204 GYNE Fracture Liver Cirrhosis DM

8/6/2019 204 GYNE Fracture Liver Cirrhosis DM

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INTRODUCTION

A clavicle fracture is a bone fracture in the clavicle, or collarbone.Claviclefractures involve approximately 5% of all fractures seen in hospital emergency

admissions. Clavicles are the most common broken bone in the human body. It ismost often fractured in the middle third of its length. Children and infants areparticularly prone to it. Newborns often present clavicle fractures following adifficult delivery. After fracture of the clavicle, the sternocleidomastoid muscleelevates the proximal fragment of the bone. The trapezius muscle is unable tohold up the distal fragment owing to the weight of the upper limb, and thus theshoulder droops.

A rib fracture is a break orfracture in one or more of the bones making upthe rib cage. The middle ribs are the ones most commonly fractured. Fracturesusually occur from direct blows or from indirect crushing injuries. The weakest

part of a rib is just anterior to its angle, but a fracture can occur anywhere. Themost commonly fractured ribs are the 7th and 10th. Rib fractures are usuallyquite painful because the ribs have to move to allow forbreathing. Even a smallcrack can inflame a tendon and cripple an arm.Rib fractures can occur withoutdirect trauma and have been reported after sustained coughing and in varioussports for example, rowing and golf often in elite athletes. They can alsooccur as a consequence of diseases such as cancer or infections (pathologicalfracture).

Cirrhosis is a consequence of chronic liver disease characterized byreplacement of livertissue by fibrous scartissue as well as regenerative nodules

(lumps that occur as a result of a process in which damaged tissue isregenerated), leading to progressive loss of liver function. Cirrhosis is mostcommonly caused by alcoholism, hepatitis B and C, and fatty liver disease buthas many other possible causes. Some cases are idiopathic, i.e., of unknowncause.The word "cirrhosis" derives from Greek, meaning tawny (the orange-yellow colour of the diseased liver).

Diabetes mellitus type 2 or type 2 diabetes (formerly called [non-[insulin]]-dependent diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder thatis characterized by high blood glucose in the context of insulin resistance andrelative insulin deficiency.While it is often initially managed by increasingexercise and dietary modification, medications are typically needed as thedisease progresses. There are an estimated 23.6 million people in the U.S.(7.8% of the population) with diabetes with 17.9 million being diagnosed, 90% ofwhom are type 2.With prevalence rates doubling between 1990 and 2005, CDChas characterized the increase as an epidemic. Traditionally considered adisease of adults, type 2 diabetes is increasingly diagnosed in children in parallelto rising obesity rates due to alterations in dietary patterns as well as in life stylesduring childhood.

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B. Objectives of the Study

The study aims to further analyze a patients condition providing the

students of NCM501204 a definite idea on how it is to care for a patient with the

same disease condition and how to interconnect all the other laboratory and

significant findings of the physician to associate to the patients current state and

condition. Proper assessment and nursing interventions are also given priority to

emphasize the importance of nursing care to an ill patient. The study also has an

objective of assessing and assisting the patient from her present condition

towards the patients improvement in a higher level of wellness.

C. Scope and Limitation of the Study

The study covers 2 days of assessment and care during our exposure at

Cagayan de Oro Medical Center (COMC) and rendered our care to the patient at

Station 4 (Private room) these includes thorough assessment, giving of nursing

interventions, analyzing of the laboratory results, relating the disease condition to

the Anatomy and Physiology of the Human body and the Pathophysiology of the

disease.

The focus of the study is limited to the time that we had our duty at

COMC, the span of time for the assessment of the patient has limited since we

had only 2 days to assess and for our nursing interventions. Also the hand writing

of the doctors at the doctors order are not legible.

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II. PATIENTS PROFILE

Name: C.B.P

Age: 79 years old

Sex: Female

Birth date: January 12, 1930

Birth place: Zamboanga De l Sur

Occupation: Housewife

Income: 300 pesos/month

Civil status: Widower

Nationality: Filipino

Informant: Patient and SonsReligion: Roman Catholic

Address: Balucot, Tambulig, Zamboanga Del Sur

Number of children 5 children

CLINICAL PROFILE

Date of admission: August 1, 2009

Time of admission: 11:35 AM

Attending physician: Dr. Chang, Dr. Sison, Dr. Tia, Dr. Pagdilao

Chief Complaint: Body malaise

Admitting diagnosis: DM, Fracture Left 8th Rib minimally displaced

Fracture of Distal Left Clavicle

Diet: Soft Diabetic Diet

Vital Signs upon Assessment: BP: 140/80mmHg

T: 36.60 C

RR: 22 cpm

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PR: 85 bpm

Patients Health History

In 2008, patient C.B.P. was admitted at Cebu and was diagnosed to have

liver cirrhosis 2004, this is because of her diet since she was young, she was

fond of eating street foods. She had been on Godex and Essentiale Natural

Meds for several years.

History of Present Illness

A case of 79 year old, female, widower, Filipino fromBalucot, Tambulig,

Zamboanga Del Sur, was admitted at Cagayan de Oro Medical Center on august1, 2009 at exactly 11:35AM accompanied by her daugther. 2 weeks prior to

admission, the patient experienced a fall at there stairs (4 steps), she was

admitted at Zamboanga by then. Due to insufficiency of the equipments of their

hospital, her children decided to transfer her at COMC here in Cagayan de Oro

City and was diagnose DM, Fracture Left 8th Rib minimally displaced Fracture of

Distal Left Clavicle.

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III. GROWTH AND DEVELOPMENT

Developmental Task Theory of Robert Havighurst

A developmental task is a task which arises at or about a certain period in

the life of an individual.

Basing on Havighurst theory our patient C.B.P. belongs in the later

maturity 79 years old stage wherein she has adjusted to decreasing physical

strength and health and the patient also has settled for a reduced income.

Psychosexual Theory of Sigmund Freud

The psychosexual stage of Sigmund Freud has five developmental

periods during which the individual seeks pleasure from different areas of the

body associated with sexual feelings.

Basing in this theory, C.B.P. belongs to the genital stage wherein she has

already achieved sexual desires. She has five children. Fortunately, She has a

good personal relationship with her children. She has fully achieved the

implications of this stage because she was able to raise a family, making a livingand doing it independently apart from her parents. The value of decision making

has already matured in the patient, upon making many decisions for herself and

her family.

Psychosocial Theory of Erik Erickson

Erik Erickson envisioned life has a sequence of levels of achievements.

Each stage signals tasks that must achieved. He believed that the greater the

task achievement, the healthier the personality of the person. Failure to achieve

the tasks influences the persons ability to achieve the next tasks.

Basing on this theory, C.B.P. belongs to the maturity Stage wherein she

has already achieved sexual desires he has 5 children at present. The patient

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feels that she has already lived longer to see her children grow up and live a life

of their own. She thinks that she already has served her purpose in this life and

found uniqueness in the life that she is leading. She accepted that all life forms

has their own end and has accepted that sooner she will have to leave his

children behind, because she is open in the concept of death but she has also

fear from it.

Cognitive Theory of Jean Piaget

Cognitive development refers to how a person perceives, thinks, and

gains understanding of his or her world through the interaction and influence of

genetics and learning factors.Basing on this theory C.B.P. belongs to the Formal Operational Phase

wherein she has solved previously encountered problems in a logical manner

and has used rational thinking. This includes overcoming financial problems and

her personal family problems.

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IV. MEDICAL MANAGEMENT

A. Medical Orders and Rationale

Doctors Order RationaleAugust 1, 200911:35 AM

Pls. admit under the serviceof Dr. Chang

Secure consent of care

TPR q4

Soft Diabetic Diet

Labs: CBC, U/A, Chest x-rayPA view, Ultrasound of theliver and gallbladder,NA+ K+

Start venoclysis with PNSS IL @ 10gtts/min

O2 2-3L/min

Med: Celecoxib 200mg BID

Intake and output monitor qshift

August 2, 2009

8:00 AM Request for FBS, crea, NA+

K+

IVF to follow PNSS 1L atsame rate.

For proper management/care.

For legal purposes

To monitor any changes in TPR

Diet for patient to provide proper

nutritionTo determine deviation and to knowany abnormalities .

To provide fluid and electrolytes andserves as a channel for any drug thatcan be administer through it (IVTT).

Provide enough oxygen.

For management of moderate tosevere pain.

To determine fluid balance going in andout from the body.

To re-evaluate the values of the result.


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For Rehabilitation

Informed Dr. Sison for co-management

Meds: Kalimate 2 sachets TID

NaHCO3 650mg 1 tab TID

Lactulose 30ml OD

Continue Celecoxib 200mgBID

Refer accordingly

August 3, 20098:50 AM

Side drip Aminoleban 500 @20cc/hr.

Repeat for FBS, crea, NA+K+

Continue Rehabilitation

Informed Dra. Tia for co-management

Turn to sides q 2 hours

Moderate high back rest

Provide footboardMeds: Amoxiclav 500 I tab TID

Itopride 50 mg TID

Pancreatin 50mg BID

For management of the fracture

For co-management

For electrolytes balance in the bodyAntacid; neutralize secreted acid.

Laxative: Prevent/treatment forconstipation.

Management of pain.

Refer any abnormalities/ anusualities.

For hepatic encelopathy due to chronicliver disease.

To monitor blood glucose level and toto check for electrolyte imbalance.

For proper managementFor co-management

To prevent bed sore.

To facilitate proper breathing

To provide comfort.

For lower tract infections.

To prevent nausea and vomiting.

For bloating and flatulence as inpancreatic insufficiency.

Refer any abnormalities/ anusualities.

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Refer accordingly

August 4, 20099:15AM

Ventolin 1 neb now

IVF to follow PNSS @10gtts/min

Treatment and prevention of asthma.


DRUG STUDY

SODIUM BICARBONATE

Classification: Acidifiers and AlkalinizersDosage/route: 650mg TID , poMechanism of Action: Restores buffering capacity of the body and neutralizerexcess acid.Specific Indication: Cardiac Arrest, Metabolic Acidosis, Systemic or UrinaryAlkalinization and AntacidContraindications: Patients who are losing chlorides because of vomiting,continuous GI suction and in those receiving diuretics that producehypochloremic alkalosis. Oral sodium bicarbonate is contraindicated for patientswith acute ingestion of strong mineral acids.

Side Effects: Tetany, Edema, Gastric Distention, Belching, and Flatulence.Nursing Precaution: To avoid risk of alkalosis, obtain blood pH, partial pressure of arterial

oxygen, partial pressure of partial carbon dioxide, and electrolyte levels.Keep prescriber informed of laboratory results.

KALIMATE

Classification: ElectrolytesMechanism of Action: After administration of Kalimate via oral, calcium ion of

Kalimate is exchanged for potassium ion in the intestinal tract, particularly aroundthe colon, and Kalimate is excreted as unchanged polystyrene sulfonate resininto the feces without digestion and absorption. In consequence, potassium inthe intestinal tract is excreted outside the body.Dosage/route: 2 sachets TID, poSpecific Indication: Prevention & treatment of hyperkalemia resulting fromacute or chronic renal failure.Contraindications: Patients w/ intestinal obstruction & stenosis, constipation.

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Side Effects: Constipation, anorexia & nausea. Hypopotassemia.Nursing Precaution: Careful administration in patients with hyperparathyroidism(blood concentration of calcium may be increased by ion exchange) and patientswith multiple myeloma (blood concentration of calcium may be increased by ionexchange).

Important: Kalimate should be administered while measuring the serumpotassium and serum calcium levels regularly to prevent overdose. If anyabnormal findings are observed, appropriate measures eg, reduction of dose orwithdrawal of the drug should be taken.

FUROSEMIDE

Classification: Loop diuretic

Dosage/route: 40 mg BID, poMechanism of Action: Inhibits the reabsorption of sodium and chloride from theascending limb of the loop of Henle, leading to a sodium-rich diuresis.

Specific Indication: Furosemide is a "water pill" (diuretic) that increases theamount of urine you make, which causes your body to get rid of excess water.This drug is used to treat high blood pressure. Lowering high blood pressurehelps prevent strokes, heart attacks, and kidney problems. This medication alsoreduces swelling/fluid retention (edema) which can result from conditions such ascongestive heart failure, liver disease, or kidney disease. This can help toimprove symptoms such as trouble breathing.

Contraindications: Contraindicated with allergy to furosemide, sulfonamides;allergy to tartrazine (in oral solution); anuria, severe renal failure; hepatic coma;pregnancy; lactation.

Side Effects: CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness,headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss

CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias,thrombophlebitis

Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura,exfoliative dermatitis, erythema multiforme

GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation,

diarrhea, acute pancreatitis, jaundice GU: Polyuria, nocturia, glycosuria, urinary bladder spasm Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and

electrolyte imbalances, hyperglycemia, hyperuricemia Other: Muscle cramps and muscle spasms

Nursing Precaution: Use cautiously with SLE, gout, diabetes mellitus.

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Give early in the day so that increased urination will not disturb sleep. Administer with food or milk to prevent GI upset. Reduce dosage if given with other antihypertensives; readjust dosage

gradually as BP responds. Measure and record weight to monitor fluid changes.

CELECOXIB

Classification:Nonsteroidal Antiinflammatory drugMechanism of Action: This medication is a nonsteroidal anti-inflammatory drug(NSAID), specifically a COX-2 inhibitor, which relieves pain and swelling(inflammation). It is used to treat arthritis, acute pain, and menstrual pain anddiscomfort. Celecoxib is also used to decrease growths found in the intestines(colon polyps) of persons with a family history of this condition. This drug worksby blocking the enzyme in your body that makes prostaglandins. Decreasing

prostaglandins helps to reduce pain and swelling.Dosage/route: 200 mg BID, poSpecific Indication: Celecoxib is licensed for use in osteoarthritis, rheumatoidarthritis, acute pain, painful menstruation and menstrual symptoms, and toreduce the number of colon and rectal polyps in patients with familialadenomatous polyposis. It was originally intended to relieve pain whileminimizing the gastrointestinal adverse effects usually seen with conventionalNSAIDs. In practice, its primary indication is in patients who need regular andlong term pain relief: there is probably no advantage to using celecoxib for shortterm or acute pain relief over conventional NSAIDs. In addition, the pain reliefoffered by celecoxib is similar to that offered by paracetamol.[1]

Contraindications: Hypersensitivity including those in whom attacks ofangioedema, rhinitis and urticaria have been precipitated by aspirin, NSAIDs orsulfonamides. Severe hepatic impairment; severe heart failure; inflammatorybowel disease; peptic ulcer; renal impairment.Side Effects: The most common adverse effects are headache, abdominal pain,dyspepsia, diarrhea, nausea, flatulence, and insomnia. Other side effects includefainting, kidney failure, heart failure, aggravation of hypertension, chest pain,ringing in the ears, deafness, stomach and intestinal ulcers, bleeding, blurredvision, anxiety, photosensitivity, weight gain, water retention, flu-like symptoms,drowsiness and weakness.Nursing Precaution:

History of GI bleeding; renal/hepatic insufficiency; asthma or allergic disorders;hypertension; monitor haemoglobin or haematocrit levels for signs of anaemia.History of cerebrovascular disease or ischaemic heart disease.

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LACTULOSE

Classification: LaxativesMechanism of Action: Lactulose promotes peristalsis by producing an osmoticeffect in the colon with resultant distention. In hepatic encephalopathy, it reduces

absorption of ammonium ions and toxic nitrogenous compounds, resulting inreduced blood ammonia concentrations.Dosage/route: 30 ml ODSpecific Indication: Used to treat constipation.Contraindications: Galactosaemia, intestinal obstruction. Patients on lowgalactose diet.Side Effects: This medication may cause gas, belching or stomach cramps. Ifthese effects continue or become bothersome, inform your doctor. Notify yourdoctor if you develop any of these effects while taking this medication: diarrhea,nausea, vomiting. If you notice other effects not listed above, contact your doctoror pharmacist.

Nursing Precaution:Monitor electrolyte imbalance. Lactose intolerance; diabetics.

Laboratory Exams:

Urinalysis Date: August 1, 2009,

Test Result SignificanceColor Yellow Normal

Transparency Clear NormalPus cells 10-21hpf Normal

RBC 5-12hpf NormalEpithelium Few NormalAmorphous Few Normal

Complete Blood Count Date: August 1, 2009

Test Result Normal Value SignificanceWBC 10,800 5,000-

10,000/mm

Increase infection,dehydration, leukemia,trauma polycythemia vera

Hemoglobin 13.8 13.7-16.7 g/dl Hemoglobin is the main

transport of oxygen andcarbon dioxide in the blood.Hematocrit 38.7 40.5-49.7 vols% Increase in erythrocythosis,

dehydration and hemo-concentration associatedwith shock

Platelet Count Adequate 150,000- Platelets (also known asthrombocytes) are the

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450,000/mm smallest formed elements ofthe blood. They are vital tocoagulation of the blood toprevent excessive bleeding.

Differential Count

Lymphocytes 15 17.4-46.2% Depressed level mayindicate an exhaustedimmune system.

Monocyte 3 4.3-10.3% Low levels are indicative of agood state of health. .

Basophil 2.5 2-3% Basophilic activity is not fullyunderstood but it is known tocarry histamine, heparin,and serotonin.

Blood Chemistry Date: August 1, 2009

Test Result Normal Value SignificancePhosphorus 5.43 2.50-50.0mgs/dL Metastatic neoplasm to bonePotassium 6.0 3.5-5.5mEq/L Increase excess IV

administration, Potassium-sparing diuretics, infection,dehydration, acidosis, bloodtransfusion, burns and trauma

Glucose 422.7 60.00-110.0 Diabetes MellitusSodium 150.6 135-145mEq/L Increase dietary or IV intake

DI, Cushings syndrome,

increase swating.

Blood Chemistry Date: August 1, 2009

Result Normal Value SignificanceCalcium 4.03 8.10-

10.40mmol/L

Acute pancreatitis, nephrosis,

Creatinine 2.93 0.6-1.1 mg/dL Increase renal failure,muscular dystrophy,hyperthyroid, acromegaly,rhabdomyolysis

Chest X-RAY Date: August 2, 2009

ImpressionCardiomegaly, LV form

HEArt enlarged

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Pulmonary congestion

Minimal Pleural effusion, bilateral

Atherosclerosis aorta

Fracture left clavicle and left 8 th posterior rib

ULTRASOUND Date: August 2, 2009

Liver and GallbladderImpression:

Contracted liver

Gall stone with sludge

Ascites Minimal

V. ANATOMY AND PHYSIOLOGY

The Skeletal System serves many important functions; it provides theshape and form for our bodies in addition to supporting, protecting, allowingbodily movement, producing blood for the body, and storing minerals.

Its 206 bones form a rigid framework to which the softer tissues andorgans of the body are attached. Vital organs are protected by the skeletal

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system. The brain is protected by the surrounding skull as the heart and lungsare encased by the sternum and rib cage.

Bodily movement is carried out by the interaction of the muscular and skeletalsystems. For this reason, they are often grouped together as the musculo-

skeletal system. Muscles are connected to bones by tendons. Bones areconnected to each other by ligaments. Where bones meet one another istypically called a joint. Muscles which cause movement of a joint are connectedto two different bones and contract to pull them together. An example would bethe contraction of the biceps and a relaxation of the triceps. This produces abend at the elbow. The contraction of the triceps and relaxation of the bicepsproduces the effect of straightening the arm.

The Ribs

The ribs are thin, flat, curved bones that form a protective cage around theorgans in the upper body. They are comprised 24 bones arranged in 12 pairs.

The first seven bones are called the true ribs. These bones are connected to thespine (the backbone) in back. In the front, the true ribs are connected directly tothe breastbone or sternum by a strips of cartilage called the costal cartilage. Thenext three pairs of bones are called false ribs. These bones are slightly shorterthan the true ribs and are connected to the spine in back. However, instead ofbeing attached directly to the sternum in front, the false ribs are attached to the

lowest true rib. The last two sets of rib bones are called floating ribs. Floating ribsare smaller than both the true ribs and the false ribs. They are attached to thespine at the back, but are not connected to anything in the front. The ribs form akind of cage the encloses the upper body. They give the chest its familiar shape.

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The Shoulder Girdle

The Shoulder Girdle, also called the Pectoral Girdle, is composed of fourbones: two clavicles and two scapulae .

The clavicle, commonly called the collarbone, is a slender S-shaped bonethat connects the upper arm to the trunk of the body and holds the shoulder jointaway from the body to allow for greater freedom of movement.

PATHOPHYSIOLOGY

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Predisposing Factor Precipitating

Age (79 y.o)Liver cirrhosisDiabetes Mellitus

Unsafe externalenvironment

Body malaise,dyspnea, pain

Fall (4 steps stairs)

Rib fracture,clavicle frature

Impaired tissueperfussion

Increase bloodglucose level

Renin-angitensin-Aldosterone-system

activation

Liver unable to synthesizeprotein/amino acid

Low fat absorption

Low protein absorption

Pleural infusion

PAIN

Impaired

oxygenation

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NURSING ASSSESSMENT (System Review Chart) Date: August 2,2009

Age (79 y.o)Liver cirrhosisDiabetes Mellitus

Unsafe externalenvironment

Body malaise,dyspnea, pain

Fall (4 steps stairs)

Rib fracture,clavicle frature

Impaired tissueperfussion

Increase bloodglucose level

Renin-angitensin-Aldosterone-system

activation

Increase sodium andwater retention

Liver unable to synthesizeprotein/amino acid

Low fat absorption

Low protein absorption

Fluid shifting to secretion

Pleural infusion

PAIN

Impairedoxygenation

Aldosterone secretion

Water and sodiumretention

EDEMA

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EENT:[ ] Impaired vision [ ] blind[ ] pain redden [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion teeth[ ] assess eyes ears nose[ ] throat for abnormality [x] no problem

RESP:[ ] Asymmetric [x] tachypnea [ ] barrel chest[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] rhonchi[ ] sputum [ ] diminished [x ] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanotic[ ] assess resp. rate, rhythm, depth, pattern,

breath sounds, comfort [ ] no problem

CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ]numbness[ ] diminished pulses [ ] edema [] fatigue[ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] pain[ ] Assess heart sounds, rate rhythm, pulse, blood

pressure, circ., fluid retention, comfort[ x ] no problem

GASTROINTESTINAL TRACT:[ ] obese [ x ] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] pain[ ] assess abdomen, bowel habits, swallowing[ ] bowel sounds, comfort [ ] no problem

GENITO URINARY AND GYNE[ ] pain [ ] oliguria [ ] color [ ] vaginal bleeding[ ] hematuria [ ] discharge [] nocturia[x ] assess urine frequency, control, color, odor, comfort[ ] gyne bleeding [ ] discharge [ x ] no problem

NEURO:[ ] paralysis [ ] stuporus [ x ] unsteady [ ] seizure[ ] lethargic [ ] comatose [ ] vertigo [ ] treamors[ ] confused [ ] vision [ ] grip[ ] assess motor, function, sensation, LOC, strength[ ] grip, gait, coordination, speech [x] no problem

MUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechie[ ] hot [ ] drainage [ ] prosthesis [x] swelling

[ ] lesion [ ] poor turgor [ ] cool [ ] flushed[ ] atrophy [x] pain [ ] ecchymosis [ ] diaphoreticmoist[ ] assess mobility, motion gait, alignment, joint function[ ] skin color, texture, turgor, integrity[ ] no problem

Name: C.B.P.BP: 140/80 mmHg T: 36.6C PR: 85 bpm RR: 22 cpm Height: 52inches Weight:

NURSING ASSESSMENT IISUBJECTIVE OBJECTIVE

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Swelling/edema

Pitting Edema (grade 1)

Adbominal distention

Wound

Dry skin

Generalized Weakness

Edema


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COMMUNICATION:

[ ] hearing difficulty

[] visual changes

[x ] denied

Comments:"dili na kyosiya ka-klaro pero sigetanaw og tv as

verbalized by watcher

[ ] glasses [ ] languages

[ ] contact lenses [ ] hearing difficulties due to age

[ ] speech difficultiesPupil size:R:3 mm L:3mm

Reaction: PERRLA (Pupil Equally Round andReactive to Light Accommodation)

OXYGENATION:

[x ] dyspnea

[ ] smoking history

[] cough

[ ] sputum

[ ] denied

Comments: lisud auiginhawa, asverbalized by thepatient.

Resp. [x ]regular [] irregular

Describe: RR is regular and it is within range.

R: unsymmetrical to the left lung

L: unsymmetrical to the right lung

CIRCULATION:

[ ] chest pain

[ ] leg pain

[] numbness of

extremities

[x ] denied

Comments: wala manko ing ana ngaproblema ang akungtiyan lang ang sakit ogayo , as verbalized bypatients watcher.

Heart Rhythm [x] regular [ ] irregular

Ankle Edema: ankle edema is present on bothextremities

Pulse Car Rad. DP Fem

R + 85bpm + +____

L + + + +____Comments: Pulse on all sites are palpabale yet weakon the radial and dorsalis pedis areas due topresence of edema.

NUTRITION:

Diet: Soft diabetic

Character

[x] recent change in

weight

[] swallowing

Difficulty

[ ] denied

Comment: Gamay ralagi iyang gaka-on amolang luguson kydaghan bya syatambal,as verbalized

by watcher.Ganiwang na ganisiya as verbalized bythe watcher

[ ] dentures [ x ]none

Full Partial With patient

Upper [ ] [ ] [ ]

Lower [ ] [ ] [ ]

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ELIMINATION:

Usual bowel pattern:

Once a day

[ ] constipation

remedy______None______

Date of last BM

August 1, 2009

[ ] diarrhea

-______None________

[x] urinary frequency

In foley catheter

[ ] urgency

[ ] dysuria[ ] hematuria

[ ] incontinence

[ ] polyuria

[ ] foley in place

[ ] denied

Comments:Patientsbowel soundsauscultated and shehas an audiblenormoactive.

Bowel sounds Audiblenormoactive bowel soundsevery 10-15 sec.

Abdominal Distention

Present [x ] yes [] no

Urine* (color, consistency,odor)

____amber or strong______

Foley if they are in place:Foley bag catheter in place

MGT. OF HEALTH & ILLNESS:

[ ] alcohol [x] denied

(amount/frequency)

[ ] SBE: Not recalled Last Pap Smear: NOT

RECAlled

LMP: Not recalled

Briefly describe the patients ability to followtreatments (diet, meds, etc.) for chronic healthproblems (if present).

Patient is able to follow treatments, such as hermedications and soft diabetic diet as prescribe by thephysician during this admission but her maintenancefor her liver cirrhosis she stop it because ofinconvenience during her follow up check up atCebu.

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY:

[x ] dry

[ ] other

[] denied

Comments: dry lagi iyangpanit na basin sapagkatigulang na, asverbalized by the watcher

[x ] dry [ ] cold [x ] pale

[ ] flushed [ ] warm

[ ] moist [ ] cyanotic

*rashes, ulcers, decubitus (describe size,

location, drainage: Healing woung at leftleg.

ACTIVITY/SAFETY:

[ ] convulsion

[ ] dizziness

Comments: Dili kayo laginiya malihok iyang abagaog likod, as verbalized bythe watcher.

[ ] LOC and orientation Patient is orientedto time, place, events and person.

Gait: [ ] walker [ ] cane [ ] other

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[x ] limited motion of

Joints

Limitation in

Ability to

[] ambulate

[ ] bathe self

[ ] other

[ ] steady [x ] unsteady

[ ] sensory and motor losses in face or

extremities No sensory and motor losseson face or extremities

[x] ROM limitations: she can move but withlimitation and with accompany.

COMFORT/SLEEP/

AWAKE:

[] pain

(location,frequencyremedies)

[ ] nocturia

[x] sleep difficulties

[ ] denied

Comments: Dili kayo siyakatulog kay galisod siyaog ginhawa, asverbalized by the watcher

[] facial grimaces

[x] guarding

[ ] other signs of pain :

Patient was able to manage the painwithin tolerable limit.

COPING:

Occupation: Housewife

Members of household: 5 members ofhousehold

Most supportive person: her five children

Observed non-verbal behavior: weaknessor fatigue

Phone number that can be reachedanytime:

Confidential

SPECIAL PATIENT INFORMATION

_Not ordered Daily weight ____N/A___ PT/OT

_140/80 mmHg BP q shift ____N/A___Irradiation

___not ordered__ _Neuro vs August 1, 2009 Urine test

____N/A_ _CVP/SG Reading not ordered 24 hour UrineCollection

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VII NURSING MANAGEMENT

A. Ideal Nursing Management

Diagnoses: Ineffective Breathing Pattern related to respiratory muscleweakness.

Intervention Rationale Investigate etiology of

respiratory failure.

Observe over-all breathingpattern.

Auscultate chest noting thepresence or absence of breathsounds.

Count clients respiration 1 fullminute and compare with desireset rate.

Check tubing of oxygen forobstruction.

To understand the underlying cause.

To attempt to correct the deficiency byover breathing.

To note the frequent crackles thatdoesnt clear with coughing.

Respirations vary depending onproblem requiring ventilatoryassistance.

Kinks in tubing prevent adequatevolume of delivery.

Diagnoses: Acute Pain related to injury to the soft tissueIntervention Rationale

Maintain immobilization ofaffected area.

Elevate and support injuredextremities.

Avoid use of plastic sheets.

Evaluate reports ofpain/discomfort.

Identify any diversionalactivities.

Apply cold/ice pack.

Relieves pain and prevent extensionof the injury.

Promotes venous return.

Promotes discomfort

Monitor effectiveness of intervention.

Prevents boredom, reduces muscletension.

Reduces edema.

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Diagnoses: Activity intolerance related to generalized weakness

Intervention Rationale Adjust activities and reduce

intensity level or discontinue

activities that cause undesired

physiologic changes.

Increase exercise and activity

level gradually.

Plan care with rest periodsbetween activities.

Assist with activities and provide

client used of assistive devices.

Promote comfort measures and

provide for relief of pain.

Provide positive atmosphere

while acknowledging difficulty of

the situation for the client.

To prevent over excretion.

To conserve energy

To reduce fatigue

To protect the client from injury

To promote comfort measures and

provide for relief of client.

Helps to minimize frustration, reduce

channel energy.

Diagnoses: Risk for ineffective peripheral Tissue Perfusion

Intervention Rationale

Provide air mattress, sheepskinpadding, bed/foot cradle.

Apply ice and elevate lowerextremities.

Administer physicians order ofmedication.

To protect the extremities.

To reduce edema.

To give comfort and reduce edema.

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Apply ace bandage to lowerextremities before arising frombed.

To prevent venous stasis

B. Actual Nursing Management

S Lisud au iginhawa as verbalized by the patient.

O Dyspnea Changes in rate and depth of respirations Increased restlessness

A Ineffective Breathing Pattern related to respiratory muscle weakness.

P At the end of 2-3 minutes, the patient will maintain respiratory

pattern.

IIndependent Maintained in moderate to high back rest. Checked tubing for obstruction. Observe over-all breathing pattern

Dependent

Set Oxygen at 3L/min

EAt the end of 2 minutes, the patient maintains her respiratory pattern.

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S sakit lagi iyang abaga og likod as verbalized by the patient.

O

Restlessness Facial grimace Guarding the affected part.

A Acute pain related to injury to the soft tissue

P At the end of 15-30 minutes the patient will able to verbalized pain

into tolerable level

IIndependent

Reinforced position (semi-fowlers) to the patient. Encouraged adequate rest periods

Reviewed ways to lessen pain, including techniques.

Discuss with significant others ways in which they can assist the

client in activities.

Dependent

Administer medication for pain.

Celecoxib 200mg BID

EAt the end of 30 minutes the patient was able to response tointerventions and verbalized relief of pain.

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SDili kayo lagi niya malihok iyang abaga og likod busa dili kayo siya

kalihok as verbalized by the watcher

O Weakness. Inability to begin activity

A Activity Intolerance related to generalized weakness

P At the end of 8 hours, the patient will be able to have gradual

return to physical movement and mobility

IIndependent Encouraged patient to do bed exercises such as arm exercises

abduction and external rotation of shoulder, hand and fingers

exercises and foot exercises. Assisted patient in activities that begins by sitting at the side of

the bed and in chair.

Assisted early ambulation of patient.

Assisted patient to performed ADL with involvement of significant

others.

Provided physical support and maintained patients safety.

EAt the end of 8 hours, the patient was able to demonstrate gradual

return to physical movement and mobility within tolerance as

evidenced by increasing ambulation and participation in personal

care activities.

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VIII. REFERRALS AND FOLLOW-UP

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IX. EVALUATION AND IMPLICATION

MEDICATIONS

The patient was instructed to continue medications

namely Kalimate 2 sachets TID, Sodium

Bicarbonate 650mg TID, Lactulose 30ml OD,

Celecoxib 200mg BID, ITOPRIDE 50mg TID,Pancreatin I tab TID

She and her significant others was advised to

comply all the medications needed as prescribed by

the physician.

Patient and significant others was instructed aboutthe proper administration of medications accordingto right dose, right time and right route, and becautious to possible side effects.

EXERCISEEncourage Range of Motion Exercises

TREATMENT

Follow medication as prescribed by the physician. Turn to sides every two hours. Provide footboard.

Maintained moderate to high back rest.OUTPATIENT

(Check-up)

The patient is advised to have her follow-up check-up oneweek after at Cagayan de Oro Medical Center, Building 1,

2nd

Floor at the clinic of Dr. Chang.

DIET

Encourage patient to eat foods rich in Vit. C like fruits toenhance the immune system.Encourage patient to increase fluid intake to maintain fluidand electrolyte balance in the body.

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PROGNOSTIC INDICATORS POOR GOODA. Onset of illness B. Duration of illness C. Precipitating factors D. Attitude and willingness to take

medication

E. Family support

After having interacted with the client for 2 days and rendered nursing

interventions, we therefore concluded that our objectives were met. Also based

on thorough observation and data gathered, we had identified that the client has

a poor prognosis since she is too old to recover from her illness and she had

experienced many complications. Although the family support system towards

the client is good, we still encourages the family to continue on supporting the

medical and emotional support of the client in gearing towards hospitalization

and consultation. They are encouraged to be sensitive to the needs and care of

the patient since she is old. We implied for a continue support system towards

the client and be cautious if theres any complains from the client or any signs of

another health problems.

B. BIBLIOGRAPHY

Kozier, B. et al. Fundamentals of Nursing, 7 th ed. Singapore: Pearson

Education South Asia PTE LTD, 2004

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Lippincott. Nursing 2007 Drug Guide, PA: Lippincott Williams & Wilkins,

2007 Phipps, et al. Medical-Surgical Nursing: Concepts and clinical

Practice, vol. 1, 5th ed Missouri: Mosby-Year Book, Inc., 1995

MIMS Philippines, 109th ed. CMPMEdica, 2006

Tortora, G.J.& Grabowski S.R.; Principles of Anatomy and Physiology; 10th

Edition; John and Wiley and Sons, Inc.; 2003.

Karch, Amy M.; Focus on Nursing Pharmacology; 3 rd Edition; Lippincot

Williams and Wilkins; 2006.

Doenges, E.M., Moorhouse, M.F. Geisslerr-Murr, A.C.; Nurses Pocket

Guide Diagnoses, Interventions and Rationales; 9th Edition; F.A. Davis

Company Philadelphia; 2004.

Documents

204 GYNE Fracture Liver Cirrhosis DM