Far Eastern University

Institute of Nursing

CASE PRESENTATION – NEURO

Submitted by:

BSN 136/ Group 142

AMATA, Angeli Grace I.

POBRERO, Mary Greyzel E.

QUEBRAL, Alf Carlo S.

REYES, Daryl M.

RUSTIA, Jhonnavie Q.

SABINO, Vangil R.

SALCEDO, Hannah Joy J.

SANTOS, Carlisse Caye P.

SUBA, Marlon C.

TABIRARA, Nicolo Paulo L.

TAN, Richard G.

TAYSON, Leah Marie C.

Submitted to:

Ma’am Sheila Paragua, RN, MAN

September 24, 2010

I. Biographic Data
Name: Mr. JCM

Address: Ilang-Ilang Ext., Payatas, Quezon City

Birth date: 5-May-1954 Age: 56 years old

Marital Status: Married Gender: Male Religion: Roman Catholic

Occupation: Security Guard (formerly 10 years ago)

Admission Date / Time: Aug. 23, 2010

Room #: 506-J

Chief Complaint: headache, shortness of breath, body weakness

Admitting Diagnosis: Intra-cerebral Hemorrhage; right basal ganglia

II. Nursing History

A. Past Health History

The client claims that he has had measles, chicken pox and mumps during
childhood. The client remembers that he had the anti-hepatitis B vaccine.
The client has no known allergies in foods and other medications. The
client has no known accidents. At 2004, the client was diagnosed with SP/
CVA Infarction at Malvar Hospital. He had received unrecalled medications
and was discharged as soon as his conditions improved. There were no
complications noted. At 2008, the client was diagnosed SP/ Myocardial
Infarction at FEU-NRMF but was also discharged as soon as his condition
improved. It was here that he was noted to be hypertensive for 30 years.
His usual BP was always noted to be 160/100 mmHg and his highest BP
was noted to be 240/120 mmHg. Before the current hospitalization, the
client remembers taking medications such as Neoblock, Calciblock,
Catapres and Furosemide.

B. Present Health History

The client was first found lying on the floor in supine position. He was
having shortness of breath, headache, dizziness, slurring of speech and
left-sided body weakness. He also had 3 episodes of vomiting of previously
ingested food, approximately about 2 cups in amount while on their way
to the hospital. Upon arriving at FEU-NRMF’s ER, lab tests were done and
he was admitted to Station 5B, Room 506-J.

C. Family History

The client’s family has a prevalent history of hypertensions and heart

problems on both sides. He notes that his sister has Diabetes Mellitus.
Other than those mentioned they have no other hereditary diseases.

III. Patterns of Functioning

A. Psychological Health

• Coping Patterns
 The client said that when he encounters problems, he would just ask for a
piece of advice from her family, friends and relatives. Then on, he thinks
of a way to solve his problems by himself. When the client experiences a
family problem, he wants his family to gather together and talk things
over and solve it. When he had his own problems, he needs someone to
talk to and listen to him and he will feel better. He also acknowledges that
God is there to help them solve their problems.

Interpretation: Coping mechanism are used to decrease stress. Many

coping behaviors are learned based on one’s family, past experiences and
socio-cultural influences and expectation. (Fundamentals of Nursing by
Taylor p.855)

Analysis: The client faces his problems head on, but also with the help of
his significant others.

• Interaction

The client describes himself as a very sociable person. He was fond of

hanging out with his peers and friends in his 30’s. Right now though, he
spends more time with his family. He is very close to his wife and children.
They communicate well with each other and seldom have arguments.

Interpretation: A healthy person can relate to others and intimately

receive gratification from social and personal roles, trust others and enter
into mutual and interdependent relationships. (Principles and Practice of
Psychiatric Nursing 8th Edition by Stuart and Laraia, p. 307)

Analysis: The client is a sociable person. But probably, sue to his ailing
health; he seems to be closer to his family right now.

• Cognitive

The client’s highest educational attainment level is that of high school

graduate. His reasons for not able to pursue a college course were
because of financial reasons. The client also doesn’t have any problems in
speaking, writing and reading.

Interpretation: A patient with proper mental status has a good appearance

and behavior, alert, and responsive, and is oriented to time and place. The
patient’s thought content should be spontaneous, natural, clear and
relevant. His/her speech must be clear and coherent. Also, the patient’s
affect or external manifestations of mood should be natural and even.
(Medical-Surgical Nursing by Smeltzer and Bare, p.1835)
Analysis: As he is still recovering from the Intra-cerebral Hemorrhage, the
client might have had trouble doing certain functions.

• Self-Concept

The client sees himself right now as an aging but a happy man. As a
father, he used to be a very strict disciplinarian to his sons when they
were still kids. Right now that they have grown up, he tries to understand
them a bit more.
 Interpretation: People with self- concept usually have greater and more
diversified self-knowledge, more realistic perceptions and expectations
and higher self-esteem, whereas those with negative self-concept find to
exhibit poorer self-knowledge, less realistic perceptions and expectations
and lower self-esteem. (Taylor, Carol, et.al. Fundamentals of Nursing, 5th
Edition, 2005 pg. 82)

Analysis: Despite his current hospitalization, the client is still a happy

person and tries to see things positively.

• Emotional

The patient’s usual mood is happy. When he gets angry he just stays silent
and later on he will be okay. He expresses his feelings to his family or
friends by giving good service to them and having quality time with them
especially his family.

Interpretation: An individual’s affect (mood or feeling tone) can affect

thinking ability. Several situations would arouse several feelings like when
people are deprived of something (money, love, food) they feel sad or
anxious & when people satisfy a need, they feel happy. Moreover,
happiness of a person may reflect a tendency toward optimism rather than
over all satisfaction with life. Happy people emphasize the positive in what
they see & remember. Sadness on the other hand is a feeling of
displeasure which can be triggered by real or imagined wrongs. Like for an
example. Experience, arouse relatively strong emotions. Facial muscles
are very responsive to emotions. They move distinctively, physical
measurement suggest, even when observers see no signs of emotion on
the face. Simply thinking happy or sad thoughts moves facial muscles in
patterns ways. Facial movements reflect the intensity of experience too.
(Medical-Surgical Nursing by Smeltzer and Bare, p.1844)

Analysis: Despite his current hospitalization, the client is still a happy

person and tries to see things positively

• Family Coping

The client currently lives with his wife and three sons under one house. He
says that when problems arise, they would have a family meeting and
discuss it all together.

Interpretation: Family can provide the social support necessary to help the
patient manage and adapt to stress. Emotional support from family
members allows open expression of feelings and helps meet love and
belonging needs. (Fundamentals of Nursing by Taylor et al.)

Analysis: The client and his family cope with the problems easily by
discussing and solving their problems as a family.
B. Socio-Cultural Patterns

• Cultural Patterns

The client stated that they practice a normal day to day activity at home.
He would spend the entire at home watching at home. During mealtimes,
the family would dine together. He and his family also enjoy holidays
together such as in the Christmas season and the New Year.

Interpretation: Culture and social interactions also influence how a

person perceives, experiences, and copes with health and illness. Each
culture has ideas about health, and these are often transmitted from
parents to children. (Fundamentals of Nursing by Kozier et al, page 178)
Analysis: The client and his family have a normal way of a family should
have and they do things the same together.

• Recreation Patterns

The client says that his only way of passing time is by watching TV. He
usually has the volume loud in order not to hear the noise from outside his
house.

Interpretation: Lifestyle refers to a person’s general way of living,

including living conditions and individual patterns of behaviors that might
affect health. (Kozier and Erbs, Vol. 1, page 301)

Analysis: The clients has a normal way of spending time.

• Environment

The client and his family had recently moved to a new neighbourhood 6
months ago. He says that their previous home was a much better place.
Right now, their new 1 storey, 2-bedroom home has poor ventilation. It is
always hot inside as there is only one window. There is always noise from
the outside caused by the neighbours and the vehicles that pass by the
street. There would also be occasional brownouts. But he notes that the
water they use is purified and their garbage is collected daily.

Interpretation: People are becoming increasingly aware of their

environment and how it affects their health and level of wellness. Pollution
of the water, air, and soil can affect the support of life. Pollution can
naturally (e.g. lightning-caused fires, producer smokes w/c pollutes air).
Poor air quality can lead to increase in asthma and other respiratory
problems. The quality of water impact the quality of soil used to grow
food. Contamination of water supply has negative effects on human
consumption. Safe, accessible and affordable housing and safe accessible
schools, road and workplaces are necessary or health maintenance.
(Fundamental of nursing by Kozier, 5th ed.Page.253)

Analysis: The client is clearly unsatisfied with his current living

environment.
• Economic

Until ten years ago, the client had once worked as a security officer. But
due to his health condition, he had to quit working and leave it to his wife
and sons to take care of the finances. The family’s current source of
income is that from his wife’s savings who worked abroad and only came
back recently. His sons also contribute by working in part-time jobs.

Interpretation: Socio-economic status has been shown to have a major

impact on health, and there is evidence that a lower status is associated
with increased risks of some diseases, mortality and life span. (BBC news,
2006)

Analysis: The client depends on his family for their source of income.

C. Spiritual Pattern

• Religious Beliefs and Practices

The client is a very devout Roman Catholic. He states that praying is

important for him because this is the only way you can communicate and
lay your burden to God. He believes in angels which God sent to every
child to serve as their guide. He would actively join in church activities. He
would also go to his church and attend mass with his wife. He also adds
that his sons do not join him as they attend separate organizations such
as the Singles for Christ or Youth for Christ.

Interpretation: Religion may be considered a system of beliefs, practices

and ethical values about divine or superhuman powers or powers
worshipped as the creator(s) and ruler(s) of the universe. Religion gives a
person a frame of reference and a perspective with which to organize
information. Religious teachings vis-à-vis health helps to present a
meaningful philosophy and system of practices within a system of social
controls having specific values, norms, and ethics. These are related to
health in that adherence to a religious code is conducive to spiritual
harmony. Illness is sometimes seen as the punishment for the violation of
religious codes and morals. (p. 209 -210, Kozier 7th edition)

Analysis: The client is a very religious person. His faith is what still keeps
him positive about himself.

• Values and Valuing

The client said that the value that his parents had been inculcated in him
is that he must learn to respect the elders, and obey his parents. He also
believes that being positive in everything makes worse things become
better in the end. He makes sure that these values are passed down to his
children.
 Interpretation: An individual is not born with values; rather, values are
formed during a lifetime from information from the environment, family,
and culture. (Fundamentals of Nursing, Taylor, p.91)

Analysis: As a father and still the head of the family, the client is very
particular with values.

IV. Activities of Daily Living

Before During Interpretation

Hospitalization Hospitalization and Analysis

Nutrition The client eats 3 Upon admission,

times a day. The the client The normal food
client was fond of previously had intake or regular
eating salty foods, NGT. After the food intake basing
fish and removal of the in the
vegetables and NGT, his appetite Recommended
would usually was the same as
Dietary Allowance
have 2 and ½ before
cups of rice per hospitalization. or RDA stated that
meal 6-11 servings of
Bread, Cereals,
rice and pasta; 3-5
servings of
vegetable groups;
3-4 servings of
food groups; 2-3
servings of milk,
yogurt, cheese
group; and 2-3
servings of meat,
poultry, fish and
beans group.

(Fundamentals of
Nursing by Taylor,
p. 1246)

Elimination The client would The client still

frequently urinate frequently Spinal cord and
at least 6 times a urinates many head injuries can
day. He says that times a day decrease the
is due to his many sensory
maintenance stimulation for
medications. defecation.
Impaired mobility
may limit the
 client’s ability to
respond to the
urge to defecate.
(Kozier and Erb’s,
Vol II, page 1327)

Exercise The client would A therapist would

always do come and visit to The normal
occasional teach and help the frequency of
stretching client do 2-3 exercise is three
exercises. exercises per day, times per week
usually stretching and the duration is
ones.
30 minutes.
(Fundamentals of
Nursing by Kozier
pg. 1065)

Ill or people in
Hygiene Because he is Due to his pain may not have
always at home immobility, the the motivation or
most time, the client can only energy to attend
client would take a take a bath every to hygiene. (Kozier
bath 4- 6 times a other day. & Erb 8th ed. p. 74)
day.

Substance Use The client is a 20- The substances

pack per year the client uses are Smoking is directly
smoker. He also the medications as linked to many
drinks alcohol ordered by forms of cancer,
when there is an physician. heart disease and
occasion. hypertension.
(Medical-Surgical
Nursing, Black,
Volume I, page 18)

Sleep and Rest The client says he The client can

cannot sleep well now sleep well, Sleep is a basic
during the night usually up to 8 human need; it is
because of his hours a day. a universal
problem with biological process
urination and common to all
bloated sides. He people. (Kozier
says he tries to be and Erb’s, Vol. II,
comfortable by page 1164)
sleeping with 3
pillows.
VI. Laboratory and Diagnostic Examination Results

Date Procedure Norms Result Interpretation

and Analysis

CHEST X-RAY Pulmonary

vascular
congestion/
edema

Left
ventricular
cardiomegaly

Left pleural
effusion

CBC RBC: 5.22 x

1012/L
Hgb: 15.30
Hct: 0.47
Lympho: 0.16
Eosino: 0.02

Blood Total 5.90

Chemistry Cholesterol:
0.0 – 5.17
mmol/L
1.90
Triglycerides:
0.0 – 1.69
mmol/L
26.25
HDL:
167
LDL:
34.54
VLDL:
85.8
CREA:
147 mg/dl
CBG: