Al-Quds University

Nursing Faculty

Data Collection Sheet

Basic Nursing II

STUDENT NAME: Salam Abdo

CLINICAL SITE: _Bethlehem Arab Society for Rehabilitation

______________________ :PERIOD OF CLINICAL PRACTICE

… GOOD LUCK
The reason for choosing this case: I chose this patient because he was a collaborator with me
and he was saying everything about himself.

:Biographic Data***

_______________________Name of penitent (initials):__RT

Age: 57 Hospital: Ward M/W Bed 8

:Admission Date

:Type OF Admission

- Allergies: Food - Drug - Not Known

____________________Diet patient on: ___ regular __diet with clear fluids

_____________________________ :Informant
:Medical Diagnosis***

Left CVA 19-10-2021 stork with carotid subtotal

:Nursing Health History***

:Chief complaint: Reason for seeking health care**

THE PT WAS SUFFERING FROM LOSS OF CONSCIONTON DIIZZENESS, VOMITING, WEEKNESS IN TH RT SIDE

:History of present illness**

THE PT HAVE LEFT CVA AND WEEKENS IN RT SIDE

HTV / DM

:Other Current health problems**

THE PT RIGHT LEG HAVE A LIMITED MOVING

______________________________________________________________________

:Past medical Health History**

THE PT HAVE HTN SINCE 2,5 Y

DM SINCE 15 Y AMIRYT +LANTUS MI

:Past surgical history **

THE PT CATHEZEZITION AND CORNRY CATDIC

__________________________________________________________________________________________________________

** :Family History

HIS FAMILY GENETICALLY HAS DM

:Psychosocial History**

HIS FAMILY WERE COMPOSED THE PT (WIFE AND SONS DUGHTERS)

HE HAVE A SUPPORTIVE SOCIAL ENVIROMENTE

:Environmental History**

THE HOME ENVIROMENT IS WELL VENTITATED AND FREE FROME AMBIENT POLLUTION
:Review of system: Physical assessment***

:General Appearance**

THE PT CONSIOUS ORIENTED CANT WALK AND HE TRANSFERING WITH CHAIR (DEPENTED)

:Skin, Hair & Nails**

THE PT HAVE NOT ANY PROBLEM IN THE SKINE (SKIN IS CORNY WITH GOOD VASCULATAITY NO
LESIONS NO BODY ODER WARM MOISR GOOD TURGOR AND SOFT AND SOME SCARE FROME OLD INJYRY
.__________________________________________________________________________________

:Head and neck**

S: THE PT CANE MOVE HIS HEAD AND SOMETIMES HE HAVE A HEADACHE a he

O:__NO MASSES THE SKULL IS BILATERAL SYMMERTICAL NORMAL SHAPE AND ZISE THE HAIR WAS SOFT
AND BLACK AND
___________________________________________________________________________________________________WHITE

Head**

S. THE PT SAID HE CANE MOVE HIS NECK

O__THER WERE NO MASSES OR NOD JUST SOME SCARS IN THE RT SIDE NORMAL TRACHEAL SIZE AND
POSITION NO ENLAARGEMENT OF THOROUD GLAND
:Hair**

S.THE PT SAID I DON’T HAVE ANY PROBLEM IN MY HAIR

O THE PT HAIR WASE SHORT THE HAIR WAS SOFT AND BLACK AND WHIT
___________________________________________________________________________________________________________

:Eyes**

S HE SIDE I DO NOT HAVE ANY PROBLEM IN MY EYES BUT I AM WEARING GLASSES

O__ There was no response for vision, the pupils were dilated, the two eyes were symmetric, there was no excessive tearing,
there was no glaucoma nor discharge, the pt. was not use glasses before his disease, his eyes didn't have any allergies from
anything, his eyes color was black, he didn't use lens, his eyebrows and eyelashes were thin

:Ears**

S: .I DON’T HAVE ANY BROBLEM IN MY HEARING AND GOOD SENSE OF HEAING

O: SYMMERTRICAL EXTEND SLIGHT FORWARD FROM THE SKULL SIMILAR IN SIZE, LOCATION ,COLOR NO
______________________________________ DISCHARG NO BLEEDING GOOD HEARING IN BOTH EARS

:Nose and sinus**

 S. GOOD SENS OF SMELL” I DO NOT HAVE ANY PROBLEM IN MY HEAR
.

O_HIS NOSE IN THE MDDLE OF THE FACE SYMMETREC_EQUAL IN SIZE IT’S CLEAN NO DISCHARGE NO
BLEEDING

:Mouth and pharynx**

. S. BECOUCE LF LEFT CVA MY MOUTH AND TONG SLANT

O: SOFT AND INTACT LIPS PINK IN COLOR COMPLETE HARD AND SOFT PLATE NORMAL IN SIZE NO
. _________________ BLEEDING

:Neck and nodes**

”S:THE PT TOLD HE DON’T HAVE ANY PROPLEM JUST SOME SCARS IN MY NECK DUE TO “MI

O: WERE NO MASSES OR NODE ENLARGEMENT, AND THERE WAS NETHIE SWELIING NOR TENDREN

:Respiratory system**

S.” MY BRATHING IS GOOD, NORMAL

.

O:_THE LUNG SOUND GOOD AND VERY NATIRAL SYMMETRICAL THROX MOVE DURING BREATHING
REGULAR RR=18 PER MINATE NO DISCHARDG NO MASS THE
:Cardiovascular system**

S. I feel that my heart normal and I do not have any problem

.

O: normal sound, normal and regular carotid and normal peripheral puls P=90/ BP=130/95

:Breast and axillary**

S. nothing abnormal
.

O: _no discharge no masses no pain

_______________________________________________________________________________________________________

:Abdomen**

S. I feel good in my Abdomen but i have not constipation in my insentient

O: Normal skin color. Soft, flat, and symmetrical, , no scars ,no masses bowlle movement not good ,hard -
sound ,constipation

General & Reproductive System***

:Male**
 S: no problem prostate and I haven’t any problem
. ___________________________________

_________________________________________________________________________________________________________O
___________________________________________________________________________________

:Rectum& Anus**

S.no problem due to constipation

_______________.___________________________________________________________________________________________

O: _no infection no masses no bleeding clean and hygiene

:Eliminations**

:Bowel **

S. the PT have not a pain but he have constipation

. _______________________________

O: no masses or enlarge organs in the bowel the sound approximately normal

___________________________________________________________________________________________________________

:Urinary**
 S. he fell he wanted to go to the bathroom 3-4 times per day
. ___________________________

____________________________________ O:.__the PT have a urinary catheter because he inability to move

_______________________________________________________________

:Diet and Nutrient**

S: he said he did not have any allergy from any kind of food but that he eat suitable tit h DM
. _________________________

O: the PT can eat anything expect the food may be effected in DM

___________________________________________________________________________________________________________
________________________________________________________________________________

:Musculoskeletal**

S : he have a limited movement due to left CVA in the RH side limited movement
. ______________________

,O:_ Muscle: bilateral symmetrical muscles, good strength but pain with movement , No tenderness, atrophy -

Skeletal: normal contour, symmetrical, joint diseases, pain with movement , extension and flexion -

:Neurological**
 S: .duo to left CVA I have limited sensory in th RH side
. _____________________

.O. Pt. alert and conscious -

Not Full movement coordination and body balance Normal reflexes history of trauma, and drinking -

:INTRAVENOUS THERAPY GIVEN TO THE PATIENT

Reason Time Time Amount Type of
for IVF ended started IVF
:SPICAIL DIAGNOSTIC TEST DONE FOR THE PATIENT

______________________________________________________________ :X-RAYS-CT SCAN-MRI…etc **

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
______________________________________

________________________________________________________ ULTRASOUNSD**
___________________________________________________________________________________________________________
_____________________________________

_________________________________________________ :ECG&ECHO **
___________________________________________________________________________________________________________
_____________________________________

Others: (CBC, KFT, LFT… ETC

Lab Pt’s value Pt’s Normal comment
investigation (1) value (2) value
WBC 9.24 10.38 4-11 NORMAL
LYM 2.39 2.34 1-4.8 NORMAL
MEUT 0.75 0.0-0.08 ABNORMAL
0,35
RBC 3.98 4.02 4.70- ABNORMAL
6.30
Hb 12.1 13.2 14.0- ABNORMAL
18.0
HCT 36,8 39.4 42-52 ABNORMAL
MCH 30.5 30.8 26-32 NORMAL
MCHC 33.0 33.3 31.0-37.0 NORMAL
%RDW 13.2 13,3 11.0-16.0 NORMAL
RDW- 50.5 50.8 37.0-54.0 NORMAL
SD

PLT 345 313 140-440 NORMAL

MPV 9.2 9.6 8-11 NORMAL
PDW 11.1 11.7 0.1-99.9 NORMAL
EO 0.05 0.21 0.00-0.50 NORMAL
Pathophysiology of the disease (In your own words) Mention references
Is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body
and the lungs .Diagnosis of Heart Failure implies interpretation of several key clinical criteria. One
inexpensive and noninvasive criteria Echocardiography allows a mathematically sound and readily
reproducible method of further elaboration of the term Heart Failure. HF is sometimes incorrectly used to
.describe other cardiac-related illnesses, such as myocardial infarction (heart attack) or cardiac arrest
Common causes of heart failure include myocardial infarction and other forms of ischemic heart disease,
hypertension, valvular heart disease, and cardiomyopathy.[4] Heart failure can cause a number of symptoms
including shortness of breath (typically worse when lying flat, which is called orthopnea), coughing, chronic
venous congestion, ankle swelling, and exercise intolerance. Heart failure is often undiagnosed because of a
lack of a universally agreed definition and challenges in definitive diagnosis. Treatment commonly consists
of lifestyle measures (such as smoking cessation, light exercise including breathing protocols, decreased salt
intake and other dietary changes) and medications, and sometimes devices or even surgery
 MEDECATION SHEET
Generic \ Dose \ Classification Side effect of medication Nursing priorities
trade name frequency
assessment, V\S,(
route\ )lab tests

NOOTROPIL Give 2 table oral 3 piracetam Blood and lymphatic system disorders: Not known: haemorrhagic
times daily for 2 .disorder
months
(2*3*2month) Immune system disorders: Not known: anaphylactic reaction,
.hypersensitivity

Psychiatric disorders: Common: nervousness. Uncommon: depression.

.Not known: agitation, anxiety, confusion, hallucination
 Nervous system disorders: Common: hyperkinesia. Uncommon:
.somnolence

ASPIRIN Give 1 table oral 1 Central nervous system (CNS) alteration

times daily for 3
month Skin problems

)3month*1*1( Gastrointestinal (GI) pain, ulceration, bleeding

Liver damage

Hearing loss

Nausea

Platelet aggregation inhibition Premature hemolysis Pulmonary edema

(salicylate-induced, non-cardiogenic Rash Kidney damage Ringing in
the ears (tinnitus)

PLAVIX75MG Give 1 table oral 1 Yellowing of your skin or eyes (jaundice) fast heartbeats, shortness of
times daily for 3 ,breath, headache
month
Fever, weakness, feeling tired, little or no urination, seizure
3*1*1( (convulsions)

MIXTARD Give 40 units AM dual-acting insulin

and 20 units PM
30VIAL 1*10 ML Lightheadedness. Dizziness. Anxiety. Nervousness.Tiredness.Feeling
hungry. Visual disturbances
 FLAMINAL Give I g Enzyme
FORTE 50 gr topical 2 alginogels
times hydrated
daily for alginates with
3 an embedded
MIEUROVIT Give 1 table others 1 months anti-bacterial .Diarrhea and itching may occur occasionally
ATC Classification
times daily for 3
TAB month enzymeView ADR Monitoring Form
)3*2*1(
)3*1*1( .system
NOOTROPIL Give 2 Central Belt
SOMAZINE give 1 SACHT oral 2 psych stimulants Nausea Constipation Diarrhea Headache insomnia (trouble sleeping)
1000MG times daily for 400MG
2 table oral
.and nootropics Analeptics
Hypotension (decrease in 30'Headache.Sleepiness.Stomac
blood pressure) Blurred vision Increase or
month 1*2*2
TABELES 3 times a h pain.Diarrhoea.Weakness.
decrease in heart rateRestlessnes

day for 2 .Nausea. Restlessness

month

)2*3*2(

Xarelto 10 Give 1 direct oral Fainting, itching, pain in your

GM table oral anticoagulants arms or legs, muscle pain,
1 times and.muscle spasms
daily for
3 months
(1*1*3)
LIPO40 gm. Give 1 Liposuction  Fluid accumulation. Numbness. .
tabs NIN table oral Infection Internal puncture. Fat
1 times a embolism. Kidney and heart
day for 3 problems. Lidocaine toxicity
month
:Main pt problem according to the NANDA

deficient knowledge about the underlying disease and methods for avoiding complications-1

Risk for Ineffective Cerebral Tissue Perfusion . .1

Impaired Physical Mobility .2

Impaired Verbal Communication .3

Acute Pain .4
Ineffective Coping .5

Self-Care Deficit .6

Risk for Impaired Swallowing .7

Activity Intolerance .8

Risk for Unilateral Neglect .9

Deficient Knowledge .10

Nursing Care Plan

Pt. Problem :left CVA

Nursing Dx: deficient knowledge about the underlying disease and

methods for avoiding complications
Nursing Interventions Rationale Evaluation
The nurse must told ALL the previous The patient s will
the patient that activities help in be stable with no
he/she must change
preventing many .complications
his/her lifestyle this
can be:
complications may
occur such as:
A-Avoiding activity
The patient will be
that that produce *Acute pulmonary
able to take the
chest pain, dyspnea, or edema.
fatigue. process of angina
*congestive heart and will avoid all
b- Losing weight if
failure. complications
indicated.

C-perusing activities
*cardiogenic shock.
that decrease stress. *dysrhythmias or
d- avoid big cardiac arrest.
meals ,smoking, and
food that increase BP *myocardial
and glucose infarction
Pt. Problem :left CVA

Nursing Dx: 1) Impaired physical mobility R/T intracranial

ischemic (embolism or thrombosis )

Short and Long Goal : Cerebral perfusion pressure will be

maintained
 Nursing Rationale Evaluation
Interventions

Raise head of bed no -Current evidence The goal is met .tissue

higher than 30 degrees suggests that elevating
–keep the PTs head the head of bed reduces perfusion :cerebral ,ne
and neck in neural ICP .this position may
position. also reduce cerebral urological status ,
perfusion and
monitor and record-
contribute to risk for blood
neurological status cerebral infarction.
-this position promotes coagulation ,medicatio
using Glasgow coma venous drainage from
the brain and decreases
n response
scale ICP.
this information is-
used to determine the
effects of stroke and
prevent life –
threatening
complications

such as sever HTN and

increased intracranial
 pressure (ICP) .specific
neurological changes
can help identify the
specific location of the
stoke

Pt. Problem :left CV

1) Nursing Dx: Anxiety R/T the length period of

 hospitalization.

Impaired physical mobility R/T paresis or paralysis ,loss of

balance and coordination

Short and Long Goal: To decrease the anxiety during hospitalization,

and prevent it .and To prevent anxiety to happen after discharge of the pt.

Nursing Rationale Evaluation

Interventions

Assist the causes of the to determine the All actions were done,
anxiety reasons. points of anxiety
-keep privacy. reasons. and the level of
-encourage his family -to decrease the level
to talk with his. of anxiety and make pt anxiety decreased, and
-stop vomiting. feel comfortable.
-decrease the level of -to form trust with the the pt felt comfort
coughing. pt.
-treat the anorexia. -to encourage the pt to
-let his to see his family
talk about his
sitting around his
problems
talking with his.

Teaching and Instructions given to patient during hospitalization related to his diseaseabout diet, exercises, life
style, managing stress, medications, comfort and rest…etc

(If needed)

*the patient undergoes physiotherapy sessions

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: Summary
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