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Nursing Case Study Admission/ Final Diagnosis I. Health History A. DEMOGRAPHICAL DATA Clients Initials: Gender: Age: 80 Female D. G. B
Religion: Iglesia ni Cristo Occupation: Self - employed Usual Source of Medical Care: Hospital Date of Admission: June 18, 2011 Initial Diagnosis: T/C AMI, DM Type 2
B. SOURCE AND RELIABILITY OF INFORMATION Information that was obtained came from the patient's chart. The patient at the time was unconscious and unable to speak.
C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS Chest Pain Difficulty in breathing Infection
D.HISTORY OF PRESENT ILLNESS/ OR PRESENT HEALTH The patient was admitted on June 18, 2011. The initial diagnosis of the patient was Acute Myocardial Infarction, DM Type 2. The patient was
E. DEVELOPMENTAL HISTORY
SYSTEM
REVIEW OF SYSTEM
No verbal cues
Unconscious Cyanotic
Weakness Fatigue
Unconsciousnes s: Inadequate cerebral perfusion and cardiogenic shock Cyanosis: Inadequate oxygenated blood circulation
No verbal cues
J. Respiratory
No verbal cues
(+) Gasping
Shortness of Breath
No verbal cues
Heartburn
No verbal cues No verbal cues No verbal cues No verbal cues (+) Edema (+) Infected wound (Left Musculoskeletal Arm pain (Commonly on left Edema: Fluid retention in the body
R. Endocrine
No verbal cues
(+) DM Type 2
Implications Procedur e Chest Xray Procedure Date 6/23,25/1 1 7/3/11 Indication Normal Values Actual Findings/ Results Further Progression in Pulmonary Edema with possible underlying pneumonia. Evidence of consolidation on the left upper lobe, subcutaneaus emphysema as ABNORMAL
A projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are among the most common
The lungs look normal in size and shape, and the lung tissue looks normal. No growths or other masses can be seen within the lungs. The pleural spaces (the spaces
seen with the tracheostomy tube in place. Heart is enlarge in size, with left ventricular prominence.
ABG
7/5/11
CBC
7/3/11
ABNORMAL
RBC's ( x 106 /ml) - 4.0 4.9 WBC (cells/ml) 4,500 - 10,000 Basophils - 0 1 (0 - 0.75%) RBC = 2.97 Neutrophil = 82% Lymphocyte = 9%
Eosinophils - 0 Monocyte = 4% - 3 (1 - 3%) Lymphocytes 24 - 44 (25 33%) Monocytes - 3 - 6 (3 - 7%) Eosinophil = 4% Basophil = 1%
Urinalysis 7/2/11
An array of tests performed on urine and one of the most common methods of medical diagnosis. A part of a urinalysis can
Color - Pale yellow to amber Turbidity Clear to slightly hazy Specific Gravity -
ABNORMAL
1.015-1.025 pH - 4.5-8.0 be performed by using urinedipsticks, in which the test results can be read as color changes. Glucose Negative RBC Negative Albumin Negative Epithelial cells Negative or Rare
Date Taken
Actual Result
ANATOMY AND PHYSIOLOGY THE HEART Function and Location of the Heart The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest. Structure of the Heart The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point and about 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it to move as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle. Chambers of the Heart The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and a bottom chamber.
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Blood Flow of the Heart The heart is completely divided into a right and left halves. These 2 halves of the heart act as separate pumps, and there is no mixing of blood between them. Each is in charge of pumping blood through one of the two blood vessel circuits.
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The right heart pumps blood to the pulmonary circuit, where the blood picks up oxygen from the lungs. The left heart then pumps it into the systemic circuit, where the blood delivers oxygen to the tissues that need it. Finally, the blood returns to the right heart and the cycle repeats itself.
Blood always leave the heart through arteries, which include the aorta and pulmonary arteries. Conversely, blood enters the heart through the veins, the largest being the pulmonary veins the vena cava.
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MEDICAL SURGICAL MANAGEMENT 1. Procedure (Surgery) Procedure/ Date Tracheostomy / July 5 2011 Indication/ Analysis A tracheostomy is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube.
A tracheostomy is usually done for one of three reasons: (1) to bypass an obstructed upper airway (an object obstructing the upper airway will prevent oxygen from the mouth to reach the lungs); (2) to clean and remove secretions from the airway; and (3) to more easily, and usually more safely, deliver oxygen to the lungs. Need for further and more aggressive surgery Infection Air trapping in the surrounding tissues or chest. In rare situations, a chest tube may be required Scarring of the airway or erosion of the tube into the surrounding structures (rare). Need for a permanent tracheostomy. This is most likely the result of the disease process which made the a tracheostomy
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NURSING RESPONSIBILITIES Preparatory Nursing Measures. In addition to routine preparation of the patient unit for postoperative care, the following measures should be planned in advance. (1) The patient will require constant attendance for at least the first 48hours. The nursing personnel must remember two important things: the patient's life depends upon a clear airway and the patient will have a temporary loss of voice. Therefore, the patient must be observed closely for airway patency and immediate action taken when any adverse signs or symptoms are present. The patient wills feel anxious about his inability to communicate with his voice. Always have the call bell available to the patient. Devise a temporary means of communication such as writing notes or (2) For the first few days postoperatively, the patient should be kept in a room where the temperature and humidity can be maintained at optimum levels. Increased temperature and humidity will help to reduce the tracheal irritation that results when inspired air has bypassed the natural warming and moisturizing of the nasopharyngeal airway. (3) The patient's room should be supplied with a variety of equipment necessary to the care of the patient. Such things include suction equipment, a sparetracheostomy tube set, and
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An open wound or ulcer can not be properly evaluated until the dead tissue or foreign matter is removed. Wounds that contain necrotic and ischemic (low oxygen content) tissue take longer to close and heal. This is because necrotic tissue provides an ideal growth medium
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-Dizziness -Drowsiness
-Adjunct in the management of: Anxiety, Preoperative sedation, conscious sedation. -Provide light anesthesia and Anterograde amnesia. -Treatment of status epilepticus/ uncontrolled seizures. -Skeletal muscle relaxant. -Management of the symptoms of
-Lethargy -Hangover -Headache -Paradoxical Excitation -Blurred Vision -Respiratory Depression -Hypotension
-Monitor BP, PR, RR prior to periodically throughout therapy and frequently during IV therapy. - Assess IV site frequently during administration, diazepam may cause phlebitis and venous thrombosis. - Prolonged highdose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient. Observe depressed patients closely for suicidal tendencies. - Observe and record intensity, duration and location of seizure activity. The initial dose of diazepam offers seizure control for 15-20 min after administration.
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Alcohol withdrawal.
Omeprazole(LO SEC)
INDICATION:
-Dizziness -Drowsiness
Assessment: 1. History: Hypersensitivity to Omeprazole or any of its components; pregnancy, lactation 2. Physical: skin lesions; reflexes; urinary output; abdominal examination; respiratory auscultation
-Maintenance of healing erosive esophagitis. -Duodenal Ulcers. -Short-term treatment of active benign gastric ulcer. -Pathologic hyposecretor y condition, including zollingerellison
-Fatigue -Headache -Weakness -Chest pain -Abdominal Pain -Acid Regurgitation -Constipation -Diarrhea -Flatulence -Nausea and Vomiting.
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-Dizziness, -Encephalopathy INDICATION: -Headache -Insomnia -Nervousness -Hearing loss -Tinnitus -Hypotension -Constipation -Diarrhea Hypertension. -Dry mouth -Dyspepsia -Nausea and Vomiting.
Lasix(FUROSE MIDE)
Diuretics
Furosemide is a very potent medication. Using too much of this drug can lead to serious water and salt/mineral loss. Therefore, it is important that you are closely monitored by your doctor while taking this medication. Tell your doctor right away if you become very thirsty or confused, or develop muscle cramps/weakness.
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Common: -Nausea -Diarrhea -Vomiting INDICATION: Ciprofloxacin(CI PROBAY) -Rash Uncommon: -Anorexia -Headache -Dizziness -Fever -GI and Abdominal pain, -Flatulence -Confusion -Vertigo
GI Drug Laxative
Infections of the resp. tract, middle ear, paranas al sinuses, eyes, kidneys, urinary tract
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Imdur Tablets are indicated for the prevention of angina pectoris due to coronary artery disease. The onset of action of oral isosorbide mononitrate is not sufficiently rapid for this product to be useful in aborting an acute anginal episode.
Discontinued: Autonomic Nervous System Disorders: Dry mouth, hot flushes. Body as a Whole: Asthenia, back pain, chest pain, edema, fatigue, fever, flu-like symptoms, malaise, rigors. Cardiovascular Disorders, General: Cardiac failure, hypertension, hypotension. Central and Peripheral Nervous System Disorders: Dizziness, headache, hypoesthesia, migraine, neuritis, paresis, paresthesia, ptosis, tremor, vertigo. Gastrointestinal System Disorders: Abdominal pain, constipation, diarrhea, dyspepsia, flatulence, gastric ulcer, gastritis, glossitis, hemorrhagic gastric ulcer, hemorrhoids, loose stools, melena, nausea, vomiting. Hearing and Vestibular Disorders: Earache, For most patients, this can be accomplished by taking the dose on arising.
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-In disturbances of calcium metabolism, such as hypercalcae mia and hypercalciuria -Up to now no interactions with other drugs or foods are known.
Overdose -In renal insufficiency The toxicity of the product in large overdoses will be that of the liposoluble vitamin D. Prolonged daily intake of larger amounts can cause symptoms of chronic toxicity such as vomiting, headache, drowsiness and diarrhoea. Acute symptoms are only seen at even higher doses. taking is caused by the vitamin B2 content (natural color of vitamin B2). Such staining is absolutely harmless.
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ADVERSE REACTION: -Exfoliative skin disorders -Serious hepatic effects -Blood dyscrasias (eosinophilia, thrombocytopenia, anemia, leukopenia)
PATIENT
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