College of nursing

Submitted by: Homer D. Elegado BSN 3A Submitted to: Mrs. Emy Lyn Unson Clinical Instructor

PATIENT ASSESSMENT DATA BASE

A.

GENERAL DATA 1. Patients Name: R.S 2. Address: Philippines 3. Age: 21 y/o 4. Sex: Male . !irth date: Mar"h # $ 1##2 %. Ran& in the 'amily: Son (. Nationality: 'ilipino ). *i+il Stat,s: Single #. -ata o. Admission: /an,ary $ 2014 12:2(AM 10. 1rder o. Admission: PNSS 12 3 21gtts/min$ Se",re *onsent$ NP1 $ *!* $ 4A $ 56ray $ se",re "onsent. 11. Attending physi"ian: -r. 'a,stino CHIEF COMPLAINT 7ehi",lar A""ident. HISTORY OF PRESENT ILLNESS 7ehi",lar A""ident 1/4/14 #pm 3 Sta. 8gna"ia 9arla" PAST HEALTH HISTORY/STATUS 9he patient had "hi"&enpox and sore eyes d,ring his "hildhood days :,t he doesnt &no; ;hat imm,ni<ations ;ere gi+en to him. =e is not ta&ing any medi"ation and he has no &no;n allergies. FAMILY ASSESSMENT R>2A981NS=8P Mother Sister !rother 'ather A?> 4 2% 1% ) S>5 'emale 'emale Male Male 1**4PA981N =o,se;i.e Sales 2ady St,dent 'armer >-4*A981NA2 A99A8NM>N9 =igh s"hool ?rad,ate *ollege ?rad,ate *ollege 4nder ?rad,ate

B. C. D.

E.

NAM> 'S MS >S -S

F. SYSTEMS REVIEW 1.) HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN

 Clien !" Pe#$e% i&n &' He(l )* Patient per"ei+es health as @Nagaga;a &o lahat pag mala&as a&o.A Clien !" Pe#$e% i&n (+&, Illne""* 8n "ontrast to health$ she per"ei+es illness as @maraming gastos pag may sa&itA He(l ) M(in en(n$e (n- H(+i ": 8n maintaining his health$ he eats +egeta:les as ;ell as meats and do ho,se hold "hores that ser+es as his exer"ise to maintain his health. C&.%li(n$e /i ) %#e"$#i+e- .e-i$( i&n" (n- #e( .en * =e a"ti+ely parti"ipates/"ooperates ;ith his treatment and ta&es medi"ation on time. 2.) NUTRITIONAL METABOLIC PATTERN* 9he smell and appearan"e o. the .ood "an trigger the "lients appetite. =e eats 3 times a day ;ith 364",ps o. ri"e. =e drin&s 12 o. ;ater per day and he "ons,mes 1 glass o. B,i"e per day. 0.) ELIMINATION PATTERN -,ring his hospitali<ation$ the patient de.e"ates on"e a day. 1.) ACTIVITY2 E3ERCISE PATTERN- Sel. C "are a:ility 06 'eeding 06 -ressing 06 !athing 06 !ed mo:ility 0 6 ?rooming 06 9oileting 86 =ome maintenan"e 876*oo&ing DDDDDothers

2egend: 06 ',ll *are 86 ReE,ires ,se o. assistan"e 886 ReE,ires assistan"e and s,per+isions :y others 8886 ReE,ires assistan"e or s,per+isions .rom another and eE,ipment and de+i"es 87 C -ependent$ doesnt parti"ipate 4.) COGNITIVE PERCEPTUAL PATTERN 9he patient has no a:normalities in hearing and doesnt ,se eyeglasses ;hen reading. =e has normal sensory per"eption. 5.) SLEEP2 REST PATTERN -,ring his hospitali<ation$ he experien"ed sleeping pro:lems. 4s,ally$ he sleeps # ho,rs per day: ( ho,rs at night and 2 ho,rs o. nap d,ring the day. =e B,st listen to m,si" ,ntil he .alls sleep.

7.) SELF2 PERCEPTION AND SELF2 CONCEPT PATTERN 9he patient .eels disappointed and at the same time ;orried :e"a,se he doesnt &no; ;here to get money .or his hospitali<ation. 8n des"ri:ing his health he stated$ @natata&ot a&o pag andito a&o sa hospitalA. 6.)ROLE2 RELATIONSHIP PATTERN

 =e has great relationship ;ith his "hildren and signi.i"ant others. 7.) COPING2 STRESS TOLERANCE PATTERN 9he patient per"ei+es stress and pro:lems in li.e as @pahirap sa :,hayA. Fhene+er he has pro:lem$ he B,st drin& al"ohol and smo&e. 18.) VALUE2 BELIEF PATTERN =e is a Roman *atholi" and he :elie+es ha+ing .aith in ?od ;ill help ,s s,rpass all the trials or pro:lems in li.e. G. HEREDO2 FAMILIAL ILLNESS

M( e#n(l * N&ne

P( e#n(l * N&ne

P( ien * N&ne

H. DEVELOPMENTAL HISTORY 9heory Stage >ri" >ri"&sons theory 20 yrs old

-e+elopmental tas& >go integrity +s. -espair

-es"ription 1lder ad,lts play a role in "hildrearing today :e"a,se many o. them gi+e "hild"are to yo,ng "hildren ;hile parents ;or&. An older ad,lt ;ith integrity .eels good a:o,t the li.e "hoi"es he/she has madeG one ;ith a .eeling

o. despair ;ishes li.e ;o,ld :egin o+er again so that things "o,ld t,rn o,t di..erently. A sense o. integrity is help.,l in a grandparent ;ho does "hild"are$ as it helps "hildren de+elop a sense o. tr,st and learn initiati+e. 9heory 'o;lers theory Stage 4ni+ersali<ing ne+erI -e+elopmental tas& Spirit,al de+elopment -es"ription !e"oming an in"arnation o. the prin"iples o. lo+e and B,sti"e.

Hmay:e

I.

PHYSICAL ASSESSMENT A. Gene#(l S,#9e: !. 9he patient is "ons"io,s$ "oherent$ appears his stated age$ alert$ and oriented :,t ;ea& in appearan"e. C. Vi (l Si;n" &' )e D(: &' P):"i$(l E<(.in( i&n 9emperat,re: 3%. 0* Respiratory rate: 2% "pm P,lse rate: )2 :pm !lood press,re: 130/100 mm=g D. Re;i&n(l E<(. 1. =ead$ =air$ and 'a"e: =ead is symmetri"al to the :ody$ normo"ephali"$ hair e+enly distri:,ted$ a:sen"e o. s&,ll de.ormities$ a:sen"e o. li"eG .a"e is ro,nd in shape ;ith dry s&in. No masses$ no l,mps and no tenderness ,pon palpation. 2. >yes: 2e.t eyelid is la"erated. 3. Nose: Symmetri"al$ same "olor as the .a"e$ m,"osa is pin&ish in "olor$ no lesions$ de.ormities and in.lammation$ no tenderness on .rontal maxillary sin,ses$ no mass$ nasal str,"t,res are .irm and sta:le. Fith inta"t nasal "an,la. 4. >ars: Symmetri"al and proportion to .a"e$ "olor is same as the .a"e$ a,ri"le le+el are eE,al$ no lesions$ de.ormities and in.lammation. . Mo,th and 9hroat: 2ips are a:le to p,rse$ no lesions and ,l"eration. !,""al m,"osa is pin&ish. ?,ms are moist$ .irm. 9ong,e is at the "enter$ pin&ish in "olor$ no lesion and ,l"eration$ has the a:ility to mo+e ,p;ard $ do;n;ard and side to side. 9onsil is not in.lamed$ pin&ish in "olor. 4+,la is at the midline o. the so.t palateG in"omplete teeth ;ith good s;allo;ing re.lex. %. Ne"& and 2ymph nodes: Proportion to head$ presen"e o. "arotid p,lse$ no in.lamed "er+i"al lymph nodes$ no tenderness ,pon palpation$ and no mass noted. (. S&in: 9he s&in is .air in "omplexion$ dry$ ro,gh ;ith poor s&in t,rgor. ). Nails: 4ntidy nail tips$ nail :eds are not pale$ ",ti"les are inta"t$ l,n,la is ;hite. Fith good "apillary re.ill. #. 9horax and 2,ngs: No presen"e o. "hest and spine de.ormities$ no lesion$ mass and tenderness. 10. *ardio+as",lar: No +isi:le p,lsation on api"al p,lse o. the patient$ no mass$ l,mps and tenderness. =eart rhythm is normal. No m,rm,rs. 11. !reast and Axilla: not per.ormed 12. A:domen: same "olor as the other parts o. the :ody$ no lesions. -,llness so,nd heard. No enlargement noted. Smoothly "onsistent so.tness$ no tenderness and masses palpated.

13. >xtremities: 9he arm o. the patient is symmetri"al to ea"h otherG the legs are symmetri"al to ea"h other II. PERSONAL/SOCIAL HISTORY A. H(+i "* (. C(''eine* 162 ",p o. "o..ee. +. S.&=in;* 9he patient smo&es 3 sti"&s a day. $. Al$&)&l* Moderate -. Te(* None e. D#,;"* =e doesnt ta&e prohi:ited dr,gs. B. Li'e" :le* not applica le C. S&$i(l A''ili( i&n* None D. R(n= in )e '(.il:* 2nd "hild in the .amily. E. T#(9el >/i )in 5 .&n )")* 9he patient didnt tra+el to .ar pla"es prior to admission. F. E-,$( i&n(l A (in.en * =igh S"hool ?rad,ate. III. ENVIRONMENTAL HISTORY 1,r patient is li+ing in a :arrio together ;ith his .amily. 9heir ho,se is made o. semi6"on"rete materials. 9heir ;ater s,pply "omes .rom NAFASA and a deep ;ell and. 9hey ha+e their o;n toilet .a"ility ;hi"h is ;ater sealed type. 9heir residen"e is near the .arm and its E,ite .ar .rom their o;n to;n$ th,s ma&ing it hard .or them to a""ess health ser+i"es. 9heir transport .a"ility is tri"y"le and tra+els .or 1 min,tes going to the to;n. IV. INTRODUCTION CEREBRAL CONCUSSION des"ri:es a :rain inB,ry ;here$ a.ter an inB,ry$ there are .,n"tional "hanges that o"",r in ho; the :rain ;or&s :,t no str,"t,ral damage "an :e seen on standard imaging tests li&e *9 s"an. Mild tra,mati" :rain inB,ry$ or "on",ssion$ "an :e de.ined as a short6li+ed loss o. :rain .,n"tion d,e to head tra,ma that resol+es spontaneo,sly. Fith "on",ssion$ .,n"tion may :e interr,pted :,t there is no str,"t,ral damage to the :rain. 9he :rain .loats in "ere:rospinal .l,id and is en"ased in the s&,ll. 9hese prote"tions allo; it to ;ithstand many o. the minor inB,ries that o"",r in day6to6day li.e. =o;e+er$ i. there is s,..i"ient .or"e to "a,se the :rain to :o,n"e against the rigid :ones o. the s&,ll$ then there is potential .or inB,ry. 8t is the a""eleration and de"eleration o. the :rain against the inside o. the s&,ll that "an "a,se the :rain to :e irritated and interr,pt its .,n"tion. 9he a""eleration "an "ome .rom a dire"t :lo; to the head or .a"e$ or .rom other :ody tra,ma that "a,ses the head to sha&e. Fhile temporary loss o. "ons"io,sness d,e to inB,ry means that a "on",ssion has ta&en pla"e$ most "on",ssions o"",r ;itho,t the patient :eing &no"&ed o,t. St,dies o. .oot:all players .ind that the most o. those a..e"ted ;ere not a;are that they had s,stained a head inB,ry.

V. ANATOMY AND PHYSIOLOGY

Brain The brain is the control center of the body. It consists of three main components: the forebrain, the brainstem, and the hindbrain. The forebrain is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function. The forebrain contains structures such as the thalam,s and hypothalam,s which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. It also contains the largest part of the brain, the "ere:r,m. Most of the actual information processing in the brain takes place in the "ere:ral "ortex. The midbrain and the hindbrain together make up the :rainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function. The hindbrain extends from the spinal cord and contains structures such as the pons and cerebellum. These regions assist in maintaining balance and e uilibrium, movement coordination, and the conduction of sensory information. The hindbrain also contains the medulla which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion.

VI. PATOPHYSIOLOGY

Predisposing factors

P#e$i%i ( in; '($ &#" For&

A""ident prone area

J J
7ehi",lar A""ident =ead 8nB,ry

A;areness 9ypeHsI o. +ehi"le

S&,ll .ra"t,re ?ood prognosis R,pt,re or la"eration o. the Middle meningeal artery

*RAN8>*91MK

=>M1RR=A?> >pid,ral =ematoma %lood collect in the epidural !pace between the skull and &ura. 8n". 8*P !"!x # momentary loss of Consciousness Interval apparent $ecovery or lucid recovery

VII. LABOLATORY CLINICAL CHEMISTRY RESULTS 9est: *!* F!* N>1 2KM M1N1 >1S !AS1 Res,lt 11. ).33 2.0( .%%) .3%) .0( Normal Range 3.(0620.1 1.%36%.#% 1.0#62.## .2406.(#0 .306.440 0.0060.)0 Signi.i"ant Fithin normal range Ne,trophils in"reased in tra,ma Fithin normal range Fithin normal range Fithin normal range Fithin normal range

R!* =?! ="t M*7 M*= R!F P29 MP7

4.#( 142 .41% )3.( 2). 11.0 214 %.#%

3.%064.%# 10)6142 .3((6. 3( )1.16#%.0 2(.0631.2 11. 614. 1 63%% %.#0610.%

Fithin normal range Fithin normal range Fithin normal range Fithin normal range Fithin normal range Fithin normal range Fithin normal range Fithin normal range

URINALYSIS

RESULTS

NORMAL VALUES

SIGNIFICANCE

PHYSICAL* *olor -ar& Kello; Stra; yello; to am:er Normal

9ransparen"y

Slightly t,r:id

*lear

8ndi"ates a:normality

CHEMICAL* Spe"i.i" ?ra+ity 1.010 1.010 C 1.030 Normal

4ro:ilinogen

Normal

0C2

Normal

Red !lood *ells

162

Normal

Protein p= !lood "ells MICROSCOPIC* R!* >pithelial *ells A 4rates/Phosphates

H6I %.0 H6I 162 'e; 'e;

H6I 4.)6) H6I

Normal Normal Normal

Gene#i$ N(.e**e.,roxime B#(n- N(.e*Le.ox D#,; Cl(""i'i$( i&n**ephalosporin se"ond C generation D&"(;e*( 0mg S87P E%M ANS9 H 6 I In-i$( i&n* .or :one and Boint in.e"tions Me$)(ni". &' A$ i&n Si-e E''e$ " C&n #(in-i$( i&n A-9e#"e E''e$ " N,#"in; C&n"i-e#( i&n

!a"teri"idal: 8nhi:its synthesis o. :a"terial "ell ;all$ "a,sing "ell death.

Na,sea N 7omiting

*ontraindi"ated ;ith allergy to "ephalosporin or peni"illin

>rythema m,lti.orme >pidermal ne"rolysis Nephrotoxi"ity

>ns,re patients sa.ety

-iarrhea

Pse,domem:rano,s "olitis

Ad+i"e the patient to in"rease .l,id inta&e to pre+ent dehydration.

Gene#i$ n(.e*Para"etamol

B#(n- n(.e*Amadol Cl(""i'i$( i&n* Antipyreti" and analgesi" D&"(;e* 211 mg 87P e+ery 4 ho,rs In-i$( i&n* 'e+er and a",te pain Me$)(ni". &' ($ i&n 8nhi:ition o. prostagalandin synthesisG does not possess anti6in.lammatory propertiesG antipyreti" a"tion res,lts .rom inhi:ition o. prostagalndins in the *NS Hhypothalami" heat6 reg,lating "enter Si-e e''e$ " Na,sea and +omiting C&n #(in-i$( i&n" =ypersensiti+ity to the dr,g A-9e#"e e''e$ " ?8: hepatotoxi"ity ?4: renal .ail,re 8nteg: rashes N,#"in; $&n"i-e#( i&n" >ns,re "lients sa.ety.

Gene#i$ N(.e* Ranitidine

B#(n- NA.e* Oanta" D#,; Cl(""i'i$( i&n* gastri" a"id se"retion inhi:itor D&"(;e* mg 87P E ) In-i$( i&n* short term treatment .or d,odenal ,l"er

MECHANISM OF ACTION *ompetiti+ely inhi:its the a"tion o. histamines at the =2 re"eptors o. the parietal "ells o. the stoma"h.

ADVERSE EFFECT 2e,&openia =epatitis ?yne"omastia 9a"hy"ardia Pain in 8M site

CONTRAINDICATION *ontraindi"ated ;ith allergy to ranitidine.

SIDE EFFECTS --i<<iness NNa,sea 77omiting **onstipation

NURSING CONSIDERATION A+oid "hanges in position >at small amo,nt o. meals Position the "lient in sitting position to a+oid aspiration >at high .i:er diet

ASS>SSM>N9

-8A?N1S8S A",te pain related to tiss,e damage

P2ANN8N? A.ter 162 ho,rs o. n,rsing inter+entions the .eeling o. pain ;ill :e a:le to de"rease .rom %/10 to 2/10pain s"ale

8N9>R7>N981N 4se pain assessment s"ale to identi.y intensity o. pain

RA981NA2> Pro+ide :aseline .or assessing "hanges in pain le+el and e+al,ating inter+entions

>7A24A981N ?oal met. 9he patients pain ;as red,"e .rom %/10 .rom 2/10

S4!/>*987> @medyo s,masa&it ang s,gat ng mata &oA as +er:ali<ed :y the patient ;ith a pain s"ale o. %/10

Assess .or pro:a:le "a,se o. pain

-i..erent etiologi"al .a"tors respond :etter to di..erent therapies. other ;ay on ho; to relie+e pain

1!/>*987> 6'a"ial grima"e 6g,arding the a..e"ted area

Position the patient to its "om.orta:le position

7/S ta&en as .ollo;s: 9emp: 3%. 0* RR: 2% "pm PR: )2 :pm !P: 130/100 mm=g

>n"o,rage relaxation te"hniE,e H-eep !reathing >xer"iseI

S&eletal m,s"le relaxation is :elie+ed to red,"e pain :y relaxing tense m,s"les and tiss,es that "ontri:,te to the pain.

Administer analgesi" H&etorola"I as ordered.

9o relie+ed pain

ASS>SSM>N9 S4!/>*987>

-8A?N1S8S 8mpaired s&in integrity related to la"erated ;o,nd.

P2ANN8N? A.ter 162 ho,rs o. n,rsing inter+ention the patient ;ill :e a:le to demonstrate te"hniE,es to pre+ent s&in :rea&do;n.

8N9>R7>N981N 8nstr,"t patient to a+oid s"rat"hing the inB,red area

RA981NA2> 9o red,"ed ris& o. dermal inB,ry ;hen it"hing is present. 9o pre+ent .,rther in+asion o. mi"roorganism that "o,ld a..e"t s&in integrity.

>7A24A981N ?oal partially met. 9he patient ;as a:le to partially demonstrate te"hniE,e to pre+ent s&in :rea&do;n

1!/>*987> 2a"erated ;o,nd on le.t eyelid 6disr,ption o. s&in s,r.a"e 67/S ta&en as .ollo;s: 9emp: 3%. 0* RR: 2% "pm PR: )2 :pm !P: 130/100 mm=g

Lept the area a..e"ted "lean and dry

8nstr,"t patient not to ,se tight "lothing 1:tain .,rther do"tors order to pre+ent it"hiness

9o pre+ent s&in irritation

9o de"rease irrita:le it"hing

ASS>SSM>N9 S4!/>*987>

-8A?N1S8S Ris& .or in.e"tion related to inB,red tiss,e

P2ANN8N? A.ter 2 630 mins o. n,rsing inter+ention the patient ;ill :e a:le to demonstrate the ;ays on ho; to pre+ent in.e"tions.

8N9>R7>N981N Monitor +ital signs

RA981NA2> Ser+es as :aseline data.

>7A24A981N ?oal met. 9he patient ;as a:le to partially demonstrate ;ays on ho; to pre+ent in.e"tions.

1!/>*987> 62a"erated ;o,nd on le.t eyelid 6disr,ption o. s&in s,r.a"e 6 irrita:le 67/S ta&en as .ollo;s: 9emp: 3%. 0* RR: 2% "pm PR: )2 :pm !P: 130/100 mm=g

Monitor ;hite :lood "ell "o,nt

Rising F!* indi"ates :odys e..ort to .ight pathogens.

Monitor the .ollo;ing signs o. in.e"tion H redness$ s;elling $ in"reased pain$ >9*I 2imited +isitors

Any s,spi"io,s drainage sho,ld :e ",lt,red.

Red,"es the n,m:er o. organisms in patients en+ironment. Anti mi"ro:ial dr,gs are toxi" to pathogens or retard the pathogens gro;th.

Administer or tea"h ,se o. antimi"ro:ial dr,gs as ordered