College of nursing

Submitted by:Homer D. Elegado

BSN 3A

Submitted to:Mrs. Glecy Ventura Clinical Instructor

PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA1. Patient’s Name: E.L2. Address: Philippines3. Age: 52 y/o4. Sex: Male5. Birth date: May 16 , 19616. Rank in the Family: Father7. Nationality: Filipino8. Civil Status: Married9. Data of Admission: February 2, 2014 9:30pm 10. Order of Admission: PNSS 1L @ 21gtts/min, Secure Consent, NPO, CBC , UA , X-ray , Utz11. Attending physician: Dr. Tugade

B. CHIEF COMPLAINT Vehicular Accident.

C. HISTORY OF PRESENT ILLNESS Vehicular Accident 2/2/14

D. PAST HEALTH HISTORY/STATUS Childhood Illness: The patient had chicken pox and mumps. Immunization: No known immunization Major Illness: None Current Medication : None Allergies: No known allergy

E. FAMILY ASSESSMENT

NAME RELATIONSHIP AGE SEX OCCUPATION EDUCATIONAL ATTAINMENT

E.L Wife 50 Female Housewife High school GraduateM.L 1st Child 28 Female Cashier High school GraduateE.L 2nd Child 16 Female Student

F. SYSTEMS REVIEW1.) HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

Client’s Perception of Health: Patient perceives health as “Dapat malakas ka lagi.” Client’s Perception about Illness: In contrast to health, she perceives illness as “mahirap at magastos” Health Maintenance and Habits: In maintaining his health, he eats vegetables as well as meats and do house hold chores that serves

as his exercise to maintain his health. Compliance with prescribed medications and treatment: He actively participates/cooperates with his treatment and takes medication

on time.

2.) NUTRITIONAL – METABOLIC PATTERN: The smell and appearance of the food can trigger the client’s appetite. He eats 3 times a day with 3-4cups of rice. He drinks 1L of water

per day and he consumes 1 glass of juice per day.

3.) ELIMINATION PATTERN During his hospitalization, the patient wears diaper and IFC because of difficulty in standing and walking.

4.) ACTIVITY- EXERCISE PATTERN- Self – care ability

0- Feeding 0 - Grooming _____others 0- Dressing 0- Toileting 0- Bathing 0- Home maintenance 0- Bed mobility 0-Cooking

Legend:0- Full CareI- Requires use of assistanceII- Requires assistance and supervisions by othersIII- Requires assistance or supervisions from another and equipment and devicesIV – Dependent, doesn’t participate

5.) COGNITIVE – PERCEPTUAL PATTERN The patient has no abnormalities in hearing.

6.) SLEEP- REST PATTERN During his hospitalization, he experienced sleeping problems. Usually, he sleeps 9 hours per day: 7 hours at night and 2 hours of nap

during the day.

7.) SELF- PERCEPTION AND SELF- CONCEPT PATTERN Not assess because the patient is tired and dhyspnic.

8.)ROLE- RELATIONSHIP PATTERN He has great relationship with his children and significant others.

9.) COPING- STRESS TOLERANCE PATTERN The patient perceives stress and problems in life as “pahirap sa buhay”. Whenever he has problem, he just drink alcohol and smoke.

10.) VALUE- BELIEF PATTERN He is a Roman Catholic and he believes having faith in God will help us surpass all the trials or problems in life.

G. HEREDO- FAMILIAL ILLNESS

H. DEVELOPMENTAL HISTORYTheory Stage Developmental task Description

Eric Erickson’s theory 35 to 50 years old Generativity vs. stagnation Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world.

Theory Stage Developmental task Description Fowler’s theory Universalizing (maybe Spiritual development Becoming an incarnation

Maternal : Asthma

Paternal : Hypertension

Patient : Hypertension

never) of the principles of love and justice.

I. PHYSICAL ASSESSMENT

A. General SurveyB. The patient is conscious, coherent, appears his stated age, alert, and oriented but weak in appearance. C. Vital Signs of the Day of Physical Examination

Temperature: 36.5 0C Respiratory rate: 47 cpmPulse rate: 78 bpm Blood pressure: 90/60 mmHg

D. Regional Exam1. Head, Hair, and Face: Head is symmetrical to the body, normocephalic, hair evenly distributed, absence of skull deformities, absence of

lice; face is round in shape with dry skin.2. Eyes: Left eyelid is lacerated.3. Nose: Symmetrical, same color as the face, mucosa is pinkish in color, no lesions, deformities and inflammation, no tenderness on

frontal maxillary sinuses, no mass, nasal structures are firm and stable. With intact nasal canula.4. Ears: Symmetrical and proportion to face, color is same as the face, auricle level are equal, no lesions, deformities and inflammation.5. Mouth and Throat not assess6. Neck and Lymph nodes: Proportion to head, presence of carotid pulse, no inflamed cervical lymph nodes, no tenderness upon palpation,

and no mass noted.7. Skin: The skin is fair in complexion, dry, rough with poor skin turgor.8. Nails: Untidy nail tips, nail beds are not pale, cuticles are intact, lunula is white. With good capillary refill.9. Thorax and Lungs: Not assess. 10. Cardiovascular: not assess11. Breast and Axilla: not performed12. Abdomen: pale in color, no lesions. Dullness sound heard. enlargement noted. Smoothly consistent softness, no tenderness and masses

palpated. 13. Extremities: The arm of the patient is symmetrical to each other; the legs are symmetrical to each other

II. PERSONAL/SOCIAL HISTORYA. Habits:

a. Caffeine: 1-2 cup of coffee.b. Smoking: The patient smokes 3 sticks a day.c. Alcohol: Moderated. Tea: Nonee. Drugs: He doesn’t take prohibited drugs.

B. Lifestyle: not applicableC. Social Affiliation: NoneD. Rank in the family: Head of the family.E. Travel (within 6 months): The patient didn’t travel to far places prior to admission.F. Educational Attainment: High School Graduate.

III. ENVIRONMENTAL HISTORY

Our patient is living in a barrio together with his family. Their house is made of semi-concrete materials. Their water supply comes from deep well. They have their own toilet facility which is water sealed type. Their residence is near the farm and it’s quite far from their own town, thus making it hard for them to access health services. Their transport facility is tricycle and travels for 15 minutes going to the town.

IV. INTRODUCTION

CEREBRAL CONCUSSION describes a brain injury where, after an injury, there are functional changes that occur in how the brain works but no structural damage can be seen on standard imaging tests like CT scan.

Mild traumatic brain injury, or concussion, can be defined as a short-lived loss of brain function due to head trauma that resolves spontaneously. With concussion, function may be interrupted but there is no structural damage to the brain. The brain floats in cerebrospinal fluid and is encased in the skull. These protections allow it to withstand many of the minor injuries that occur in day-to-day life. However, if there is sufficient force to cause the brain to bounce against the rigid bones of the skull, then there is potential for injury. It is the acceleration and deceleration of the brain against the inside of the skull that can cause the brain to be irritated and interrupt its function. The acceleration can come from a direct blow to the head or face, or from other body trauma that causes the head to shake. While temporary loss of consciousness due to injury means that a concussion has taken place, most concussions occur without the patient being knocked out. Studies of football players find that the most of those affected were not aware that they had sustained a head injury.

V. ANATOMY AND PHYSIOLOGY

BrainThe brain is the control center of the body. It consists of three main components: the forebrain, the brainstem, and the hindbrain. The forebrain is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function. The forebrain contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. It also contains the largest part of the brain, the cerebrum. Most of the actual information processing in the brain takes place in the cerebral cortex. The midbrain and the hindbrain together make up the brainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function.The hindbrain extends from the spinal cord and contains structures such as the pons and cerebellum. These regions assist in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information. The hindbrain also contains the medulla which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion.

VI. PATOPHYSIOLOGY

VII. LABOLATORYURINALYSIS

RESULTS NORMAL VALUES SIGNIFICANCE

Vehicular Accident

Head Injury

Precipitating factors Work

• Awareness• Type(s) of vehicle

S/Sx* momentary loss ofConsciousnessInterval apparent Recovery or lucid recovery

Predisposing factors

• Accident prone area

Epidural Hematoma

Good prognosis

Rupture or laceration of the Middle meningeal artery

Inc. ICP

Blood collect in the epiduralSpace between the skull and Dura.

HEMORRHAGE

CRANIECTOMY

Skull fracture

PHYSICAL:

Color

Transparency

CHEMICAL:

Specific Gravity

Urobilinogen

Red Blood Cells

Protein

pH

Blood cells

MICROSCOPIC:RBC

Epithelial Cells

A Urates/Phosphates

Tea color

Slightly turbid

1.020

Normal

1-2

(-)

6.0

(-)

1-2

Few

Few

Straw yellow to amber

Clear

1.010 – 1.030

0 – 2

(-)

4.8-8

(-)

Presence of RBC in the urine

Indicates abnormality

Normal

Normal

Normal

Normal

Normal

Normal

Generic Name:MetroclopramideBrand Name:MaxolonDrug Classification:Anti emetic Dosage:2mL ivp q8 Indication: Relief of symptoms of acute and recurrent diabetic gastroparesisMechanism of Action Side Effects Contraindication Adverse Effects Nursing Consideration

Stimulates nutility of upper GI tract without stimulating gastric biliary or pancreatic secretions.

Drowsiness

Nausea

Diarrhea

Contraindicated with allergy to metoclopramide

AkathisaAnxietyparkinsonism

Ensure patient’s safety

Avoid physically active activity

BRAT diet, increase fluid intake monitor intake and output.

Generic name: Ampicillin

Brand name:Principen

Classification: Antibiotic

Dosage: 1gm IV q8

Indication: Antibiotic

Mechanism of action Side effects Contraindications Adverse effects Nursing considerations

Bactericidal action against sensitive organisms, inhibits synthesis of bacterial cell wall causing cell death

Nausea and vomiting

Diarrhea

Abdominal pain

phelbitis

Hypersensitivity to the drug GI: hepatotoxicity

GU: renal failure

Integ: rashes

Ensure clients safety.

BRAT diet

Encouraged relaxation technique

Warm compress to the affected site.

Generic Name: Ranitidine

Brand NAme: ZantacDrug Classification: gastric acid secretion inhibitorDosage: 50mg IVP q 8 Indication: short term treatment for duodenal ulcer

MECHANISM OF ACTION

ADVERSE EFFECT CONTRAINDICATION SIDE EFFECTS NURSING CONSIDERATION

Competitively inhibits the action of histamines at the H2 receptors of the parietal cells of the stomach.

Leukopenia Hepatitis Gynecomastia Tachycardia Pain in IM site

Contraindicated with allergy to ranitidine.

DDizziness

NNausea

VVomiting

CConstipation

Avoid changes in position

Eat small amount of meals

Position the client in sitting position to avoid aspiration

Eat high fiber diet

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE

“medyo sumasakit ang sugat ng mata ko” as verbalized by the patient with a pain scale of 6/10

OBJECTIVE

-Facial grimace

-guarding the affected area

V/S taken as follows:Temp: 36.50C RR: 47 cpmPR: 78 bpm BP: 90/60 mmHg

Acute pain related to tissue damage

After 1-2 hours of nursing interventions the feeling of pain will be able to decrease from 6/10 to 2/10pain scale

Use pain assessment scale to identify intensity of pain

Assess for probable cause of pain

Position the patient to it’s comfortable position

Encourage relaxation technique (Deep Breathing Exercise)

Administer analgesic (ketorolac) as ordered.

Provide baseline for assessing changes in pain level and evaluating interventions

Different etiological factors respond better to different therapies.

other way on how to relieve pain

Skeletal muscle relaxation is believed to reduce pain by relaxing tense muscles and tissues that contribute to the pain.

To relieved pain

Goal met.

The patient’s pain was reduce from 6/10 from 2/10

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE

OBJECTIVE

Lacerated wound on left eyelid

-disruption of skin surface

-V/S taken as follows:Temp: 36.50C RR: 47 cpmPR: 78 bpm BP: 90/60 mmHg

Impaired skin integrity related to lacerated wound.

After 1-2 hours of nursing intervention the patient will be able to demonstrate techniques to prevent skin breakdown.

Instruct patient to avoid scratching the injured area

Kept the area affected clean and dry

Instruct patient not to use tight clothing

Obtain further doctors order to prevent itchiness

To reduced risk of dermal injury when itching is present.

To prevent further invasion of microorganism that could affect skin integrity.

To prevent skin irritation

To decrease irritable itching

Goal partially met.

The patient was able to partially demonstrate technique to prevent skin breakdown

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE

OBJECTIVE

-Lacerated wound on left eyelid

-disruption of skin surface

- irritable

-V/S taken as follows:Temp: 36.50C RR: 47 cpmPR: 78 bpm BP: 90/60 mmHg

Risk for infection related to injured tissue

After 25-30 mins of nursing intervention the patient will be able to demonstrate the ways on how to prevent infections.

Monitor vital signs

Monitor white blood cell count

Monitor the following signs of infection ( redness, swelling , increased pain, ETC)

Limited visitors

Administer or teach use of antimicrobial drugs as ordered

Serves as baseline data.

Rising WBC indicates body’s effort to fight pathogens.

Any suspicious drainage should be cultured.

Reduces the number of organisms in patient’s environment.

Anti microbial drugs are toxic to pathogens or retard the pathogen’s growth.

Goal met.

The patient was able to partially demonstrate ways on how to prevent infections.