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Aging Ward
Created By :
Maryudela Afrida
Nursing Departement
2013
Nursing Assesment
1. Identity
Name : Mr. W
Ward : Adult Ward
Age : 37 yr.
Sex : Male
Medical Diagnose : Status Epileptikus
Assesment Date : 13 November 2013
2. Chief Complain
The patient unconscious, get intubation with bird ventilator. Patient cannot eat
because the ventilation.
3. Health History
a. Past History
The patient was alcohol drinkers since 10 years ago. He has smoking history.
b. Recent History
The patient has been shocked 2 hours before enter the hospital. He has been
brought to the Ubonlart Hospital, but he referred to the Khon Kaen Hospital.
When he canme to the Khon Kaen Hospital, he was unconciuss, and difficult to
breath.
4. Physical Examination
a. Head
No Hematom, ananemis conjunctiva, unicteric sclera, the hair is wet caused by
evaporation, there was no secret in the nose, mucous membran was pink. There is
an oropharingeal and endotracheal tube in his mouth, it was dirty. There is a little
secret in the mouth.
b. Neck
Nothing enlargement of the tyroid gland and lymph.
c. Lung
Inspection : there was sternum depression, and aditional respiration
muscle.
Percution : dullness
Auscultation : crepitation, wheezing, and ronchi.
d. Heart
Inspection : ictus cordis is not seen.
Percution : dullness
Auscultation : s1-s2 regular.
e. Abdomen
Inspection : Abdomen is flat, nothing tenderness.
Auscultation : 8 x/mnt.
Percution : tymphani.
f. Ekstermity
Upper : motoric scale is 6, sometime it was agitation, no pitting
edema.
Lower : motoric scale is 6, sometime it was agitation, no pitting
edema.
5. Laboratory Test
WBC GROUP
Netrofil 94,4 88 % 43,7-70,9 High
Limfosit 2,5 6,6 % 20,1-44,5 Low
Eosinofil 0 0 % 0,7-9,2 Low
Blood Chemistry
BUN 30 mg/dL 6 - 20 High
Cr 2,42 mg/dL 0,70-1,20 High
Albumin 3,4 g/dL 3,5-5,2 Low
Co2 19,5 mMol/L 22,0-29,0 Low
Calsium 6,7 mg/dL 8,6 - 10,2 Low
Fosfor 2,5 mg/dL 2,7-4,5 Low
Blood Gas
pCO2 29,7 mmHg 35-45 low
PO2 401,3 mmHg 83-108 high
TCO2 20,5 mMol/L 21-32 low
Hct 34 % 40-54 low
PATOFISIOLOGY OF STATUS EPILEPTICUS
Potential to sepsis
due to pneumonia
Potential to O2
O2 inhale
Conscious changed impairment due to
decrease
ineffective respiration
from seizure
Immobility
Potential to O2
O2 ET & Ventilator (Bird) impairment due to
impairment ineffective respiration
from seizure
patent restlessness,
times confusion,
Identifies significant
airway present.
clearance. 4. Auscultate
No Breath Sound.
Cyanosis. 5. Monitor
respiratory
Good
patterns,
Conscious.
including rate,
depth, and effort.
6. Monitor blood
gas values and
pulse oxygen
saturation levels
as available.
7. Assist with
clearing
secretions from
pharynx by
suction of the
oral pharynx if
necessary.
8. Provide oral care
every 4 hours.
9. Administer
oxygen as
ordered.
3. Cannot eat due to Client Outcomes 1. Determine Risk for imbalanced
Patient receiving
ET. healthy body nutrition problem
food
Data : appropriately weight for age resolved with NGT
and prevention
Patient used ET of nutritional and height. feeding.
and ventilator. status changed 2. Assess client's Patient get feeding
evidenced by :
The patient ability to obtain from NGT 300 ml
cannot eat Patient and use essential and 100 ml water.
received
byself. feedding as
nutrients. Patient given
docter 3. Give the intravenous therapy :
perscreption
aditional D5%
(300ml x ...)
Weight, nutrition by
BMI, MAC
orogastric tube.
(Mid Arm
Circle), TSF 4. Evaluate client's
is within
laboratory
normal
range. studies (serum
Free of signs
albumin, serum
of
malnutrition total protein,
serum ferritin,
transferrin,
hemoglobin,
hematocrit,
vitamins, and
minerals).
5. Consult with
dietitian for
actual calorie
count.
4. Potential to Client Outcomes 1. Reposition the pt Risk for Impaired
The skin
pressure ulcer due at least once skin integrity
integrity is good
to immobility evidenced by : every two hours. problem solved
Data : 2. Keep the skin partially with
No Wound
patient got clean and dry. reposition patient
Regains
bedrest at long 3. Monitor skin regularly
integrity of
time. condition at least
skin surface
once a day for
Pt’s skin has
color or texture
no signs of
changes,
worsening or
dermatological
advanced
conditions, or
impairment.
lesions.
5. Can’t do ADL Patient 1. Assess patient's In this case, patient
(bathing/hygiene, Outcomes need for cannot capable to
toileting, and The patient’s assistive compliance ADL
dressing) related to self care being devices. with own self but
immobilization. done by assisted 2. Assist patient in this problem has
Data : the nurse accepting been solved with
Patient got evidenced by : necessary assistance from nurse
bedrest at long The mouth is amount of and family to
time. clean, dependence. implement ADL
Patient can’t mucose 3. Provide privacy
take a bath, membran is during dressing.
toileting, and moist. 4. Provide
dressing by him The skin is frequent
self. clean, and assistance as
the integrity needed with
is good. dressing.
5. Maintain
privacy during
bathing as
appropriate.
6. Assist patient in
removing or
replacing
necessary
clothing and
assist patient to
getting bath.
7. Give the patient
pampers to
assist the
toileting.
8. Do the mouth
care periodicly.
SUMMARIZE
The family ask permission to the docter, to bring the patient go home. The family kept
the Thai culture that every people in their family should die in the home. The family bring the
patient go back to the home at 13 November 2013 night.