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Demographic Data This is a case of C. D., a 34 year old male patient who is married, a roman catholic, a high school graduate who works as a sales representative and lives at District I Sampaloc, Manila. Admission Data This is the first time that the patient was admitted to the hospital who is ambulatory and was accompanied by his wife and sister. Chief Complaint The chief complaint of the patient is pain at the epigastric area that intensifies while moving and with the pain scale of 9/10. History of Present Illness 3 weeks prior to admission, while the patient was at work, he experienced pain at the epigastric area. The patient was brought to their company clinic and was given a pain reliever that caused the pain to decrease. 4 days prior to admission, the pain came back and got intensified that caused the patient to be rushed to Ospital ng Tondo. The physician ordered an ultrasound of the abdomen and the result showed cholecystitis with cholelithiasis. The patient was given pain reliever (Tramadol) but this time, the pain is not relieved. 1 day prior to admission, the patient experienced nausea and vomiting and the vomitus is yellow in color. The patients family decided to transfer the patient to Ospital ng Maynila. Past Medical History According to the patient, he had neither childhood illness nor injuries. The patient also had no disease or injury during adulthood and no known allergies to food or drug. The current medication that the patient is receiving is Tramadol that is a pain reliever. Family History According to the patient, his mother has Hypertension while his father has Diabetes Mellitus. Neither of his 2 siblings have illness nor injury.

Gordons 11 Functional Health Patterns 2|Page

a. Health Perception and Health Management: Before the patient had illness, he perceives his health as good and has his check up whenever he feels sick. Now that he had an illness, he still believes that he can manage the situation by having an early detection and treatment of the disease. b. Nutritional- Metabolic Pattern: Before the patient developed the illness, he had good appetite and eats whenever he wants. The patient is alcoholic who often drinks weekly and usually consumes high fat and salt diet. But now, the patient has poor appetite and perceives that he must discontinue drinking alcohol and consuming high fat and salt diet. c. Elimination Pattern: Before the patient got hospitalized, he usually urinates 3- 4 times a day and defecates once a day. But now, he urinates twice a day and is able to pass a stool once a day although he usually felt that the pain on the epigastric area intensifies while moving. d. Activity and Exercise: Before, the patient usually goes to work as a sales representative from 8am to 5pm. Now, the patient is not able to go to work and usually rests to reduce the pain he is experiencing. e. Cognitive- Perceptual Pattern: Before, the patient does not feel any pain on his body and was able to do self- care activities independently. Now, the patient cannot do selfcare activities on his own because the pain that he is experiencing makes him feel weak and intensifies while moving. The patient is oriented and able to describe the pain and does not currently experiencing sensory malfunction despite of pain. f. Sleep and Rest Pattern: Before, the patient sleeps 5 hours a day and does not have any difficulty sleeping. Now, the patient usually sleeps 8 hours a day although he had difficulty sleeping despite of pain. g. Self- Perception and Self Concept Pattern: Before the patient become sick, he usually views himself as an independent person and can take care of himself. Now, the patient is uncomfortable since he experiences pain that disrupts his activities of daily living.

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h. Role Relationship Pattern: Before, the patient provides the needs of his family and often brings his children to school and works all day to earn money. Now, the patient seems to feel that this hospital admission will cause change in the relationship role since he needs his family to take care of him while he is in the hospital. i. Sexuality- Reproductive Pattern: Before, the patient usually has sexual intercourse twice a month and does not feel any difficulty and pain. Now, the patient does not feel the urge to do that certain activity since he is experiencing pain on the epigastric area. j. Coping and Stress Tolerance: The patient usually handles his problems by facing it and finding solutions. He is not seeking help from any health or psychiatric unit to solve his problems rather, he is seeking advice and support from his family. k. Values and Belief: The patient is a Roman Catholic and believes that the most important thing in life is to do good things to others. He does not have any belief that is contradicted to the health services rendered.

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Assessment Subjective Data: Masakit ang tiyan ko. As verbalized by the patient.

Nursing Diagnosis Acute pain related to inflammatory process as evidenced by reports of pain,

Planning After the implementation of nursing interventions, the client will report pain is relieved or controlled and demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Intervention Independent Nursing Interventions: a. Promote bed rest, allowing client to assume position of comfort.

Rationale

Evaluation After the implementation of nursing

a. Bedrest in lowFowlers position reduces intraabdominal pressure.

interventions, the client: Verbalized the pain is reduced. Pain scale: 5/10 Blood pressure: 130/ 70 mmHg PR: 82 bpm Able to demonstrat e relaxation 6|Page

Objective Data: Temp: 35.7 C PR: 98 bpm RR: 21 bpm BP: 140/ 70 mmHg Pain scale: 9/ 10 Facial mask of pain Patient looks pale

and changes in blood pressure (BP) and pulse.

b. Encourage use of relaxation techniques such as deepbreathing

b. Promotes rest, redirects attention, and may enhance coping.

exercises. Provide diversional activities. c. Make time to listen to and maintain frequent contact with client. c. Helpful in alleviating anxiety and refocusing attention, which can relieve pain. Dependent Nursing Interventions a. Administer pain reliever medications as ordered. a. To reduce pain experience d by the patient.

activities.

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b. Note response to medication, and report to physician if pain is not being relieved.

b. Severe pain not relieved by routine measures may indicate developing complicatio

Collaborative Interventions: a. Maintain nothing by mouth (NPO) status; insert and maintain nasogastric (NG)

ns and the need for further interventio n. a. Gastric secretions that stimulate release of cholecysto 8|Page

suction, as indicated.

kinin and gallbladder contraction s.

Assessment Subjective Data: Wala akong gana kumain at nasusuka ako. As verbalized by the patient.

Nursing Diagnosis Imbalanced Nutrition: Less than body requirements

Planning After the implementation of nursing interventions, the client will report nausea and vomiting is relieved or

Nursing Intervention Independent Nursing Interventions:

Rationale

Evaluation After the implementation of nursing

a. Ask patient
about likes/dislike s and preferred meal schedule.

a. Involves patient in planning and enables patient to make decision with the guidance of appropriate diet.

interventions, the client: Verbalized nausea and vomiting is reduced. Able to eat meal at a preferred meal schedule 9|Page

Objective Data: Temp: 36.3 C PR: 96 bpm RR: 23 bpm BP: 140/ 70 mmHg

controlled and will be able to eat appropriate foods at a preferred meal schedule.

 Patient has poor appetite and does not want to eat Patient looks pale Patients vomitus is yellow in color

b. Useful in

necessary for improveme nt of health.

b. Provide a
pleasant atmosphere at mealtime; remove noxious stimuli.

promoting appetite/re ducing nausea.

c. A clean mouth enhances appetite. d. May lessen nausea and

c. Provide oral
hygiene before meals.

d. Offer
effervescent drinks with meals, if tolerated. Dependent

relieve gas. .

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Nursing Interventions a. Administer antiemetic medications and intravenous fluid as ordered.

a. To prevent vomiting experience d by the patient and to replace fluid loss through vomiting. b. Nausea and vomiting

b. Note response to medication, and report to physician if nausea and vomiting is not being

not relieved by routine measures may indicate developing complicatio ns and the need for 11 | P a g e

relieved.

further intervention .

Collaborative Interventions: a. Begin lowfat, low salt diet as indicated. a. Limiting fat content reduces stimulation of gallbladder and pain associated with incomplete fat digestion and is helpful in preventing 12 | P a g e

recurrence.

Assessment Subjective Data: Ano na ba ang mangyayari sa akin kapag naoperhan na ako?. As verbalized by the patient.

Nursing Diagnosis Knowledge deficient regarding condition, prognosis and treatment related to lack of knowledge as evidenced by

Planning After the implementation of nursing interventions, the client will: Verbalize understanding of disease process, prognosis, and potential complications. Verbalize

Nursing Intervention Independent Nursing Interventions: a. Provide explanatio ns of reasons for test procedures and preparatio n needed. b. Discuss

Rationale

Evaluation After the implementation of nursing

a. Information can decrease anxiety, thereby reducing sympathetic stimulation.

interventions, the client: Verbalized understanding of disease process, prognosis, and potential complications. Verbalized 13 | P a g e

Objective Data: Patient wanted to learn

request for information

about his condition and prognosis.

understanding of therapeutic needs. Initiate necessary lifestyle changes and participate in treatment regimen.

hospitaliza tion and encourage informed choices.

b. Provides knowledge base from which patient can make and prospective treatment as indicated. Effective communication and support at questions, expression of concern; this time it can

understanding of therapeutic needs. Initiated necessary lifestyle changes and participated in treatment regimen.

c. Discuss signs/symp toms requiring medical

diminish anxiety.

c. Indicative of progression of 14 | P a g e

interventio n,

disease process/develo pment of complications requiring further intervention.

Drug Name/ Classification Generic Name: Tramadol

Indication/ Dosage Indication: Moderate to severe pain

Action Unknown. A central acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid

Adverse Reaction Actual Adverse Reactions: GI: nausea, vomiting Skin: diaphoresis

Contraindication Contraindicated to patients hypersensitive to drug and other opioids. Serious hypersensitivity reactions can

Nursing Consideration Reassess patients level of pain at least 30 minutes after administra tion. Monitor CV

Patient Teaching Tell patient to take drug as prescribe d and not to increase dose or interval 15 | P a g e

Classification: Opioid Analgesic

Dosage: 50 mg PO OD

Possible Adverse

occur, usually after the first

receptors and inhibit reuptake of norepinephrine and serotonin.

Reactions: CNS: dizziness, headache, confusion CV: vasodilation EENT: visual disturbances GI: constipation, dry mouth GU: urinary retention Respiratory: respiratory depression Skin: rash

dose.

and respiratory status; withhold dose and notify prescriber if respiration s decrease or rate is below 12 breaths per minute. For better analgesic effect, give drug before

dosage unless ordered by prescriber . Caution ambulator y patient to be careful when rising and walking because drug produces dizziness.

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onset of pain. Monitor patient for drug dependenc e

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LABORATORY

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