PAMANTASAN NG LUNGSOD NG PASIG

Alcalde Jose Street, Kapasigan, Pasig City

COLLEGE OF NURSING

GRAND CASE STUDY:

Janine Jordan Gelia Lacson Marichelle Laomoc William Vincent Mabbayad John Dean Macasaet Mark Almond Montoya Carmela Obayan

GROUP E

Dulce Reyes Krizel Joy Tingzon Devena Pauline Uypala Laureanne Venus Nerissa Villanueva Jhune Emmanuel Villegas Martha Faye Viray

GROUP H

INTRODUCTION
I. OBJECTIVES A. GENERAL OBJECTIVE Within our group case study, we would be able to develop and evaluate clinical assessment to effectively manage the patient through determining significant signs and symptoms, history and main etiology of the disease and by doing so, allowing us to gain more knowledge and learn new skills. We will also be able to improve our patient-centered way of caring for clients having same disease condition thereby developing therapeutic use of self. Specific Objectives: To know the risk factors that would contribute to the causation of the disease To determine the physiologic changes undergone by the patient with regards to the condition. To recognize the health history of the patient as basis for evaluating the disease condition. To be familiar of the medical and surgical procedures being done to the patient To formulate appropriate nursing intervention and effective care plan in the course study To acquire beneficial knowledge that may improve the students foundation in relation to the disease Every 53 seconds someone experiences a stroke; a stroke is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. If the flow of blood in an artery supplying the brain is interrupted for longer than a few seconds, brain cells can die, causing permanent damage. But how extensive can the damage be? There are many studies and theories on how strokes can affect the human body in regards to cognition, behavior, and emotion. Among these studies it has been noted that these deficits have a tendency to be strongly dependent upon the hemispherical location of the damage. Cognitive and emotional changes have been mentioned by at least 50% of stroke patients and their partners, but it was found that more problems were reported by relatives than the stroke patients themselves. Most frequently mentioned changes were irrespective of side of lesion, were mental slowness, memory disabilities, less initiative and hyperemotionality. Forty percent of stroke victims experience moderate to severe impairments requiring special care. These stoke victims are commonly immobile and needs to be assisted to perform activities of daily living (ADLs). The chosen patient on our case study had a stroke and became immobile for almost a year. Being immobile is never an easy thing. Patient needs somebody to fully take care of them due to severe immobility. Because of long time immobility, patient developed bed sores. Bed sore is a skin ulcer that comes from lying in one position for a long time,

that the circulation in the skin is compromised by the pressure, particularly over a bony prominence. Bed sores also known as decubitus or pressure ulcers. It is an ischemic necrosis and ulceration of tissues overlying a bony prominence which has been subjected to prolonged pressure against an external object like a bed condition continues to present a major health care problem not only for hospitalized older adults but for other immobilized individuals. The condition results to impaired skin integrity related to unrelieved, prolonged pressure. The predictions and prevention of pressure ulcers is therefore is one of the priorities in the health care field. The prevalence of pressure ulcers ranges from 3 to 11 percent in hospitalized elderly patients. For nurses and other caregivers who work with elderly patients, identifying risk for developing pressure ulcers, treating ulcers, and reducing their negative effects is a significant element of comprehensive and holistic care. By exercising analytic and assessment skills and by taking simple steps to reposition bedridden elderly patients, nurses can provide the kind of care that significantly enhances skin integrity even among patients who are bedridden for lengthy periods of time.

REASON

FOR CHOOSING THIS CASE

Case study is very important in Nursing; it provides us vast knowledge on the cases of patients. We interview the patient to know their health history, we study the laboratory result and physically assess them to be able to know the right nursing and medical management. With case studies, we can also evaluate the effectiveness and quality of health care services provided to the patient. Choosing this case, to consider sepsis secondary to Decibitus Ulcer, among other cases really catches our attention due to clinical signs of decubitus ulcer which occurred in the patient, there are some complications also related to the diseases diagnosed almost a year ago and our group wanted to give care for her to lessen the risk of developing more pressure ulcer, furthermore the client is not able to move on her own and needs full assistance. Elderly people need someone who has care for them, to get proper care. We should respect an elderly needs and wants. The body of an elderly needs a great amount of attention. Many questions were being formulated on our minds and to satisfy the curiosity we have decided to select this case for our case study. The knowledge that we will gain on this case study will be gladly imparted to others. We could also clear up some misunderstandings or misconceptions about Decubitus Ulcer.

ANATOMY
The skin is the body's largest organ, covering the entire body. In addition to serving as a protective shield against heat, light, injury, and infection, the skin also: PARTS OF THE SKIN Epidermis All the information is skin. The thickness brain in a central area of the brain, called The epidermis is the outer layer ofcompiled by theof the epidermis varies in different types of skin. It is the thinnest on the eyelids at .05 mm and the thickest on the palms and soles at 1.5 The striatum works the striatum, which controls many aspects of bodily motion. mm. The epidermis contains 5 layers: stratum basale, stratum spinosum, stratum granulosum, stratum licidum, with other areas of the brain, including a part called the substantia nigra, to stratum corneum

HOW BRAIN CONTROLS MOVEMENT

send out the commands for balance and coordination. These commands go

The bottom layer, the stratum the spinal cord through nerve networks to the muscles that from the brain to basale, has cells that are shaped like columns. In this layer the cells divide and push already formed cells intoto move will then help you higher layers. As the cells move into the higher layers, they flatten and eventually die. The top layer of the epidermis, the stratum corneum, is made of dead, flat skin cells that shed about every 2 weeks. The entire nervous system is made up of individual units called nerve cells. Dermis communicate with each other, location cells use .3 variety of and 3.0 The dermis also varies in thickness depending on thenerve of the skin. It is a mm on the eyelidchemical messengers called neurotransmitters. Neurotransmitters carry messages mm on the back. The dermis is composed of three types of tissue that are present throughout - not in layers. Specialized Dermal Cells The dermis contains many specialized cells and structures. The Neurotransmitters also with the erector pili muscle system to to each follicle. hair follicles are situated here allow the nervous that attaches communicate with the body's muscles and translate thought into motion. One especially important Sebaceous (oil) glands and apocrine (scent) glands are associated with the follicle. This messenger is eccrine (sweat) glands, but they are not associated with hairsubstantia nigra. layer also contains dopamine, which is manufactured in the follicles. Blood vessels and nerves course through this layer. The nerves transmit sensations of pain, itch, and Dopamine is crucial to human movement and is the neurotransmitter that temperature. helps transmit messages to the striatum that both initiate and control There are also specialized nerve cells called Meissner's and Vater-Pacini corpuscles that transmit the your sensations of touch andbalance. These dopamine messages make sure that muscles movement and pressure. Subcutaneous Tissue The subcutaneous tissue is a layer of fat and connective tissue that houses larger blood vessels and nerves. When a dopamine message is needed, a nerve and that produces dopamine This layer is important is the regulation of temperature of the skin itselfcell the body. The size of this layer varies gathers packetsand from person tofilled with dopamine particles. These packets throughout the body within itself person. Skin performs the following functions: release Protection: an anatomical barrier from pathogens and The dopaminethe internal and the dopamine particles into the synapse. damage between particles flow 1. across the synapsebodily defense; Langerhans cells in the skin on part of the adaptive immune external environment in and fit into special pockets are the outside of the system. neighboring, or receiving, nerve cell. The receiving cell is now stimulated to 2. send onSensation: contains a variety of nerve endings that react toof dopamine and pressure, the message, so it gathers its own packets heat and cold, touch, passes vibration, message to the somatosensory system and haptics. along the and tissue injury; seenext nerve cell in the same way. 3. Heat regulation: the skin contains a blood supply far greater than After the receiving cell has been stimulated to pass alongits requirements which the message, the allows precise control of energy loss by radiation, convection and conduction. Dilated blood vessels pockets perfusion and heatloss, while constrictedback into the synapse. To fine-tune then release the dopamine vessels greatly reduce cutaneous blood flow and increase coordination of movement, these "used" dopamine particles, along with any conserve heat. 4. Control of that did not skin provides a into a dry and on the receiving cell, excess dopamineevaporation: theoriginally fit relativelypocket semi-impermeable barrier to fluid loss. Loss of this by a contributes in the synapse called MAO-B. This is an are broken down function chemical to the massive fluid loss in burns. 5. Aesthetics the precise control of muscle and can assess our much or too important step inand communication: others see our skinmovement. Too mood, physical state and attractiveness. little dopamine can disrupt the normal balance between the dopamine system 6. Storage and synthesis: acts as a storage center for lipids and water, as well as a means of

Nerve cells serve as a "communication network" within your body. To

between nerve cells by crossing the space between cells, called the synapse

Pressure Ulcer

work smoothly, under precise control, and without unwanted movement.

carrying the dopamine move to the end of the nerve cell, open a "window," and

NERVOUS SYSTEM

and another neurotransmitter system, and interfere with smooth, continuous movement.

ENDOCRINE SYSTEM

All cells in the body need to have oxygen and nutrients, and they need their wastes removed. These are the main roles of the circulatory system. The heart, blood and blood What Insulin Does vessels work together to service the cells of the body. Using the network of arteries, veins and capillaries, blood ferries carbon dioxide to the lungs (for exhalation) and picks up oxygen. Four hormones are produced by the Langerhans islet cells. Insulin From the small intestine, the blood gathers food nutrients and delivers them is to every cell. produced in the B cells, glucagon in the A cells, somatostatin in

Insulin is a hormone produced by the pancreas (a gland that releases a digestive juice into the intestine). The pancreas is composed of acinar cells, which produce digestive enzymes, and the islet cells of Langerhans, which produce hormones.

Blood promotes anabolism (building up of tissues) and inhibits catabolism Blood consists of: (breaking down of tissues) in muscle, liver, and fat cells. It Red blood cells - to carry oxygen increases the rate of synthesis (blending) of glycogen, fatty acids, White blood cells - that make up part of the immune system and needed for clotting Platelets - proteins. Lack of insulin causes diabetes mellitus (a disease characterized by excess wastes float in this liquid. Plasma - blood cells, nutrients andsugar in the blood and other body fluids). The heart Insulin's most important feature is its ability to increase the rate of The heart pumps the(a crystalline sugar) absorption by cells. Glucose is the glucose blood around the body. It sits inside the chest, in front of the lungs and slightlymost efficient The heart is actuallyfound in almost all cells. four to the left side. fuel used by and a double pump made up of Insulin chambers. The contractions of the chambers make the sound of heart beats.

the D cells, and pancreatic polypeptide in the F cells. Insulin

causes a decreased concentration of glucose in the blood and causes the cells The right side of the heart to store glycogen (a starchlike substance), mostly in the liver. (atrium or auricle) the entry of other sugars and amino The right upper chamber It also promotes takes in deoxygenated blood that is loaded with carbonacids into the muscle and fat cells. Insulin is therefore responsible dioxide. The blood is squeezed down into the right lower chamber (ventricle) and taken by an artery to the lungs where the carbon and foris replaced quantity of for promoting fat storage in fat cells dioxide the total with oxygen. protein in the body.

The left side of the heart The oxygenated blood travels back to the heart, this time entering the left upper Insulin Production chamber (atrium or auricle). It is pumped into the left lower chamber (ventricle) and then Insulin production is stimulated by high levels more. into an artery. The blood starts its journey around the body once of glucose and

inhibited (limited) by lower levels of glucose. Insulin regulates

Arteries glucose with glucagon. Glucagon catabolizes (changes into a Oxygenated blood is of simpler composition) glycogen to glucose and also product pumped from the heart along arteries, which are muscular. Arteries divide like tree branches until they areGlucagon can be given to the aorta, which raises the blood sugar. slender. The largest artery is increase the connects to the heart and picks up oxygenated blood from the left ventricle. The only blood sugar when intravenous pulmonary artery, which runs between artery that picks up deoxygenated blood is the (by needle) glucose cannot be given. Glucagon takes about twenty minutes to raise the blood the heart and lungs.

sugar. Intravenous glucose raises it instantaneously, which is why

CIRCULATORY SYSTEM

Capillaries The arteries eventually divide down into the smallest blood vessel, the capillary. Capillaries are so small that blood cells can only move through them one at a time. Oxygen and food nutrients pass from these capillaries to the cells. Capillaries are also connected to veins, so wastes from the cells can be transferred to the blood. Veins Veins have one-way valves instead of muscles, to stop blood from running back the wrong way. Generally, veins carry deoxygenated blood from the body to the heart, where it can be sent to the lungs. The exception is the network of pulmonary veins, which take oxygenated blood from the lungs to the heart.

Increasing Age(64y/o) (+) Hx of hip dislocation (Left Leg)

Physical Immobility
Client was usually placed on the wheel chair Produced prolonged pressure on bony prominences (sacral area)

S/P CVA with left sided weakness(117-2010) ) Diagnosed with Parkinsons disease(117-2010)

F D
Decreases HDL level Sedentar y lifestyle Formation of fatty streaks in the blood vessels Narrowing of the lumen Increase CBG 321 mg/dL (5-2-2011)

Diagnosed of Diabetes MellitusType 2 (14 yrs ago)

M7 M1

Possible Atheroscleros is Inc. Triglyceride 2.57mmol/L (4-29-2011)

Physical Therapy 3x/wk Decreased blood circulation on the area

STAGE I Redness of skin STAGE II Superficial Damage (Blistering/breakdo wn of skin)

M6

C
Dec. HDL 0.3 mmol/L (4-29-2011) Initial tissue and cellular damage

Reperfusion Injury

M5

B
Temporary Ischemia

Need for insulin therapy Impaired insulin secretion

SWELLI NG

Leukocyte extravasation causing phagocytosis Increased vascular permeability

Inflammatory response

Blood re-enters tissue

PATHOPHYSIOLOGY
Release of chemical mediators as well as free radicals in response to tissue damage

REDNES S

Changes in vascular flow Pyrogen activate hypothalamic thermoregulation

Restored blood flow reintroduces oxygen withincellsthat damages cellular proteins,DNA, and theplasma membrane

HEA T

Bradykinin release pyrogen

Contribute to

Contribute to

S/P Left Hip Replacement (1-17-2010)

Insulin receptors become resistant to insulin

Decrease glucose entering the cells

Increase blood glucose level

Blood becomes viscous

Body compensates by increasing amount of insulin secreted by the pancreas Beta cells cannot keep up by the increasing demand for insulin

LEGEND
Signs and Symptoms Contributing Factors Medication Laboratory Results Patients existing Medical Maintenance

A
Damage to the cell's membrane may in turn cause the release of more free radicals Destruction on skin integrity

B
Leukocytes may also build up in smallcapillaries Obstruction leading to more ischemia Further decreased in blood supply to tissues Poor wound healing Ulceration left heel (S2) Redness right heel (S1) M2 M4

C
Poor circulation The WBCs in the blood, which are vital in the healing process, are unable to do their job

Heart has difficulty pumping the blood

Increase peripheral resistance against arterial wall Increase blood pressure: BP = 150/80 mmHg

Causes formation of thrombus/plaques Travels into the blood vessels HEART BRAIN

Cells and tissues die

Formation of wound

Worsening of wound and getting infected

Knowledge deficit about proper Mngt. Soiled linens, poor self care Poor wound care

Causing obstruction in the blood flow M8 CHEST PAIN Inadequat e blood supply in the heart tissues Increase Trop1 (4-28-2011)

Ulceration enlarges extending deep into the fascia, and muscle

Hypoxia

CVA

STAGE IV Full thickness loss of skin and subcutaneous tissue and extension into muscle

inc WBC. inc neutron, dec. lympho (4-28-2011)

Increased body temperature 4/29/11 Temp: 38.2

MI

Invasion and proliferation of microorganism in the bloodstream

Continued activation of the inflammatory mediators

Sepsis

Increase CK (4-28-2011)

Produces foulsmelling drainage

(+) wound at sacral area approximate ly 2.5 wide and 1 deep at the center

M2

M3

M2

M1 Clopidogrel 75 mg OD through NGT M2 Metronidazole 500mg IV q12 MEDICATIONS M3 - Ampicillin/Sulbactam 750mg TIV q12 M4 - Paracetamol 300mg TIV q4 M5 - Humulin 70/30 30 u pre-breakfast 20 u pre-dinner M6 Fenofibrate 100mg/tab OD through NGT M7 Sinemet 1tab OD through NGT M8 ISMN 60g/tab tab q HS

THEORETICAL FRAMEWORK
Dorothea Orems Self Care Deficit Model
Self care theory is based on four related concepts : (1) Self care defined as the activities an individual performs independently to maintain personal well being; (2)Self care agency that refers to individuals ability to perform self care activities;(3) Self care requisites which known as measures or action taken to provide self care and; (4)Therapeutic self care demands that refers to activities required to meet existing self care requisites. A patient with previous stroke, decubitus ulcer, diabetes mellitus and Parkinsons disease, there is a lack of self care of the client which results to formation of bedsores and immobility. Patients performance of self care includes active range of motion to prevent contractures and effective wound care for the bedsores, appropriate diet modification for management of blood sugar and determining its effect on certain medications the client takes. For the self care agency, the patients significant others provides necessary care and needs of patient during hospitalization like providing the necessary needs such as medications and toiletries. Due to the presence of illness, the client cannot follow the therapeutic regimen effectively as well as perform necessary self care management she needs. For self care requisites ,due to the left sided weakness from previous stroke the client is unable to participate in effective self care activities especially active and passive range of motion, turning herself side to side and ambulating herself; presence of decubitus ulcer at her sacral area prevent her from ambulating herself and performing wound care, uncontrolled levels of blood sugar prevents her from in taking appropriate diet and diagnosis of Parkinsons disease affects her behavioral approach in the interventions especially nursing care. While in the therapeutic self care demands, the planned actions for the client in order to achieve and maintain optimum health were not followed as expected due to the presence of illness. Collaboration of healthcare team and significant other is very important for implementing necessary actions for the patient. Significant others may perform passive range of motion for the client guided and instructed by healthcare provider; Frequent monitoring of blood sugar as necessary as possible and instructing the significant others the diet of client; Performing effective daily wound care for the decubitus ulcer can be done by relatives guided by healthcare providers and encouraging patient to do self care activities gradually.

NURSING HEALTH HISTORY

BIOGRAPHIC DATA 1. Name: Patient M 2. Address: Pasig City 3. Age: 64 y/o 4. Gender: Female 5. Marital Status: Married 6. Occupation: Former Lotto Operator 7. Religion: Catholic 8. Source of medical care: Daughter and SSS 9. Birthday: May 19, 1946 10. Birthplace: Pasig City 11. Admitting diagnosis: T/C Sepsis secondary to Decubitus Ulcer, DM type II, HCVD 12. Attending Physician: Dr. Marquez ; Dr. Gardon ; Dr. Lim ; Dr. Ramos

CHIEF COMPLAINT Lumalaki na kasi yung bedsore niya eh, hindi na namin makontrol yung paglaki kaya dinala na namin siya dito sa ospital, as verbalized by the clients significant other. HEALTH HISTORY A. History of Present Illness Last January 17, 2010, the client suffered from stroke that result to her accident at the bathroom of their house causing her fracture at her left lower extremity. According to her significant other, the ball-and-socket joint up to the upper part of the femur was detached and fractured. As a surgical treatment, the client underwent metal hip replacement at Lourdes Hospital. Since then, the client became partially dependent and was partially immobile for almost a year. Patient M has her own physical therapist that visits her at home thrice a week. This was the only time that she can do the best way of doing Range of Motion exercises. When her husband was just the only one who will take care of her, Patient M would rather be on bed or just be placed on a wheelchair. These factors lead to the formation of the pressure ulcer at the clients lumbosacral area with a measurement of 3 inches wide, 5 inches in height and 1 inch deep at

the center. There was also a pressure ulcer present at her left heel with a measurement of 1 inch wide. B. Past History Patient M has a previous hospitalization at Lourdes hospital last January 2010 because of her accident causing her fracture and she also suffered from stroke that causing her left sided weakness. The present hospitalization was her second hospitalization. She was also diagnosed of Type II Diabetes Mellitus and was a known hypertensive since she was on her late 50s. Before the incident, she was observed to be irritable, restless and manifests slowed movements by her husband. He stated that her wife became wayward and does whatever she likes. They were surprised when she was diagnosed of Parkinsons disease when she was admitted at Lourdes hospital because of her fracture. She also had a maintenance medication of Amlodipine for her hypertension. She uses Sinemet (Carbidopa and Levodopa) for her Parkinsons disease and started using it a year ago. To manage her Diabetes, she first used Oral Hypoglycemic Agents and just only started using Insulin (Humulin N 70% and Humulin R 30% ; 30 units in AM and 20 units in PM) 2 years ago because OHA cant control anymore her blood sugar. She first used silver sulfadiazine ointment for the management of her pressure ulcer but they discontinue using it because they observed that using this ointment doesnt help relieving the said pressure ulcer so they shifted to povidone iodine and perceived that it was more effective. They used triple solution for the pressure ulcer at her ankle but didnt use it to her pressure ulcer at the back. She has no known allergies to any foods and drugs. C. Family History of illness
DECEASED Diabetes Mellitus Hypertension

Mother

Father

DECEASED Liver Cancer Hypertension

Patient M (FEMALE,64) Diabetes Mellitus Hypertension Parkinsons disease CVA

Husband 64 y/o No disease

2nd Child (FEMALE,40) History of Jaundice 1st Child (FEMALE,42) No disease 2nd Child (MALE,22) DECEASED Aneurys m

3rd Child (MALE,35) Ment ally

4th Child (MALE,23) DECEASED No disease

PAIN ASSESSMENT Since Patient M became verbally unresponsive 2 weeks prior to admission, she wasnt able to report or communicate any kind of pain or discomfort. According to her significant other, she completely opens her eyes whenever they try to stretch her flexed extremities. The stretching of her extremities can be the one causing her discomfort and even pain. Since the client is verbally unresponsive, the client wasnt able to rate her pain or discomfort.

FUNCTIONAL HEALTH PATTERNS 1. Health Perception & Health Management Pattern The clients general health is obviously disturbed because of the presence of her illness and because of the physical changes that are happening at the moment, especially the formation of the unwanted pressure ulcers. Her significant other helps in managing her health on the hospital by cooperating with the nurses and doctors and also by doing what they are saying. According to her significant other, the client was an occasional alcohol drinker on her late twentys up to her 40s. The specific quantity or the number of bottles that the client can consume was not accurately known by the significant other. He just stated that the client totally stopped drinking when she developed Diabetes and she realized that she was old enough, that taking care of her body at this golden age of her life was the vital part. Her significant other also stated that Patient M never smoked or consumed cigarette on her entire life. The client was fond of having regular check ups with her doctor, especially on the management of her Diabetes, Parkinsons disease and pressure ulcer. She also uses a glucometer to monitor her blood sugar. She gets blood sugar twice a day, one in the morning and one in the afternoon. She also had her own physical therapist that visits her at their home thrice a week. Her last schedule to her physical therapist was 1 week prior to admission. 2. Nutrition & Metabolic Pattern Before hospitalization the patients usual diet is more on fruits and vegetables. She loves to eat monggo. She less consume chicken, fish, meat and pork. She avoids consuming fats and foods that high in cholesterol. She also loves eating hotcakes as her snack in the late afternoon. She consumes at least cup of rice per serving and usually eats 3-4 times a day. According to her husband, she can eat by herself but she ate very slowly and has difficulty on chewing. They usually crushed the foods that she consumes to make it soft and to make it easy for her to chew. She usually consumes 4-5 glasses of water per day. Now on her hospitalization, the doctor first prescribed her diet to be Soft Diet with Strict Aspiration Precautions. But the client suffers from loss of appetite and experienced difficulty on swallowing so they decided to insert a Nasogatric Tube and ordered an osteurized feeding of Nutren of 1,600kcal divided into 6 equal doses. Her usual fluid intake was at least 380cc per day. The

oral medications that she intake was crushed and given in between her feeding. According to her husband, there is no change on her physical appearance since the client got hospitalized. She first had an IVF of D5W 500cc for 16 hours. Then it was changed to PNSS IL x 12 hours last May 1 - 2, 2011 because she underwent blood transfusion. Then it was again shifted into D5W 500cc x 16 hours hooked at her left hand. 3. Elimination Pattern Before hospitalization, the client wears medium diaper for her urination and defecation. According to her husband, he changes the soiled diaper of the patient 3 4 times a day. 2 out of the 4 diapers were fully soaked with yellowish urine. Her husband also noticed that ants was seen He also states that the patient usually defecates twice, one in the morning and one in the evening. Her stool was soft, formed and brownish in color. Since the client was verbally unresponsive, we werent able to identify whether there is presence of any difficulty and discomfort in urinating and defecating. Presently on her hospitalization, she was inserted with a foley catheter attached to a urine bag. She eliminates urine at least 1550cc per day. Her urine is yellow in color. She still wears diaper and defecates at least once a day, still with soft, formed and brownish stool. But last May 3 5, 2011, the client experienced watery, yellow-brown stool with at least 4 5 times a day. 4. Activity & Exercise Pattern Before hospitalization, the client was already partially dependent and partially immobile for more than a year. She was able to move and sit, but of course with the assistance of her significant other. The only time that Patient M was to do the best way of doing Range of Motion exercises passively is when her physical therapist will visit her. This was also her very form of exercise. When her husband was just the only one who will take care of her, Patient M was rather just be on bed or just be placed on a wheelchair. She prefers using wheelchair because she had a hard time using crutches. She also had a left sided weakness since she was stroked last year. She spends her leisure time by just sleeping or watching television. Presently, her activities became more sedentary. She was just on bed, sleeping and resting. The doctor ordered her to be placed on Complete Bed Rest without Bathroom Priviledges. She was also placed on Moderate High Back Rest. She was decorticated and the significant other was having a hard time to do passive ROMs. She was turned side to side by her significant other every 2 hours as ordered by the doctor and as instructed and thought by the student nurses. Level 0 Level 1 Level 2 Level 3 Level 4 Full self-care Requires use of equipment or device Requires assistance or supervisions person Requires assistance or supervisions person/device Is dependent and does not participate Before hospitalization:

from from

another another

Feeding: Bathing: Toileting: Feeding: Bathing: Toileting:

0 2 2 3 2 2

Bed Mobility: 2 Dressing: 2 General Mobility: 3 During Bed Mobility: Dressing: General Mobility:

Grooming:

hospitalization: 2 Grooming: 2 2 2

5. Sleep & Rest Pattern Before hospitalization, the clients sleep pattern was usually 7 hours. According to her husband, she sleeps very well and doesnt have the need to take any sleep medications. Her sleep is continuous and usually wakes up early. She always does daytime naps. She always does watching television, but most of the time, she was asleep. Presently, her husband noted that she still sleeps most of the time, day and night. She usually sleeps for at least 8 9 hours. She also often wakes up intermittently. She just wakes up whenever she will be fed, when changing her soiled clothes and diapers and sometimes, when someone is visiting her. 6. Cognitive-Perceptual Pattern

The client has no hearing and visual difficulty before and during the hospitalization. He doesnt wear any hearing aids or eye glasses. According to her husband, he thinks that Patient M cannot remember him anymore. She is not responsive to him unlike to her other family members. She observed that Patient M smiles at them. 7. Self - perception & Self-concept Pattern According to her husband, prior to hospitalization, Patient M doesnt share any of her feelings to her husband anymore. But he can say that Patient M decreased her self - confidence because she doesnt want to go outdoors anymore. She just prefers watching television. Since the client was verbally unresponsive, she wasnt able to share any of her feelings or her thoughts to the changes happening in her. 8. Role Relationship Pattern There were definitely changes in his role as a mother to her child and as a wife to her husband who is already 64 years old. She lives with her husband and her eldest child which is a medical technologist at PCGH. Her eldest stands as the breadwinner of the family. Her husband was the one taking care of her most of the time. According to her husband, their eldest cant take care of her mother since she was busy on her job. Her husband together with their child was the only one handling the problems that occur in the family. Her 2nd child died last 2005 because of aneurysm, and on that scenario, we can see that her relationship pattern was already impaired. Patient Ms illness has definitely effects on the family. She wasnt able to do her role normally and she was the one being taking cared of.

Presently, Patient Ms relationship with her husband was really strong. He was always on the side of his wife no matter what happen. He even also stated to us that, masama magpapalit palit ng asawa, kahit anong mangyari, di ko siya iiwan. 9. Sexuality - Reproductive Pattern Because of his hospitalization, his sexual life was obviously not a priority for her. She has no history of STDs. She also got menopausal at the age of 45. According to Erik Eriksons psychosocial developmental task, she is under the Generativity vs. Stagnation stage, at this stage, it is vital for her to share something for others and be productive. We can see that she can be under stagnation she lacks productivity which can result to her dissatisfaction in life. 10. Coping Stress Tolerance Pattern

According to her significant other, he cant say whether Patient M is under stressed or not. Since she doesnt usually share her thoughts, he doesnt have any idea what causes her wifes stress. According to him, Di ko kasi talaga napapansin yun eh, madalas lang naman kasi nakahiga lang siya. Since she was verbally unresponsive, she wasnt able to report any things or events that make her stressed. But obviously she was stressed of her present condition. 11. Value Belief Pattern

The client is a Catholic. According to her significant other, they always pray together and never forget the Almighty God even before hospitalization. Prior to hospitalization, they dont really go to church because it is difficult for Patient M to go outdoors and often refuses to. Her husband said that the management and interventions that are done to her are acceptable and doesnt offend any of their beliefs and practices. Her husband also stated that, maswerte nga kami eh, kasi hindi siya pinapabayaan ng Panginoon, hanggang ngayon kasama ko pa din siya.

PHYSICAL EXAMINATION
PRE-PHYSICAL EXAM
May 5, 2011 I. Vital Signs: Temperature: 36.2C Pulse Rate: 78 bpm Respiratory rate: 22 cpm BP: 150/80mmHg II. General Appearance GCS 8 (E:4 V:1 M:3) Sleeping at bed On MHBR Tired and weak looking Decorticated (+) left sided weakness (+) muscle rigidity III. Skin Dry Light brown in color (+) pressure ulcer at the lumbosacral area with a measurement of 2.5 inches wide and 1 inch deep at the center (+) pressure ulcer at the left heel measuring 1 inch wide IV. Eyes Anicteric sclera PERRLA No visual difficulties V. Ears VI. Nose Negative discharge No hearing difficulties Negative discharge Septum in midline (+) Nasogastric Tube With 02 of 3-4 lpm via NC (+) white curd like exudate Coated tongue (+) tartar on teeth Yellowish teeth

VIII. Neck No palpable lymph nodes IX. Chest and Lungs 1:2 AP Ratio (-) retractions (-) cough (-) wheezes (-) fremitus (+) crackles at the base of the left lung X. Heart Precordim AP No murmurs

XI. Abdomen Soft, flabby abdomen NABS XII. Genitals With foley catheter attached to urine bag at 600cc level for 4 hours XIII. Upper Extremities With IVF at left hand of PNSS 1L x 12 hours with a regulation of 21 22 gtts/min (+) Flexion of both arms with a grade of 3/5 (+) tremors Capillary refill > 2 seconds Weak pulses Closed left fist Cold and clammy Pale No edema XIV. Lower Extremities (+) Flexion of both legs

VII. Mouth Dry lips Cracked lips Impaired swallowing Decreased cough and reflex (+) Desquamation of lips

gag

 (+) pressure ulcer at left heel measuring approximately 1 inch wide

Cold and clammy No edema

POST-PHYSICAL EXAM

LABORATORY STUDIES
SECTION OF HEMATOLOGY April 28, 2011 TEST Hemoglobin Hematocrit Platelet Count WBC Neutrophils Lymphocytes Prothrombin Time Active Partial Thromboplastin Time (Cardiac Markers) Troponin I This is used for early diagnosis of MI. <0.01 ug/L 1.29 HIGH May indicate presence of small infarct and myocardial injury. This is done to measure how long it takes blood to clot and to check for bleeding problems. This test is used to evaluate blood disorders, possible reaction to inflammation and infections.

INDICATION

NORMAL VALUE 120.0-160.0 g/L 0.40-0.54 g/L 150.0-400.0 x 10 g/L 4.50-11.0 x 10 g/L 0.35-0.65 g/L 0.20-0.40 g/L 10.0-14.0 sec 27.70-34.10 sec

RESULT 95.0 LOW 0.29 LOW 372 26.8 HIGH 0.98 HIGH 0.02 LOW 11.4 33.7

INTERPRETATION May indicate anemia or nutritional deficiency. Normal

May indicate presence of infection.

Normal result indicates ability of the liver to synthesize clotting factors.

SECTION OF CLINICAL CHEMISTRY April 28, 2011 TEST INDICATION Creatinine Urea Potassium Sodium

CK CK-MB

NORMAL VALUE RESULT (Protein & Protein Metabolites) 53-132.5 mmol/L 131 This is done to determine any 11.9 2.5-7.1 mmol/L renal problems. HIGH (Electrolytes) 3.6-5 mmol/L 3.6 This is done to determine 132 electrolyte and acid-base 137-145 mmol/L LOW imbalances. (Cardiac Markers) 900 30-135 U/L Use to diagnose acute MI and HIGH risk stratification for unstable 0-16 U/L <1 angina

INTERPRETATION Normal May indicate possible renal problem. Normal Low result due to her maintenance of sinemet. It reduces sodium levels. Indicates possible myocardial infarction. Normal

SECTION OF BLOOD CHEMISTRY April 29, 2011 TEST INDICATION This is done to determine Glucose the amount of glucose and uric acid in the blood Uric Acid that affects the present condition. This is done to determine the amount of lipid components in the blood that affects the present condition.

NORMAL VALUE 3.61-5.83 mmol/L 149-446 mmol/L (Lipids)

RESULT 3.62 559 HIGH

INTERPRETATION Normal May indicates possible gout that is why the patient is taking allopurinol. An increased value is possibly due to her increase intake of food high in carbohydrates and sugar (hotcake). May indicates poorly controlled diabetes mellitus. Normal Normal

Triglycerides HDL LDL Cholesterol

0-2.26 mmol/L 1-1.6 mmol/L 0-3.36 mmol/L 0-5.2 mmol/L

2.57 HIGH 0.3 LOW 0.98 2.5

SECTION OF CLINICAL CHEMISTRY April 29, 2011 TEST INDICATION Creatinine Urea

NORMAL VALUE RESULT (Protein & Protein Metabolites) 53-132.5 mmol/L 91 This is done to determine any 8.1 2.5-7.1 mmol/L renal problems. HIGH (Liver Function Test) 14-36 U/L 9-52 U/L 110 HIGH 82 HIGH

INTERPRETATION Normal May indicate possible renal problem. Indicates tissue damage as a result of decubitus ulcer (bed sore). May also indicate liver damage. May indicate possible liver damage.

AST ALT

This is done to determine any malfunction in the liver. AST may also release after injury or death of cells.

SECTION OF MICROBIOLOGY May 1, 2011 Specimen and Blood No growth after 24.7 hours of incubation

SECTION OF CLINICAL CHEMISTRY May 3, 2011 TEST INDICATION HbA1c This is done to determine how well blood glucose levels have been controlled during the prior 3 to 4 months.

NORMAL VALUE 6.6-8.8 %

RESULT 8.69 %

INTERPRETATION Normal

DRUG STUDY
CLASSIFICATION and MECHANISM OF ACTION Generic: Laxatives. Cause an Lactulose influx of fluid in the Brand Name: intestinal tract by Duphalac increasing the Lilac osmotic pressure within the intestinal 30cc qHS lumen. Bacterial through NGT metabolism of the drug to lactate and other acids which are only partially absorbed in the distal ileum and colon augments the osmotic effects of DRUGS INDICATION -heart disease -liver damage ADVERSE EFFECTS GI -abdominal discomfort assoc. with flatulence and intestinal cramps -nausea -vomiting -diarrhea on prolonged use CONTRAINDICATIO N -Patient who require low lactose diet. -Galactosemia or dissacharide deficiency -intestinal obstruction NURSING MANAGEMENT -Assess mental condition (clearing confusion, restlessness, irritability) -Monitor possible adverse reaction. -Monitor Input and Output

Generic: Clopidogrel Brand Name: Plavix 75 mg OD through NGT

lactulose. The distention of the colon due to increased fluid enhances intestinal motility and secretion. Decrease in the lumenal pH (due to bacterial metabolism) further increase motility and secretion. It also lowers intestinal absorption of ammonia presumably due to inc. utilization of ammonia by intestinal bacteria Anticoagulant/Antipl atelet Thrombolytic.Blocks ADP receptors, which prevent fibrinogen binding at that site and thereby reduce the possibility of platelet adhesion and aggregation

-Reduction of atherosclerotic events -MI

GI -GI bleeding -GI disturbances -Diarrhea SKIN -purpura -bruising -hematoma -rash -pruritus EENT -Epistaxis URINARY -hematuria OPTHA -eye bleeding CNS -intracranial bleeding GI

-Hypersensitivity -severe liver impairement -pregnancy and lactation -active pathological bleeding

-Assess for symptoms of stroke/ MI during treatment -monitor signs of bleeding -monitor liver function test.

Generic:

H2-Receptor

-prevent ulcer

-Hypersensitivity

Use caution in

Ranitidine Brand Name: Zantac 50mg TIV q8

Antagonist. Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion.

(NPO)

Generic: Metronidazole Brand Name: Zolvex 500mg IV q12 ANST

Antiprotozoal. Direct-acting amebicide/trichomo nacide. It binds to bacterial and protozoal DNA to cause loss of helical structure, strand breakage, inhibition of nucleic acid synthesis and cell death

-infections in the intra-abdominal, skin and skin structure -bacterial septicemia

-abdominal discomfort -nausea -vomiting -constipation -pancreatitis -hepatocellular effects CARDIO -Cardiac arrhythmias -bradycardia CNS -headache -somnolence -fatigue -dizziness -hallucinations -depression -insomnia HEMATO -agrunulocytosis -aplastic anemia -thrombocytopenia -granulocytopenia GENERAL -hypersensitivity reaction. GI -anorexia -GI disturbances -nausea -less freq. vomiting -diarrhea EENT -dry mouth -furred tongue -unpleasant metallic taste -watery eyes if applied near to the eyes CNS -convulsive seizure

-history of acute porphyria. -long term therapy

presence of renal r hepatic impairment; monitor for side effects; instruct patient not to take any new medications without consulting the physician.

-blood dyscrasias -active CNS dse -hypersensitivity to imidazole -TB -1st tri of pregnancy -lactation

-obtain baseline info on pxs infection -obtain C&S before beginning drug therapy -assess for allergic reaction -monitor for possible drug induced interaction -monitor renal function -assess for overgrowth of

-headache -dizziness -psychiatric disorder SKIN -rash -pruritus -transient redness -mild dryness -burning -skin irritation URINARY -darkening of the urine HEMATO -leukopenia GENERAL -weakness GENERIC: Ampicillin/Sul bactam BRAND NAME: Unasyn 750mg TIV q12 ANST Penicillins. Belonging to the penicillin group of beta-lactam antibiotics, ampicillin is able to penetrate Grampositive and some Gramnegative bacteria. It differs from penicillin only by the presence of an amino group. That amino group helps the drug penetrate the outer membrane of gramnegative bacteria. Ampicillin acts as a competitive inhibitor of the enzyme transpeptid This combination medication is used to treat a wide variety of bacterial infections. It is known as a penicillin-type antibiotic. It works by stopping the growth of bacteria. This antibiotic treats only bacterial infections. It will not work for viral infections. GI -diarrhea that is watery or bloody - nausea -vomiting -stomach pain -bloating CNS -fever - headache EENT -sore throat -black, or "hairy" tongue thrush (white patches or inside your mouth or throat) SKIN -severe blistering, peeling -red skin rash GENERAL -chills -hypersensitivity reactions to any of the penicillins.

infection -monitor bowel pattern

-Determine previous hypersensitivity reactions to penicillins, cephalosporins, and other allergens prior to therapy. -Lab tests: Baseline C&S tests prior to initiation of therapy; start drug pending results. -Report promptly unexplained bleeding (epistaxis, ecchymoses) -Monitor patient carefully during the first 30 min after initiation of IV therapy for signs of hypersensitivity

ase, which is needed by bacteria to make their cell walls. It inhibits the third and final stage of bacterial cell wall synthesis in binary fission, which ultimately leads to cell lysis

-body aches -flu symptoms

GENERIC: Paracetamol BRAND NAME: Biogesic Tempra 300mg TIV q4

Antipyretic/Analgesi c. Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilataion. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its minimal effect on peripheral prostaglandin symthesis.

-Decrease fever -Mild to moderate pain

GI -N/V -abd. Pain - hepatotoxicity -hepatic seizure CNS -drowsiness -stimulation -drowsiness -delirium -coma SKIN -rash -urticaria -jaundice HEMATO -leukopenia -neutropenia -hemolytic anemia -thrombocytopenia -pancytopenia URINARY -renal failure GENERAL -hypersensitivity

-Hypersensitivity -Intolerance to tartrazine, alcohol, table sugar, saccharin

and anaphylactoid reaction. Serious anaphylactoid reactions require immediate use of emergency drugs and airway mngt. -Observe for and report symptoms of superinfections -Monitor I&O ratio and pattern. Report dysuria, urine retention, and hematuria. -Assess for fever or pain -assess allergic reaction -assess hepatotoxicity -monitor liver or renal functions -check I&O

GENERIC: Allopurinol BRAND NAME: Elavil 100mg/tab OD through NGT

Uricosurics. Inhibits xanthine oxidase, an enzyme involved in the synthesis of uric acid without disrupting the biosynthesis of essential purine. Results in dec. uric acid level.

-gout -hyperuricemia

-cyanosis GI -abd. Pain -dyspepsia -diarrhea -gastritis -N/V -hepatic necrosis -elevated liver enzyme -hepatitis -hepatomegaly CNS -drowsiness -gen. seizure -headache -nueritis SKIN -alopecia -ecchymosis -skin rash -cho;estatic jaundice HEMATO -leukocytosis -leucopenia -thromocytopenia MUSCULO -lipodystrophy ENDO -insulin resistance -hypoglycemia GENERAL -allergic reactions

Contraindicated to patients who have hypersensitivity to drug

-Monitor uric acid level -Tell patient to report any unusual reactions from the drug

GENERIC: Insulin, human isophane susp & insulin recombinant BRAND NAME: Humulin 70/30 30 u prebreakfast 20 u pre-

Intermediate-acting Insulins. Decreases blood glucose; by transport of glucose into cells and the conversion of glucose to glycogen indirectly increases blood pyruvate and lactate, decreases phosphate and pottassium

Management of type 2 DM which cannot be controlled by diet, exercise or weight reduction alone

-hypoglycemia -insulinoma -hypersensitivity reactions -diabetic coma

-monitor FBS -monitor urine ketones -monitor body weight -assess for hypoglycemic reaction -observe inj. Site for s/sx of local hypersensitivity -assess for hyperglycemia

dinner

GENERIC: Fenofibrate BRAND NAME: Nubrex 100mg/tab OD through NGT

Fibric Acid Derivative. It is a fibric acid derivative whose lipid modifying effects reported in humans are mediated via activation of peroxisome proliferatoractivated receptor type alpha (PPAR). Through activation of PPAR fenofibrate inc. the lipolysis and elimi -nation of atherogenic triglyceride-rich particles from plasma by activating lipoprotein lipase and reducing production of apoprotein CIII. Activation of PPAR also induces an inc. in the synthesis of apoproteins AI and AII, which leads to a reduction in VLDL and LDL containing apoprotein B and an inc.in the high-

hypertriglyceridae mia

GI -Digestive, gastric or intestinal disorders -abdominal pain -nausea -vomiting -diarrhea -flatulence Skin -Rashes -Pruritus -urticaria or photosensitivity reactions.

-pregnancy or lactation -liver insufficiency -presence of gallstones -renal insufficiency -hypersensitive to fenofibrate and/or excipients, known photoallergy or phototoxic reaction during treatment with fibrates or ketoprofen.

-monitor BP -monitor electrolytes, blood studies -assess hydration status -assess nutrition -monitor bowel pattern

GENERIC: Levodopa/Car bidopa BRAND NAME: Sinemet 1tab OD through NGT

density lipoprotein fraction (HDL) containing apoprotein AI and AII. In addition, through modulation of the synthesis and catabolism of VLDL fractions, fenofibrate increases the LDL clearance and dec. small and dense LDL, the levels of which are elev. in the atherogenic lipoprotein phenotype, a common d/o in pts at risk for coronary heart disease. Antiparkinsonism. Levodopa is converted to dopamine via the action of a naturally occurring enzyme ca lled DOPA decarboxylase. This occurs both in the peripheral circulation and in the central nervous system after levodopa has crossed the blood brain barrier. Activation of central dopamine receptors improves the

Treatment of symptoms of idiopathic Parkinson disease (paralysis agitans), postencephalitic parkinsonism and symptomatic parkinsonism associated with carbon monoxide and manganese poisoning.

CARDIO -Cardiac irregularities -palpitations -hypertension -phlebitis -orthostatic hypotension -MI -palpitation -syncope. CNS -Paranoid -delusions -psychotic episodes -depression -suicidal ideation -dementia -convulsions -hallucinations -dizziness

-Narrow-angle glaucoma -undiagnosed skin lesions or prior history of suspected melanoma -concurrent use of or within 2 wk of MAOIs.

symptoms of Parkinson's Disease, however, activation of peripheral dopamine receptors causes nausea and vomiting. For this reason levodopa is usually administered in combination with a DOPA decarboxylase inhibitor (DDCI), in this case carbidopa, which is very polar (and charged at physiologic pH) and cannot cross the blood brain barrier, however prevents peripheral conversion of levodopa to dopamine and thereby reduces the unwanted peripheral side-effects of levodopa. Use of carbidopa also increases the quantity of levodopa in the bloodstream that is available to enter the brain.

-choreiform -dystonic and other involuntary movements -fatigue -malaise -bradykinetic episodes (ie, on-off phenomenon) -confusion -headache -increased libido -insomnia -paresthesia. EENT Diplopia -blurred vision. GI -Nausea -anorexia -vomiting -GI distress -epigastric pain -GI bleeding -dry mouth -duodenal ulcer -constipation -diarrhea. -Elevated LFT results -hepatotoxicity GENITO -Dark urine -urinary retention -urinary incontinence -priapism -UTI -urinary frequency. HEMATO -Hemolytic and nonhemolytic anemia -thrombocytopenia -leukopenia

GENERIC: Liver silymarin BRAND NAME: Carsil 1 tab TID aftermeals through NGT

Supplement. The anti-hepatotoxic effect of Silymarin is associated with the competitive interaction with the receptors of the relevant toxins in the hepatocyte membrane, and with a more general action of protective nature (Vogel 1975). The biflavonoids are assumed to possess a vitamin-C-sparing effect. They have an anti-inflammatory action and improve

-hepatic injury due to DM

-agranulocytosis.. HYPERSENSITIVITY -Angioedema -bullous lesions (including pemphiguslike reactions) -pruritus -urticaria. MUSCULO -Back pain -muscle cramps -shoulder pain. RESPI -Dyspnea -upper respiratory tract infection. GENERAL -Flushing -chest pain -increased sweating -dark sweat GI -Occasional laxative effects -Abdominal bloating -diarrhea -flatulence -loss of appetite -anorexia -nausea -stomach upset.

-Hypersensitivity -pregnancy -lactation

-monitor for adverse reaction -monitor liver function

GENERIC: Isosorbide Mononitrate BRAND NAME: Cardismo 60g/tab tab q HS

the synthesis of proteins and glycoproteins, as well as the peroxidation of lipids in the liver. Clinically, the above effects are translated into improved signs and symptoms, and lowered values of the transaminases, g-globulines and blood bilirubin. Organic nitrites. Similar to other nitrites and organic nitrates, Isosorbide Mononitrate is converted to nitric oxide (NO), an active intermediate compound which activates the enzyme guanylate cyclase (Atrial natriuretic peptide receptor A). This stimulates the synthesis of cyclic guanosine 3',5'monophosphate (cGMP) which then activates a series of protein kinasedependent phosphorylations in the smooth muscle cells, eventually

-angina pectoris

CNS -Throbbing headache -dizziness -postural hypotension SKIN Flushing CARDIO -tachycardia (but paradoxical bradycardia has occurred).

CARDIO -Hypotensive conditions -hypovolaemia -hypertrophic obstructive cardiomyopathy -aortic stenosis -cardiac tamponade -constrictive pericarditis -mitral stenosis HEMATO -marked anaemia CNS -head trauma -cerebral Haemorrhage EENT -closed-angle glaucoma

-Headache may be a marker for drug activity; do not try to avoid by altering treatment schedule; aspirin or acetaminophen may be used for relief -Dissolve SL tablets under tongue; do not crush, chew, or swallow -Do not crush chewable tablets before administering -Avoid alcohol -Make changes in position slowly to prevent fainting

resulting in the dephosphorylation of the myosin light chain of the smooth muscle fiber. The subsequent release of calcium ions results in the relaxation of the smooth muscle cells and vasodilation.

NURSING CARE PLAN

ASSESSMENT
SUBJECTIVE: S.O. states: Bed ridden na kasi siya sa bahay pa lang. Tapos nagkaroon ng bed sore at yung bedsore niya yung dahilan ng pagkaospital niya. Nadulas kasi siya sa banyo last year, tapos naoperahan. Simula noon hindi na siya nakakalakad. S.O said that she has history of CVA and diagnosed of Parkinsons disease and Diabetes Mellitus OBJECTIVE: Generalized body weakness especially on Left side Unable to move extremities Motor response: (+) flexion of extremities = 3/5 Patient cant move in bed independently VS: BP:150/80 mmHg PR:98 bpm RR:25 cpm Temp:36.2C (+) wound at lumbosacral area approximately 2.5 wide and 1 deep at the center (+) wound at left heel approximately 1 wide (+) blood tinge on wound dressing (+) foul odor from the wound Decrease Hgb level: 95 g/L Decrease Hct level: .29 CBG: 321 g/dL Post BT of 1 u PRBC and S/F 2 u PRBC; Blood type: A+ Doctors order: For debridement once CP cleared

DIAGNOSI S
Impaired skin integrity related to decreased peripheral circulation secondary to prolonged bed rest as evidenced by wound at sacral area approximately 2.5 wide and 1 deep at the center and wound at left ankle approximately 1 wide

PLANNING
GOAL: After 3 m0nths of nursing intervention, the client will be able to display timely healing of bed sore. After 4 days of nursing intervention: 1. The client will be able to prevent recurrence of new bed sore. 2. The client will be able to display improvement in the healing of her wound. OBJECTIVES: After 8 hours of nursing intervention: 1. The client will maintain skin integrity of other body parts. 2. The significant other will be able to identify at least 3 ways how to prevent recurrence of bed sore and prevent infection.

INTERVENTION
INDEPENDENT: Monitor VS especially Temp and assess wound for any signs of infection. Assess other body parts to determine any new occurrence of bed sore. Measure size of wound daily to determine if the wound is worsening. Perform wound care and change dressing accordingly. Perform/Teach S.O about the following: Turn patient side to side q 2 Put pillows on areas of high pressure Change linens/diapers/clothing accordingly. Maintain skin dry and free from moisture. Provide passive ROM Encourage use of egg mattress COLLABORATIVE: Review CBC result and CBG and facilitate BT: 2 u PRBC properly typed and cross matched. Follow up/assist in wound debridement. Give medications as prescribed by physician.

EVALUATION
After 8 hours of nursing intervention: 1. The client had the following VS: BP: 160/80 mmHg PR: 80 bpm RR: 21 cpm Temp: 36.8 C CBG: 235 g/dL 2. The client maintained skin integrity of other body parts. 3. The significant other was able to identify at least 3 ways how to prevent recurrence of bed sore and prevent infection. After 4 days of nursing intervention: 1. The client was able to prevent recurrence of new bed sore. 2. The client was able to display improvement in the healing of her wound: Wound at sacral area approximately 2.5 wide and 1 deep at the center Wound at left ankle approximately .5 wide

ASSESSMENT SUBJECTIVE: S.O said that she has history of CVA last 2010 and diagnosed of Parkinsons disease and history of hip dislocation S.O. states: Simula nung nadulas siya at naoperahan hindi na siya nakakapaglakad, wala siyang saklay pero may wheelchair siya sa bahay. OBJECTIVE: Generalized body weakness especially on Left side Unable to move and decortication of extremities (+) hand tremors Muscle rigidity Client is fully dependent on S.O and does not participate in activities Observed assistance from significant other while doing ADLs. Feeding: 4 Bathing: 4 Bed mobility: 4 Dressing: 4 Grooming: 4 General mobility: 4 (+) wound at sacral area approximately 2.5 wide and 1 deep at the center (+) wound at left heel approximately 1 wide

DIAGNOSIS Impaired physical mobility (Level IV) related to generalized body weakness especially on left side and history of hip dislocation

PLANNING GOAL: After 2 m0nths of nursing intervention, the client will be able to resume her activities of daily living prior to admission. After 4 days of nursing intervention, the client will be able to at least increase strength of her extremities. OBJECTIVES: After 8 hours of nursing intervention: 1. The client and S.O will be able demonstrate techniques that enable resumption of activities and prevention of injury. 2. The client will be able to maintain position and function of skin integrity of other body parts and prevent worsening of bed sore.

INTERVENTION INDEPENDENT: Measure size of wound daily to determine if the wound is worsening. Assess other body parts to determine any new occurrence of bed sore. Support body parts with high risk of developing bed sores with pillows. Provide and teach client about safety measures such as keeping the side rails raised. Assist client in activities of daily living such as in feeding and bathing. Provide passive ROM.

EVALUATION After 8 hours of nursing intervention: 1. The client and S.O will be able demonstrate techniques that enable resumption of activities and prevention of injury. 2. The client will be able to maintain position and function of skin integrity of other body parts and prevent worsening of bed sore. After 4 days of nursing intervention, the client was able to at least increase strength of her extremities.

Provide wound care, change dressing and turn side to side q 2. COLLABORATIVE: Encourage client to continue consultation with physical therapist. Give medications as prescribed by physician.

ASSESSMENT
SUBJECTIVE: S.O states: Mamaya pwede bang linisan natin ung loob ng bibig kasi parang may puti puti na yung loob ng bibig. OBJECTIVE: On NPO since admitted (4/27/11) With NGT at right nostril with 1,600 kcal of Nutren into 6 equal feeding Patient unable to speak (+) Dry lips (+) Cracking lips (+) Desquamation of lips (+) white curd like exudate Coated tongue (+) tartar on teeth Yellowish teeth

DIAGNOSIS
Impaired oral mucus membrane related to prolonged NPO more than 24 hours

PLANNING
GOAL: After 4 days of nursing intervention, the client will be able to restore and maintain integrity of oral mucosa. OBJECTIVES: After 8 hours of nursing intervention: 1. The client will be able to demonstrate a decrease in symptoms noted in defining characteristics. 2. The S.O will be able to identify at least one specific intervention to promote healthy oral mucosa.

INTERVENTION
INDEPENDENT: Routinely inspect oral cavity and throat for inflammation. Provide routinely mouth care. Lubricate lips and provide commercially prepared oral lubricant solution. Wet lips as necessary to decrease thirst and prevent dry and cracking lips. Provide gum massage and assist S.O in tongue brushing with cotton tip applicators. Teach significant other about proper oral hygiene to client.

EVALUATION
After 8 hours of nursing intervention: 1. The client had the following: Dryness, cracking of lips and desquamation was lessened White curd like exudate was lessened Tartar on teeth was lessened 2. The S.O will be able to identify at least one specific intervention to promote healthy oral mucosa.

ASSESSMENT
SUBJECTIVE: S.O states: Tignan mo yung kamay niya nurse, ok lang ba na parang namumutla yan tsaka malamig kasi. S.O said she was dignosed of DM OBJECTIVE: LOC: Obtunded (opens eye to loud voice and seems unaware of the environment. Unable to speak GCS: 8/15 (E:4;V:1;M:3) VS: BP:150/80 mmHg PR:98 bpm RR:52 cpm Temp:36.2C With O2 inhalation via NC @ 4lpm (+) weakness of extremities Capillary refill >2 seconds Weak pulses Cold clammy skin ER O2 sat: 90% Pale hands and feet (+) wound at sacral area approximately 2.5 wide and 1 deep at the center (+) wound at left heel approximately 1 wide Decrease Hgb level: 95 g/L Decrease Hct level: .29 CBG: 321 g/dL Increase BUN 8.1 mmol/L ABO typing: A+ Post BT of 1 u PRBC S/F 2 u of PRBC

DIAGNOSI S
Ineffective tissue perfusion related to decrease hemoglobin concentration in blood

PLANNING
GOAL: After 4 days of nursing intervention, the client will be able to improve or increase tissue perfusion as evidenced by improvement in the defining characteristics. OBJECTIVES: After 8 hours of nursing intervention: 1. The client will be able to demonstrate with assistance behaviors that help improve circulation. 2. The S.O will be able to participate in the plan of care to improve patients body circulation.

INTERVENTION
INDEPENDENT: Monitor VS for baseline data. Assess for mental status, perform NVS as necessary. Monitor O2 saturation and capillary refill. Maintain O2 inhalation via NC at 4 lpm. Provide passive ROM. Turn patient side to side every 2 hours.
COLLABORATIVE: Encourage client to continue consultation with physical therapist. Facilitate 2 u of PRBC properly typed and cross matched when blood is available. Facilitate repeat CBC as ordered by physician. Give medications as prescribed by physician.

EVALUATION
After 8 hours of nursing intervention: 1. The client had the following: BP: 160/80 mmHg PR: 80 bpm RR: 21 cpm Temp: 36.8 C CBG: 235 g/dL Capillary refill > 2 secs 2. The client was able to demonstrate with assistance behaviors that help improve circulation. 3. The S.O was able to participate in the plan of care to improve patients body circulation. After 4 days of nursing intervention, the client was able to improve or increase tissue perfusion as evidenced by:

ASSESSMENT
SUBJECTIVE: S.O states: Sabe ni Dr. Marquez, lalagyan daw ng butas dito sa may stomach kasi daw baka mapunta yung gatas sa baga niya. Pero hindi kami papayag kasi mahirap ng butasan pa uli, baka lalong lumala. Yung sugat nga sa likod di gumaling galing tapos dadagdagan pa. OBJECTIVE: On NPO since admitted (4/27/11) With NGT at right nostril with 1,600 kcal of Nutren into 6 equal feeding Decreased cough and gag reflex Impaired swallowing Unable to move in bed independently Unable to move extremities (+) crackles

DIAGNOSIS
Risk for aspiration related to NGT insertion

PLANNING
GOAL: After 4 days of nursing intervention, the client will be able to prevent aspiration. OBJECTIVES: After 8 hours of nursing intervention: 1.The S.O will be able to identify at least 1 way how to prevent aspiration. 2.The client will be able to maintain placement of NGT tubing.

INTERVENTI ON
INDEPENDENT: Assess for abdominal distention. Check placement of tube prior to feeding. Elevate head of the bed at least 30 prior to feeding. Maintain head of the bed elevated at least 30 minutes after feeding. Note for stomach residual. If > 100 mL do not feed the client. Maintain patient on NPO. Always assess fullness when feeding, do not continue feeding if not tolerated by patient.

EVALUATION
After 4 days of nursing intervention, the client will be able to prevent aspiration as evidence by: After 8 hours of nursing intervention: 1. The S.O was able to identify at least 1 way how to prevent aspiration. 2. The client was able to maintain placement of NGT tubing.

CLINICAL PATHWAY
Patients Name: Marcelo, Potenciana Diagnosis: t/c Sepsis secondary to Decubitus Ulcer, DM Type II, HCVD in failure Admission Date: April 28, 2011

04/28/11 1st day ASSESSMENT Emergency Room (3:45am) Vital signs: oBP 90/60mmHg o Temp. 36.70c oPR 105bpm oRR 20cpm GCS 10 (E-4 V-1 M-5) O2 saturation 90% (+) Body malaise Lethargic Unresponsive with blank stare Anicteric sclera but slightly pale palpebra Inability to speak Tachycardic (+) Crackles at left base lung (+) ulcer on sacral area oGrade 2-3 (+) Bipedal edema Shy pulse, CRT: >2secs LABORATORY PROCEDURES Emergency Room For the following laboratory studies: CXR-PA Lumbo-Sacral X-Ray CBC with PC , PT, APTT Na, K, Crea ABO typing Trop I UA Blood GS/CS NOTE: CXR-PA (not done) Lumbo-Sacral X-Ray (not done) CBC with PC, PT, APTT o Hemoglobin 95g/L (low) o Hematocrit 0.29 g/L(low) o Platelet 372 x 10g/L(normal) o WBC 26.8 x 10g/L (high) o Neutrophils 0.98 g/L(high) o Lymphocytes 0.02 g/L(low) o PT 11.4secs(normal)

04/29/11 2nd day Phil Health Ward (FMW) Vital Signs o BP 110/60mmHg o RR 23cpm o PR 100bpm o Temp 37.90c GCS 11 (E-4,V-1,M-6) Awake Lethargic Generalized weakness With ongoing D5W 500cc x 16 @ left hand (250cc level) With O2 via nasal cannula at 4 lpm Febrile (-) DOB

04/30/11 3rdday Phil Health Ward (FMW) Vital Signs o BP 120/80mmHg o RR 23cpm o PR 89bpm o Temp 37.30c GCS 9 (E-4,V-1,M-4) 8:00am GCS 8 (E-4,V-1,M-3) 12:00n CBG 221mg/dL (6:00am) CBG 385mg/dL (12:00n) Lethargic Awake Generalized weakness With ongoing D5W 500cc x 16 @ left hand (350cc level) With O2 via nasal cannula at 4 lpm (-) DOB (+) difficulty in swallowing and unable to eat

Phil Health Ward (FMW) For the following laboratory studies: HBA1C Lipid profile 2D echo with doppler Still for the following laboratory studies: CXR-PA Lumbo-Sacral X-Ray UA Blood GS/CS NOTE: Lipid profile o Glucose 3.62 mmol/L (normal) o Urea 8.1 mmol/L (high) o Creatinine 91 mmol/L (normal) o Cholesterol 2.5 mmol/L (normal) o Triglycerides 2.57 mmol/L (high) o HDL 0.3 mmol/L (low)

Phil Health Ward (FMW) Still for the following laboratory studies: CXR-PA Lumbo-Sacral X-Ray UA Blood GS/CS HBA1C 2D echo with Doppler Variance Financial Problem Unavailability within hospital facility

05/04/11 7th day ASSESSMENT Phil Health Ward (FMW) Vital Signs o BP 130/80mmHg o RR 22cpm o PR 85bpm o Temp 37.80c GCS 8 (E-4,V-1,M-3) Lethargic, Awake Blank stare Febrile CBG 356 mg/dL(6am) With ongoing D5W 500cc x 16 @ left hand (150cc level) Hooked to O2 via nasal cannula at 4 lpm (-) DOB (+) Crackles (+) LBM (yellow brown watery stools, 5x BM) Phil Health Ward Still for the following laboratory studies: CXR-PA (for results) UA (for results) 2D echo with Doppler (done and for results) Lumbo-Sacral X-Ray For the following laboratory study: Fecalysis Variance Financial Problem Unavailability within hospital facility MEDICATIONS Phil Health Ward (FSXW) Continue medications ordered: Amlodipine 10mg OD Metronidazole500mg TIV q 8 Ampi-Sulbactam 750mg TIV q 8 Ranitidine 50mg TIV q 8 Clopidogrel 75mg/tab 1 tab OD Lactulose 30cc q HS Sinemet 1tab OD ISMN 60mg tab q HS O2 4 lpm via nasal cannula

05/05/11 8th day Phil Health Ward (FMW) Vital Signs o BP 140/70mmHg o RR 22cpm o PR 82bpm o Temp 37.40c GCS 8 (E-4,V-1,M-3) Lethargic, Awake Blank stare CBG 359 mg/dL(6am) With ongoing D5W 500cc x 16 @ left hand (250cc level) Hooked to O2 via nasal cannula at 4 lpm (-) DOB (+) Crackles

LABORATORY PROCEDURES

Phil Health Ward Still for the following laboratory studies: CXR-PA (for results) UA (for results) 2D echo with Doppler (for results) Fecalysis (for results) Lumbo-Sacral X-Ray Variance Financial Problem Unavailability within hospital facility

Phil Health Ward (FSXW) Continue medications ordered: Amlodipine 5mg OD Metronidazole500mg TIV q 8 Ampi-Sulbactam 750mg TIV q 8 Ranitidine 50mg TIV q 8 Clopidogrel 75mg/tab 1 tab OD Lactulose 30cc per orem OD Sinemet 1tab OD ISMN 60mg tab q HS O2 4 lpm via nasal cannula