THE OXFORD COLLEGE OF NURSING

1st Phase, J.P. Nagar, Bangalore – 560 078

CASE STUDY – 5

Subject : ADVANCED CONCEPTS OF HEALTH

AND NURSING

Submitted to:

Ms. BEENA MARREL

H.O.D. Dept of MEDICAL SURGICAL NURSING
E T C M COLLEGE OF NURSING
KOLAR.

Submitted by:

POORNIMA.R

1st yr M.Sc Nursing

E T C M COLLEGE OF NURSING

KOLAR.
INTRODUCTION

As a part of the curriculum and partial fulfillment of our clinical training in

Advanced concepts and components of nursing, I was posted to various departments
at NIMHANS, from 01/10/2008 to 22/10/2008. I selected the patient by Name Mrs.
Dolly Deb, aged 45 yrs, suffering from Koch’s Spine, admitted in Head injury ward at
NIMHANS, for case study presentation by using Gordon’s functional health status
assessment format.

1. DEMOGRAPHIC DATA

Name : Mrs. Dolly Deb

Age : 45 Years

Sex : Female

Date of Admission : 10/12/2008 at 10 AM.

Guardian and Contact address : W/o. Chittaranjan Deb, Birbum, West Bengal.

Information given by : Mrs. Kaberi, (Patients daughter in law).

Admission medical diagnosis : D6 Koch’s spine.

2. VITAL SIGNS

Height : 160 cms

Weight : 52 kgs (approx)

Temp : 98.4o F (Axilla)

Pulse : 76 / min

Respiration : 20/min

B.P : 110/70 mmHg (Right hand, lying position)

110/70 mmHg (Left hand, lying position)

3. ORIENTATION TO UNIT

The following have been explained to patient and patient’s relatives:

Bed operation/side rails : Yes

Visitation policy : Yes

Bath room/Bed pan – urinal : Yes

Lounge : Yes

TV/Telephone : Yes

Meal/Canteen hours : Yes

Smoking policy : Yes

Call system/bed –bathroom : N/A

Floor restriction : Yes

Newspaper/mail : N/A

Chaplan services : N/A

4. HEALTH PATTERN ASSESSMENT

Reason for hospitalization/chief complaint: Mrs. Dolly Deb, was apparently alright
2 months back to start with, she had back ache, localized to lower back, severe, non
radiating, continuous, was not relieved by analgesics. Patient was taken to local
hospital from there, patient had received tablets but patient was not got relief from
pain, patient had noticed sudden weakness in both lower limbs. She was unable to
walk and became bed ridden. During this episode, patient had urinary retention, for
which patient was catheterized.

No h/o tingling, numbness, trauma, swelling.

No history of HTN / TB / DM / ASTHMA.

Recent illness/exposure to communicable disease: Patient has no exposure to any

communicable diseases other than the present condition – Koch’s spine.

Previous hospitalization/surgeries: Patient does not have any history of previous

hospitalization and surgeries.
What others health problem have you had: She had no history of any disease.

Statement of patient’s general appearance (include condition of hair, skin, and

nails): Patient looks neat, tidy and well groomed. Patient looks worried, reserved,
depressed due to her present health condition. She has a tattoo mark over both
hands towards medial surface, does not have any other lesions and scars on skin.
Hairs are clean, healthy and equally distributed.

Tobacco use : No

Smoking : No

Alcohol use : No

Allergies : No history of any allergies to food, dust, drugs etc.

Any medications : Patient does not use any medications.

5. NUTRITION / METABOLIC

Special diet: Patient is a pure vegetarian. Physician has advised to take protein,
calcium rich diet such as milk, protein powders and vitamin supplement.

Supplements diet: Physician has advised to take protein powder and vitamins
supplements

Appetite: Decreased.

Weight loss / gain: Patient has lost body weight. Weight could not be assessed as
she is bed ridden.

Nausea / Vomiting: No.

GI pain: No.

Condition of oral mucous membranes: Oral mucous membrane is healthy, no

ulceration. Tongue is coated.

Dental condition: All teeth are intact in both lower and upper jaw, yellowish
discoloration with dental carries on the upper right and left molars, pre molars, and
incisors. No dentures. Gums and buccal mucosa: Pink, moist and smooth, no lesion
or ulceration noted.
Skin: Warm, and moist. Wrinkled skin due to old age.

Edema: No edema.

Wounds/drains/dressings: Patient has Grade I bed sore over sacral region. Sterile
dressings are applied over the sore.

Skin problems: Patient has Grade I bed sore over sacral region.

I.V: No.

Ryle’s Tube : No.

6. ELIMINATION

Abdominal tenderness/ distension: Absent.

Bowel sounds: Bowel sounds are heard.

Any problems with hemorrhoids/involuntary stool: No hemorrhoids. Bowel

movements are regular.

Usual bowel pattern: She passes stool atleast once a day.

Bladder habits: Patient is on Foley’s catheter.

7. CARDIOVASCULAR STATUS

Peripheral pulse : 76 / min.

Neurovascular check : Normal

Chest pain/radiation : Absent

Jugular vein distention : No

Heart murmur : No

Pacemaker : No

Presence of A-V shunt : No

Arterio-venous bruit : No
Monitor/rhythm : Yes

Homodynamic monitoring : Yes

8. RESPIRATORY STATUS

Respiratory pattern : Normal and regular, 20/min.

Lung sounds : Normal

Cough/production : No

Oxygen supplement: No

Respiration tubes : No

Ventilatory assistance : No

9. ACTIVITIES OF DAILY LIVING / MOBILITY STATUS

Reference scale ADL Mobility Status

0 – Total independence Feeding : 4 Bed mobility :4

1 – Assist with device Meal preparation : 4 Cart transfer : 4

2 – Assist with person Bathing : 4 Chair/toilet transfer: 4

3 – Assist with person Cleaning : 4 Ambulance :4

and device Dressing : 4 ROM :4

4 – Total dependence Shopping : 4 Handedness :

Right
Grooming :4
Able to use : Yes.
Laundry :4

Toileting :4
Reasons for ADL / Mobility limitations: Patient has poor muscle tone and weakness
of both lower limbs.

Devices used for assist: Pillows, air cushion, water mattress, side rails, back rest.

Do you need assistance with transportation: As the patient is fully bed ridden, she
requires assistance in transportation to laboratories for investigative procedures.

Level of consciousness: Conscious.

Oriented to: Well oriented.

Behaviors: Courteous, soft speech, obeys commands, social.

History of epilepsy/seizures/parkinson’s: Nothing significant.

10. REFLEXES:

Eyes/sight : Pupils are equal and reactive to light.

Hand grasp : Intact.

Movement of extremities : Patient moves both upper extremities. ROM is good.

Unable to move both lower extremities. Poor muscle tone and weak.

11. SENSORIUM:

Eyes/Sight : Visual acuity for near and distant vision is normal.

Patient does not wear spectacles.

Ears/Hearing : Normal. Rinne’s test, Weber’s test normal.

Rhomberg’s sign could not be tested as the patient is

bed ridden.

Nose/smell : Normal. Patient is able to recognize the smell of coffee

Powder and lemon.

Tongue/taste : Normal. Patient is able to recognize the taste of sugar.

Skin/touch : Normal. Patient is able to recognize the sense of light

touch with cotton whip, sharp and blunt object.

Numbness/tingling : No

Dizziness : No

12. COGNITIVE / PERCEPTUAL

Pain: Patient is able to perceive pain.

Method of pain management: Inj. Diclofenac 1 amp bd is administered.

13. COGNITION

Primary language: Bengali. Other languages known are Hindi, Orriya.

Speech deficit: No.

Any learning difficulties: No.

14. SLEEP / REST:

Adequate: Patient complains of inadequate sleep during night.

Method to promote sleep: Quite and calm environment is provided, a glass of warm
milk provided to drink during bed time.

15. SELF PERCEPTION / SELF CONCEPT

Are there any ways you feel differently about yourself since you have been ill /
hospitalized: N/A

Description of non-verbal behaviors: No

16. ROLE/RELATIONSHIP
Do you live with family: Patient lives with her Son, daughter in law and grand
children. Her husband expired 3 yrs back.

Family feeling regarding hospitalization: Family members are depressed, and

worried. They are satisfied with the care and treatment provided in the hospital.

Who are the people that will help you most at these times: Son, daughter in law,
relatives and friends.

Are you employed: No

Occupation: No

Are you presently in school: No

17. SEXUALITY / REPRODUCTIVE

Menopausal: The patient achieved menopause five years back.

Monthly self-breast exam: Not performed.

Vaginal discharge/bleeding/lesion: Nothing significant.

Receiving medical attention? No.

18. COPING / STRESS

Have you experienced any recent stressful situation in addition to your illness: No

19. VALUE / BELIEF

Will illness / hospitalization interfere with the following?

Spiritual or religious practices? Yes

Cultural beliefs or practices? Yes

Familial tradition? Yes

20. INVESTIGATIONS

Blood investigations

SL. PATIENT’S
INVESTIGATIONS REFERENCE VALUE
NO VALUE

1 Glucose 90 mg/dl 70 – 110 mg/dl

2 Urea 19 mg/dl 3.0 – 7.0 mg/dl

3 Creatinine 0.7 mg/dl 0.6 – 1.5 mg/dl

4 Total biluribin 0.6 mg/dl 0.1 – 1.0 mg/dl

5 SGOT 24 U/L 7 – 27 U/L

6 SGPT 22 U/L 1 – 21 U/L

7 Sodium 133 mEq/dl 135 – 145 mEq/dl

8 Pottassium 3.9 mEq/dl 3.5 – 5.0 mEq/dl

9 Chloride 102 mEq/dl 100 – 106 mEq/dl

10 Grouping ‘B’ Positive

11 Alkaline Phosphate 202 UL

MRI Spine: Shows collapse of D6 vertebrae with inflammation / infective changes in

D5 vertebrae with adjacent pre vertebral right para vertebral and epidural abscess.

21. MEDICATIONS:

DRUG DOSAGE SCHEDULE

Tab. Rifampicin 600 mg 1-0-0

Tab. Chloramphenicol 500 mg 1-0-0

Tab. Septran 200 mg 1-0-1

Tab. Rantac 150 mg 0-1-0

Tab. BC 1 mcg 0-1-0

 THEORY APPLICATION

OREM’S THEORY OF SELF CARE DEFICIT

For Mrs. Dolly Deb

Mrs. Dolly Deb, was apparently alright 2 months back to start with, she had
back ache, localized to lower back, severe, non radiating, continuous, was not
relieved by analgesics. Patient was taken to local hospital from there, patient had
received tablets but patient was not got relief from pain, patient had noticed sudden
weakness in both lower limbs. She was unable to walk and became bed ridden.
During this episode, patient had urinary retention, for which patient was
catheterized.

No h/o tingling, numbness, trauma, swelling.

No history of HTN / TB / DM / ASTHMA.

AREAS AND PRIORITY ACCORDING TO OREM’S THEORY OF

SELF-CARE DEFICIT
1. Water
2. Food
3. Elimination
4. Activity/ Rest
5. Solitude/ Interaction
6. Prevention of hazards
7. Promotion of normalcy
8. Maintain a developmental environment.
9. Prevent or manage the developmental threats
10. Maintenance of health status
11. Awareness and management of the disease process.
12. Adherence to the medical regimen
13. Awareness of potential problem.
14. modify self image
 15. Adjust life style to accommodate health status changes and MR
CONCLUSION
The theory of self-care deficit when applied could identify the self care
requisites of Mrs. Dolly Deb from various aspects. This was helpful to provide care in
a comprehensive manner. Patient was very cooperative. The application of this
theory revealed how well the supportive and educative and partly compensatory
system could be used for solving the problems in a patient with Koch’s Spine.