increase with
age.
 Bone deformities. Abnormal bone growth and a deficiency in bone mineral density can
cause bone deformities such as a curved spine (scoliosis) or bowed lower leg.
 Tumor on the optic nerve (optic glioma). These tumors usually appear by age 3, rarely
in late childhood and adolescence, and almost never in adults.
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 Learning disabilities. Impaired thinking skills are common in children with NF1 but are
usually mild. Often there is a specific learning disability, such as a problem with reading
or mathematics. Attention-deficit/hyperactivity disorder (ADHD) also is common.
 Larger than average head size. Children with NF1 tend to have a larger than average
head size due to increased brain volume.
 Short stature. Children with NF1 often are below average in height.
Neurofibromatosis 2
Neurofibromatosis 2 (NF2) is much less common than NF1. Signs and symptoms of NF2 usually
result from the development of benign, slow-growing tumors in both ears (acoustic neuromas),
which can cause hearing loss. Also known as vestibular schwannomas, these tumors grow on the
nerve that carries sound and balance information from the inner ear to the brain.
Signs and symptoms generally appear in the late teen and early adult years, and can vary in
severity. Signs and symptoms can include:
 Gradual hearing loss
 Ringing in the ears
 Poor balance
 Headaches
Sometimes NF2 can lead to the growth of schwannomas in other nerves of the body, including
the cranial, spinal, visual (optic) and peripheral nerves. Signs and symptoms of these
schwannomas can include:
 Numbness and weakness in the arms or legs
 Pain
 Balance difficulties
 Facial drop
 Vision problems or the development of cataracts
Diagnosing Neurofibromatosis 1 (NF1)
A diagnosis of NF1 is made in children with two or more of the following criteria:
 Skin lesions (neurofibromas)
 Multiple “café au lait” spots (light coffee-colored spots)
 Freckling in the groin and armpits
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 Eye abnormalities, including Lisch nodules (tiny pigmented tumors in the iris)
 Certain skeletal abnormalities
 A family member with NF1.
Café au lait spots (left) and axillary freckling under the armpits (right)
Children with NF1 who develop scoliosis may be diagnosed with

either dystrophic (degenerative) or non-dystrophic forms of the condition. Non-
dystrophic scoliosis resembles idiopathic adolescent scoliosis, with similar types of curves and
curve patterns, according to Roger F. Widmann, MD, Chief of Pediatric Orthopaedic Surgery at
Hospital for Special Surgery (HSS).
Treatment for non-dystrophic scoliosis can include bracing as well as surgery.
Instrumentation is used to realign the spine and bone grafting is performed to help achieve
fusion. While the health risks associated with non-dystrophic scoliosis are less pronounced, these
curves can modulate into dystrophic scoliosis over time and therefore need to be monitored
carefully until the child reaches maturity.
NIH has seven diagnostic criteria for neurofibromatosis type 1. Two must be met for the
diagnosis of neurofibromatosis type 1. Genetic testing is not routinely done.
1. Six or more cafe-au-lait spots, greater than 5 mm prepubertal and greater than 15 mm
post-pubertal
2. Two or more neurofibromas or one or more plexiform neurofibroma
3. Axillary or groin freckling
4. Optic glioma
5. Two or more Lisch nodules
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6. Sphenoid dysplasia, dysplasia or thinning of long bone cortex
7. First-degree relative with neurofibromatosis type 1
MEDICAL MANAGEMENT:
A major role of the health care provider is to explore avenues for symptomatic treatment. It is
imperative that the patient and health care provider maintain open communication. As long as an
individual does not exhibit serious manifestations of NF such as debilitating tumors or a
malignancy, the health promotion needs are similar to that of any healthy individual. The
following are recommendations for implementing a plan of care in the NF patient:
1. Referral to a physician with experience treating NF: most major cities have NF clinics
staffed by physicians who specialize in the diagnosis and treatment of NF. Patients not
exhibiting serious problems are encouraged to see their NF specialist yearly.
2. Neurofibromas can cause pain, tenderness, and itching; there is currently no
treatment for them. Diphenhydramine has been shown to give comfort and relief for
itching.11 Routinely removing neurofibromas is futile because they most likely will
recur.12 Removal may be indicated when the neurofibromas affect quality of life such as
discomfort in wearing a bra or impair the ability to shave. In these cases, referral to a
dermatologist or surgeon may be advised.
3. Yearly eye examinations by an ophthalmologist are essential in children under the
age of 10 and may be necessary in older children. It is important for the health care
provider to detect any visual changes through a review of systems interview and physical
examination. Referral as indicated.
4. Annual monitoring of blood pressure should be conducted. Vascular disease has
received little recognition in relation to NF. In some cases, the widespread changes in the
vascular system may lead to organ damage.
5. Because of the unpredictability of the disease process combined with the possible
erratic growth of deforming cutaneous neurofibromas, depression and/or anxiety are
common manifestations. Depression and anxiety screening should be conducted at every
visit with possible referral for counseling and or medications if indicated. Support groups,
face-to-face or online, often provide invaluable social and emotional support and should be
recommended.3
6. Roughly 40% of children with NF1 have learning disabilities. Problems with spatial
memory and learning, social and/or behavioral problems, and attention-deficit/hyperactivity
disorders are common features. The etiology of these problems is unknown, but enhanced
concentration and improved test scores have been noted in patients receiving
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methylphenidate.15 The health care provider needs to assess school performance and
socialization.
7. Genetic counseling is imperative in this population. Patients and families must be
aware that NF1 is an autosomal dominant disorder. An affected individual has a 50%
chance of passing the disorder to their offspring. Clinicians should be aware that half of NF1
cases are inherited, whereas the other half occurs as a result of a spontaneous gene mutation
at conception.3, 5 The patients and their family should be counseled on family planning.
Although 75% of neurofibromas carry progesterone receptors, there is little to no correlation
between combined estrogen/progesterone oral contraceptive use and neurofibroma growth in
women taking this medication. However, significant neurofibroma growth was noted in 2
women who used depot medroxyprogesterone acetate; therefore, women with NF may need
to avoid high-dose progesterone
Because NF1 is a progressive disorder with no known cure, research trials are continually
initiated to devise better methods to care for individuals with NF. Individuals can be referred
to research trial websites that outline the purpose and inclusion criteria for current studies.
MEDICATIONS
Managing pain is an important part of treatment for schwannomatosis. Your doctor might
recommend:
 Drugs for nerve pain such as gabapentin (Neurontin, Gralise, Horizant) or pregabalin
(Lyrica).
 Tricyclic antidepressants such as amitriptyline
 Serotonin and norepinephrine reuptake inhibitors such as duloxetine (Cymbalta)
 Epilepsy medications such as topiramate (Topamax, Qudexy XR, Trokendi XR) or
carbamazepine (Carbatrol, Tegretol, others)
SURGICAL MANAGEMENT
Surgery and other procedures
Your doctor might recommend surgery or other procedures to treat severe symptoms or
complications of neurofibromatosis.
 Surgery to remove tumors. Symptoms can be relieved by removing all or part of tumors
that are compressing nearby tissue or damaging organs. If you have NF2 and have
experienced hearing loss, brainstem compression or tumor growth, your doctor might
recommend surgery to remove acoustic neuromas that are causing you problems.
Complete removal of schwannomas in people with schwannomatosis can ease pain
substantially.
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 Stereotactic radiosurgery. This procedure delivers radiation precisely to your tumor and
doesn't require an incision. Stereotactic radiosurgery might be an option to remove
acoustic neuromas if you have NF2. Stereotactic radiosurgery can help preserve your
hearing.
 Auditory brainstem implants and cochlear implants. These devices might help
improve your hearing if you have NF2 and hearing loss.
The effects of neurofibromatosis on bone and spine

In infants and children, neurofibromatosis type I can interfere with the development of the spine.
The disease can affect the protective covering of the spine, called the dura. Increased pressure in
the spinal fluid due to neurofibromas of the spinal nerves can result in dural ectasia, which is a
ballooning out of a sac that contains the cerebrospinal fluid. This condition may result in pain in
the back and limbs, bladder control problems, and numbness in severe cases.
 Neurofibromatosis may cause tumors on an around the spinal cord. Even benign tumors
in this area can cause pain and weakness in the most severe cases.
 Scoliosis, an irregular side curvature of the spine from left to right, and kyphosis, or a
rounded or forward angulated back, occur together or separately in about one in five
people with neurofibromatosis type I.
 Osteoporosis is common among neurofibromatosis type I sufferers, who generally have
lower bone density by age than healthy individuals.
 While physical therapy may be able to relieve minor structural problems with the spine,
definitive treatment often requires orthopedic surgery. Orthopedic spine surgery, can
correct these conditions and restore quality of life to the patient with neurofibromatosis.
Scoliosis and neurofibromatosis
Children with neurofibromatosis type I develop one of two forms of scoliosis, dystrophic or non-
dystrophic scoliosis. Non-dystrophic scoliosis, even in children with neurofibromatosis, is quite
similar to “typical” scoliosis, called adolescent idiopathic scoliosis.
Dystrophic scoliosis, on the other hand, is a form of scoliosis that occurs due to bony changes
related to neurofibromas affecting the spine. Dystrophic scoliosis is identified by looking for
specific features on X-rays of the spine. For patients and their families, dystrophic scoliosis is
known as a more severe form of scoliosis. It may also occur with abnormally thin ribs, weakened
vertebral bones, and severe spinal curvatures including kyphosis and rotational deformities and is
often associated with dural ectasia.
Treatment for scoliosis due to neurofibromatosis is challenging, particularly when dystrophic
scoliosis is present. Effective treatment requires the knowledge and skill of an experienced
orthopedic surgeon who specializes in scoliosis treatment.
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II. CLINICAL SUMMARY

A. GENERAL DATA PROFILE
NAME: PATIENT J.M.

GENDER: MALE
ADDRESS: BALER, AURORA
BIRTHDAY: MARCH 3, 2001
BIRTH PLACE: BALER, AURORA
SPOUSE NAME: N/A
MOTHER’S NAME: SUSILE
FATHER’S NAME: JAIME
NATIONALITY: FILIPINO
RELIGION: ROMAN CATHOLIC
OCCUPATIONS: N/A
DATE OF ADMISSION: FEBRUARY 4, 2019
ADMITTING DIAGNOSIS: NEUROFIBROMATOUS TYPE 1
NEUROMUSCULAR SCOLIOSIS
ADMITTING PHYSICIAN: DR. JOSHUA JOSEPH F. NOCOM
B. CHIEF COMPLAINT:
The patient’s chief complaint is Back Deformity, which is related to the
presenting neuromuscular levoscoliosis (left thoraco-lumbar scoliosis) resulting from the
patient’s known diagnosis of Neurofibromatosis Type 1.
NURSING HISTORY:
HISTORY OF PRESENT ILLNESS:
The patient is a known case of Neurofibromatosis Type 1; Neuromuscular Scoliosis, that
has been diagnosed during the patient’s infancy and continuously treated medically and
surgically with frequent medical check-ups and hospital visitations and confinement. This
admission beginning from February 4, 2019 is the patient’s 41st hospital stay. However, the
patient is known to be serviced since November of 2016. History of seizures related to
manifestations of neurofibromas infiltrating peripheral nervous system nerves and disturbing
spinal nerve function.
a. Childhood Illness:
Diarrhea , fever, cough, common colds, nausea, vomiting
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b. Immunizations: BCG, measles, OPV, DPT, Hepa B
c. Allergies:
No known allergies.
d. Incidents: Seizure episodes in 2016 ; initially treated with Phenytoin OD; now started
Phenobarbital 20mg tab; continued seizure precautions in case of recurrent incident
e. Hospitalizations:
Since childbirth, the patient has frequent hospital visitations because of the early
diagnosis of his specific chronic disease.
f. Medications used or currently taking: none

g. Domestic travel:
Restricted to Baler, Aurora area only.
D. FAMILY HISTORY:
No family history of Neurofibromatosis, Scoliosis or any orthopedic disease or disorder.
E. SOCIAL HISTORY
ERIK ERIKSON’S PSYCHOSOCIAL DEVELOPMENT THEORY

STAGE AGE CENTRAL INDICATORS INDICATORS
TASK OF NEGATIVE
POSITIVE OF
RESOLUTION RESOLUTION
Adolescence 12-18 years Identity vs Role The adolescent If the adolescent
old Confusion must make a cannot make
conscious search deliberate
for identity. This decisions and
is built on the choices, especially
outcome and about vocation,
resolution to sexual orientation,
conflict in earlier and life in general,
stages. role confusion
becomes a threat.
Young 18-40 years Intimacy Vs People who are Failure results in

Adulthood old Isolation successful in loneliness and
resolving the isolation. Adults
conflict of the who struggle with
intimacy versus this stage
isolation stage experience poor
are able to romantic
develop deep, relationships. They
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meaningful might never share
relationships deep intimacy with
with others. their partners or
might even
struggle to develop
any relationships at
all.
The client’s age, which is 18 years old, stands at the borderline of the two stages of Erik
Erikson’s Psychosocial Development Theory: The stage during adolescence which is the
“Identity vs Role Confusion” stage which occurs from twelve to eighteen years old, and the
“Intimacy vs Isolation” stage which occurs from age eighteen to forty years old. Erikson’s
theory of psychosocial development proposes that people pass through a series of stages centered
on social and emotional development. At each point in a person’s life, he or she faces a
developmental conflict that must be resolved. People who overcome these conflicts are able to
achieve psychological skills that ultimately last the rest of a person’s life. Those who fail to
master these challenges will continue to struggle.
One thing that made Erikson’s theory unique is that unlike many other developmental theories,
the psychosocial stages look at how people change and grow over the course of the entire
lifetime. These adult stages continue to play an important role in each individual's development.
This sixth stage of development begins in early adulthood and is centered on the formation of
lasting relationships. Those who are successful at this stage are able to forge deep relationships
and social connections with other people.
The reason we chose this theory is because the client’s chronic diagnosis of
Neurofibromatosis Type 1 which manifests a condition of Neuromuscular Scoliosis, affects the
patient’s psychosocial state. The major clinical manifestations of the disease are related to body/
back deformity which presents abnormal or even disturbing general appearance of the patient
which may hinder the patient’s ability to form satisfying peer groups or intimate relationships
that people his age normally have.
Lucena City
F. ENVIRONMENT/ LIVING CONDITION
The patient’s sister verbalized that they live in a house in proximity to a lake that is characterized
as unclean and filled with trash due to the other people living near them. They also described the
area as a “squatter.” They also described their main water source as “poso” or a well of water,
used for both drinking and for bathing.
G. PHYSICAL ASSESMENT
PHYSICAL NORMAL ACTUAL INTERPRETATION

ASSESMENT FINDINGS FINDINGS
GENERAL -clear in appearance - not in distress - patient underweight,
APPEARANCE and well groomed - weak and thin in with noted lack of
-cooperative appearance appetite
-5ft (height) -rationale for
under/malnourish
-marked deviation of 47kg. (weight )
thorcolumbar spine
to the left. Backdeformity
(Levoscoliosis)
SKIN -with good skin turgor -Flat, light brown (cafe au lait spots)
spots on the skin These harmless spots
are common in many
people. Having more
than six cafe au lait
spots is a strong
indication of NF1.
They are usually
present at birth or
appear during the first
years of life. After
early childhood, new
spots stop appearing.
-Freckling in the Freckling usually

armpits and groin appears by ages 3 to 5.
area. Freckles are smaller
than cafe au lait spots
and tend to occur in
clusters in skin folds.
Lucena City
HAIR -evenly distributed - Normal
hair
-thick hair
NAILS -with good capillary -Normal
refill of 1-2 seconds
-with pinkish nail
beds
-with clean and short
Nails
SKULL AND FACE -mouth uniform - Normal
consistency absence
of nodules and masses
-rounded and smooth
skull contour
-symmetrical facial
movement
EYES -no eye discharges With greyish sclera -Nerves in the eyes
-with anicteric sclera both are also affected by
-eyebrows hair evenly formation of small
distributed/skin intact tumors.
-symmetrical facial
movement
EARS -Auricle color same Normal

as facial skin
-Auricle are mobile
firm and not tender
-Able to hear both
ears
-no edema and
discharges
MOUTH -pinkish lips
-without missing teeth -Normal
-with pink gums
-no foul odor
-with symmetrical
contour
MUSCULOSKETAL -symmetrical Thin (Upper) and
(UPPER AND -no athrophy (Lower) Extremities
LOWER -with full range of
EXTREMETIES) motion
Lucena City
- Symmetrical -normal -
- With normal
sound
CHEST - Normal chest
expansion
-No abdominal -normal

distension
-Flat rounded
ABDOMEN abdomen
-Symmetrical contour
-No surgical incision
H. PATTERNS OF FUNCTIONING
FUNCTIONAL BEFORE DURING INTERPRETATIO
HEALTH PATTERN HOSPITALIZATION HOSPITALIZATIO N
N
Health management  Self Medication • Second time to be >He is just seeking
pattern hospitalized medical attention in
severe cases that
needed attention
Nutritional / Metabolic
 Number of meals  4x a day - 2x a day The number of his
per day  Slight appetite - Lack of meals he is taking
 Appetite  7x a day appetite is decreased during
 Glass of water - 4x a day hospitalization and
per day his appetite
decreased also as
 Height and well as his water
Lucena City
weight intake as result to
his weight loss.
Elimination
 Frequency of  4x a day  2x a day The frequency of
urination  Moderate - Scanty his urination
 Amount of urine - every other decreased and also
the amount
per day day
The frequency of
 Frequency of Once a day his bowel
bowel movement elimination also
decreased.
Activity and exercise  Active in daily  Inactive;
activities prefers His not in active
 Exercise •Independent  Dependent, doing exercise
and to other
 Fatigability on parent activities due to
 Activities of hospitalization
Daily Living
Cognitive/ Perceptual  Oriented to -Oriented to The cognitive and

 Orientation time place and time place perceptual status of
 Responsiveness person and person the patient is still
 Responds -Responds intact and normal.
appropriately to appropriately
verbal and to verbal and
physical stimuli physical
stimuli
Roles/ Relationship  A good
 Kind/Cheerful
 As a son  Caring son  Patient
maintains a
harmonious
relationship
 Kind to his with parents and
parents and siblings.
siblings
Lucena City
Values/Beliefs  Patient believes  He has  Even if he
in God and awareness suffered
always pray. that God from an
really exist own
diagnosis
the patient
never blame
God instead
his
awareness
became
stronger
than before
Self Perception / Self  Have a high  Have a low  Due to long
Concept self worth / self-worth/ term
importance importance. hospitalizat
ion he
thinks have
a small self
worth
importance.
Coping / stress  he seek for He still seek  Family is
some advice to for some his
her family and advice to his Inspiration
family. to cope the
friends
stress.
I. COURSE IN THE WARD
Date Medical Management Rationale
02/04/19 1. Please admit to room of 1. to provide the most adequate

1:40 P.M. choice under children’s and professional nursing care
orthopaedics for the patient and thoroughly
2. DIC: Dr. Nocom assess and analyse the patient’s
3. DAT condition upon admission
2. the main physician is the
Lucena City
4. V/S qshift and record health team member that will

5. Diagnostics: supervise and direct the flow
6. CBC, ESR, CRP, CT, PT, of the patient’s overall medical
PTT, INR surgical treatment
7. Blood Type – crossmatching 3. Specified diet will influence
8. Na, K, Cl, BUN, Crea, the patient’s recovery and
TPAG, CXR, urinarlysis proper nutritional status.
9. Tx: No medications for now 4. To provide baseline data
10. Refer to DIC on laboratory 5. Diagnostics provide data that
exams will help for the official
diagnosis of the patient
6. Diagnostic results will most
likely influence the chosen
medications, in this case
results are not available yet.
o CBC - Complete Blood
Count provides a
general survey of the
health status of the
patient based on serum
and blood levels and
possible abnormalities
that may help with
accurate diagnosis.
o ESR –Erythrocyte
Sedimentation Rate;
this increases when the
body’s immune system
causes inflammation
due to injury or
infection.
o CRP –C-reactive
Protein is a blood test
marker for
inflammation in the
body (this will rise in
response to
inflammation)
o CT – can help with
visualization of small
nodules or formation of
tumors, which cannot
be seen in a plain film
Lucena City
X-ray.
o PT & PTT & INR –
assesses normal
clotting factor in the
patient
7. BT – Blood Transfusion;
Crossmatching; in case the
patient will need transfusion of
blood or serum
8. Na, K, Cl – to assess the
patient for any abnormality in
electrolyte/ fluid levels
9. BUN, Crea- to assess the
patient for normal kidney
function/ urinary elimination
10. TPAG- Total Protein and
Albumin/Globulin – measures
the total amount of types of
protein in the serum portion of
the blood.
11. CXR – Chest X-ray; to analyse
pictures/ radiographs
12. Urinalysis – to assess for any
abnormality in urine
elimination that can help in
forming accurate diagnosis.
13. The physician will base his
treatment on the data the
diagnostic tests provide.
5:30 P.M. 1. Kindly refer to SSU for co-mgt. 1. For application of halo-traction,
(Dr. DelaDingco informed); for this necessitates collaboration of
application of Halo-traction other orthopaedic/ spinal specialist
physicians.
02/06/19 1. --will update once with halo- 1. Efficiency is necessary; the
7:26 A.M. traction already available physician must know as soon as
possible when the equipment
needed is ready so as to proceed to
the actual surgery.
02/10/19 1. Obtain consent (for application 1. Consent is a crucial part of any
of traction tomorrow at ER as surgical procedure and must be
Lucena City
on-call under local + sedation) completed before the application
2. No prep meds of the halo-traction on the patient.
3. Request whole spine CT, whole
spine MRI (not needed for
procedure)
4. NPO 12 mn
2/11/19 ---------ANESTHESIA----------
9A.M.
1. For OR 1. Proper pre-operative

2. Secure consent measurements must be done which
3. NPO includes referral, consent
4. IVF D5LR 1L x 8hrs completion, nothing per orem and
5. Pls. prepare proper IVF application to the
a. Paracetamol 600mg patient to ensure adequate fluids
electrolytes and provide a pathway
in case there is a need to
administer emergency drugs
2. Paracetamol is an NSAID
analgesic which provides
preliminary, general analgesic
effect and post-op general
analgesic effect on the patient.
2/21/19 1. NPO 12mn 1. To properly prepare the patient for
2. Obtain consent the surgical procedure; application
3. No prep. meds c.o.unit of halo-traction
4. Refer 2. To have a further check on
patient’s condition accurately.
3. Provide pathway for fluids and
electrolytes and any possible IV
5. Kindly ff. up official CT & MRI medications.
results
6. Telephone Order:
a. To start IVF PNSS 1L
KVO
2/22/19 1. For rescheduling 1. Rescheduling a surgical procedure

2. DAT means new pre-operative measures
3. Monitor IVF must be done in relation to the new
Lucena City
date of the procedure.
2. DAT is the patient’s diet before
pre-operative measurements and
preparation
3. IV Fluid provides adequate fluid
and electrolytes.
2/25/19 1. For application of halo-traction 1. Halo-traction is used to
under local immobilize and protect the
2. Instruct NPO cervical spine and neck, especially
3. Obtain consent in cases of scoliosis, in order to
4. Refer properly align the delicate vertebra
of the cervical spine, which are
important for vital body functions
such as respiration and regulation
of heartbeat.
2/26/19 1. S/P application of halo-traction 1. Informing the nurse and other
2. For transfer back to ward members of the health team of the
3. Hook to traction @15lbs. completion of the application of
4. Refer---- halo-traction..
5. Celecoxib 200mg/cap BID for 3 2. Post-operative nursing care is
days crucial so as to promote healing
immediately after a surgical
procedure and prevent post-
operative complication.
3. Traction relieves pressure on the
spinal column, which is important
in the patient diagnosed with
scoliosis.
4. Effective collaboration
necessitates frequent referral
towards other members of the
health team.
5. This medication is a nonsteroidal
anti-inflammatory drug (NSAID),
specifically a COX-2 inhibitor,
which relieves pain and swelling.
Lucena City
2/27/19 1. Patient may transfer to 1. Wheelchair is utilized for easier patient

wheelchair with traction @ 15 transfer.
lbs. as needed 2. Phenobarbital is an anticonvulsant,
2. Start Phenobarbital 90 mg/tab which is therapeutic for the patient
once a day diagnosed with Neurofibromatosis 1, in
which the patient is more prone to
experience seizures due to the pathology
of the disease.
3:45 P.M. 1. Pls. give Epiresone 50 mg/tab 1. Epiresone is a skeletal muscle relaxant;
BID under consideration of the patient’s
2. Mefenamic Acid 500mg/tab Q8 inclination for seizures which is
PRN for Pain frequently manifested in a
Neurofibromatosis Type 1.
2. Mefenamic acid isan analgesic which
provides post-operative pain relief for the
patient.
3/3/19 1. Please do bed sore 1. A common complication ensuing post-
8:00 A.M. precaution (apply egg operative clients especially in orthopaedic
crate mattress) cases (complications of immobility) are
pressure sores/ bed sores.
For traction x-ray
Cervical AP
Thoracolumbar AP
Lumbosacral AP
Continue daily PM track care
Refer
3/4/19 1. Please carry out pedia-neuro 1. Frequent imaging diagnostics are

12:56 orders crucial for in-depth and accurate
P.M. 1. Carry out x-ray at OPD assessment and analysis of the patient’s
o ---spine APL c/o DIC prognosis.
2. Refer
3/6/19 1. Please increase traction wt. to 1. Previous weight used for traction.
12:05 18lbs. 2. Frequent nurse’s notes update and
2. For removal of halo-traction tom. proper patient chart update provide for
Then re-application after MRI more efficient patient care.
3. May do wheelchair rides as long
as traction is maintained
Lucena City
4. Refer
2 P.M. --------------TO PT--------------------------- --------------TO PT-----------------------------
1. GBCE 1. GBCE is Gravity Balanced

2. Maintenance EXS to (B) L.E Compliant Exoskeleton to improve
x L.E major muscles condition of musculoskeletal
3. Bed motility skills strength.
4. May do wheelchair ride 2. Maintenance of Exoskeleton
5. Bed to wheelchair transfer off apparatus to bilateral lower
traction + place traction back extremity and lower extremity
once on wheelchair major muscles in order to
6. Refer accordingly. condition muscle and strengthen
the lower limbs.
3. Increasing motility while in bed
----------TO NURSES------------------------ will increase muscle use and
therefore, muscle strength.
1. To main service, before transfer Metabolism is also improved with
3 P.M. to wheelchair, secure proper increase in motility.
weight of traction and length of 4. Wheelchair rides will provide for
suspension on wheelchair. more efficient transfer.
2. Prior to PT program, the 5. Continuous traction maintained
resident’s DIC should initiate the even while on wheelchair.
transfer from bed to wheelchair. 6. Referral is crucial to other
3. Initial transfer from bed to members of the health team for
wheelchair; done. inter-correlated interventions.
4. May note wheelchair ride.
5. May start PT program. ----------------TO NURSES-------------------
6. Transfer with precaution and
proper stabilization 1. Proper traction weight should
7. Refer accordingly. be identified so as to prevent
injury related to traction
related accident (secondary to
underweight or overweight
traction weight).
2. Transfer from bed to
wheelchair is necessary for the
patient to be sent to the area
assigned for PT programs.
3. ---
4. Wheelchair ride provides for
nurse-patient interaction.
5. PT program is essential for
Lucena City
improvement and rehabilitation

of musculoskeletal strength
6. Precaution and proper
stabilization are crucial to
prevent complication or injury.
7. Referral is essential for proper
relaying of information
between health care team
members.
3/7/19  Halo removed. 1. Halo traction usually lasts
9:35 A.M.  Please have MRI done today. between 6-12 weeks and must
be removed after this duration
of time so as to prevent
possible infection due to
overstaying length of
application of skeletal traction.
2. MRI post-removal of halo-
traction must be done to
observe for any complications
that might have occurred from
the removal of the skeletal
traction.
1. For reapplication of halo- 1. Halo traction must be re-
traction tomorrow @ ER. applied so as to preserve the
2. Secure consent. proper alignment of the spinal
3. Therapeutics column.
a. Celecoxib 200mg/cap of 2. Consent is necessary for any
12 hrs. PRN for pain. surgical procedure.
4. Refer 3. Celecoxib is classified as an
NSAID analgesic, which
provides pain relief for the
patient about to undergo
reapplication of skeletal
traction.
3/8/19 1. Re-application of Halo-Traction 1. Re-application of Halo-Traction is
6:40 P.M. Done necessary in order to continue maintaining
2. Attach to 18 lbs. traction proper alignment of the cervical spine.
3. Daily pin track care 2. 18 lbs. is the specified traction weight
4. W.O.F. Assess sensorium, by the physician for this specific patient
nausea/ vomiting, headache that will help with proper traction force
for the patients’ affected spinal column
area.
Lucena City
3. Frequent pin site care is essential so as
to prevent possible infection related to
open wound secondary to skeletal traction.
4. Deterioration in sensorium, nausea and
vomiting and headache are
pathognomonic signs of classic
complications related to cervical spine
affectation.
3/10/19 1. Continue daily pin track care 1. Frequently clean the pin site insertion
8:49 AM 2. Please do bed sore prec. of skeletal traction to prevent infection at
1. Q2 bed turning portal of entry.
2. Apply egg-crate mattress 2. Bed sores are a common complication
3. For cervical APL, thoracolumbar of immobilized patients or patients that
APL, Lumbosacral APL with traction are frequently in bed.
tomorrow  frequent bed turning prevents increased
4. Refer pressure on joints, therefore, preventing
progression of pressure ulcers
Egg-crate mattresses provide equalized
pressure throughout the patient’s body.
3. Cervical, thoracolumbar, and
lumbosacral anterior, posterior and lateral
radiographs must be analysed to provide
assessment data.
4. Referral is crucial for efficient inter-
correlated therapeutic interventions for the
patient.
3/17/19 1. For x-ray tomorrow @ OPD with 1. X-ray of the whole spine provides for a
4:17 P.M. traction: whole spine broader scope of assessment of the
2. Continue pin track care patient’s entire spinal column, in which
3. Continue bed sore precaution any affectation throughout the entire spine
4. Refer will be observed.
2. Frequent pin track care to prevent
infection.
3. Bed sores will remain a possible
complication so long as the patient stays
immobile or frequently in bed.
3/24/19 1. Continue daily pin track care To continue preventing complications of

10:11AM 2. Continue bed sore precaution immobility.
3. Refer
3/27/19  Continue pin track care To continue preventing complications of

4:20 PM immobility.
Lucena City
4/3/19 1. Request traction x-ray of cervical 1. X-ray of parts of the spine must be
4:50 PM spine AP, Lat, thoraco-lumbar AP – assessed while the patient has an applied
lateral skeletal traction.
2. Continue pin track care 2. Pin track care continued to prevent
3. Refer infection at site of insertion of skeletal
traction.
4/5/19 1. May do traction x-ray of cervical 1. Cervical spine must be assessed

spine AP Lat. through radiographic imaging in order to
2. Defer thoraco-lumbar AP-Lateral observe proper positioning in affected
area.
4/7/19 1. Refer to dietary for evaluation 1. Dietary evaluation necessary for

11 A.M. 2. Request CBC, CT, BT, PT, PTT, maintaining proper nutritional status in
Chest X-ray AP – Lat, Urinalysis, TPAG patient.
3. Refer 2. The aforementioned diagnostic
laboratory tests and imaging diagnostics
will provide in-depth data about the
patient’s condition.
04/10/19 ----------------------SSU---------------------- ----------------------SSU-----------------------
1. Daily pin track care 1. Patient has been transferred to new
2. Request x-rays, urine received area, proper pin track care must be done to
prevent infection
2. X-rays provide imaging assessment for
the prognosis of patient’s disease.
04/23/19 1. Please request x-ray of whole spine 1. Whole spine x-ray will provide
tomm @ OPD (with D.I.C) assessment data for prognosis and
progression of the patient’s disease.
04/16/19 1. Bed turning q 2hr. 1. Bed turning to prevent pressure sores/
2. Bed sore precaution improve bed motility for improved
3. Daily pin track care metabolism.
2. Bed sore precaution implemented
because patient is often situated in his bed.
3. Frequent pin track care necessary for
prevention of infection.
4/27/19 1. Manual traction change to 20 lbs. 1. Patient able to handle heavier traction
12:30 PM 2. Refer weight (increased traction weight provides
for greater force of pull, decreasing
pressure on the affected area of the spinal
column).
4/29/19 -----------------To nurses-------------------- -----------------To nurses----------------------
6:50 PM 1. Prescription for Phenobarbital 1. Phenobarbital is an anticonvulsant;
attached to chart. which provides therapeutic effect for the
patient diagnosed with Neurofibromatosis
Lucena City
Type 1, in which a frequent clinical
manifestation is seizures.
5/16/19 1. Please retrieve latest MRI and CT 2. MRI and CT scans provide detailed
7:51 AM images of the spinal cord and nerve
tumors/ neurofibromas.
5/28/19 1. Refer to IM once requested labs 1. Internal medicine will provide more
available analysis on requested lab results providing
2. Request accurate.
2. The aforementioned diagnostic
i. CBC, CT, BT, PT, PTT laboratory tests and imaging diagnostics
ii. BUN, Crea, Na, K, Cl will provide in-depth data about the
iii. TPAG patient’s condition.
iv. CXR AP- Lab 3. Pulmonary and pt. evaluation.
v. Urinalysis
3.For pulmo-clearance once schedule
confirmed
4.Refer to rehab for neuro-clearance
J. LABORATORY DIAGNOSTIC EXAM

Hematology Deparment 04/08/2019
Component Result Normal Range Interpretation Implication Nursing

Responsibiliti
es
Lucena City
Red Blood Cells 5.18 4.0-6.0x10^12/L
Hemoglobin Mass 140 Male 140-180 g/L
Hematocrit 0.45 0.37-0.57
Leukocytes Count 7.11 4.8-10.8x10^9g/L
DIFFERENTIAL
COUNT 0.56 0.40-0.74
Segmenters 0.31 0.19-0.48
Lymphocytes 0.06 0.03-0.09
Monocytes 0.07 0.00-0.07
Eosinophils 0 0.00-0.02
Basophils
Reticulocytes 262 150-450x10^9g/L
Platelet Count
INDICES 87 82-92 fl
MCV 27 28-32 pg Decreased Mean Borderline
Corpuscular anemic; decreased
Volume number of
erythrocytes
MCH 31 32-36 % Decreased Mean Borderline anemic
Corpuscular
Hemoglobin
Concentration
MCGC 10’00” 5-10 mins
Clotting Time
(Lee and White) 1’00” 1-7 mins
Bleeding Time
(Ivy’s Method)
COAGULATIONS
STUDIES 15.00 11-15 seconds
Prothrombin Time 77.0
PT% Activity 1.22
PT INR 34.7 22-45 seconds
Activated PTT

Responsibilities
Hemoglobin Mass 136 Male 140-180 g/L Decreased Level Risk for Encourage dietary
anemia measures to
improve
Lucena City
Hematocrit 0.43 0.37-0.57 hemoglobin
DIFFERENTIAL
COUNT 0.55 0.40-0.74
Monocytes 0.06 0.00-0.07
Eosinophils 0 0.00-0.02
Basophils
Reticulocytes 249 150-450x10^9g/L
Platelet Count
Quantitave CPR
INDICES 86 82-92 fl
MCV 27 28-32 pg
MCH 32 32-36 %
MCGC 5’00” 5-10 mins
Clotting Time
(Lee and White) 1’30” 1-7 mins
Bleeding Time
(Ivy’s Method)
COAGULATIONS
STUDIES 16.1 11-15 seconds
Prothrombin Time 74
PT% Activity 1.23
PT INR 30.9 22-45 seconds
Activated PTT
05/27/2019

Responsibilities
Hemoglobin Mass 136 Male 140-180 g/L Decreased Level Risk for Encourage dietary
Lucena City
anemia measures to improve
Hematocrit 0.43 0.37-0.57 hemoglobin
DIFFERENTIAL
COUNT
Monocytes 0.07 0.03-0.09
Eosinophils 0.06 0.00-0.07
Basophils 0 0.00-0.02
Reticulocytes
Platelet Count 249 150-450x10^9g/L
Quantitave CPR
INDICES
MCV 86 82-92 fl
MCH 27 28-32 pg
MCGC 32 32-36 %
Clotting Time 5’00” 5-10 mins
(Lee and White)
Bleeding Time 1’30” 1-7 mins
(Ivy’s Method)
COAGULATIONS
STUDIES
Prothrombin Time 16.1 11.7-15.3 seconds
PT% Activity 74
PT INR 1.23
Activated PTT 30.9 27.2-32 seconds
BLOOD TYPING RESULT FORM
Component Result
ABO BLOOD TYPE AB positive
Rh GROUP

Responsibilities
Red Blood Cells 5.30
Hemoglobin Mass 147
Lucena City
Hematocrit 0.47 Decreased Level Risk for anemia Encourage
Leukocytes Count 6.24 dietary
DIFFERENTIAL measures to
COUNT improve
Segmenters 0.47 hemoglobin
Lymphocytes 0.36
Monocytes 0.08
Eosinophils 0.08
Basophils 0.01
Reticulocytes
Platelet Count 224
Quantitave CPR 0.01
INDICES
MCV 89
MCH 28
MCGC 31
Clotting Time 9’30”
(Lee and White)
Bleeding Time 2’00”
(Ivy’s Method)
COAGULATIONS
STUDIES
Prothrombin Time 15.40
PT% Activity 79.3
PT INR 1.18
Activated PTT 33.9

Responsibilities
Hemoglobin Mass 1.30 Male 140-180 g/L
Hematocrit 0.38 0.37-0.57
DIFFERENTIAL
COUNT
Monocytes 0.07 0.03-0.09
Eosinophils 0.08 0.00-0.07
Basophils 0 0.00-0.02
Reticulocytes
Platelet Count 259 150-450x10^9g/L
Quantitave CPR <0.10 0.6 mg/dl
INDICES
MCV 78 82-92 fl
MCH 26 28-32 pg
Lucena City
MCGC 34 31-38 %
ESR (Westergren) 10 Less than 15
mm/hr
Clinical chemistry department 05/27/2019

Responsibilities
Blood Urea Nitrogen 3.22 3.2-7.1 mmol/L
Creatinine
SGOT/AST 39.65 58-110 mmol/L Decrease Level
SGPT/ALT 17.27 17-59 U/L
Total Protein 13.89 < 50 U/L
Albumin 69.53 63-82 g/L
Globulin 42.86 35-50 g/L
A/G Ratio 26.67 28-32 g/L Decrease Level
Sodium 1.61 1.50-3.1
Potassium 137.8 135145 mmol/L
Chloride 3.56 3.5-5.5 mmol/L
103.8 98-108 mmol/L
Clinical chemistry department 04/08/2019

Responsibilities
Total Protein 62.49 60-83 g/L
Albumin 44.24 35-55 g/L
Globulin 18.25 22-32 g/L Decrease Level
A/G Ratio 2.42 1.50-3.1
Clinical chemistry 2/5/19

Responsibilities
Creatinine 77-115 mmol/L
Albumin 63.70 35-55 g/L
A/G Ratio 21.12 1.50-3.1
Sodium 2.02 135-145 mmol/L
Potassium 140.3 3.5-5.5 mmol/L
Chloride 4.05 98-108 mmol/L
103.0
Urinalysis 2/6/2019
Lucena City
Component Result Normal range Interpretation Implication Nursing
responsibilty
Color YELLOW
Ph 6.0
Transparency HAZY
Specific Gravity 1.020
Glucose NEGATIVE
Protein NEGATIVE
MICROSCOPIC
FINDINGs :
CELLS:
RBC 0.2 /hpf
PUS CELLS 0.2 /hpf
SQUAMOUS
EPITHELIAL 0.2 /hpf
CELLS FEW
BACTERIA MODERATE
MUCUS
THREADS
Clinical Chemistry Department 4/08/2019

Responsibilities
Albumin 44.24 35-55 g/L
A/G Ratio 2.42 1.50-3.1
Clinical chemistr Department 2/5/2019

Responsibilities
Creatinine 77-115 mmol/L
Albumin 63.70 35-55 g/L
A/G Ratio 21.12 1.50-3.1
Sodium 2.02 135-145 mmol/L
Potassium 140.3 3.5-5.5 mmol/L
Lucena City
Chloride 4.05 98-108 mmol/L
103.0
IMAGING/ RADIOGRAPHS
Date 03/07/2019
Examination PLAIN MRI OF THE WHOLE SPINE
Clinical Data: Back Deformity. Diagnosed to have neurofibromatosis type 1.

Findings:
Comparison is made with previous MRI of the whole spine dated 02/02/2018
Again noted are bilateral nodular and elongated infiltrative lesions diffusely involving in the cervical thoracic,
lumbosacral spines nerves including the cervical and lumbosacral plexus bilaterally, consistent with extensive
plexiform neurofibromas, similar to the previous study. There is involvement of the radial and ulnar nerves,
intercostal nerves, and sciatic and proximal femoral nerves bilaterally as visualized not significantly changed.
Theres is also extension to the occipital subcutaneous region pleura, superior mediastinum, chest wall,
retroperitoneal space paraspinal and gluteal muscles bilaterally, most prominent along the right thoracolumbar
region and retroperitonium not significantly changed.
There is associated marked thoracolumbar levoscoliosis , with apex T11-12 similar to the previous tidy. There is
loss of the usual cervical and lumbar lordosis. The vertebrae demonstrate normal heights and marrow signal.
There is no pathologic disc bulging or focal disc herniation at any level. The spinal cord is intrinsically normal
IMPRESSION:
Extensive bilateral plexiform neurofibromas involving the cervical, thoracic, and lumbosacral spinal nerves
including the cervical and lumbosacral plexus bilaterally, with involvement of the radial and ulnar nerves,
intercostal nerves and sciatic and proximal femoral nerves bilaterally, similar to the previous study dated
02/02/2018. There is also extension to the occipital subcutaneous region, pleura, superior mediastinum, chest
wall, retroperitoneal space, and paraspinal and gluteal muscles bilaterally, most prominent during the right
thoracolumbar region and retroperitoneum, not significantly changed. The findings are indicative of
neurofibromatosis type 1.
Associated marked thoracolumbar levoscoliosis, with apex at T1 to T12, similar to the previous study.
No pathologic disc bulging or focal disc herniation at any level.
Date of Examination: 02/15/19

Date of Interpretation: 2/18/19
Examination PLAIN MRI OF THE WHOLE SPINE
RESULT OF EXAMINATION: CT SCAN WHOLE SPINE

Multiple axial, coronal and sagittal non contrast CT images of whole spine were obtained and revealed
the following:
There is marked deviation of the thoracolumbar spine to the left with a Cobb’s angle measuring close
to 90 degrees. There is a mild rotatory component. No definite evidence of any spinal canal.
Narrowing however lack of intrathecal contrast precludes optimal evaluation.
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Pleural thickening is noted in the right upper hemithorax.
Incidentally, mucosal thickening is seen in the ethmoid & maxillary sinuses bilaterally (polysinusitis)
IMPRESSION:
MARKED THORACOLUMBAR LEVOSCOLIOSIS WITH ROTATORY COMPONENT.
Date of Examination: 4/7/19
Date of Interpretation: 4/24/19
EXAMINATION: CHEST X RAY
RESULT OF EXAMINATION: CT SCAN WHOLE SPINE
No active parenchymal infiltrates.
Marked leftward deviation of the thoracolumbar spine with rotatory component.
(END OF REPORT)
K. IMPRESSION / DIAGNOSIS
IMPRESSION/DIAGNOSIS:
MACROSCOPIC AND MICROSCOPIC DESCRIPTION:

The specimen consists of cream white soft tissue fragments measuring 0.7cm in aggregate. Block
all.
Microscopic examination was performed.
RADIOLOGICAL FINDINGS:
IMPRESSION:
INCIDENTAL NOTE: PLEURAL EFFUSION, LEFT
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RADIOLOGICAL FINDINGS:
CHEST X-RAY
There are hazy infiltrates seen at both lungs heart not enlarged. Trachea is at the midline left
sulcus is blunted. The identifiable bony elements are unremarkable.
IMPRESSION:
PNEUMONIA
PLEURAL EFFUSION LEFT
III. CLINICAL DISCUSION OF THE DISEASE
A. ANATOMY AND PHYSIOLOGY

THE PERIPHERAL NERVOUS SYSTEM
The peripheral nervous system (PNS) is the connection between the central nervous
system and the rest of the body. The CNS is like the power plant of the nervous system. It creates
the signals that control the functions of the body. The PNS is like the wires that go to individual
houses. Without those “wires,” the signals produced by the CNS could not control the body (and
the CNS would not be able to receive sensory information from the body either).
Neurons
Neurons are the cells considered to be the basis of nervous tissue. They are responsible for the
electrical signals that communicate information about sensations, and that produce movements in
response to those stimuli, along with inducing thought processes within the brain. An important
part of the function of neurons is in their structure, or shape. The three-dimensional shape of
these cells makes the immense numbers of connections within the nervous system possible.
Parts of a Neuron
The main part of a neuron is the cell body, which is also known as the soma (soma = “body”).
The cell body contains the nucleus and most of the major organelles. But what makes neurons
special is that they have many extensions of their cell membranes, which are generally referred
to as processes. Neurons are usually described as having one, and only one, axon—a fiber that
emerges from the cell body and projects to target cells. That single axon can branch repeatedly to
communicate with many target cells. It is the axon that propagates the nerve impulse, which is
communicated to one or more cells. The other processes of the neuron are dendrites, which
receive information from other neurons at specialized areas of contact called synapses. The
dendrites are usually highly branched processes, providing locations for other neurons to
communicate with the cell body. Information flows through a neuron from the dendrites, across
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the cell body, and down the axon. This gives the neuron a polarity—meaning that information
flows in this one direction. Figure 1 shows the relationship of these parts to one another.
Figure 1. Parts of a Neuron. The major parts of the neuron are labeled on a multipolar neuron
from the CNS.
Where the axon emerges from the cell body, there is a special region referred to as the axon
hillock. This is a tapering of the cell body toward the axon fiber. Within the axon hillock, the
cytoplasm changes to a solution of limited components called axoplasm. Because the axon
hillock represents the beginning of the axon, it is also referred to as the initial segment.
Many axons are wrapped by an insulating substance called myelin, which is actually made from
glial cells. Myelin acts as insulation much like the plastic or rubber that is used to insulate
electrical wires. A key difference between myelin and the insulation on a wire is that there are
gaps in the myelin covering of an axon. Each gap is called a node of Ranvier and is important to
the way that electrical signals travel down the axon. The length of the axon between each gap,
which is wrapped in myelin, is referred to as an axon segment. At the end of the axon is the axon
terminal, where there are usually several branches extending toward the target cell, each of
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which ends in an enlargement called a synaptic end bulb. These bulbs are what make the
connection with the target cell at the synapse.
A motor unit consists of
 An anterior horn cell
 Its motor axon
 The muscle fibers it innervates
 The connection between them (neuromuscular junction)
The anterior horn cells are located in the gray matter of the spinal cord and thus are technically
part of the CNS. In contrast to the motor system, the cell bodies of the afferent sensory fibers lie
outside the spinal cord, in dorsal root ganglia.
Nerve fibers outside the spinal cord join to form anterior (ventral) motor nerve roots and
posterior (dorsal) sensory nerve roots. The ventral and dorsal roots combine to form a spinal
nerve. Thirty of the 31 pairs of spinal nerves have dorsal and ventral roots; C1 has no sensory
root .
Figure 3. Other Neuron Classifications. Three examples of neurons that are classified on the
basis of other criteria. (a) The pyramidal cell is a multipolar cell with a cell body that is shaped
something like a pyramid. (b) The Purkinje cell in the cerebellum was named after the scientist
who originally described it. (c) Olfactory neurons are named for the functional group with
which they belong.
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ANATOMY OF A NEUROFIBROMA/ SCHWANNOMA
Neurofibromatosis
Neurofibromatosis (NF) is a genetic disorder that affects cell growth in the nerve tissues. NF
produces tumors in the skin, internal organs, and nerves that may later become cancerous. It can
also affect bones, causing severe pain and may result in learning disabilities, behavioral
dysfunction, and hearing and vision loss.
There is no cure for neurofibromatosis.
Neurofibromas may affect any organ in the body (especially cutaneous and subcutaneous).
Histology is focused on Schwann cells (progenitor cells of neurofibromas) and fibroblasts.
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Schwann Cells: Any of the cells that surround the axons of the peripheral nerves, forming the
myelin sheath of myelinated nerve fibers and providing support for non-myelinated nerve fibers.
Also called neurilemma.
Schwannoma: is a type of nerve tumor of the nerve sheath. It's the most common type of
benign peripheral nerve tumor in adults. It can occur anywhere in your body, at any age.
 A schwannoma typically comes from a single bundle (fascicle) within the main nerve and
displaces the rest of the nerve. When a schwannoma grows larger, more fascicles are
affected, making removal more difficult. In general, a schwannoma grows slowly.
Fibroblasts: A type of cell found in connective tissue throughout the body that produces
collagen and other proteins found in the extracellular (between cells) spaces.
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Neurofibromatosis Type 1 causes many formations of neurofibromas in extremities and the

skin; forming just beneath the skin surface and along peripheral nerves.
Children with NF1 frequently develop orthopaedic problems. The two most common are spine
deformities, particularly scoliosis - a curvature of the spine in a sideways or lateral orientation -
and tibial dysplasia, which refers to failure of the tibia (shin bone) to develop appropriately.
Patients with tibial dysplasia may also have a tendency to fracture and to develop pseudarthrosis,
which refers to failure of the fracture to heal properly. Tibial dysplasia can also result in limb
length discrepancy, where one leg is longer than the other. Other children with NF1 may develop
overgrowth of a limb without any underlying bony abnormalities; in these cases, the underlying
problem is soft tissue overgrowth.
In contrast to NF1, NF2 is associated with “acoustic neuromas” that may affect hearing and
balance and frequently do not have any orthopaedic manifestations of their disease. As a result,
this interview will focus on issues related only to NF1.
X-ray images of dystrophic (left) and non-dystrophic (right) scoliosis

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Scoliosis of the spine; posterior view
CLINICALLY RELEVANT ANATOMY: SCOLIOSIS

The vertebral column consists of 24 separate bony vertebraes, together with 5 fused vertebrae
that form the sacrum, and usually 4 fused vertebrae that form the coccyx. These 24 separate
vertebrae can be divided in three categories: 7 cervical vertebrae, 12 thoracic vertebrae and 5
lumbar vertebrae. Variations can occur such as Hemivertebrae and fused vertebrae. The anterior
pillar of the spine has weight-bearing and shock-absorbing functions. There is an intervertebral
disc between adjacent vertebral bodies; with the exception of the first and second cervical
vertebrae. Each disc consists of a nucleus pulposus surrounded by an annulus fibrosus. The
posterior pillar comprises the apophyseal joints that are formed by the articular facets on the
articular processes.
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Spinal anatomy; lateral view.
When viewed from the side, the vertebral column displays five curves in the upright posture:
 Cervical curves
There are two normally occurring curves in the cervical spine: the upper cervical curve
extending from the occiput to the axis, and the longer lordotic curve of the lower cervical
spine extending from the axis to the second thoracic vertebrae. The upper cervical curve
is convex forwards and is the reverse of the lower cervical curve.
 Thoracic curve
This curve is concave forwards, extending from T2 to T12. The concavity is due to
greater depth of the posterior parts of the vertebral bodies in this region. In the upper part
there is often a slight lateral curve with the convexity directed to either the right or left.
 Lumbar curve
The lumbar curve is convex forwards and extends from L1 to the lumbosacral junction.
 Sacral curve
The curve extends from the lumbosacral junction to the coccyx. Its anterior concavity
faces downwards and forwards.
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Neuromuscular scoliosis:
Neuromuscular scoliosis is caused by insufficiency of active stabilizers (including the muscles
and tendons surrounding the spinal column like the musculus longus capitis or the musculus
longus colli) of the spine like cerebral palsy, spinal muscular atrophy, spina bifida, muscular
dystrophies or spinal cord injuries.
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B. PATHOPHYSIOLOGY BOOK BASED / CLIENT BASED

I. Book Based
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II. Client Based
IV. NURSING PROCESS

A. LONG TERM OBJECTIVES
The study aims to improve airway breathing and circulation, boost patient’s immunity and
prevent complications of the client through collaborative management with physician
therapist associate with the nutritionist.
B. PRIORITIZED LIST NURSING PROBLEM
PROBLEM RANKING JUSTIFICATION

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Ineffective airway clearance Airway must be given the first

related to the increased attention as based on the rule of
production of respiratory ABC which is Airway, Breathing
secretions 1 and Circulation. In addition,
difficulty of breathing can cause
anxiety to the client that is why,
immediate attention must be done
Ineffective breathing pattern This demands immediate
related to decreased lung treatment/ care and subsequent
expansion medical attention. This also needs
2 attention as based on the rule of
ABC, which is Airway,
Breathing, and Circulation.
Risk for infection related to It is prioritized because based on
compromised immune the Types of Nursing Diagnosis
system 3 the patient’s health is at “risk”
and may likely happen
Altered comfort related to Pain management is considered
severe pain at left breast because without adequate
secondary to Breast CA as knowledge and management , it
evidenced by expressive 4 could aggravate distress. Thus
behaviors. pain alleviation plays a vital role
in rendering care.
Presence of anemia reduces O2
available for cellular uptake and
Altered tissue perfusion 5 contributes to fatigue. Thus,
managing the problem will
improve the client condition.
Constipation related to Alleviation of discomfort will
dehydration and poor eating improve clients condition and
habits as evidence by 6 well being.
absence of stool.
C.NCP (based on the sequence of prioritized problem)
Pneumonia
ASSESSMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATIO
S N
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Subjective: Ineffective Short Term INDEPENDENT: After 8 hours
“nahihirapan po airway Goal:  Encourage  Deep of nursing
akong huminga” as clearance deep breathing intervention,
verbalized by the related to After 8 hours breathing promotes Goal Partially
patient the of nursing exercises oxygenation Met.
increased intervention, before The patient
Objective: production secretions will controlled was able to
 Rapid of be mobilized, coughing
breathing/ respiratory airway  To improve >demonstrate
tachypnea secretions patency will productivity coughing and
 Cough with be maintained  Assist of the cough deep breathing
free of patient in exercise every
yellow  Adequate
secretions, as coughing
sputum fluid intake 1-2 hours
production evidenced exercises during the day
enhances
 Diminished patient’s  Increase liquefaction
and ability to fluid intake, of >Client’s
adventitious effectively as pulmonary respiratory rate
breath cough out appropriate secretions is not within
sounds secretions, and normal range
(crackles) clear lung facilitates (RR – 27)
 Dyspnea sounds, and expectoratio
 V/S taken as uncompromis ns of mucus >Inspiratory
follows: ed respiratory  Provides a crackles can
T: 36.4 rate basis for still be heard at
P: 97 bpm  Monitor evaluating the right lower
R:33 bpm rate, rhythm, adequacy of lobe
BP: 120/90 depth , and ventilation
O2 effort of  To promote >Cough
Saturation:92 respirations drainage of continues to be
% secretions productive
and better
 Assist lung
patient into expansion
moderate  Decreased
high back airflow
rest occurs in
positions areas
consolidate
 Auscultate d with fluid.
lung fields, Bronchial
noting areas breath
of decreased sounds
of absent (normal
airflow and over
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adventitious bronchus)
breath can also
sounds occur in
consolidate
d areas.
Crackles,
rhonchi, and
wheezes are
heard on
inspiration
and/or
expiration
in response
to fluid
accumulatio
n, thick
secretions,
and airway
spasm/obstr
uction
 To help
loosen and
DEPENDENT:
clear the
 Administer mucus from
ordered the airways
medications (mucolytics
such as ); decreased
mucolytic resistance in
agents. the
Bronchodilat respiratory
ors, airway and
expectorants increased
(No airflow to
Medication the lungs
with (bronchodil
pending ators) and to
biopsy) loosen and
clear mucus
and phlegm
from the
respiratory
tract
(expectorant
s)
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 A variety of
respiratory
therapy
treatments
may be used
to open
constricted
airways and
 Administer liquefy
nebulization secretions.
s as needed
Difficulty of Breathing
ASSESSMENT DIAGNOS PLANNIN INTERVENTION RATIONALE EVALUATI

IS G ON
Subjective: Ineffective After 30 INDEPENDENT: Goal Met.
“nahihirapan po ako breathing minutes of  Elevated  Elevation of
sa paghinga ko” as pattern nursing head of the the bed After 30
verbalized by the related to interventio bed for facilities minutes of
patient decreased n, the about 30 respiratory nursing
lung client will degrees and function by intervention,
Objective: expansion experience ask the use of the client will
 Rapid lessened client to gravity. It experience
shallow difficulty assume also lessened
breathing of dorsal decreases difficulty of
 Dyspnea breathing recumbent pressure on breathing as
 Use of as position the abdomen manifested by
intercostal manifested when decreased in
 V/S taken as by assuming the RR from 27
follows: decreased position bpm to 20
T: 36.4 in RR from  Promote bpm with the
P: 97 bpm 27 bpm to chest absence of
R:33 bpm 20 bpm expansion nasal flaring
BP: 120/90 with the  Precipitators and presence
O2 absence of of allergic of calm
nasal  Encouraged breathing
Saturation:9 type of
flaring and deep
0% respiratory
presence of breathing
reactions that
calm exercises
can trigger or
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breathing  Kept exacerbate
environment onset of acute
pollution to episode
a minimum  Assesses the
condition of
the client
 Helps in
 Monitored giving
respiratory adequate
patterns, oxygen to the
including client
rate, depth,
and effort
DEPENDENT:
 Gave
supplement  Assess the
al oxygen condition of
as ordered the client
(2LPM via
nasal
cannula)
COLLABORATI
VE:
 Obtained
blood
specimen
for Arterial
Blood Gas
study
Immune Compromised
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATI
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N ON
Subjective: Risk for Short Term:  Provide  Body After 2 hours
“medyo mahina na po infection isolation/ Substance of nursing
s’ya ngayon kesa related to After 2 hours monitor Isolation intervention,
dati, parang ang dali compromised of nursing visitor as (BSI) Short Term
n’ya pong dapuan ng immune intervention, indicated should be Goal is Fully
sakit ngayon” as system patient will: used for Met as
verbalized by the all evidenced by:
relative > demonstrate infections
different ways patients. >Demonstrati
Objective: to prevent Wound/ on of
Breast Cancer Stage4 infection linen different
Easily get sick isolation ways to
Long Term: and hand prevent
 V/S taken as washing infection such
follows: After 3 days may be as:
T: 36.4 of nursing all that is  Monit
intervention, required ored
P: 97 bpm patient will: for visito
R:33 bpm draining rs as
>will not wounds. sugge
acquire Patients sted
infection with by
diseases health
transmitte provi
d through der
air may  Frequ
also need ent
airborne positi
and on
droplet chang
precautio es
ns.  Cover
Reverse ing of
isolation/ mout
restriction h by
of visitors the
may be famil
needed to y
protect when
the ever
 Wash immune they
hands with suppresse cough
antibacteria d patient
l soap
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before/after After 2 days
each care  Reduces of nursing
activity risk of intervention,
even if cross- Long Term
gloves are contamin Goals are
used ation Fully Met as
because evidenced by:
gloves
may have >Absence of
unnoticea infection
 Encourage/ ble
provide defects,
frequent get torn
position or
changes, damaged
deep- during
breathing/ use
coughing
 Good
exercises
pulmonar
 Encourage y toilet
patient’s may
family to reduce
cover respirator
mouth and y
nose with compromi
tissue se
 Prevents
spread of
infection
via
airborne
droplets
SEVERE PAIN
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Altered After 8 hours > Observe > Observation After 8 hours
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“sobrang sakit comfort of nursing nonverbal cues and may not be of nursing
po ng aking related to intervention pain behavior congruent with intervention, the
kaliwang dede severe pain at the verbal reports or patient was able
hanggang left breast patient’s pain may be only to rate the pain
balikat” as secondary to scale will indicator present scale from 9 to 6.
verbalized by Breast CA as decrease when client is
the patient. evidenced by from 9/10 to unable to
expressive 5/10 verbalize
OBJECTIVE behaviors.
> Determine pain > Information
- With history, (location, provides
guarding frequency, duration, baseline data to
behavior intensity using a evaluate need
- with facial rating scale of 0-10) for, and
grimace effectiveness of
- with pain interventions
scale of 9/10 > Provide non-
- restlessness pharmacological > Promotes
- reduced measures such as relaxation and
interaction massage helps refocus
with others. repositioning and attention.
back rub: as well a
diversional
activities such as
music, reading and
watching television. > Enables client
to participate
> Encourage the actively in non-
use of stress drug treatment
management skills of pain and
and complimentary enhance sense
therapies such as of control pain
relaxation produces stress
techniques, and, in
visualization guided conjunction
imagery, bio- with muscle
feedback ,laughter, tension and
music, internal
aromatherapy and stressors,
therapeutic touch. increases
client’s focus on
self, which in
turn increases
the level
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of pain.
> Goals in
maximum pain
> Evaluate pain control and
relief at regular minimum
intervals. Adjust interference
medication regimen with ADL’S
as necessary
> This
information
helps establish
> Inform client and realistic
relatives of the expectations and
expected confidence in
therapeutic effects own ability to
and discuss handle what
management of side happens.
effects.
> A wide range
of analgesics
may be
> Administer employed RTC
analgesics as manage pain.
indicated.
ANEMIA
DIAGNOSIS
SUBJECTIVE: Altered tissue After 8 hours >Have client rate >To helps in After 8hours of
“Nalulula at perfusion of nursing fatigue, using a developing a nursing
nanghihina ako” related to intervention numeric scale, such plan for intervention goal
as verbalized by poor nutrition the patient as the managing CRF was partially met
the patient. as evidenced will be report Multidimensional to improve the patient was
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by weakness improve Fatigue Inventory client’s quality reported and
OBJECTIVE and fatigue sense of (MFI), if possible, of life. improved sense
and decreased energy. and the time of the of energy.
- with presence Hgb level of day when it is most
of body 10.8g/dL. severe
weakness and
fatigue. >Recommend quiet >Frequent rest
- Apprehension atmosphere, bed periods and/or
- Poor appetite rest if indicated naps are
(2x a day) needed to
- Decreased conserve and
Hgb level = >Monitor restore energy.
10.8 g/dL physiologic >Tolerance
response to activity, varies greatly
such as changes in depending on
BP or heart and the stage of the
respiratory rate disease
process,
nutrition state,
fluid balance,
and reaction to
>Perform pain therapeutic
assessment and regimen.
provide pain >Poorly
management. managed
cancer pain can
>Encourage contribute to
nutritional intake. fatigue.
>Adequate
intake and use
of nutrients is
necessary to
meet energy
needs and
>Encourage build energy
adequate fluid reserves for
intake. activity
>Prevents
dehydration,
>Provide which increase
supplemental fatigue.
oxygen as indicated >Presence of
anemia or
hypoxemia
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reduces O2
available for
cellular uptake
and contributes
to fatigue.
CONSTIPATION
DIAGNOSIS
SUBJECTIVE: Constipation After 8hours > Determine stool > Assists in After 8 hours
“Hindi ako related to of nursing color, consistency, identifying of nursing
mapatae isang dehydration intervention, frequency and causative or interventions, the
lingo na” as and poor the client will amount. contributing client was able to
verbalized by the eating habits establish or factors and establish or
patient. as evidence by return to appropriate return to normal
absence normal interventions patterns of bowel
OBJECTIVE of stool. patterns >Inadequate functioning
of bowel >Monitor intake fluid intake
- Unable to functioning. and output may potentiate
defecate for constipation
one week
- With > Bowels
abdominal > Auscultate bowel sounds are
distention sounds generally
and pain decreased in
upon constipation
palpation
- Poor > Encourage > Sufficient
appetite increased fluid fluid intake is
- intake of 2500 – necessary for
3000 ml/day within the bowel to
cardiac tolerance. absorb
sufficient
amounts
of liquid to
promote proper
stool
> Recommend consistency.
Avoiding gas-
forming foods such
as nuts, peas and > Decrease
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spicy foods gastric distress
> Instruct client onand abdominal
a high-fiber diet, as
distension
appropriate > Fiber absorbs
water, which
adds bulk and
softness to the
stool and
speeds up
>Monitor laboratory passage
studies such as through the
electrolytes as intestines
indicated
> Electrolyte
imbalances
> Discuss use may be result
of stool softeners, of, or
mild stimulants, contribute to
bulk forming altered GI
laxatives or enemas function
as indicated. > Facilitates
Monitor defecation
effectiveness when
constipation is
present
D. Discharge Plan (M.E.T.H.O.D)

 Medication
o The patient has to continue the medications given.
Name of Drug Dosage & Route Curative Effects Side Effects

Frequency
Fluimucil 600 mg P.O. Mucolytic Agent Fever, Runny
Nose, Sore
Throat
Appebon 1 tab P.O. Dietary Stomach upset,
Supplement pain,
constipation
Algesic 1 tab PRN for P.O. Pain Reliever Constipation,
pain drowsiness,
dizziness
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Pulmodual Neb Q4 PRN for Inhalant Bronchodilator Dry mouth,
SOB nausea,
constipation
Cefixime 200mg P.O. antibiotic Severe stomach
or abdominal
pain, persistent
nausea or
vomiting
Azithromycin 500mg P.O. antibiotic Stomach upset,
diarrhrea/ loose
stool, nausea,
vomiting or
abdominal pain
 Fluimucil 600mg
 Prednisone 20mg
 Appebon 1 tab
 Algesic 1 tab PRN for pain
 Pulmodual Neb. Q4 PRN for SOB
 Cefexime 200mg
 Azithromycin 500mg
 Environment/Exercise
Type of Activity allowed/ to be continued:

o Deep Breathing Exercises
o Light Activities
Procedure or Steps:
1. Sit up straight as you prepare to do these exercises. Keep you backbone fully upright with
your shoulders pulled back as you get into position
2. Inhale slowly and deeply. Slowly fill your lungs with air. Think about how pure, fresh and
cleansing this “new” air is for your body
3. Focus on how your lungs feel as they fill with air. Notice how they expand. Pay attention to
how your diaphragm moves to make room for more air in your lungs
4. Exhale slowly. Release the air from your lungs until they are completely empty. Feel your
lungs contracting as your expel all of the “old” air from your body
Use of Equipment (if any): No equipment’s necessary
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Restrictions: Strenuous Activities
 Therapy/Treatment
o Comply with medications
o Increase Fluid Intake
o Utilize Deep Breathing Exercise for at least twice a day
 Health Teaching
( ) clinic appointment schedules ( ) use of alternative medicines
( ) follow-up laboratory examinations ( ) relapse prevention measures
( ) understanding and knowing what to do with side effects of medications
( ) Others: Health Teaching on Deep Breathing Exercise
 Out-Patient
o Advise the patient’s family to follow-up checkup as physician’s ordered
 Diet
a. Prescribed Diet:
- Diet as Tolerated
b. Restrictions
- No restrictions

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Manuel S.

Enverga University Foundation

COLLEGE OF NURSING ALLIED HEALTH SCIENCES

In partial fulfillment of the requirements for

NURSING CASE STUDY

Diagnosis Incidence of Scoliosis

Cerebral palsy (2 limbs involved) 25%

Myelodysplasia (lower lumbar) 60%

Spinal muscle atrophy 67%

Friedreich ataxia 80%

Cerebral palsy (4 limbs involved) 80%

Duchenne muscular dystrophy 90%

Myelodysplasia (thoracic level) 100%

Traumatic paralysis (<10 years) 100%

Table 1. Incidence of Neuromuscular Scoliosis

c. Significance of the study

v. Conceptual Theoretical Framework

Theory of Nursing System

 The NF1 gene provides instructions for making a protein called neurofibromin. This

Children with NF1 who develop scoliosis may be diagnosed with

The effects of neurofibromatosis on bone and spine

II. CLINICAL SUMMARY

NAME: PATIENT J.M.

f. Medications used or currently taking: none

ERIK ERIKSON’S PSYCHOSOCIAL DEVELOPMENT THEORY

Young 18-40 years Intimacy Vs People who are Failure results in

F. ENVIRONMENT/ LIVING CONDITION

PHYSICAL NORMAL ACTUAL INTERPRETATION

-Freckling in the Freckling usually

EARS -Auricle color same Normal

-No abdominal -normal

Cognitive/ Perceptual  Oriented to -Oriented to The cognitive and

I. COURSE IN THE WARD

Date Medical Management Rationale

02/04/19 1. Please admit to room of 1. to provide the most adequate

4. V/S qshift and record health team member that will

1. For OR 1. Proper pre-operative

2/22/19 1. For rescheduling 1. Rescheduling a surgical procedure

2/27/19 1. Patient may transfer to 1. Wheelchair is utilized for easier patient

3/4/19 1. Please carry out pedia-neuro 1. Frequent imaging diagnostics are

1. GBCE 1. GBCE is Gravity Balanced

improvement and rehabilitation

3/24/19 1. Continue daily pin track care To continue preventing complications of

3/27/19  Continue pin track care To continue preventing complications of

4/5/19 1. May do traction x-ray of cervical 1. Cervical spine must be assessed

4/7/19 1. Refer to dietary for evaluation 1. Dietary evaluation necessary for

J. LABORATORY DIAGNOSTIC EXAM

Component Result Normal Range Interpretation Implication Nursing

Hematology Deparment 05/27/2019

Component Result Normal Range Interpretation Implication Nursing

Component Result Normal Range Interpretation Implication Nursing

BLOOD TYPING RESULT FORM

Hematology Deparment 02/04/2019

Component Result Normal Range Interpretation Implication Nursing

Hematology Deparment 02/22/2019

Component Result Normal Range Interpretation Implication Nursing

Clinical chemistry department 05/27/2019

Component Result Normal Range Interpretation Implication Nursing

Clinical chemistry department 04/08/2019

Component Result Normal Range Interpretation Implication Nursing

Clinical chemistry 2/5/19

Component Result Normal Range Interpretation Implication Nursing