A nursing case study on : Alzheimer's Disease

8/13/2019 A nursing case study on : Alzheimer's Disease

1/22

NURSING HEALTH ASSESSMENT

I.FINAL DIAGNOSIS

Alzheimers

II. HEALTH HISTORY AND PHYSICAL ASSESSMENT

A. Demographic (Biog raphical Data)

1. Clients Initial C.A.T

2. Gender Female

3. Age/B-day/B-place 83 Y.O. / 8-24-1930 / Cebu

4. Civil Status Married

5. Nationality Filipino

6. Religion Roman Catholic7. Address & Telephone Number Blk 14 Lot 40 Phase 1 Solar Homes

Subd. Dasmarinas City, Cavite 4114

(0917-363-****)

8. Educational Background High School

9. Occupation Housewife

10. Source of Medical Care Clinic

11. DOA 3-2-2013 @ 1:30 pm

B. SOURCE AND RELIABILITY OF INFORMATION

The client was unable to prove any information; she remained asleep throughout both

duty rotations. Her daughter in laws, son and husband served as her primary source of

information. The patients chart served as a secondary source of information. Laboratory

and other diagnostics were derived from the patients chart. Some information were

derived from the patients chart.

C.CHIEF COMPLAINTS

Lagi syang nanghihina as verbalized by pts daughter in law.

Napansin naming nahihirapan syang humingaas verbalized by the husband.


2/22

D. History of Present Illness

The pts Alzheimers disease came about 7 years ago in Cebu. It began when

she was brought to Sotos Hospital for a check-up d/t a lump on her neck. The patient

had no complaints of it being painful but it was diagnosed as a cancerous tumor.

Surgery was not offered as an option for her d/t her old age; it would be harder for her to

recover. As an alternative, medication was prescribed to her as a form of therapy.

Although a promising outcome was not given, the patient and her family took the

chance with hope. The doctor warned them of the possible side effects of the

medication which was Alzheimer Disease. Months passed but the tumor was still the

size of a large marble; at around 6 months, the entire family accepted this and just

decided to continue living the rest of her life with her as normal and comfortable as

possible.

The pt use to work as a ticket checker at a theatre, but was forced to quit due toher disease. While her cancer did not seem to progress, her Alzheimers did on the

other hand. Along with her progressing disease, the pt complained of knee pain. In the

early stages, she would forget where the pots and pans were, or what she was doing in

a certain room as she would be entering it. But the disease progressed and began to

get worst 3 years ago. Her husband took over the everyday tasks that she use to do

such as cook, clean, laundry and groceries.

The pt was administered to the St. Paul Emergency Room on March 2, 2013 at

9:20 am. By 1:30pm, she was transferred to the O.B ward in a private room. She had an

intravenous line of She had vital signs of Based on her laboratory results, she wasgiven the prescribed medications at the proper times.

E. PAST HEALTH

a. Pediatric/Childhood/Adult Illness

The client had no any major or serious illness during her childhood. Her

husband and children stated that she lived a healthy life. However she did smoke a lot

of cigarettes. The patients husband stated that she already had the chicken pox when

she was 15 but no other complications happened except for a few scars that it left.

There were times when the patient had the flu and sometimes accompanied by a cough

but it does not cause her serious harm because she is fully immunized.


3/22

b. Injuries and Accidents

The patients daughter in law verbalized that the only time the patient had a

serious accident was last July when the patient was left home alone. The daughter in

law explained that the patient was left on her wheel chair in the front yard within closed

confines of their home while the husband left quickly to buy something. Meanwhile, the

daughter in law was in her own home next door but was unaware of her being alone by

herself. Since the patient has Alzheimer, she is unaware of the aftermaths of every

action; she rolled her wheelchair down the stairs and she rolled with it all the way down.

The patients daughter in law further stated that the patient had suffered from

cuts, bruises, a fever and a bump on the head. She was quickly rushed to the nearest

clinic called GMF in Bayan.

.

c. Hospitalizations and Operations

The daughter in law stated that she has not been hospitalized or operated on

except for the time she visited the hospital in Cebu for a check-up and this recent

hospitalization. She further explained that the pt was not admitted to the hospital during

the times of delivering her children; she gave birth at a clinic.

d. Reproductive History

The patients husband said that the patient had her menarche when she was 11

years of age. She was spending some time in the fields with a few friends when one ofher friends noticed a large red stain on her dress. Perplexed, she quickly ran home to

use to restroom. To her surprise, she saw her entire underwear drenched with blood.

The husband said that the client mentioned to him before that it was around 14 years of

age that she began to develop her breasts and pubic hair. She did not develop any

acne during or before her menstruation but she did experience dysmenorrhea. The

patient had a regular menstruation cycle.

On September 1930, when she was 40 years of age, she had her LMP. The

patient had 7 children total, and all of them were full term. Her husband stated that her

family had no history of any reproductive diseases and whenever she had her monthly

period, she experienced dysmenorrhea, but the blood coming out was of small amount.

Her cycle was normal, but there were times that the client experienced heavy

menstruation and it made her feel sick maybe due to blood loss, but other than that,

there were no complications. She did not take any oral contraceptive pills to delay her

pregnancy.


4/22

e. Immunization

BCG: / - / At Birth / - / School Entrance

DPT: / - / 1stdose /- / 2

nddose /- / 3

rddose

OPV: /- / 1stdose /- / 2nddose /- / 3rd dose

AMV: /- /

TT: /- / 1stdose /- / 2

nddose /- / 3

rddose /- / 4

thdose /- / 5

thdose

HBV: /- / 1stdose /- / 2

nddose /- / 3

rddose

Others:

f. Allergies

/ / Foods, please specify: NONE

/ / Drugs or medications , please specify: NONE/ /Chemicals, please specify NONE

/ / Other environmental allergens, please specify NONE

g. Medications

The patients daughter in law stated that the client did not take any other

medications prior to her hospitalization other than OTC drugs such as Biogesic and a

Pharex, a vitamin B Complex for her bones which would be taken OD as 50ml tablets.

It was also mentioned that she use to take medication for her cancer, but the

family could not recall its name.

GENERIC NAME: Multivitamins and MineralsBRAND NAME: Pharex

.INDICATION: Vitamin B-complex deficiencies, neuritis, polyneuritis, diabetic

neuritis, neuralgia, lumbalgia, sciatica, intercostals and trigeminal

neuralgia, peripheral neuroparalysis arthralgia and myalgia.

GENERIC NAME: ParacetamolBRAND NAME: BiogesicINDICATION: Relief of fever, minor aches and pain felt. The drug may relief

fever through central action in the hypothalamic heat regulatingcenter


5/22

F. FAMILY HISTORY : Family was unable to provide

The family of the patient was unrecalled by the family members. However, theson stated that all deaths in the patients side of the family were due to old age; the

patient is the last living.

The family of the patients husband has no diseases. His parents died d/t old

age, while all 3 of his siblings are still alive and well. His sister Lydia is 78 years of age,

his brother Pedro is 65 and is currently a mayor in Cebu, and Angeles, his other brother

is also alive and well.

There is no evident disease in their children as verbalized by the patients son.

The son verbalized that she had a very good relationship with her husbands family and

as well as her own family. The husband stated that not once did their children hear them

have an altercation because they made sure that it was done behind closed doors and it

was talked out.

G. SOCIO-ECONOMIC HISTORY

Family Members Occupation Monthly Income

Corazon Trinidad Theatre Php2,500

Regulo Trinidad Acevedo Optical Php2,500

Giogany Trinidad Engineer Php50,000

Giovannie Trinidad Electrician Php18,000

Giodinno Trinidad Watch Repair Php1,000

Giosinne Trinidad Optical Php20,000

Gualberto Trinidad Watch Repair/Fisherman Php2,000/day

Although the client has many children that works for a living, only one that works abroad

sends them money to live off on a day to day basis. When the client use to work at the

theatre, she made Php2,500/month as well as her husband, Regulo Trinidad who

worked at Acevedo Optical. Their son, Giogany is an engineer that makes


6/22

Php50k/month, Giovannie is an electrician who made Php18k/month, and Giodinno is a

watch repair man that made Php1k/month. Their daughter Giosinne works at an optical

clinic and makes Php20k/month while Gualberto is both a watch repairman as well as a

fisherman and brings in php2k/day. Their daughter who works abroad named Maria

Gemma works as a secretary at a hotel but her income is unknown because she does

not call often.

H. PSYCHOSOCIAL ASSESSMENT

PATIENTS AGE: 83 years old

DEVELOPMENTAL STAGE: Maturity to death

DEVELOPMENTAL TASK : Integrity vs. Despair

As we grow older and become senior citizens, we tend to slow down our productivity,

and explore life as a retired person. It is during this time that we contemplate our

accomplishments and are able to develop integrity if we see ourselves as leading a

successful life. Erik Erikson believed if we see our lives as unproductive, feel guilt about

our pasts, or feel that we did not accomplish our life goals, we become dissatisfied with

life and develop despair, often leading to depression and hopelessness. Success in this

state will lead to the virtue of wisdom.

Due to her current state, the client was unable to provide any information regarding herself. However, her husband and son were able to provide as much as they can. The

family explained that during the early stages of her sickness when she was still lucid,

the patient expressed that whatever happens to her, that she wanted them to know that

she does not regret anything that has happened to her in life. Although she was not able

to finish school because she married early, she does not regret it because she had a

very loving and meaningful relationship with her husband. Her husband always showed

her worth while her children always reassured her that they loved her. They further

explained that the client stated that she accepted what was happening to her a long

time ago because she feels that she has lived her life to the fullest though it is of a

simple one.


7/22

I. FUNCTIONAL ASSESSMENT

1. Self con cept, Self Esteem

The clients last educational attainment was 3rd

year in High School. She was 15

years old when she ceased attending so that she can help her family by working. She

had plans on returning but she met her soon to be husband and was married by the age

of 17. It was reported by her children that she did not regret dropping out of school nor

marrying at an early age because she had a happy marriage life with beautiful, loving

and obedient children. She felt her worth was not measured by the educational

attainment she received but in someone higher; she felt her life was lived to the fullest

and she did not think any less of herself.

2. Occupat ion

In the past, the client worked as a ticket clerk at a movie theatre. Though her job

was repetitive each day, she enjoyed it because she saw many different kinds of people

and she enjoyed conversing with many of them. She made around php2,500 each

month. With her husbands income, they were able to make just enough to provide for

her familys needs. She only made just enough and would try to save if there was any

left over from what they spent each month.As the clients disease progressed, she was

forced to quit her job. She did not participate in any community activities nor volunteer

due to her illness.

3. Ac tivi ty and Exercise

While she was still well, the client exercised by walking at least 1 kilometer every

day down the street from her home. Her daily chores also served as her means of

exercised. She did not do any sports or other strenuous activities. Her body remained

healthy because of the healthy food she would consume everyday and just the right

amount of exercise her body needed. Currently, the family would take turns to massage

her muscles and slowly stretch out her joints and do some minimal ROM exercises

since she is not able to do so by herself. Most of her time is spent sitting on her

wheelchair at home watching people and vehicles pass by their house or watching tv.

Back in the day, she did not have any hobbies, so as a means of passing time or

relaxing, the patient smoked cigarettes.


8/22

4. Sleep and Rest

As verbalized by her husband and daughter in law, the patient rarely sleeps for

unknown reasons. Her usual sleeping patter is 3 hours per day. It was explained that

even back then when she was healthy, the most she would sleep each night would be

4-5 hours. The amount of sleep the patient receives each day seems to be enough as

evidenced by not falling asleep during the day and looking wide awake. Once in a while,

the patient would take a nap when she feels like it on her wheelchair. The family would

then transfer her to the bed so that she is able to sleep comfortably.

5. Nutr i t ion /El imination

Patient voids urine 2-3 times a day, and drinks small sips of water that is

equivalent to 3-4 glasses of water each day. Her urine is clear and yellow. It was statedthat patient does not complain of any pain whenever urinating or passing of stool. There

are no other diseases that run in the family in relation to painful urination and

defecation.

The client eats 3 meals a day plus an afternoon snack. Ever since her disease

began to progress, her husband has been preparing the meals, shops for their groceries

at the market and washes all the dishes. The client always has her husband to eat with

her; she is now spoon fed small portions of food at a time to avoid aspiration. The

money that they receive each month from their daughter allocated for groceries and

other bills are enough to suffice their needs. It was reported by the husband that around

1k is spent every 2 days for their food. As a way to prepare food, a gasoline stove isused. The patient prefers foods such as bananas, mangoes, mashed potatoes and

foods as such that are soft in consistency.

6. Interperson al Relation ship /Resou rces

The patient shares her home with her husband, one dog and one cat. Their pets

help the patient relax and be entertained, says her husband. The animals are very

loving and somehow know to behave and be gentle when around her. Only one of her

sons live right next door along with the patients daughter in law and grandchildren. The

daughter in law stated that the grandkids are very fond of their grandparents and love to

give her hugs and kisses and tell stories. They understand her situation and are very

patient with her and love her regardless. All her grandchildren that live next door, ages

24, 32, 24, 12 and 9 visit her every single day. The patients daughter in law is very

helpful in helping in things that the patients husband needs help in doing; moreover she

helps take care of the patient as if it was her own mother. The rest of her children are all


9/22

spread out in places such as Trece, Bulacan, Makati and Bicol and also in the United

States. They visit whenever there is a special occasion. When the patient was still well,

she was the one to do all of the cleaning and cooking in the house. Her family members

were very proud to boast that she makes excellent meals such as pinakbet, sinigang,

bicol express and such. Her family are always there for emotional and physical needs.

7. Coping and Stress Management

Family was not able to provide information

8. Enviromen tal Hazards

The patients home is a one story house safe with a gate and bars on their

windows. Their large windows serve as a fire escape in case of a fire emergency. Boththe patient and her husband have been residing in their home for 5 years. Although they

like their house, the husband complains that their neighborhood is a bit chaotic. There is

a lot of noise from street children fighting and neighbors quarreling; there are also a lot

of tambays. Facilities such as the grocery store, drug store, church and healt h care

facilities are nearby and you would only need to ride a tricycle or jeep to reach them.

The chapel is within their compound while for groceries, they just take a tricycle to get to

Bayan. According to the patients husband, there has been an incident of theft from their

maid that they had for 2 months; even though they welcomed her into their homes and

tried to treat her so that she felt at home, she still stole 10k pesos. The monthly

allowance the couple receives is sufficient enough to provide for their every day needsas well as repairs in the house if need be. The patients husband receives around 3,500

pesos a month from his pension, plus 12,000 pesos from their daughter abroad each

month. Two-thousand a month is spent on electricity and water, one-thousand is paid

for the house, 2,000 pesos each week for food and other miscellaneous things.

J. REVIEW OF SYSTEMS

SYSTEM REVIEW OF

SYSTEM

PHYSICAL EXAMINATION

1. General ASSESSMENT:

Received pt on semi-fowler position

Patient was sleeping.


10/22

With venoclysis of D5LR 1L X 24O

hooked at LMCV, running at a rate of

13-14 gtts/min, received at 450 cc,

intact and infusing well.

With vital signs as of 4 pm

o T: 36.7oC

o PR: 70 bpm

o RR: 19 cpm, regular with

bilaterally equal chest

expansions

o BP: 110/80 mmHg

Capillary refill


11/22

family member.

5. Ears Wala naman

siguro as

verbalized by

family member

INSPECTION:

(-) discharges on external ear

(-) hearing aides

6. Nose and sinuses Okay naman

siguro- as

verbalized by the

family member

INSPECTION:

(+) some nasal flaring

(-) lesions

(-) nasal discharges

Sinuses are clear upon

transillumination

PALPATION:

(-) tenderness on sinuses

7. Mouth and throat Medyo natutuyu

lng labi nya

INSPECTION:

Dry lips and oral mucosa

(+) gag reflex

(-) hx of any infections on throat (-) mumps

PALPATION:

(-) swelling

8. Neck Meron nga syang

buko sa leeg nya

INSPECTION:

(+) lump on right side of neck

9. Breast and axilla Wala naman

kaming

napapansin

Family refused

10. Respiratory Ayun, minsan INSPECTION:


12/22

nahihirapan sya

huminga

(+) cough

Symmetrical thoracic breathing

RR: 19 cpm, regular with bilaterally

equal chest expansions

AUSCULTATION

(+) wheezing

(+) crepitus

PERCUSSION

Hyperresonant sound was produced

upon percussion

11. Cardiac Wala namansyang dinadaing

saamin as

verbalized by

family.

INSPECTION: Regular rhythm bilateral

AUSCULATATION:

Apical Pulse 70 bpm at 5TH

ICS MCL

on the left

Normal heart sounds

Regular rate

12. Gastrointestinal Wala naman

siguro. Pero

pansin naming,

madalas syang

nagkakagas as

verbalized by

family member.

AUSCULTATION:

Normal bowel sounds @ 10 BS per

minute

PERCUSSION

Tympanic sounds were produced

PALPATIONS:

Non tender

Normal liver span

No enlarged organs


13/22

13. Urinary Wala naming

problema as

verbalized by

patients family

member.

No physical Examination

14. Genitalia Wala naman

syang problema

as verbalized by

patients family

member

Family refused

15. Peripheral

Vascular

May mga sugat

sya as

verbalized byfamily member.

INSPECTION:

(-) varicosities on lower extremities

(+) bed sores Capillary refill


14/22

III. LABORATORY STUDIES AND DIAGNOSTICS

TEST INDICATIONS NORMAL ACTUAL NURSING

RESPONSIBILITIES

CBC

3-6-13

The complete

blood count (CBC)

is a screening test,

used to diagnose

and manage

numerous

diseases. It can

reflect problems

with fluid volume

(such as

dehydration) or

loss of blood. It

can show

abnormalities in

the production, life

span, and

destruction of

blood cells. It can

reflect acute or

chronic infection,allergies, and

problems with

clotting.

WBC : 5.010.9

RBC : 4.25.4

HEMAGLOBIN:

12.015. 0

HEMATOCRIT:

37.047.0

>Differential

Count

Segmenters:

50-70

Lymphocytes:

20-40

Platelet Count:

150-500

8.3

L 3.9

L 11.1

L 34.1

H 79

21

402

PRETEST:

Positively identify the

patient using at least

two unique identifiers

before providing care,

treatment, or services.

INTRATEST:

If the patient has ahistory of allergic

reaction to latex, avoid

the use of equipment

containing latex.

Instruct the patient to

cooperate fully and to

follow directions.

Direct the patient to

breathe normally and

to avoid unnecessary

movement.

Observe standard

precautions, and


15/22

follow the general

guidelines.

Remove the needle

and apply direct

pressure with dry

gauze to stop

bleeding.

Observe/assess

venipuncture site for

bleeding or hematoma

formation and secure

gauze with adhesive

bandage.

Promptly transport the

specimen to the

laboratory for

processing and

analysis.

POST-TEST:

A report of the results

will be sent to therequesting HCP, who

will discuss the results

with the patient.

Depending on the

results of this

procedure, additional

testing may be

performed to evaluate

or monitor progression

of the disease process

and determine the

need for a change in

therapy. Evaluate test

results in relation to


16/22

Urine

Analysis

3-5-13

A urinalysis

consists of a

number of

physical,

chemical and

microscopic tests

of a urine sample

as part of a

checkup to help

diagnose aurinary tract or

metabolic

disease.

Routine Physical

A routinephysical examoften includes aurinalysis toscreen for earlysigns of medicalproblems.

Abnormal wasteproducts orabnormal levelsof cells mayindicate disease.

MonitoringDisease

For patients whoalready have anexisting conditionlike diabetes orkidney disease,

Bun : 2.14-7.14

Creatine :45-84

Uric Acid:

142.8339.2

Na : 135148

Random Blood

Sugar : 6.1 8.02

K : 3.55.3

3.5

46

163.0

140

L 4.7

3.5

the patient's

symptoms and other

tests performed.

1. Instruct thepatient to voiddirectly into a

clean, dry

container.Sterile,

disposable

containers are

recommended.Women should

always have a

clean-catch

specimen if amicroscopic

examination is

ordered. Feces,discharges,

vaginal

secretions and

menstrual bloodwill contaminate

the urinespecimen.

2. Collectspecimens form

infants andyoung children

into a disposable

collection

apparatusconsisting of a

plastic bag with

an adhesivebacking aroundthe opening that

can be fastened

to the perinealarea or around

the penis to

permit voiding


17/22

urinalysis helpsto monitor theirstatus anddetermineswhether their

course oftreatmentrequiresadjustment.

Urinary TractSymptoms

Patients whohave urinarysymptomsundergourinalysis to helpdoctors diagnoseurinary tractdiseases, likeinfections.

Abnormal testresults in such

cases commonlyinclude bloodand increasedwhite cells in theurine.

directly to the

bag. Dependingon hospital

policy, the

collected urine

can betransferred to an

appropriate

specimencontainer.

3. Cover allspecimenstightly, label

properly and

send

immediately to

the laboratory.4. If a urine sampleis obtained froman indwelling

catheter, it may

be necessary toclamp the

catheter for

about 15-30

minutes beforeobtaining the

sample. Cleanthe specimen

port withantiseptic before

aspirating the

urine samplewith a needle and

a syringe.

5. Observe standardprecautions when

handling urine

specimens.

6. If the specimencannot be

delivered to the

laboratory ortested within an

hour, it should be

refrigerated or


18/22

have an

appropriatepreservative

added.

B. PHARMACOTHERAPEUTICS/MEDICINES

GENERIC (BRAND)

NAME

CLASSIFICATION

STOCK DOSE

INDICATION

DOSAGE

FREQUENCY

N.R.

G: Fluimucil

B: NAcetyl-L-

C: Mucolytic

SD: 600mg/tab c

I: Treatment of respiratoryinfections characterized by thick

and viscous hypersecretions:

acute bronchitis, chronic

bronchitis, and its

exacerbations; pulmonary

emphysema, mucoviscidosis

Nursing Considerations forClients Taking Fluimucil

Due to the high dosesrequired, the patient shouldbe watched for an overdosage of this medication,signs may include nausea


19/22

glass water and bronchieactasis

D: 600mg/tab with glass

water

F: OD in the evening

and vomiting.

Nurse should also WOFincreased blood pressure andhypoxia.Patients suffering from

bronchial asthma must bestrictly monitored duringtherapy. Shouldbronchospasm occur, the txmust be suspendedimmediately. It should beused with caution in asthmaticpatients and patients with ahistory of peptic ulceration.The possible presence of asulfur-like odor does notindicate an alteration of the

product but is a characteristicof the active ingredientcontained in preparation. It ispreferred not to mix otherdrugs with Fluimuci solution.

Patient Teachings for

Clients Taking Fluimucil:

Hypersensitivityreactions have been

reported in patientsreceivingacetylcysteinincludingbronchospasm,angioedema,rashes, and pruritus.Other adverseeffects include N/V,fever, syncope,sweating, blurred

vision, anddisturbances of liverfunction. Any signsshould be reportedimmediately.


20/22


21/22


22/22

HEALTH ASSESSMENT

(DLS-UMC)

SUBMITTED BY:

Jesslee M. Llanes SN15BSN 2-1

SUBMITTED TO:

Mrs. Daisy Doctor RN, MAN

March 20, 2013

A nursing case study on : Alzheimer's Disease

Documents

Transcript of A nursing case study on : Alzheimer's Disease