Medical Surgical Case Study I

Medical Surgical Case Study
I. Objectives

A. Knowledge:

1. Identify the main problem based on data gathered.
2. Distinguish the problem as acute or chronic.
3. Analyze the patient’s condition according to it’s signs and symptoms.
B. Skills:
1. Assess the common signs and symptoms of the main problem.
2. Formulate a pathophysiology that correlates to the main problem identified.
3. Formulate an efficient Problem list, Nursing Care Plan and Discharge plan according to data gather.
C. Attitude:
1. Observe confidentiality while interacting with the patient’s family.
2. Gain trust among the people involved.
3. Show attentiveness while dealing with the family and the patient.
II. General Data
Name : M. E.
Address : Central Ma­ao
Age : 74 y.o.
Status : Married
Educational Status : Undergraduate
Occupation : Chief Transportation Officer
III. Assessment
A. Nursing Assessment

1. General Description of the Client
When we first enter the room, the foggy surrounding took our attention. Patient M.E. was lying on bed, semi­conscious. Patient M.E. has IVF bottle attached to his left metacarpal vein, oxygen tank in his left side, Foley Catheter at his right side below his bed, and pulse oximeter on his left index finger. Patient M.E. was so weak, ill and half of his body cannot move due to his condition. We were wondering what could be his illness since it was our first time to encounter that kind of condition and he had a tracheotomy tube. We felt pity but we nurses know our limitations. The important thing is that we care and help ill people.
2. Significant Assessment
Physical Assessment
Normal Findings Deviation from Normal Skin ­Skin color is uniform within normal range
­Skin return to its natural shape after being tented between thumb & fingers. ­Skin temp. is not normal
­Presence of scars
­Dry skin Hair ­Dry & oily hair
­Not evenly distributed hair
­Presence of dandruffs infestation Head (scalp & face) ­Rounded; smooth skull contour
­Absence of masses & nodules ­Sunken fontanel Eye & Vision ­Both eye is coordinated
­Right eye reacts to light
­Pupil are equal & round ­Sunken eyeball
­Red eyes
­Cloudy iris
­Left eye is not reactive to light
Nose -Normal symmetry -Mucosa is dark
-Presence of blackhead at nostrils Ears -Color same as facial skin, mobile, firm not tender -Localized areas of redness Mouth -Presence of mouth sores and lesions
-Dental stains Neck -Absence of Acanthosis Nigrecans -Presence of palpable lymph nodes
-Uncoordinated and presence of discomfort if its move
-Presence of tracheotomy tube at the neck Thorax & Lungs -Normal breathing upon inspection and auscultation Abdomen -Normal skin integrity Breast & Axillae -Skin is intact -Presence of freckles (black and red) Upper Extremities -Has normal contour of the right shoulder, elbow and wrist -Paralysis at the left shoulder, elbow and wrist Fingernails -capillary refill < right fingernails
-Highly vascular pink in color -Presence of white spot at the nails
-Fingernails untrimmed
-Capillary refill > left fingernails Lower Extremities (hip, thigh, legs) -No deformities -Toenails untrimmed
3. Nursing History (Gordon’s Assessment)
A. Health Perception- Health Management Pattern
Merely as we review with his medical history and diagnostic test, his recent status doesn’t have any deviation at all. But then his suffered common colds for years as time passed everything seems to be going smoothly as he recovers from colds. M.E son verbalized “gina kataru na sa kung kis.a pero du ka ok man sa iya.” M.E has been smoking for several years and stop for 10 years.
B. Nutritional-Metabolic Pattern
Since M.E is on NGT feeding, the normal daily intake and typical fluid is not being measured properly, since he depend on OTF formula in sustaining its nutritional status. M.E losses weight for the food that it is introduced to him not somehow ideal. With regards to his eating pattern, there’s no claimed. It is because M.E’s NGT placement is always check before during NGT feeding. But then M.E’s has lesions on the mouth and this lesion doesn’t heal for about 4 days of rendering care to him. And most of all M.E experiencing signs of dehydration thus having mouth sores and dryness of skin. M.E is having dental caries and stains.
C. Elimination Pattern
Most often M.E’s bowel elimination pattern is normal, characterized by a soft, brownish stool, he defecate every morning but then considering the facts, that M.E is semi-conscious thus he doesn’t given BP. That’s why he always wear diaper if in case he defecate. And with his urinary elimination pattern, M.E doesn’t have problem at all. It because its hourly urine output is within the normal range, its urine is characterized as an amber colored urine.
Feeding: III Grooming: III Bathing: II General Mobility: III Toileting: III Cooking: IV Bed Mobility: III Home Maintenance: IV Dressing: III Shopping: IV
D. Sleep- Rest Pattern
M.E encounters problems on sleeping, one of which is insomnia. In which M.E’s son verbalized “Kun kis.a gakakibot ko na sa iya kay mga tunga2 sang kagabehun gakabugtaw nasa.” But then, M.E’s son advised M.E not to drink carbonated drinks such as coke, sprite, and royal, and should limit sleeping in the morning.
E. Cognitive- Perceptual Pattern
Aging is the most influential factor that affects most of the sense of M.E, thus no wonder that both hearing and vision are affected, making its functions becomes deteriorated. Sometimes M.E is having a short term memory thus enabling him to be forgetful. M.E’s daughter says that “kun di sa gani kapadumdum ginaremind gina sa permi para di malipat bla haw! And if there’s pain or any discomfort occurred M.E stick to herbal remedies for he believed that there’s no side effects.
F. Self-Perceptual-Self-Concept Pattern
Since the cognitive status of M.E is not yet ready to accommodate everything. But he gather some data from his sibling. Patient M.E was a responsible father. He works overtime to sustain his family. Since his youngest child is still studying. According to his wife he stopped smoking and drinking 10yrs ago.
G. Role-Relationship Pattern
M.E. lives with his family. They consider it as an extended family. There family composed of 8 children, his wife, together with the family of his children. M.E. together with his wife talks and settle their problems ahead of time. All of the family needs are all dependent on him. All of the family members felt frustrated about what happened to their father and they felt much pity because they can see what their father struggle in order to live.

B. Medical

1. Medical History
3days Pt’s complained of numbness of left upper and lower extremities which later noted to weak and unable to walk. He was then brought to local hospital and admitted. 1day PTA, he was noted to be drowsy DDA, progression decrease in sensory and later unresponsive, prompted to transfer to TDH.
History: (+) HPN x 2yrs-no maintenance meds
(-) DM (-) BA (-) FDA
Alcoholic drinker, previously smoker
2. Admitting Diagnosis/ Initial Impression
CVD right MCA problem bleed
Sepsis secondary to aspiration pneumonia
3. Laboratory/ Diagnostic Examination
Laboratory Test and Diagnostic Examination findings were taken every day by a medical technologist on duty. The results show different changes each day. The given below are abnormal findings from different test being recorded at the patient’s chart:

Date: July 08, 2010
ABG Results

Exam Result Normal Values pH 7.54 7.35 – 7.45 pCO2 29.6 35 – 45 mmHg B.E. 3.5 + – 2
Date: July 09, 2010
ABG Results

Exam Result Normal Values pH 7.50 7.35 – 7.45 pCO2 32.1 35 – 45 mmHg pO2 66 80 – 100 % B.E. 2.4 + – 2 Date: July 10, 2010
ABG Results

Exam Result Normal Values pH 7.43 7.35 – 7.45 pCO2 41.8 35 – 45 mmHg pO2 67 80 – 100 % B.E. 3 + – 2 Fio2 40% T-Piece HCO3 27.8 22 – 26
Date: July 11, 2010
K and Na Test

Test Result Reference Values Na 143.0 135.00 – 148.00 mg/dl K 4.70 3.50 – 5.30 meq/L
IV. Discharge Plan
Problem Level of Care Action Plan/ Healthcare Diet:
-Soft diet via NGT as ordered.

-Instruct the family to perform Range of Motion exercises.

-Encourage the family to let the patient to have proper personal hygiene, such as oral hygiene and regular bed bath.



DOSAGE: 0.025% 500mcg/vial

-Follow up Check up as scheduled by the physician.
Body Weakness Promotive


Rehabilitative – Instruct the family not to continue transferring the patient from one place to the other if they notice some facial grimace coming from the patient.

-Instruct the family to perform tracheostomy care to prevent further infections.
-Instruct the family to continue the medicines for healing and recovery of the patient.
-Instruct the family to let the patient begin therapy, once able, through the help of a physical therapist, to return to normal state and resume his normal activities.
V. Evaluation

After 4 days of exposure at The Doctor’s Hospital, we were able to meet with the objectives and goals of our study. The patient is semi-conscious until now and is ready for discharge if their family can have all the equipments and apparatus needed so that they could continue sustaining their father’s needs in prolonging life.

VI. Bibliography

Public Health Nursing in the Philippine, pp.187-188
Public Health Nursing in the Philippine, pp.277-278
Nursing Care Plan by: Marilynn Doenges and Alice Murr, pp 238-240
Medical Surgical Nursing by: Workman, pp. 1028-1030
Theoretical Foundations of Nursing: The Philippine Perspective by: Octaviano
and Balita, pp.132

Colegio San Agustin- Bacolod
College of Nursing
Medical- Surgical Case Study

Submitted to:
Ms. Sheila Bariso, RN, MN
Clinical Instructor

Submitted by:
Group 29 / N3H
Aguilar, John Romulo
Bacomo, Darwin
Galimba, James Bryan
Abad, Flordelyn
Acuyong, Mary Faith
Augusto, April Rose
Baquiran, Paula Marie
Birondo, Katherine
Daquel, Sunshine
Delatado, Omega Kristal

July 19, 2010