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Case Study and Care Plan

Practice of Fundamentals of Nursing
October 22nd, 2012

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Case Study:
Historical and Physical Assesment
Physical Hystory
J.Q. is a 69 year old white male patient who was admitted to PMR ward due to right posterior frontal lobe CVA (Cerebrovascular Accident = stroke). He also continued undergoing hemodialysis on Mondays, Wednesdays and Fridays. The patient continues hemodinamically stable, in no acute distress and no fever reported. Vitals have been relatively within normal limits. Labs were ordered for further evaluation.

J.Q. also suffers from colitis, diabetes mellitus and has a fistule on his left arm. He is at risk of fall due to paralysis of his right side. He is also at risk of aspiration, pneumonia and has an order for antiembolic stockings. He is being observed because his Dilantin level is low (4.1) (normal levels go from 10 – 20), low hemoglobin of 10.5, low hematocrit value of 31.5 and high creatinine level of 4.42. He needs moderate assistance, this meaning that he can perform normal self-care activities on a 50%. When this medical problems have been taken care of he will be discharged to be cared at home by his wife. He is on a diet of 22000 kcal with snacks. Psychosocial History

He is a Catholic who enjoys going to church and talking to people there. Family History
He is married and has children and grandchildren.

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Current Assesment:
Problems:
J.Q. has several medical problems, some of them existed prior to the admittance to the hospital. 1. CVA – reason to be admitted at the hospital
* Right parafalcine posterior frontal lobe. Small infarct * Seizures de novo
2. Deconditioning
* Prolongued ICU stay (39 days)
* Aspiration pneumonia
* Colitis
3. Comorbidities
* End stage chronic kidney disease on hemodialysis
* Past CVA right sided hemiparesis
* Involuntary movements
* Type II Diabetes Mellitus
* Hypertension
* Peripheral Neuropathy
* Retinal Detachment
* Right eye blindness
* Nephrolithiasis (asymptomatic)
* Right Inguinal hernia
* Spinal Stenosis in cervical region
* Gastric Ulcer
* Colonic Polyps
* Chronic kidney Disease
* Sleep Apnea
* Hyperlipidemia
* Coronary Artery Disease
* Low back pain

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Terminology:

1. Hemodialysis- A method of mechanically cleansing the blood outside of the body, in order to remove various substances that would normally be cleared by the kidneys. Hemodialysis is used when an individual is in relative, or complete, kidney failure. 2. Atiembolic stocking- A close-fitting, usually knitted covering for the foot and leg made from nylon, silk, cotton, wool, and similar yarns. 3. Dilantin - an anticonvulsant drug (trade name Dilantin) used to treat epilepsy and that is not a sedative. 4. Creatinine-A compound formed by the metabolism of creatine, found in muscle tissue and blood and normally excreted in the urine as a metabolic waste. Measurement of creatinine levels in the blood is used to evaluate kidney function. 5. Seizures De Novo- Seizures that occur for the first time in a patient and not necessarily are caused by epilepsy. 6. Comorbidities- two or more coexisting medical conditions or disease processes that are additional to an initial diagnosis. 7. Hemiparesis- Slight paralysis or weakness affecting one side of the body. Also called hemiamyosthenia. 8. Peripheral Neuropathy- is damage to nerves of the peripheral nervous system, which may be caused either by diseases of or trauma to the nerve or the side-effects of systemic illness. 9. Nephrolithiasis- Renal calculi, kidney stones. A kidney stone is a solid mass made up of tiny crystals. One or more stones can be in the kidney or ureter at the same time. 10. Inguinal hernia- Hernia in the oblique passage in the lower anterior abdominal wall, through which passes the round ligament of the...
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