Presentation Of Medical Terminology

JULIA LEONOR HUARINGA LAGOMARSINO, RN

SELF CARE DEFICIT (BATHING, HYGIENE,DRESSING, GROOMING) R/T COGNITIVE IMPAIRED.

Self Care Deficit, Dressing and Grooming Related To Neuromuscular Impairment

Self Care Deficit, Dressing and

DEMOGRAPHIC DATE • PATIENT: DC • DOB: 08/16/1951 • ADM DATE: 10/10/2000 • NEUROLOGIST : NUNEZ FRANCISCO. • DIAGNOSIS: ALZHEIMER

… ASSESSMENT/INTERVIEW •Mr. X is a 53-year-old male who presents memory loss and sometimes forgets entire experience.

•His wife thinks that something is wrong with him because that over the last year, Mr. X has become more and more forgetful, and rarely remembers later. And she also states that he forgets appointments and phone calls, sometimes just after he hangs up the phone. •He is being gradually written/spoken directions.

unable

to

•He is gradually unable use notes as reminders.

follow

… ASSESSMENT/INTERVIEW also states he is being gradually unable to • His wife take care for self, forgets how to wear his clothes,, don’t want to eat, etc. • Mrs. X states that over the last year, her husband has had problems walking, like he can fall down easily. • Over the last 6 months, he keep walking around the house and going out very often. • He also reports urinary incontinence over the last 6 months. Mr. X describes it as "not being able to control it."

PATIENT’S PAST HISTORY • Mr. X's father died at the age of 49 from a heart attack. • His mother is still alive and is in a nursing home, he moved there after having a stroke 3 years ago and now he has Alzheimer also. • His brother and sister are in good health. • M.r X had a head injury 10 years ago, after a car accident.

TREATMENT • • • • • • • • • •

DRUGS Rivastigmine (Exelon) Twice a day. Donepezil (aricept) once a day Tacrine (Cognex) 4 times a day. Valium…….PRN SUPPLEMENTS Folate (Vitamin B9) Cyanocobalamine(vitamin B12) Ginko Biloba Vitamin E

PHYSICAL EXAMINATION • • • • • • •

Temp: 98°F BP: 170/110 Pulse: 95 Resp: 19/min Height: 5'11" Weight 293 HEENT: Within normal limits Motor Biceps: 5/5 bilaterally Triceps: 5/5 bilaterally Quadriceps: 3/5 bilaterally Hamstrings: 3/5 bilaterally

PHYSICAL ASSESSMENT •Sensory: Pin-prick and temperature sensation and simple touch are intact. Vibration is normal in upper extremities, but diminished in lower extremities bilaterally. •Neurological - Reflexes: Biceps: 2+ bilaterally Brachioradial: 2+ bilaterally Patellar: 3+ bilaterally Ankle: 4+ bilaterally Plantar Response: Extensor bilaterally

PHYSICAL ASSESSMENT •Propioception and Cerebellar Function: Finger to finger: no follow indication, abnormal Heel to shin: no follow indication abnormal Rapid alternating movements. Not achieve this movement. Joint position : normal • Gait: Mr. X's gait is abnormal, walking in a shuffling manner. He is mildly ataxic. • Cranial Nerves: II-XII are intact.

MENTAL ASSESSMENT Mental Status: •Patient seems confused, restlessness and wandering •He is oriented to person, but not place or time. •He exhibits dyscalculia. •Immediate recall is impaired. • When asked to act out combing his hair or shaving, the patient could not do so. • Complex commands were difficult for the patient to follow. • Judgment was impaired as was the ability to describe simple analogies.

NURSING DIAGNOSIS • •

•

•

IMBALANCED NUTRITITON,LESS THAN BODY REQUIEREMENTS R/T LACK OF SELF-CARE, AND INCREASED METABOLIC DEMANDS. GOAL: 1.- Will maintain appropriate weight. 2.-Display normalization of laboratory values and be free of signs of malnutrition as reflected in defining characteristics. INTERVENTIONS: 1.- To assess causative/ contributing factors 2.- Give him extra calories. 3.- Supervised meals and help with feeding. IMPLEMENTATION; 1.- Determine client’s to ability to chew, swallow, and status of denture. 2.- Give him extra calories as indicated in balanced diet. 3.- Supervised meals and help with feeding

NURSING INTERVENTIONS AND RATIONALITIE • •

•

•

SELF CARE DEFICIT (BATHING, HYGIENE,DRESSING, GROOMING) R/T COGNITIVE IMPAIRED. GOAL: 1.- Identify individual areas of weakness/needs. 2.- Identify resources than can provide assistance.. INTERVENTIONS: 1.- To assess causative/ contributing factors 2.- To evaluate degree of disability. 3.- To assist in correcting/dealing with situation.. IMPLEMENTATION; 1.- Determining age and development issues affecting/habilityof individual to participe in own care. 2.- Identify degree of individual impairment. 3.- Practice and promote short term goals settings.

EVALUATION 1. Patient is assisted for family and a care giver (every 12 hours.) 2. Patient chew and swallow easily. 3. Patient receive balanced meals, as requirement. 4. Maintain normal weight and is being helped with feeding 5. Patient has his eyes, ears and as denture checked. 6. Patient has been helping for Family and care givers, understanding his world. 7. Patient wear his clothes daily, helps watering plants with assistance of family or caregiver.