Student
Case Study and Care Plan
Practice of Fundamentals of Nursing
October 22nd, 2012
1
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.
2
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 *
Practice of Fundamentals of Nursing
October 22nd, 2012
1
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.
2
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 *
References: …………………………………………………………….9