2. Nursing Assessment 1

5/24/2018 2. Nursing Assessment 1

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II. NURSING ASSESSMENT

A. Personal Data

1. Demographic Data

Patient X is 71 year old married man, who was born in Barangay San Fernandino

Concepcion Tarlac, Philippines on the 25thday of March in 1943. He is 5 feet, 5 inches

tall and 60 kg with a normal BMI of 22. He is a Filipino who is currently residing in one of

the subdivisions in Concepcion Tarlac, Philippines. He is a father of 2 daughters and 1son. He was admitted at the Private Room Hospital X last February 15, 2014 with a

diagnosis of Evans Syndrome and was discharged 4 days later with final diagnoses of

Evans Syndrome. Newly Diagnosed Diabetes Mellitus Type 2 Poorly Controlled, Upper

Respiratory Tract Infection, and Gouty Arthritis.

2. Socio-Economic and Cultural Factors

Patient X belongs to a nuclear type of family as he is currently residing with

her second wife (Wife B) and their daughter. He became a widower after his first

wife (Wife A) died at the age of 51 years more than a decade ago, leaving him

with their two children, Daughter A and Son A who are now living independently.

He is the eldest member of the family and also considered to be the secondary

breadwinner as he is now earning less from his pension as a retired School

Principal than Wife B. Patient X receives 21,000 pesos of monthly pension while

f f f


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Wif B 42 000 f h k t t i f th

and a PhD in 1987 from Pampanga Agricultural College. He taught for a

couple of decades in several public schools in Angeles City and eventually

promoted as a High School Principal. He worked as a principal then for

several secondary public school Tarlac City and he spent his last 3 years

before his retirement at the age of 65 years old in a private High School in

Tarlac City.

Being a baptised as a Catholic, Patient Xusually goes to Sunday mass ata nearby Parish. He observes Catholic Holidays the like the Holy Week and

Christmas. He also follows religious beliefs like abstinence of meat during

Holy Week.

Growing up in the urban, Patient X was not raised with many Filipino

superstitious belief specifically that of concerning health. Also, he do not

believe in any traditional and faith healers. He had never sought consultation

from any herbolarios, manghihilots and mananawas that are very common in

the Philippines. He, however, believes in the power of water therapy.

Whenever he is sick and feeling unwell, he would take a lot of water as he

believe that it has cleansing power and water can eliminate toxins from the

body. The specific amount of water was not provided by the patient but

mentioned that he just takes around twice as much as his normal daily water

i t k hi h i d 1 5 lit d P ti t X ti d th t h d t


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i t k hi h i d 1 5 lit d P ti t X ti d th t h d t

himself. The dish would usually be enough until dinner. The main ingredient

for his lunch is usually composed of pork and beef. His favourite meals are

pork sinigang(pork stew with vegetables) and nilagang baka (beef stew with

vegetables). After eating his dinner and doing the dish, he would then take a

siesta until 3 in the afternoon where he would wake up and eat his afternoon

snack that he would usually buy from a nearby carinderia (canteen). He

would usually buy bulalo (beef shank soup), pansit (rice noodles) and

banana-cue (deep fried sugar-coated banana) or sometime he would justmake his own sandwich spread. He would usually eat his afternoon snack

while watching the television. At 5 PM during weekdays, he would have to

fetch his wife at their corner street to accompany her going home by walking.

The walk would usually take 15 minutes back and forth. Her daughter is sent

home at around 5:15 pm by the school bus. He would then prepare for dinner

by commonly reheating the dish he cooked earlier. Her wife would then wash

the dishes as he watch the television after dinner. He would usually sleep

around 8 at night after taking a bath.

Patient X is currently living with Wife B and Daughter B in a one storey

building in an approximately 400 square meter house in one of the

subdivisions in Tarlac City with 4 bedrooms and 3 bathrooms. Daughters A

have described their subdivision to be quiet and peaceful. Their garbage is

b i ll t d b th b ll t d il b i Th i f


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8

A. Family Health Illness(Genogram)

Father

85 y/o

Fracture

Mother

92 y/o

HPN

Legend

-Deceased

PATIENT X

71 y/o

Gouty Arthritis

HPN

Evans syn.

Wife A

51y/o

Lung CA

H erth

Wife B

51y/o

Lung CA

Hyperthy

Brother 1

69 y/o

HPN

Emphysema

Sister 1

66 y/o

Asthma

Myoma

Sister 2

62 y/o

HPN

Sister 3

61 y/oBrother 2

53y/o

Sister in

Law

68 y/o

HPN

Niece 1

45y/o

SLE


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B. Family Health Illness (Synthesis)

The above figure shows the schematic diagram of the consanguinity relationship

of the patient only up to the first degree as the patient himself can no longer accurately

remember his second degree family members. Beginning with the paternal side of the

genogram, it can be seen that Patient Xs father has deceased from a fracture sustained

from a fall as accounted by the patient at the age of 85 years old. His mother, on the

other hand is still alive with no known morbidity aside from hypertension with nomaintenance drug at the age of 92 years old.

Patient Xbelongs to a 6 children nuclear family. Patient X is the eldest among

his other 5 siblings at the age of 71 years old and he is currently diagnosed with Gouty

Arthritis, hypertension and Evans Syndrome. He is followed by his Brother 1 who is 2

years younger than him and currently suffering from emphysema and also hypertension.

Sister 1 is the eldest female sibling of Patient X. She is 66 years old who had a history of

Asthma and was diagnosed with Myoma. Sister 1 is followed by Sister 2. She is currently

diagnosed with hypertension. Sister 3 is the youngest female sibling of Patient Xat the

age of 61 years old and she is alive and well. The youngest of all his siblings is Brother 2

who is only 53 years old and known hypertensive.

The patient was actually first married to Wife A. They had 2 children. Wife A died

t th f 51 ld d t L C i 2001 P ti t X t i d i 2005


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C. History of Past Illness

The history of patients past illness includes all medical conditions that the patienthad which are identified to be non-associated with the patients current medical

diagnosis. As the patient himself and his daughter could no longer recall some

information regarding Patient Xs health history, some of the data gathered may be

inadequate and contains some uncertainties with regards to date and specific treatment.

Patient X is known hypertensive for more than 2 decades but did not take any

medications for this illness. This is because his blood pressure is only Stage I and he did

not experience any severe signs, symptoms and complications of the illness.

A couple of years ago, Patient X experienced severe joint pain and was later on

diagnosed with Gouty Arthritis. He was then maintained on Colchicine, Allopurinol and

Celecoxib. He was quite religious in taking his maintenance drugs for only about 7

months then he gradually stopped his medications as he no longer feel any joint pain.

He would take these medications as necessary and as soon as he feels that the joint

pain is coming back.

According to Daughter A, Patient X is not a sickly person. He seldom has flu,fever, cough, throat infection, and non-serious medical conditions. He firmly believes in

water therapy, hence whenever he is experiencing such common sickness, he would


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D. History of Present Illness

On December 1 2013, Patient X started to feel that he is easily fatigued by his

daily activities as he can no longer finish what he would usually do in a day. He did not

tell anybody, but it was noticed by Wife B. This progressed for about a week, hence Wife

B contacted Daughter A on December 6, 2013 to consult Patient Xs condition as

Daughter A is nurse. Daughter A suspected that her father has Emphysema because of

his smoking history (1/2 pack of cigarette from the age of 21 to 50). The morning after

Daughter A was informed of his fathers condition (December 7, 2013), Daughter A

brought her father to the OPD section of the secondary hospital where she works. They

consulted to an Internal Medicine doctor that they know (Daughter in Law A). Patient X

was subjected to several routine laboratory and diagnostic procedure. Interestingly, his

lungs was unremarkable, but his haemoglobin level was very low (73 g/L). For thisreason, he was admitted in the institution. He stayed in the institution for 2 days. On the

first day of admission, the main treatment discussed to them was blood transfusion of

two units of packed red blood cells to which they consented. He was subjected to a

blood typing and cross-matching test. The blood sample sent was reportedly to have

haemolysed on the way to the laboratory and so another blood sample was obtained.

This time, the serum specimen was sent to the laboratory with no delay, and yielded a

blood type of A positive. During the first 3 minutes of the transfusion the patient felt like

he was palpitating and began to feel sick. The blood transfusion was immediately


8/54

with an unrecalled value, but the platelet count of the patient is also now below normal

level. The doctor decided to confine the patient with an admitting diagnosis of Anemia

and treat him with a blood transfusion a single unit of Packed Red Blood Cells, but this

time it was concluded that the patient has an O Positive blood type. There was no

transfusion reaction noted. The haemoglobin level of the patient increased to a satisfying

level for the haematologist to send him home after an overnight stay. He was medicated

with IV Hydrocortisone (Solu-Cortef) during the stay. The patient was discharged with a

diagnosis of Autoimmune Hemolytic Anemia, Immune Mediated Thrombocytopenia(Evans Syndrome). The patient was discharged with home medications of Prednisone

30 mg 2 tablets once a day and Iron and Multivitamins (Iberet), both to be taken for 7

days. Starting this period, Patient X and his Wife decided to get a maid to do the

household shores

Patient X returned for a follow-up check up on December 27, 2013 in the OPD of

the tertiary hospital. His CBC results were now normal and he was maintained on Iberet

for his present condition and Celecoxib for his gouty arthritis. On January 10, 2013, 2

PM Patient X returned for another follow-up check-up where his blood hematology did

not show any abnormal result. After the consultation, the patient together with his Sisters

and Wife B, went to the pharmacy to buy Iberet as his maintenance drug (5PM), the

patient was already feeling sick by then. Wife B thought that he was just tired because ofthe long ride. They immediately went home for Patient X to get a rest. They got home at

5:30 PM and Patient X finished his dinner at 6:30 PM. Five minutes later, Patient X felt


9/54

(Hospital X) where he was admitted with a diagnosis of Evans Syndrome and Diabetes

Type 2 on February 15, 2014 at 11 AM.


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E. Physical Examination

FIRST DAY OF HOSPITALIZATION

Date of Admission: February 11, 2014 11 AM

First Nurse-Patient Interaction, February 23, 2014 11-AM-2PM

Initial physical examination (lifted from the chart, assessed and accomplished by the

Residence Doctor on Duty)

Vital signs at Emergency Room:

BP: 130/90 mmHg

HR: 108 bpm

RR: 18 bpm

T: 36.8C

Skin: (-) Rashes (+) Jaundice(-) Bruises (-) Lumps

Head: (-) Headache (-) dizziness (-) head injury

Eye: (+) Icteric Sclera (+) Pale palpebral conjunctiva(-) bleeding (-)discharge

Ears: (-) Tinnitus (-) earaches (-) discharge (-) hearing impairment


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General Appearance

Patient X was lying supine on a bed at moderate high back rest, awake; withGlasgow Coma Scale of 15 (Eye=4, Verbal=5 Motor=6) i.e. spontaneous eye opening,

conscious and coherent, obeys verbal command such as raising extremities with no

difficulties; with Oxygen therapy at 2 liters per minute; With an on-going IVF of #1PNSS

1L x 60cc/hr at approximately 900 cc level infusing well over the right cephalic vein with

no signs of infiltration and phlebitis. The patient appears generally pale and with mild

jaundice. Appeared comfortable; Patient X was hypertensive, tachycardic, with

normorhythmic and symmetrical lung expansion.

Vital Signs:

Time BP in

mmHg

HR per

minute

RR per

minute

Temperature

in oC

1:30PM 130/70 96 21 363:30PM 120/70 96 21 36.4

8:15PM Refused 89 28 37.39:15PM 110/60 109 24 Refused

12:30AM 110/70 91 24 36.7

4:45AM 110/70 90 23 36

Hair and scalp: Upon inspection, the hair was noted to be short that is grayish to whitish

in color. It was evenly distributed, moderately oily; with no dandruff and infestation noted.


12/54

Eyes: The hair of His eyebrows are evenly distributed and symmetrically aligned with no

of flakes, scars and lesions noted. His eyelashes were evenly distributed and slightly

curled outward. He has positive blinking reflex on both eyes. The skin around the eyes

was intact, there were no discharges and discolorations observed. His eyelids close

symmetrically. No edema was seen in the periorbital region. Pale palpebral

conjunctiva noted. No edema or tenderness over lacrimal gland observed. Eye color

was dark brown with Arcus Senilis corneae noted. He mild icteric sclera was also

seen

Ears: His auricles have the same color as the facial skin, symmetrical and are aligned

with the outer canthus of the eye. They are firm, non-tender and recoil as they were

folded. The distal end of the external canal contains tiny hair follicles with scant amount

of dry light yellow cerumen inside. No abnormal discharges were noted during theassessment. Patient has a no hearing loss.

Nose: His nose is centrally positioned on the face, symmetrical in size and shape and

has the same color as the face. There were no discharges for the nares and no nasal

flaring was noted. There were no lesions masses and tenderness. Airway patency

cannot be assessed since the patient is on mechanical ventilator through endotracheal

tube. Facial sinuses are not tender and not inflamed.


13/54

Chest: His skin was intact, uniform in color and temperature. There were no deformities

noted. No adventitious sounds noted upon auscultation. Patient X was not having

laboured breathing, no episodes of shortness of breath and was observed although the

patient was tachypneic.

Heart: Apical heart beat was present upon auscultation with a point of maximal impulse

at the 5th intercostal space left midclavicular line at slightly above normal rate in an

isolated event but in regular rhythm. There was no ectopic beats or murmurs present

upon auscultation.

Abdomen: The skin of Patient Xs in his abdominal area is uniform in color, flabby, soft,

non-distended. There was no tenderness noted, symmetrical contour. Normal bowel

sounds were heard upon auscultation.

Bowel: There was no bowel elimination within the day.

Bladder:No bladder distention noted upon inspection of Patient Xs suprapubic area and

the patient is voiding freely.


14/54

Neurological Assessment

Glasgow Com a Scale

Date February15, 2014

Eye 4

Verbal 5Motor 6

Total 15

Behavior

Patient is comfortable andappears weak with some during assessment.

Sensorimotor Functioning Gross motor and balance test: Cannot be assessed since the Patient is on

complete bed rest.

Fine motor test: Patient Xis able to write in a small writing board as instructed

Bones and joints: Fusiform swellingwas observed over the index and middle

finger of both hands. With minimal, tolerable pain over the lower extremities.

The patient can bend knees and other joints with no difficulty.

Mental Status: Patient Xappears to be weak yet oriented to time, person and

place after a series of questions given that he answered through writing in a


15/54

CRANIAL NERVE

Name, Type andFunction

ASSESSMENT

TECHNIQUES

NORMAL

FINDING

ACTUAL

FINDING

I. Olfactory

Sensory

Sense of smell

Asked to close eyes andto identify different mildaromas such as dilutedalcohol and soap suds.

The patientwill identifydifferent mildaromascorrectly by

means ofsmelling of itand being ableto point outwhich is which.

The patientwas able toidentify the mildaromascorrectly.

II. Optic

Vision and visualacuity

Covered one eye at atime then instructed readthe textbook shown to his

from 14 inches away.

The patient willidentify thepicture shown

to him

Patient Xwasnot able to readthe textbook

shown to hisfrom 14 inchesaway.\ withoutthis eyeglasses.

III. Oculomotor

Motor

Extraocular eyemovement

M t f th

Assessed direct andconsensual response byinstructing the patient tofollow the pen not using

his head. Assessed foraccommodation by usingthe penlight to see thereaction of the pupil.

The patientwill follow thepen correctlyand easily. For

pupil, it willperformconstrictionupon light and

The patientwas able tofollow the peneasily and

correctly. Hispupils at 3mm insize performedconstriction and


16/54

Ophthalmic,

maxillary andmandibular sensoryand motor

Sensation ofcornea and skin offace and nasalmucosa

Jaw movement

Chewing andmastication

the lateral sclera of eye toelicit blink reflex. To test

deep sensation, we usedalternating blunt andsharp ends of a safety pinover the same area. Totest light sensation, wehad the client close hiseyes and wipe a wisp ofcotton over the clientsforehead and paranasal

sinuses.

eyes when thecotton is being

touched. Forskin, he willidentify thepresence ofcotton in hisface and alsoidentify if it issharp or blunt.

after cottontouched his

eyes; he felt thecotton; and healso identified ifthe object issharp or blunt bypointing writing itout in the writingboard.

VI. Abducens

Motor

Moves eyeballlaterally

Extraocularmovement

Assessed direction ofgaze by looking at theside without using head.

The patient willmove his eyessymmetrically.

Patient Xwasable to move hiseyessymmetrically.

VII. Facial

Motor and sensory

Facial expressions

Instructed the client to

smile, raise theeyebrows, frown, puffcheeks and close eyestightly. Asked client toid tif i t t

The patient

will perform alleasily andsymmetrically.

The patient

was able toperform allactivity easilyand

t i ll


17/54

he watch test

IX.Glossopharyngeal

Motor and sensory

Swallowing ability

Posterior 1/3 of the

tongue

Instructed the client tosay Ah and ask thepatient to move tongue indifferent directions thenplaced the tonguedepressor inside hismouth until he does hisgag reflex and let himswallow afterwards.

The patient willperform side toside movementand also upand downmovement ofhis tongue.

The patientwill elicit gagreflex andswallowafterwards

The patientwas able to doall movementeasily. Positivegag reflex waspositive and nodifficulty inswallowing wasnoted.

X. Vagus

Motor and sensory

Sensation ofpharynx and larynx

Swallowing

vocal cordmovement

Assessed by instructingthe client to open hismouth, speak andswallow.

The patientwill speakclearer andlouder and willeasily swallow.

The patientwas able to openhis mouth, speakand swallow.

XI. Accessory

motor

We instructed client toshrug against resistancefrom our hand. And turn

The patientwill shrug hisshoulder

The patientwas able toshrug his


18/54

THIRD DAY OF HOSPITALIZATION

Second Nurse-Patient Interaction, February 17, 2014 6AM-7PM

Patient X was lying supine on a bed at moderate high back rest, awake; with

Glasgow Coma Scale of 15 (Eye=4, Verbal=5 Motor=6) i.e. spontaneous eye opening,

conscious and coherent, obeys verbal command such as raising extremities with no

difficulties; with Oxygen therapy at 2 liters per minute; With an on-going IVF of #4 PNSS

1L x 80cc/hr at 450 cc level infusing well over the right cephalic vein with no signs of

infiltration and phlebitis. The patient appears generally pale and with mild jaundice.

Appearedcomfortable; Patient Xwas hypertensive, tachycardic,with normorhythmic

and symmetrical lung expansion.

Vital Signs:

Time BP in

mmHg

HR per

minute

RR per

minute

Temperature

in oC

8:30AM 130/70 103 24 36.1

12:35PM 130/70 116 24 36

4:40PM 130/70 104 24 36

8:50PM Refused


19/54



Skull and face, skull size, shape and symmetry: The skull of the client was round and it

had a smooth contour, hence a normocephalic skull. There were no masses, nodules or

depressions on the skull upon palpation.

Facial features: He had symmetrical facial features and movements. His naso-labial

folds were also noted to be symmetrical. No facial edema noted. Liver spots of less than

5 mm were noted to be moderate and evenly distributed throughout the face. Wrinkles

over the forehead, and cheeks were also noted.








seen


20/54

cannot be assessed since the patient is on mechanical ventilator through endotracheal

tube. Facial sinuses are not tender and not inflamed.

Mouth: Lips are dry and pale but there were no cracks present. Patient X has a

complete edentulism.He has dentures on his upper and lower gums. The tongue was

moist pinkish to red with no cracks and bleeding. The patient has no difficulty sticking out

is tongue as instructed by the nurse-researcher.

Neck: The neck muscles are of equal size and shape. His head was in midline position.

There was no jugular vein distention noted. Upon palpation, there were no lymph nodes

noted. Trachea is positioned in the middle of the neck, with spaces equal on both sides.






at the 5th intercostal space left midclavicular line at slightly above normal rate in an


21/54

Extremities:

Upper Extremities- upon inspection, the skin was noted to be dry. Liver spots

were noted to be moderately and evenly distributed over both upper extremities;

Patient X was able to raise all extremities with no difficulties. Muscle strength

was 5/5 on both upper extremities. Fusiform swelling of the index and middle

fingers of both handswas also noted. Fingernails were short and clean; pale

finger nail bedswere noted; capillary refill test of less than 2 seconds after His

nail was pinched.

Lower Extremities- upon inspection, the skin was noted to be dry. Negative

Homans sign. Toenails were short and clean. Pale nail beds were again

noted. Muscle strength were 5/5 on both lower extremities


Glasgow Com a Scale


Eye 4

Verbal 5Motor 6Total 15


22/54



small board provided by the nurse.


23/54

FOURTH DAY OF HOSPITALIZATION

Third Nurse-Patient Interaction, February 18, 2014 6AM-2PM

General Appearance

Patient Xwas sitting on a chair, awake; with Glasgow Coma Scale of 15 (Eye=4,

Verbal=5 Motor=6) i.e. spontaneous eye opening, conscious and coherent, obeys verbal

command such as raising extremities with no difficulties; with Oxygen therapy at 2 liters

per minute; With an on-going IVF of #5PNSS 1L x 10cc/hr at approximately 900 cc levelinfusing well over the right cephalic vein with no signs of infiltration and phlebitis. The

patient appears generally pale and with mild jaundice. Appearedcomfortable; Patient

X was hypertensive, tachycardic, with tachypneic and symmetrical lung expansion

with a febrileepisode.

Vital Signs:

Time BP in

mmHg

HR per

minute

RR per

minute

Temperature

in oC

8:00AM 110/70 112 32 37

8:15AM 100/60 106 26 37.1

10:00AM 90/60 108 24 37

12:00PM 100/50 110 22 38.1


24/54



Skull and face, skull size, shape and symmetry: The skull of the client was round and it

had a smooth contour, hence a normocephalic skull. There were no masses, nodules or

depressions on the skull upon palpation.

Facial features: He had symmetrical facial features and movements. His naso-labial

folds were also noted to be symmetrical. No facial edema noted. Liver spots of less than

5 mm were noted to be moderate and evenly distributed throughout the face. Wrinkles

over the forehead, and cheeks were also noted.








seen


25/54

tube. A nasal cannula is placed on both nares for oxygen therapy. Facial sinuses are not

tender and not inflamed.

Mouth: Lips are dry and pale but there were no cracks present. Patient X has a

complete edentulism.He has dentures on his upper and lower gums but was noted to

be removed by that time. The tongue was moist pinkish to red with no cracks and

bleeding. The patient has no difficulty sticking out is tongue as instructed by the nurse-

researcher.

Neck: The neck muscles are of equal size and shape. His head was in midline position.

There was no jugular vein distention noted. Upon palpation, there were no lymph nodes

noted. Trachea is positioned in the middle of the neck, with spaces equal on both sides.







26/54

Bladder: Patient X is voiding freely. No bladder distention noted upon inspection of

Patient Xs suprapubic area.

Extremities:

Upper Extremities- upon inspection, the skin was noted to be dry. Liver spots

were noted to be moderately and evenly distributed over both upper extremities;

Patient X was able to raise all extremities with no difficulties. Muscle strength

was 5/5 on both upper extremities. Fusiform swelling of the index and middle

fingers of both handswas also noted. Fingernails were short and clean; pale

finger nail bedswere noted; capillary refill test of less than 2 seconds after his

nail was pinched. Palms were also noted to be pale.

Lower Extremities- upon inspection, the skin was noted to be dry. Negative

Homans sign. Toenails were short and clean. Pale nail beds were again

noted. Muscle strength were 5/5 on both lower extremities


Glasgow Com a Scale


Eye 4Verbal 5


27/54

Bones and joints: Fusiform swellingwas observed over the index and middle

finger of both hands. With minimal, tolerable pain over the lower extremities.

The patient can bend knees and other joints with no difficulty.



small board provided by the nurse.

CRANIAL NERVE

Name, Type and

Function

ASSESSMENT

TECHNIQUES

NORMAL

FINDING

ACTUAL

FINDING

I. Olfactory

Sensory

Sense of smell

Askedto close eyes and

to identify different mildaromas such as diluted

alcohol and soap suds.

The patient

will identifydifferent mild

aromas

correctly by

means of

smelling of it

and being able

to point out

which is which

The patient

was able toidentify the mild

aromas

correctly.


28/54

Extraocular eye

movement

Movement of the

sphincter of pupil

Movement of

ciliarys muscle of

lens

his head. Assessed for

accommodation by using

the penlight to see the

reaction of the pupil.

pupil, it will

perform

constriction

upon light and

dilation when

light removed.

correctly. His

pupils at 3mm in

size performed

constriction and

dilation. His

pupils were

round and

equally reactive

to light and

accommodation.

IV. Trochlear

Motor

Moves downward

and laterally

Assessed for upward,

downward and lateral

ocular movement without

moving the head.

The patient

will be able to

do the six

ocular

movements.

The patient

was able to

perform the

ocular

movements

without moving

the head.

V. Trigeminal While the client looked

upward, we lightly touch

h l l l f

The patient

will blink his

h h

The patient

was able to blink

f


29/54

mastication

VI. Abducens

Motor

Moves eyeball

laterally

Extraocular

movement

Assessed direction ofgaze by looking at the

side without using head.

The patient willmove his eyes

symmetrically.

Patient Xwasable to move his

eyes

symmetrically.

VII. Facial

Motor and sensory

Facial expressions

Anterior 2/3 of the

tongue

Instructed the client to

smile, raise the

eyebrows, frown, puffcheeks and close eyes

tightly. Asked client to

identify various taste

place on tip side of

tongue, salt, sour,

chocolate candy(sweet)

The patient

will perform all

easily andsymmetrically.

The patient

will identify

what is the

appropriate

The patient

was able to

perform allactivity easily

and

symmetrically

yet

The patient

was able to

identify what is


30/54

he watch test

IX.Glossopharyngeal

Motor and sensory

Swallowing ability

Posterior 1/3 of the

tongue

Instructed the client tosay Ah and ask the

patient to move tongue in

different directions then

placed the tongue

depressor inside his

mouth until he does his

gag reflex and let him

swallow afterwards.

The patient willperform side to

side movement

and also up

and down

movement of

his tongue.

The patient

will elicit gag

reflex and

swallow

afterwards

The patientwas able to do

all movement

easily. Positive

gag reflex was

positive and no

difficulty in

swallowing was

noted.

X. Vagus

Motor and sensory

Sensation ofpharynx and larynx

Assessed by instructing

the client to open his

mouth, speak and

swallow.

The patient

will speak

clearer and

louder and will

easily swallow.

The patient

was able to open

his mouth, speak

and swallow.


31/54

muscles side to side and up and

down.

head to all

movements

XII. Hypoglossal

motor

protrusion of

tongue, movement

and strength

Asked the client to

protrude tongue at

midline then move it side

to side and up and down.

The patient

will do all

movements

given.

The patient

was able to do

all movement

instructed.


32/54

36

E. Laboratory and Diagnostic Procedures

E.1. Laboratory Procedures

* Indicates a special preparation for the procedure

Laboratoryprocedure(Specimen)

Date OrderedDate of Result

Results Normal ValuesGeneral and Patient

IndicationAnalysis and Interpretation

CHEMISTRY

Creatinine(Serum)

Date OrderedFeb 15, 2014

11 AM

Date of ResultFeb 15, 2014

11:57 AM


5:30PM


6:20 AM

105.21mmol/L

101.10mmol/L

70-138.00 umol/L

Creatinine is a chemicalwaste product that'sproduced by the musclemetabolism and to a

smaller extent by eatingmeat. Healthy kidneysfilter creatinine and otherwaste products from theblood. The filtered wasteproducts leave the bodyin the urine.

If the kidneys aren'tfunctioning properly, anincreased level ofcreatinine mayaccumulate in the blood.

A serum creatinine testmeasures the level ofcreatinine in the bloodand gives you anestimate of how well thekidneys filter (glomerularfiltration rate). A

The two determination ofpatients Serum Creatininelevel revealed both normalresults that implies that there

is no impairment in the kidneyfunctions of the patient


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creatinine serum test canmeasure creatinine in thebloodstream (MayoClinic, 2013)

Patient X was subjectedto the test as a routineprocedure for patientsthat are suspected tohave a decreased kidneyfunction based on theconstellation of clinicalmanifestation andfindings gathered by thehealth care team fromhim.

Potassium(Serum)


11 AM


11:34 AM

Date Ordered

Feb 17, 20145:30PM


6:02AM

4.96 mmol/L

3.85 mmol/L

3.50-5.50 mmol/L

This test measures theamount of potassium inthe blood. Potassium(K+) helps nerves andmuscles, including thecardiac muscles tocommunicate. It alsohelps move nutrients intocells and waste products

out of cells.

Abnormalities in SerumPotassium level mayindicate kidneydysfunction as it ismainly mainly controlledby the hormonealdosterone that is

Two out of 2 examinations ofserum potassium levelindicated a normal value whichindicates that the patientsweakness is not due toelectrolyte imbalancespecifically hypokalemia.


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regulated by the kidneyitself.

The indication of the testto the patient is to look

for possibleabnormalities in the levelof potassium in the bloodthat may have causedthe patients lowerextremity weakness.

Sodium(Serum)


11 AM


11:34 AM


5:30PM


6:02AM

131.6

132.6

135-145 mmol/L

Measurement of serumsodium is routine inassessing electrolyte,acid-base, and water

balance, and renalfunction. Sodiumaccounts forapproximately 95% of theosmotically activesubstances in theextracellularcompartment, providedthe patient is not in renalfailure or has severehyperglycemia.

The test for serumsodium was indicated forPatient X to examinepossible electrolyteimbalance that may haveresulted from patientscurrent diagnosis

The study showed anabnormally low serum sodiumlevel on bothdeterminationnormal levels of

Na-

in Patient Xs serum.

This result is coherent with hisHematocrit findings showingbelow normal values that mayhave contributed to dilutionalhyponatremia as shown in thistable.

Liver Enzymes Date Ordered AST (Aspartate The examination yielded


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(Serum) Feb 15, 201311 AM


11:34 AM

SGOT/AST36.53

SGPT/ALT34.05

0.00-37 U/L

0.00-42.00 U/L

Phosphatase) test istypically used to detect aliver injury or an activeor chronic liver problem.The heart can also

release AST, so it isimportant to look at theentire set of liver tests,rather than just this onetest. AST levels can bedramatically affected byshock, low bloodpressure or any othercondition that deprivesthe liver of blood andoxygen. Whilst ALT

(AlanineAminotransferase) isused to detect liverinjuries and long-termliver disease. Highlyelevated levels mayindicate active hepatitisfrom any cause,including virus, alcohol,drug or toxin. Someprescription and over-

the-counter medicationscan cause an increase in

ALT levels. ALT levelscan be dramaticallyaffected by shock, lowblood pressure or anyother condition thatdeprives the liver of

values within normal range,hence it can be concluded thatthe patients condition is nothepatic in nature and there isno liver involvement in the

case.


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blood and oxygen.

Liver injuries can causehypersplenism leading to

filtering out of blood cellsincluding RBCs leadingto anemia. To rule outsuch possibilities in thepatients condition, thepatient was subjected tothe test.

Cardiac Panel(Serum)


5:30PM


6:02AM

CKMB0.40 ng/mL

Troponin I0.57 ng/mL

Less than 5.0ng/mL

Less than 1.0ng/mL

The CPK-MB test isa cardiac marker used toassist diagnoses of anacute myocardial

infarction. It measuresthe blood levels of twovariants(isoenzymes CKM and CKB) of theenzyme phosphocreatinekinase.

Troponin I is a part of thetroponin complex. Itbinds to actin in thin

myofilaments to hold theactin-tropomyosincomplex in place. Humantroponin I is presented incardiac muscle tissueinjury to myocytescauses the release ofTroponin I into thebloodstream..

All results were normal,confirming that there is nocardiac involvement in thecondition of the patient.


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As Patient Xs signs andsymptoms is highlysuggestive that it mayaffect the heart function

leading to cardiac injury,the physicians subjectedthe patient to cardiacpanel test to confirmPatient Xs diagnosis

Random BloodSugar

(Serum)


11 AM


11:04 AM

513.27mg/dl

70-127mg/dl

Random blood sugar(RBS) measures bloodglucose regardless ofwhen the patient last ate.Several randommeasurements may be

taken throughout theday. Random testing isuseful because glucoselevels in healthy peopledo not vary widelythroughout the day.Blood glucose levels thatvary widely may mean aproblem. This test is alsocalled a casual bloodglucose test. Random

testing is not used todiagnose diabetes.

The patient wassubjected to the test todetermine the possibilityof diabetes for furtherevaluation and earlydetection and treatment

The results were abnormallyhigh. As RBS is non-confirmatory of DiabetesMellitus, in the case of PatientX, his physician determinedthat the patient needs further

evaluation, a Fasting BloodSugar level determination.


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to prevent thecomplication thatdiabetes andhyperglycemia mayimpose to the patients

current condition.

*Fasting BloodSugar

(Serum)


5:30PM


6:00AM

177.64mmol/L

70-127mg/dL

Fasting blood sugar(FBS) measures bloodglucose after the patienthas not eaten for at least8 hours. It is often thefirst test done to checkforprediabetes anddiabetes. This will

determine if the patientcan normally control thelevel of sugar in theblood after several hoursof not taking any foodwhich may confirmdiabetes.

The patient wassubjected to the test ashis physicians are

suspecting diabetesmellitus due to hisabnormally high RBSresult as stated above

An abnormally high result wasobtained from the test whichconfirms that the patient isdiabetic.

Further monitoring andtreatment was done for thisspecific type of condition of the

patient.
http://www.webmd.com/food-recipes/guide/fastinghttp://www.webmd.com/hw-popup/prediabetes-impaired-glucose-tolerancehttp://www.webmd.com/hw-popup/diabeteshttp://www.webmd.com/hw-popup/diabeteshttp://www.webmd.com/hw-popup/prediabetes-impaired-glucose-tolerancehttp://www.webmd.com/food-recipes/guide/fasting


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Blood Uric Acid Date OrderedFeb 17, 2014

5:30PM

Date of Result

Feb 18, 20146:40AM

0.46mmol/L

0.20-0.42mmol/L

The blood uric acid testmeasures the amount ofuric acid in a bloodsample. Uric acid isproduced from the

natural breakdown ofyour body's cells andfrom the foods eaten.Most of the uric acid isfiltered out by the kidneysand passes out of thebody in urine. A smallamount passes out of thebody in stool. But if toomuch uric acid is beingproduced or if the

kidneys are not able toremove it from the bloodnormally, the level of uricacid in the bloodincreases. High levels ofuric acid in the blood cancause solid crystals toform within joints. Thiscauses a painfulcondition called gout.

The patient has a historyof gouty arthritis andtherefore he wassubjected to the test.

The test yielded a positivelyalthough slightly high resultwhich confirms the existenceof high uric acid level in theblood of the patient

contributing to the presence offusiform gouts and swollenfinger and toes of the patientas a result of gouty arthritisitself.

Serum Bilirubin Date OrderedFeb 15, 2013

11 AM

Date of Result Total

Total Bilirubin0.12-1.23 mg/dl

Direct Bilirubin0.00-0.20

Bilirubin is made in thebody when old red bloodcells are broken down.The breakdown of oldcells is a normal, healthy

The result of the test revealedabnormally high values whichindicates that the patients

jaundice originated from thepresence of hemolysis. It also


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Feb 15, 201312:30 AM

Bilirubin5.05mg/dl

DirectBilirubin

1.24mg/dl

process. After circulatingin your blood, bilirubinthen travels to your liver.In the liver, bilirubin isexcreted into the bile

duct and stored in yourgall bladder. Eventually,the bilirubin is releasedthe small intestine as bileto help digest fats andultimately excreted withyour stool.

Bilirubin attached tosugar is called direct orconjugated bilirubin,

and bilirubin withoutsugar is called indirector unconjugatedbilirubin. All the bilirubinin your blood together iscalled total bilirubin.

The test was conductedto determine the theselevels which may confirmthe source of jaundice to

the patient, ruling out anypossibility of othercondition.

ruled out the possibility ofhepatic impairment based fromthe result of the liver enzymesas mentioned above.


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HEMATOLOGY

SerumReticulocyte

Count


11 AM

Date of Result

Feb 15, 201312:30 AM

Patient Value

11.7% 0.5-1.5%

A reticulocyte count is ablood test that measureshow fast red blood cellscalled reticulocytes aremade by the bone

marrow and released intothe blood. Reticulocytesare in the blood for about2 days before developinginto mature red bloodcells.

The reticulocyte countrises when there is a lotof blood loss or in certaindiseases in which redblood cells are destroyedprematurely, such ashemolytic anemia. Also,being at high altitudesmay cause reticulocytecounts to rise, to helpyou adjust to the loweroxygen levels at highaltitudes.

The test was done todetermine the extent ofhemolysis of the patientfor early detection andmanagement.

As the patients condition isautoimmune in nature, it wasexpected that the hemolysisrate is very high and thereforethe serum reticulocyte count

generated an abnormally highvalue to almost 10x the normalrange.

Complete BloodCount

(Serum)

OUT-PATIENTFeb 10, 2014

Hct0.33

Hgb110

Hematocrit is a bloodtest that measures thepercentage of the volumeof whole blood that ismade up of red blood

Patient Xs haematocritpercentage and haemoglobinlevels are consistentlyabnormally low andprogressing. This strongly


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11 AM


11:45 AM

WBC13.5

Lymphocyte0.22

Monocyte0.06

Platelet224

Hct0.31

Hgb100

WBC14

Neutrophil0.0460

Lymphocyte0.36

Monocyte0.04

Hct0.41-0.50%

Hgb140-175g/L

WBC4.50-11.00 x109/L

Neutrophil0.18-0.70

Lymphocyte

0.10-0.48

Monocyte0-0.4

Platelet150-400 x 109/L

cells. Hemoglobin is theiron-containing oxygen-transport metalloproteinin the red blood cells.WBC or the white blood

cells are used todetermine infection orinflammation occurring inthe body.Neutrophilgranulocytesare the most abundanttype of white blood cellsin humans and form anessential part of theinnate immune system.Lymphocytesare a type

of white blood cell thatprovide a means forspecific and nonspecificimmunity againstantigens. Monocytesarea type of white blood cellthat attack bacteria orviruses. Plateletshelpthe blood clot.

As a routine in any

medical situation theCBC of Patient X wasexamined to determineany abnormalities forearly diagnosis andmanagement.Furthermore, Patient Xscondition involves thedestruction of 2 blood

suggest the presence of rapiddestruction of the Red BloodCells of the patient.Furthermore, it can also beseen that the Platelet count of

the patient are also decliningwhich means that theexacerbation of his condition isactually a combination ofhaemoglobinemia andtherombycytopenia a rare casein Evans syndrome. TheWBC of the patient on theother hand is remarkably highin the first two determinations,this may be due to the

presence of upper respiratorytract infection of the patientupon admission.


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5:30PM


6:20AM

Platelet167

Hct0.18

Hgb57

WBC8.16

Neutrophil0.77

Lymphocyte0.35

Monocyte0.05

Platelet108,000

component i.e.haemoglobin andplatelet.


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MICROSCOPY TEST

Urinalysis(Mid-Stream

Urine)

Date OrderedFeb 15 2014

11 AM


12:56 PM

ColorYellow

TransparencyClear

pH:6.0

SpecificGravity

1.010

RBC0-1/HPF

Albumin:Trace

Sugar4+

Epithelial cellRare

BacteriaRare

Color:Amber - Yellow

Transparency:Clear

pH:4.5-8.0

Specific Gravity:1.005-1.035

RBC0-5 Hpf

AlbuminNone

SugarNegative

Epithelial CellRare To None

BacteriaRare to None

Urinalysis serves as aroutine laboratoryexamination among

patients urine sample toindicate any possibleurinary abnormalitiessuch as infection andabnormalities in theurinary tract of thepatient.

It was done to Patient Xas it is a routineprocedure in the hospital.

Patient X is suffering from aseverely high blood sugar levelupon admission with a value of

more than 513.27 mg/dl. Thisresulted to the ineffectivefiltering of the kidneys toserum glucose therebyallowing these glucose to passinto the urine, thereforeglucosuria.


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Urine Ketone Date OrderedFeb 15 2014

11 AM

Date of Result

Feb 15, 201412:56 PM

Negative

Negative

Ketones are producednormally by the liver aspart of fatty acidmetabolism. In normalstates these ketones will

be completelymetabolised so that veryfew, if any at all, willappear in the urine. If forany reason the bodycannot get enoughglucose for energy it willswitch to using body fats,resulting in an increasein ketone productionmaking them detectable

in the blood and urine.

The test was done to thepatient to assess theseverity of his Diabetesfor early detection andprevention ofcomplications.

The patient was testednegative for urine ketones.This indicates that the patientsbody is still able to utilizecarbohydrates as a source of

glucose to fuel metabolicdemands.


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Nursing Responsibilities for Venipuncture:

Before:

1. Confirm the patients identity

2. Obtain a history of the patient complaints, including a list of known allergens.

3. Obtain a history of the patient gastrointestinal, hematopoietic, immune and respiratory system, as well as result of previously

performed tests and procedures.

4. Obtain a list of medications of the pt. is taking. The requesting health care practitioner and laboratory should be advised if the

patient regularly uses these products so that their effects can be taken into consideration when reviewing results.

5. Explain the procedure to the patient

6. Prepare the client as necessary for the laboratory procedure that he would undergo.

* FBS- Requires 8 hours of fasting

Some institutions would require NPO including medications. This should be confirmed to the patients phys ician accordingly.

During:

1. Venous blood is used for the test.

2. EDTA (lavender top vacuum tube) is used as the anticoagulant in the collection tube.

After:

1. Observe venipuncture site for bleeding or hematoma formation.

2. Apply pressure to the venipuncture site with a dressing.3. Evaluate the results in relation to the patient symptoms and other tests performed.

4. Record all procedures done.


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Capillary Blood Glucose

A capillary blood specimen is often taken to measure blood glucose when frequent tests are require or when a venepuncture

cannot be performed. This technique is less painful than a venepuncture and easily performed. Hence, clients can perform this

technique on themselves.

Indication

To determine or monitor blood glucose levels of client at risk for hypoglycaemia or hypoglycaemia

Patient Xwas clinically diagnosed with latent Diabetes Mellitus Type II, hence the physician ordered that the patients

capillary blood glucose to be monitored frequently to avoid hyperglycemia which may worsen the patients current medical condition.

Nursing responsibilities for Capillary Blood Glucose test:

Before:

Confirm the patients identity

Explain the procedure to the patient

During:

Turn on the glucometer.

Determine where you are going to puncture for blood, generally the fingertip.

Wash your hands with soap and water and dry them. Insert a glucose test strip into the glucometer.

Pierce the side of the patients fingertip with a lancet device or free needle to obtain a drop of blood.

Place your fingertip at the edge of the glucose strip and hold it to allow the strip to absorb the blood drop.Wipe any excessblood away with gauze.

Read the glucose value that appears on the glucometer display.

After:

Record the glucose readings and relay result to the physician and dispose the materials used in the proper trash bin


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Date Time ResultIn mg/dl

ManagementInsulin in Units via

SC injection

February 15 8 PM 252 5 HRFebruary 16 6 AM 184 2HR

12 NN 74 0

6 PM 164 6 HR

10 PM 264 0February 17 6 AM 252 0

12 NN 310 8 HR

6 PM 189 8 HR

10 PM 241 6 ApidraFebruary 18 6 AM 289 8 Apidra; 20 Lantus

12 NN 198 12 Apidra

6 PM 168 12 Apidra

10 PM 340 12 Apidra

February 19 6AM 189 12 Apidra; 26 Lantus

0

50

100

150

200

250

300

350

8:00 6:00 12

Re

sultsinmg/dl


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Analysis and Interpretation

The table and trend graph above shows that the patients blood glucose levels

are highly from day 1. It can be noticed that the trend graph is highly variable .

This means that the patients Diabetes Mellitus II is poorly controlled and

managed since the patient cannot maintain a stable bloog sugar level throughout the

day even with the presence of insulin being given and his foods are being given

quantitatively and periodically specified by the dietician.


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Diagnosticprocedure


Results

General and Patient Indication Analysis and Interpretation

Chest X-Ray

Feb15, 201410AM

Feb 16, 20142PM

INTERPRETA

TION

Both lungs

are clear

Heart is

within normal

size and

configurationAorta is with

calcified

plaque

Other chest

structures

are not

remarkable

IMPRESSION

1.

Clear Lungs

A chest radiograph, commonly called

a chest X-ray (CXR), is 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 films taken,

being diagnostic of many conditions. like all

methods of radiography, chest radiography

employs ionizing radiation in the form of X-

rays to generate images of the chest.

Patient Xwas subjected through a series of

several Chest X-Rays during his

confinement at Hospital X so as to

determine the progression and

effectiveness of his pulmonary condition.Chest X-Rays served as a basis for his

physicians in decision making when it terms

of managing his condition.

Since the Patient was

complaining of Shortness ofbreath, it was justifiable toperform such diagnosticprocedure to diagnose anyproblem that may beoriginating from the respiratorysystem. The radiographrevealed a normal lung whichmeans that the problem is notrespiratory in nature.

Arteriosclerotic Aorta on the

other hand is common and canbe considered normal amongthe aged.


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Nursing Responsibilities for X-ray:

Before:

Verify doctors order.

Explain the procedure to the patient; its purpose and how it is done.

Inform the patient that there are no food or fluid restrictions.

Instruct patient to remove belt or metal buttons and underclothes and to put on a gown. Inform patient that the test is painless and takes only 5-10 minutes to complete

Dur ing:

Assist in positioning the patient so that x-ray films can be obtained from the most useful angles.

After:

Assist the patient in returning to his comfortable position.

Document the date and time the procedure was done.

2.

Arterioscleroti

c Aorta


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Diagnosticprocedure


Results

General and Patient Indication Analysis and Interpretation

Electrocardiogram(ECG/EKG)

Feb15, 201410AM

Feb 18, 20141PM

Normal Sinus

Rhythm

Normal Sinus

Rhythm

An electrocardiogram (EKG or ECG) is a

test that checks for problems with the

electrical activity of your heart. An EKG

translates the heart's electrical activity into

line tracings on paper. The spikes and dips

in the line tracings are called waves. See a

picture of the EKG components and

intervals

Indications

Anelectrocardiogram (EKG or ECG) is

done to:

Check the heart's electrical activity.

Find the cause of unexplained chest

pain, which could be caused by a heart

attack, inflammation of the sac surrounding

the heart (pericarditis), or angina.

Find the cause of symptoms of heart

disease, such as shortness of breath,

dizziness, fainting, or rapid, irregular

The results for both readingswere normal indicating that thepatients condition is not

affecting cardiac system yetnor it is cardiac in nature.
http://www.webmd.com/hw-popup/electrocardiogram-ekg-or-ecghttp://www.webmd.com/hw-popup/electrocardiogram-ekg-or-ecg


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heartbeats (palpitations).

Find out if the walls of the heart

chambers are too thick (hypertrophied).

Check how well medicines are

working and whether they are causing side

effects that affect the heart.

Check how well mechanical devices

that are implanted in the heart, such as

pacemakers, are working to control a

normal heartbeat.

Check the health of the heart when

other diseases or conditions are present,

such as high blood pressure, high

cholesterol, cigarette smoking, diabetes, or

a family history of early heart disease.

In the case of Patient X, ECG was done to

determine heart involvement in the case as

the patient is complaining of shortness of

breath every now and then which may

greatly influence the hearts normal

functions.


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Nursing responsibilities for Electrocardiography

Before:

Confirm the patients identity by asking his name.

Explain to the patient that an ECG evaluates the hearts electrical activity.

Describe the test, including who will perform it, where it will take place, and how long it will last.

Tell the patient that electrodes will be attached to his arms, legs, and chest and that the procedure is painless. Explain that

during the test hell be asked to relax, lie still, and breathe normally.

Advise the patient not to talk and move during the next because the sound of his voice may distort the ECG tracing.

During:

Place the patient in a supine position. Have the patient expose his chest, both ankles, and both wrists for electrode placement. Provide a chest drape until the chest

leads are applied.

Apply water soluble lubricant on areas of electrode placement.

Turn on the machine and check the paper supply.

After:

Disconnect the equipment, remove the electrodes, and wipe the lubricant from the patient with a moist cloth towel. Wash the

lubricant from the electrodes and dry them thoroughly.

Label each ECG strip with the patients name, date and time of the procedure, and the practitioners name.

Report abnormal ECG findings to the practitioner.

Document.

Documents

2. Nursing Assessment 1