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Nicolas, Jean Therese
ASSESSMENT
I. Patient’s Biographical Data
NAME : Mrs. Green
ADDRESS : NHV, Tigbe, Norzagaray, Bulacan
DATE OF BIRTH : November 26, 1946
BIRTHPLACE : Leyte
BIRTH HISTORY : Home Birth
AGE : 62 years old
SEX : Female
HEIGHT : 5’1”
WEIGHT : 42 kgs.
FATHER’S NAME : Deceased
MOTHER’S NAME : Deceased
NO. of SIBLINGS : Six (6)
ORDINAL POSITION IN
THE FAMILY : Eldest
CIVIL STATUS : Widowed
NATIONALITY : Filipino
MEDICAL DIAGNOSIS : Acute Gastroenteritis
CHIEF COMPLAINT : Loose watery stool and vomiting
HISTORY OF PRESENT ILLNESS
Prior to admission, the patient complains
of loose watery stool and vomiting.
HEAD: The patient’s head was round and in proportion w/ the body.
Hair color is white and has no dandruff and lice. The patient’s
general appearance of face indicates a feeling of weakness.
NECK and SHOULDERS: The veins and clavicle are visible. The
shoulders are asymmetrical. The neck muscles are weak.
EYES: The patient’s eyes are symmetrical to the ears. She manifested a
blurred vision due to aging. Pale conjunctivae was noted. Sunken
eyes was observed. The eyes appeared dry due to dehydration.
EARS: The client’s ear manifested a good hearing balance. There were
no discharges noted.
NOSE: The client’s nasal septum is intact and in the midline. There were
no discharges noted. Airs move freely as the client breathes through
the nose.
MOUTH and THROAT: The client’s mouth has presence of lesions due
to frequent vomiting. 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.
CHEST: The chest is symmetric. The skin was sagged. The thorax is
elliptical.
Creatinine
The creatinine of the patient is 0.6 mg/dl, the normal
finding of the creatinine is 0.5-1.7 mg/dl. Creatinine is
exerted entirely in kidney and therefore directly
proportional to glomerular filtration rate.
HEMATOLOGY
Hemoglobin
The hemoglobin of the patient is 90g/L. The
normal findings of hemoglobin is 115 to 155g/L. There
is a decrease in hemoglobin that may possibly cause
hemolytic anemia and bone marrow suppression.
Hematocrit
The hematocrit of the patient is 26%, the
normal finding is 36 to 46%. Hematocrit measures the
percentage of red blood cells in the total blood volume.
It reported as percentage because it is the proportion of
RBC’s to the plasma. There is also a decrease in
hematocrit that may possibly cause diet deficiency
anemia.
WBC Count
The WBC count of the patient is 5.0 x 10g/L, the
normal findings of WBC is 4 to 11x10g/L. High WBC count are
often seen in the presence of bacterial infection; by contrast,
WBC count may be low if a viral infection is present.
RBC Count
The RBC count of patient is 3.11 x 10 g/L, the
normal finding of RBC is 4-7 x 10 g/L. Her RBC count
decreases and the possible cause of this is Iron Deficiency
Anemia.
Differential Count
The result of the patient lymphocyte is 19%, the
normal value is 25-35%. There is a decrease in lymphocyte that
may cause severe malnutrition.
The result of patient monocytes is 4%, the normal
value is 2-5%.
ANATOMY AND PHYSIOLOGY
DIGESTIVE SYSTEM
Ingestion of Pathogens
Increased Peristaltic
Movement
Diarrhea
DRUG STUDY
Drugs Mechanism Indication Contraindication Adverse Nursing
of action effect consideration
Generic
name; Decrease Control of Renal Few when . do not exceed
Paracetamol fever by pain due to insufficiency taken in usual dose of 4g/24hour
Hypothalamic headache, anemia, therapeutic in adults and
Brand name; effect Dysmenorrh clients with doses. 75mg/kg/day in
Acetaminophen leading to ea, cardiac or Chronic and children.
sweating muscular pulmonary even acute
and pain and disease are toxicity can .do not
Classification vasodilation. Arthritis To more develop after take for more than
reduce susceptible to long syptom- 5 days for pain in
non-narcotic fever in acetaminophen free usage children, 10days
analgesicDos bacterial or toxicity. for pain in adults,
age; adults; viral or more than 3
325-650mg infections. days for fever in
every 4 adults or children
hour(per without consulting
orem)Caplets provider.
, capsules,
oral liquid, or .take
syrup extended relief
product with water;
do not crush, chew
or dissolve before
swallowing.
Drugs Mechanism Indications Contraindications Adverse Nursing considerations
of action effect
Generic name; Dopamine Parenteral; Gastrointestinal CNS; . inject slowly IV order 1-
Metoclopramide antagonist facilitates hemorrhage, restlessness, 2mins to prevent
that acts small obstruction or drowsiness, transient feelings of
Brand name; by bowel perforation; fatigue, anxiety and restlessness.
reglan increasing intubation, epilepsy. anxiety, Check packaged insert if
sensitivity Stim insomnia, drugs is to be admixed.
Classifications; to gastric headache,
gastrointestinal Acetylchol emptying, dizziness
stimulant ine results and
in Increase
Dosage; increased intestinal
10mg motility of Transit of
IV q8 the upper barium to
GI tract aid in
and radiologic
relaxation Examinatio
of the n of
pyloric stomach.
sphincter
and
duodenal
bulb.
Gastric
emptying
time and
GI transit
time are
shortened.
Drugs Mechanism Indications Contraindications Adverse Nursing consideration
of action effect
Generic name; Iron is .prophylaxis Hemosiderosis, Constipation, . For infants and young
Ferrous sulfate absorbed and peptic ulcer, gastric children, administer liquid
from the treatment of irritation, preparation with a
Brand name; duodenum iron nausea, dropper. Deposit liquid
feosol and upper deficiency abdominal well back against the
Classification; jejunum by and iron cramps, cheek.
anti anemic iron active deficiency anorexia, . Eggs and milk and
mechanism anemias. vomiting, coffee and tea consumed
Dosage; adults, through the .dietary diarrhea, dark with a meal or 1hour after
150-250mg (1-2 mucosal supplement colored may significantly inhibit
time per day) cells where it for iron. stools. absorption of dietary iron.
Per orem combines . Do not crash or chew
with the sustained release
protein products.
Transferrin.
NURSING CARE
PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
.
3.)Establish 24 -Advice intake -To provide -Establish 24
hrs. fluid of foods with hydration hrs. fluid
replacement, high fluid replacement,
needs, and content needs, as
routes, as ordered
ordered.
DEPENDENT