s

URDANETA CITY, PANGASINAN COLLEGE OF NURSING

Submitted by: MALLAR, ADRIAN G BSN 3/GROUP 4 Submitted to: Mrs.Emy Lyn Unson Clinical Instructor

PATIENT ASSESSMENT DATA BASE A. GENERAL DATA Patients Name: L.F Address: San Nicolas, Pangasinan Age: 35 Sex: Male Birth Date: January 1, 1978 Rank in the family: Father Nationality: Filipino Civil Status: Married Date of Admission: August 5, 2013 @ 12:30 pm Order of admission: TPR every shift, BRAT, CBC, Creatinine, Urinalysis, Fecalysis, BUN, PNSS 1L for 6 hours, , Paracetamol 500mg 1 tab every 4 hours PRN, Cefuroxime 750mg SIVP every 8 hours, Hyosine NBB IVP every 8 hours Attending Physician: Dr. Campus B. CHIEF COMPLAINT With the chief complaint of diarrhea. C. HISTORY OF PRESENT ILLNESS Prior to admission, the patient experienced 3 days of diarrhea watery for 3 times ,and abdominal pain with no consultation done. D. PAST HEALTH HISTORY/STATUS 1. 2. 3. 4. 5. Childhood Illness: He experienced fever, diarrhea Immunization: he completed all his immunizations. Major Illnesses: None Current Medication: the patient is taking paracetamol 500 mg OD Allergies: The patient has no allergies on medications, foods and beverages he is taking.

E.

FAMILY ASSESSMENT

Name

Relation

Age

Sex

Occupation

Educational Background High school Undergraduate Student

A.F

Wife

34

Housewife

C.F

Child

11

N/A

D.F

Child

N/A

Student

F.

SYSTEMS REVIEW Gordons 11 Functional Health Patterns Assessment HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN Mr. L.F. perceived health as kapag malayo ako sa sakit.. malayo kame sa gastusin pang ospital and Mr. LF actively cooperates on medications and treatment being prescribed. NUTRITIONAL METABOLIC PATTERN The thoughts of food can trigger the patients appetite. According to Mr. L.F his usual food; he eats 3 times a day with 2 cups of rice and 1 viand per meal. His usual daily menu is meat, pork and chicken, she drinks 6 8 glasses of water per day. He also drinks coffee every morning ELIMINATION PATTERN According to Mr.. L.F. he usually defecates 2 times a day, the color of her stool is golden brown, normal odor of stool and formed stool. Mr. L.F. is not using any laxative. he is usually urinates 3 4 times a day, the color of his urine is yellow with a transparency of turbid color and it is aromatic.

ACTIVITY EXERCISE PATTERN Self care ability 0 Feeding I Bathing 0 Bed mobility Legend: 0 Full care I Requires use of equipment II Requires assistance or supervision from others III Requires assistance or supervision from another, and equipment and a device IV Dependent; doesnt participate 0 Dressing I Toileting III Home maintenance 0 Grooming II Cooking I Others

COGNITIVE PERCEPTUAL PATTERN Upon whispering, the patient can hear the words that are being whispered. According to him he is not using any hearing aids. The patients vision is normal and he can read the words appropriately. Upon applying slight pressure on the hands of the patient, he is responds actively. he can also differentiate two different odors such as perfume and smell of food. In order for the patient to learn, he read magazines and by the use of media.

SLEEP REST PATTERN According to Mr. E.M., before sleeping, he watches television programs, and he does not have any alteration in his sleeping pattern. Usually, Mr. E.M. sleeps at 9 pm to 6 am and he takes afternoon nap about 2 hours. According to him, he doesnt experience any alterations during his hour sleep; he is not using any sleeping aids.

SELF PERCEPTION AND SELF CONCEPT PATTERN Mr. E.M. says that he is weak and has a limitation in food and movement. According to him, he was proud because he knew that having a wife and children was happy, he is responsible father, kind, caring, and loving. he says that her strengths and weakness is her family.

ROLE RELATIONSHIP PATTERN According to Mr. E.M., he establishes a harmonious relationship towards his family and significant others.

SEXUALITY REPRODUCTIVE PATTERN According to Mr. L.F, they were sexually active before he got sick..

COPING STRESS TOLERANCE PATTERN Mr. E.M. perceived stress and problem in life as mahirap lalo na kung na e-stress ako dahil sa kalagayan ko ngayon, lalo naman masakit saka looban ang magkasakit tapos nagkakaproblema ang pamilya ko para lang maghanap ng pang gastos sa pang araw araw napangangailangan lalo n angayon may saki tako at wala man lang maitulong kundia ngmagpagaling para maging maayos na ang lahat, pero kapag may problema ako tinatawag ko lang ang mga kaibigan ko

VALUE BELIEF PATTERN According to Mr. L.F., he regularly attends Sunday mass for him to have good health, to continue to give them blessings from the lord especially his two childrens. he believes in is a roman catholic

G.

HEREDO FAMILIAL ILLNESS PATERNAL MATERNAL

GRANDFATHER

GRANDMOTHER

HYPERTENSION

DIABETES MELLITUS

PATIENT L.F AGE

H.

PHYSICAL ASSESSMENT A. General Survey 1. Overall appearance and grooming: Upon assessment, the patient appears untidy and not groomed. 2. Actual height and weight vs. ideal body weight: Normal 3. Symptoms of distress: The patient has no symptoms of distress. 4. Posture and gait: On his condition, he cant stand and walk independently. 5. Affect and mood: Upon assessment, LF is showing unhappy mood. 6. Vital signs of the day of physical examination Blood pressure: 90/60 mmhg Temperature: 37.9C Respiratory rate: 35 breaths per minute Cardiac rate: 84 bpm

B. Regional exam- utilize IPPA technique Hair, head and face Has normal skull. (normocephalic) Smooth contour No nodules or masses Smooth and uniform consistent Palpebral fissures equal in size and asymmetric facial movement Hair is evenly distributed, slightly thin, silky and no presence of lice and infestation Eyes Nose Ears

Eyebrows are evenly distributed, intact, symmetrically aligned and equal movement Eyelashes are equally distributed and curled slightly outward Eyelids are intact, no discharge and discoloration, close symmetrically Bulbar conjunctiva is transparent Capillaries sometimes evident Palpebral conjunctiva is shiny, smooth and pink in color No tenderness and masses over lacrimal gland and also on nasolacrimal duct Cornea is transparent, shiny, and smooth

External is symmetric and straight, no discharge and flaring and uniform in color, no tenderness and lesions Mucosa pink, clear watery discharge, no lesions Nasal septum intact and in midline

Auricles are same as color of the face, mobile firm, no tender Pinna recoil after it is folded

Mouth and throat The lips were dry due to dehydration. The throat was functioning well. No dentures. (+) tartar. There is a black discoloration in the enamel. (+) breath odor. Neck and lymph nodes Neck muscles equal in size Head centered Head moves coordinated, smooth movement with no discomfort Not palpable enlarged lymph over the entire neck

 Nails

Fingernail plate shape convex curvature, smooth texture, highly vascular and pink Intact epidermis

Thorax and lungs Chest symmetrically aligned Spinal column is straight, right and left shoulders and hips are at the same height Posterior thorax uniform in color Skin intact Chest wall intact, no tenderness, and masses Mild retraction and crackles present Cardiovascular Peripheral pulses are on symmetric pulse volume Limbs no tender Breast and axilla Skin uniform in color Skin intact Round areola and bilaterally the same Nipples everted and equal in size No tenderness, masses and nodule Abdomen The skin of the abdomen is unblemished and uniform in color. Symmetric abdominal contour flattened and rounded. Audible bowel sounds. Symmetric movements cause by respiration. No tenderness noted.

Extremities Muscle equal in size on both sides of the body Muscles and tendons have no contractures Firm muscles while at rest No deformities, tenderness nodules on joint Muscles equal in strength on both body size

 Genitals Not performed Rectum and anus Not Performed

I.

PERSONAL / SOCIAL HISTORY Habits / Vices o o o o o Caffeine : the patient drinks 2 cups of coffee a day Smoking : the patient is smoking and consume 10 sticks a day Alcohol : the patient occasionally drinks alcohol, beer 2 to 3 bottles Tea : the patient doesnt drink tea Drugs : none

Lifestyle The patients lifestyle is to work in the farm in the morning and goes home in the afternoon Social Affiliation The patient hang out with his friends and occasionally to have drinking session

Rank in the Family Father Educational Attainment College Level

J.

ENVIRONMENTAL HISTORY

The patient is living with his wife and children Their house is along the street, bungalow and made up of cement. They have vegetable garden where sometimes they get their food. Health center is 2 km away from their house.

K.

INTRODUCTION

Gastroenteritis is a catchall term for infection or irritation of the digestive tract, particularly the stomach and intestine. It is frequently referred to as the stomach or intestinal flu, although the influenza virus is not associated with this illness. Major symptoms include nausea and vomiting, diarrhea, and abdominal cramps. These symptoms are sometimes also accompanied by fever and overall weakness. Gastroenteritis typically lasts about three days. Adults usually recover without problem, but children, the elderly, and anyone with an underlying disease are more vulnerable to complications such as dehydration. The majority of cases in children globally are caused by rotavirus, while in adults norovirus is more common, at least in the United States. Less common causes include bacteria or their toxins, and parasites. Transmission may occur due to improperly prepared foods, contaminated water or close contact with those who are infectious. Children infected with rotavirus usually make a full recovery after a few days. Dehydration is a common complication of diarrhea and a child with mild or moderate dehydration may have a prolonged capillary refill, poor skin turgor and abnormal breathing. In areas with poor sanitation repeat infections may lead to malnutrition stunted growth and delayed development.

L.

ANATOMY AND PHYSIOLOGY

The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules). On the way to the stomach: the esophagus - After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down. In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. In the small intestine - After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food. In the large intestine - After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon. The end of the process - Solid waste is then stored in the rectum until it is excreted via the anus. Digestive System Glossary: alimentary canal - the passage through which food passes, including the mouth, esophagus, stomach, intestines, and anus. Anus - the opening at the end of the digestive system from which feces (waste) exits the body. Appendix - a small sac located on the cecum. Ascending colon - the part of the large intestine that run upwards; it is located after the cecum. Bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine.

cecum - the first part of the large intestine; the appendix is connected to the cecum. chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion. Descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon. Digestive system - (also called the gastrointestinal tract or GI tract) the system of the body that processes food and gets rid of waste. Duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum. Epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe. Esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the stomach. Gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small intestine. Gastrointestinal tract - (also called the GI tract or digestive system) the system of the body that processes food and gets rid of waste. Ileum - the last part of the small intestine before the large intestine begins. Intestines - the part of the alimentary canal located between the stomach and the anus. Jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum. Liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins. Mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process (breaking down the food). Pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and proteins in the small intestine. Peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you to eat and drink while upside-down. Rectum - the lower part of the large intestine, where feces are stored before they are excreted. Salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules. sigmoid colon - the part of the large intestine between the descending colon and the rectum. stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the stomach, it is churned in a bath of acids and enzymes. transverse colon - the part of the large intestine that runs horizontally across the abdomen.

M.

. Pathophysiology

ingestion of bacteria

irritation of the intestine

infllamatition of the intestinal tract

sign and symptoms

diarrhea, nausea and vomiting, and abdominal pain and cramps.

N.

. LABORATORY

Type of Examination: COMPLETE BLOOD COUNT

RESULTS

NORMAL VALUES

SIGNIFICANCE

Hemoglobin

128

136-175 g/L

May indicate erythrocytosis.

Hematocrit

0.38

0.39-0.52

My indicate polycythemia.

WBC

13.2

4.5-10x10g/L

Increased valus may suggest infection. Decreased values may suggest anemia May indicate immune defiency.

RBC

5.23

4.5-5.0

Lymphocytes

0.53

.21-0.40

Monocytes

0.11

0.00-0.07

May indicate viral infection.

Neutrophils

0.36

0.36-0.66

FECALYSIS

Results Physical properties: Color Consistency Light brown Watery

Analysis

Normal d/t profuse secretion of water and electrolytes

Remarks: No oral intestinal parasite seen

TYPE OF EXAMINATION: URINALYSIS RESULTS COLOR: Yellow APPEARANCE: Cloudy pH: 5.0 Specific gravity: 1.026 NORMAL VALUES Pale yellow Clear 4.6 to 8.0 1.003 to 1.030 SIGNIFICANCE -color is influence by urine concentration and ingredients. -Bacteria, excessive crystals, or cells cause cloudiness. -Urine becomes alkaline(pH more than 7) with urinary tract infection or severe alkalosis. -Specific gravity is elevated in dehydration as kidney try to conserve fluid, and decreased in over hydration as they try to rid the body of fluid. -Due to inflammation, protein molecules pass into urine. -Glucose in urine occurs most frequently as a symptom of diabetes mellitus.

PROTEIN: +2 GLUCOSE: Negative

0 0

O.

Drug Study Generic Name:Paracetamol Brand Name:Biogesic Drug Classification:Analgesic/ Anti pyretics Dosage:500mg; 1 tab q4 Indication:For fever Mechanism of Action Contraindication Adverse Effects o o o o o o o o o Side Effects Nursing Consideration

Paracetamol reduces the synthesis of prostaglandin which are responsible for the mediation of pain and fever

Contraindicated to hypersensitivity to paracetamol

Methemoglobin emia Hemolytic Anemia Neutropenia Thrombocytope nia Pancytopenia Urticaria Hypoglycemic coma Jaundice

Nausea& Vomiting

Report Nausea and Vomiting these are signs of toxicity Take with food or milk to minimize GI upset

Minimal GI upset

Report pain that persists for more than 3 5 day

Generic Name:Cefuroxime Brand Name:Kefox Drug Classification:Cephalosporin second generation Dosage:750mg SIVP q8 ANST ( - ) Indication: for bone and joint infections Mechanism of Action Contraindication Adverse Effects o Side Effects Nursing Consideration

Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death.

Contraindicated with allergy to cephalosporin or penicillin

o o o

Erythema multiforme Epidermal necrolysis Nephrotoxicity Pseudomembr anous colitis

Nausea & Vomiting

Report Nausea and Vomiting these are signs of toxicity

Diarrhea Tell to client that diarrhea is normal because it is the response to medication used to treat bacterial infection.

Avoid alcohol while taking this drug and for 3 days after because severe reactions may occur.

P.

. List of Identify Problems According to Priority

Acute pain related irritation of the bowel wall. Hyperthermia related to disease process Fluid volume deficient related to active fluid loss.

ASSESSMENT S> Masakit yung tiyan ko. Pain scale of 8/10 O> with guarding behavior >grimace noted >irritable at times >easy fatigability >Abdominal Pain >Weak in appearance >Limited range of motion >Reduced interaction with people >sleep disturbances

DIAGNOSIS Acute pain related irritation of the bowel wall.

PLANNING Within 30 mins 1 hour of rendering proper nursing interventions the patient will be able to report pain is relieved / controlled by the pain scale of 8/10 to 4/10.

INTERVENTION Perform comprehensive assessment of pain scale, include location, quality, severity and duration. Note the clients locus of control.

RATIONALE To assess etiology/ precipitating contributory factors. Individuals with external locus of control may take a little or no responsibility for pain management. Observations may or may not be congruent with verbal reports indicating need for further evaluation. To evaluate clients response to pain.

EVALUATION After 30 mins 1 hour of rendering proper nursing interventions the patient will be able to report pain is relieved / controlled by the pain scale of 8/10 to 4/10.

Observe non-verbal cues seen by the patient.

Ascertain clients knowledge of and expectations about pain management. Review clients previous experiences with pain and methods found either helpful or unhelpful for pain control in the past.

To know what proper implementations to be rendered to the client.

Work with client to prevent pain. Instruct the client to report as soon as it begins.

Timely interventions are more likely to be successful in alleviating

 Provide a quiet environment, calm activities to the patient. Provide comfort measures.

pain. To promote relaxation.

To provide nonpharmacologic pain management. Encourage diversional activities To alleviate attention and comfort to relief pain

Instruct the client the use of relaxation exercises such as deep breathing. Instruct client to avoid foods such as milk and chocolate. Indentify way of minimizing the pain such as; firm mattress, good body mechanism. Administer analgesics to maintain acceptable level of pain if not contraindicated and as prescribed. Monitor effectiveness of pain medications

Deep breathing exercises may reduce pain sensation. Milk and chocolate increases gastric motility. Helps relieve pain.

To decrease pain.

To promote timely intervention/ revision of plan of care

ASSESSMENT

DIAGNOSIS

PLANNING After 1 2 hours of nursing intervention, the patients temperaturewill decreased from 37.9c to 37.3c and maintain the normal body temperature

INTERVENTION Assess the onset of fever Observation of vital signs ( temperature, blood pressure, pulse and respiration ) Instruct the patient to drink plenty of water

RATIONALE To identify pattern fever patient Vital signs is a reference to determine the patients general condition Increased body temperature resulting in increased evaporation of the body so it needs to be balance with a lot of fluid intake With vasodilation can increase evaporation which accelerate the decline in body temperature Thin clothing helps reduce the evaporation of

EVALUATION After 1 2 hours of nursing intervention, the patients temperature was decreased from 37.9c to 37.3c and maintain the normal body temperature

Subjective: mainit ang pakiramdam ko as verbalized by the patient.

Hyperthermia related to disease process

Objective: o o o o Warm to touch Nausea Headache Vital signs Temp.: 37.9c PR: 84 RR: 35bpm BP: 90/60

Give tepid sponge bath

Advice not to wear a thick blanket and

clothing Give intravenous fluid therapy and medications according to physicians program.

the body Infusion of fluid is very important for patients with high temperature

ASSESSMENT S> Tubig yung tae ko. O> elimination of watery stool at 3-5 times a day >dry lips >dry skin >pale and weak in appearance >skin turgor of 3-4 seconds >Vomiting

DIAGNOSIS Diagnosis: Fluid volume deficient related to active fluid loss

PLANNING Within 3-4 hours of rendering proper nursing interventions the client will be able to replace fluid volume loss.

INTERVENTION Note possible diagnosis that may create a fluid volume deficient Monitor Input & Output

RATIONALE To assess causative/ precipitating factors To ensure accurate fluid status To evaluate degree of fluid deficit To evaluate degree of dehydration. To know what food to be given by the preference of the client. To prevent dehydration & maintain hydration status For proper fluid replacement.

Assess skin turgor regularly Note physical signs of dehydration. Note clients preferences regarding fluids and foods with high fluid content. Maintain adequate hydration and increase fluid intake Keep fluid within the clients reach and encourage frequent intake as appropriate.

EVALUATION After 3-4 hours of rendering proper nursing interventions the client will be able to replace fluid volume loss.

>abdominal
cramping

>nausea >fatigue >dry mucous

membrane

Instruct client to have oral care.

To prevent injury to the mucosal lining and to prevent from dryness

 For pharmacological management. Administer medications as prescribed by the physician. Administer Intravenous fluids as prescribed Restrict solid food intake, as indicated Young individuals are quickly affected by fluid volume deficit To allow for bowel rest and to reduced intestinal workload

Discuss factors related to occurrence of dehydration. Recommend restriction of caffeine as indicated Dont allow patient to sit or stand up quickly as long as circulation is compromise.

To have knowledge about the disease and know the prevention. Caffeine has diuretic. To prevent more fluid loss. To avoid orthostatic hypotension and possible syncope.

VII.

ONGOING APPRAISAL The patient shows progressive recovery and is responding well to both medical and nursing intervention. Comfort measures given.

VIII.

DISCHARGE PLAN Medication Instruct the patient to continue the medications if the doctors order

Exercise Diet Advice patient to increase fluid intake Advice the client for BRAT diet Encouraged the patient to eat foods rich in vitamins and minerals Encourage the patient to have exercise daily