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...