CLINICAL SCENARIO: Nursing Health History A. Patients Profile Name:

Question Answered step-by-step CLINICAL SCENARIO: Nursing Health History A. Patients Profile Name:Patient VABBirthday: September 10, 1961 Age: 59 years old Sex: Male Nationality: Filipino Religion: Roman Catholic Marital Status: Married Address: Alaminos, Laguna Date of Admission: August 20, 2020 Time of Admission: 12:05 am Chief Complaint: Numbness on the Right Leg Final Diagnosis: Tetanus Grade IIIHISTORY OF PRESENT ILLNESS 3 weeks prior to confinement, patient tripped on a rock with steel having linear lacerated wound on his right knee. Wound was cleaned with alcohol. No consultation and no medication taken. 1 week prior to confinement, the patient started feeling numbness on the right leg which prompted to seek consultation at San Pablo Community General Hospital and was admitted for 1 week. The Patient was then referred to San Lazaro Hospital. PAST MEDICAL HISTORYPatient VAB has hypertension but no maintenance medication taken for the past 1 year. Patient has no asthma and diabetes. He is not taking vitamins and other medications except over the counter drugs when he has fever or not feeling well. Patient has a history of fall involving his left leg. He never undergone any type of surgery. He has no known allergy to food and medication.FAMILY HISTORY (+) Hypertension (+) Diabetes Mellitus (-) Cancer PERSONAL AND SOCIAL HISTORY Patient is a 47 pack year smoker. He consumes 2 bottles of beer twice a week. He prefers to eat rice, fish and vegetables. He enjoys his leisure time in gardening. He gets along with his neighbors pretty well. He likes going to his friends by walking. He is a sweet and loving husband. ADMISSION ORDER The patient was admitted on August 20, 2020 at 12:05 am with a chief complaint of numbness of the right leg and was admitted to satellite ICU of San Lazaro Hospital, hooked to PNSS 1L at 150 cc/hr. Patient was subjected to the following laboratory procedures: CBC, BUN, Creatinine, SGPT, SGOT, ABG, RBS, UA. Patient was given Tetanus Toxoid 0.5 ml IM, Metronidazole 500 mg IV every 6 hours, Diazepam 10 mg IV every 4 hours, Baclofen 10 mg 1 tab TID, Clopidogrel 75 mg 1 tab OD, Atorvastatin 40 mg/tab 1 tab ODHS, Losartan 50 mg 1 tab OD, Amlodipine 10 mg 1 tab OD, Paracetamol 300 mg TIV q4 PRN, Omeprazole 40 mg/capsule 1 tab OD, Piperacillin + Tazobactam 4.5 g/TIV q6, Acetylcysteine 600 mg/tab OD/HS, Tranexamic Acid 500 mg IV q8 PRN, Ferrous Sulfate 1 tab OD, Budesonide 200 mcg/dose q12 and Ceftriaxone 2g OD. Additional diagnostic tests were also conducted the following days are GS/CS test, CBG, CT Scan with contrast, Chest X-ray, Na, K and ECG. Bed side care implemented to the patient that includes proper positioning, bed sore precaution, turning the patient to side at least every 2 hours, I & O monitoring, suctioning of secretions PRN, monitoring of vital signs, LOC, and neurologic status, monitoring of fever, spasm and hypotension episodes. Crackles were also monitored including dyspnea and respiratory distress. Edema, decubitus ulcer and phlebitis were also assessed and monitored. The patient was also provided an oxygen therapy via tracheostomy, pulse oximeter monitor was attached to the patient, physical examinations were conducted, tracheostomy care was provided, chest physiotherapy was initiated and OF through NGT was given and bladder training was also conducted. COURSE TASKS: 1. Make at least 2 days course in the ward based on the admission order and some activities happened in the ward. Health Science Science Nursing NCMA 312 Share QuestionEmailCopy link Comments (0)