St. Paul University System
College of Nursing and Allied Health Sciences
NURSING CARE STUDY
(Application of Nursing Process)
Name: Arellano,AiginaLucelle H.BSN IIIDate: July 23, 2012
Arriola, Pauline Christine R.
A. General Information
B. Client’s initials: DLB Rm/Wd:5SOUTHEAS/5052A
Date Admitted : November 9, 2012
Age: 59 Sex:F CS:Widowed Nat. FilipinoRel. Roman Catholic
Educ. Attainment: Elementary Graduate Graduate Occupation: None Admission Complaint/s : Decreased Consciousness
Admitting or Working Diagnosis : Central Nervous system Infection secondary to TB meningitis,Bacterial Admitting VS: T-37.4 P-74 Beats/min R-25 Breaths/min BP-130/90 Weight 56kgHeight:145 cm Arrived on unit by: N/AAccompanied by: her niece
Brief description of the diagnosis / surgery performed:
Tuberculous meningitis is an infection of the membranes covering the brain and spinal cord (meninges). Tuberculous meningitis is caused by Mycobacterium tuberculosis, the bacteria that cause tuberculosis. The bacteria spread to the brain from another site in the body.
C. Nursing History (Based on the Functional Health Pattern by Gordon) 1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
2.1 Client’s description of her/his health:
Before Admission: Decreased Consciousness
At present: Central Nervous System secondary to TB Meningitis
2.2 Health Management:
Self : exercise regularly through doing household chores
Drink a lot of fluids
Taking enough rest
Family and Children :
Client’s brother mentioned that the client’s has 3 children. The eldest has his own family and the two kids were taken care by her. He also mentioned that their uncle provides food for them sometimes.
2.3 History of present illness:
The patient had decreased level of consciousness. Her niece stated that at first, the patient experienced headache and just took some rest for temporary relief. Prompted consult and subsequent admission
2.4 Past illnesses:
The clien’t brother didn’t mention that the patient has any past illnesses.
2.5 History of hospitalization (when, where and why):
Two days prior to admission, client experienced decreased level of consciousness that’s why her family decided to admit her in the hospital.
2.6 History of illness in the family:
2.7 Expectations of hospitalization:
‘ Sana naman kahit paano ay bumuti ang lagay niya “ As verbalized by the bother of the client..
2.8 Anticipation of problem with caring, for self upon discharge:
The client’s brother stated that he knew how to feed the client via Nasogastric Tube and needs patient to turn every two hours.
2.9 Knowledge of treatment or practices prescribed:
The client’s brother aware that the client has medicines to take for her recovery.
2.10 Reaction to above prescriptions:
“Tiwala naman po kami sa mgaa doktor na makakaya niyang mapabuti ang lagay ng kapatid ko. Sundin na lang namin kung anong sabihin niya ” as verbalized by the client.
2. NUTRITION AND METABOLIC PATTERN
3.11 Usual food intake (before admission)
Breakfast:1 cup of rice
1-2 glass of water
Lunch:1 cup of rice
1-2 serving of nilagangbaboy
1 serving of mixed veggies
1-2 glass of water
Supper:1 cup of rice
1 serving of fish
1 glass of water
3.12 Usual fluid intake (type, amounts):
The client consumes water, normally about 7-8 glasses per day.
The client prefers water only.
3.13 Any food/fluid restrictions:
Foods with high fat salt and fat.
3.14 Any problems with ability to eat:
The client stated that she has no problem in eating.