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Published by ksnipers12

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Published by: ksnipers12 on Jan 26, 2010
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University of Southern Philippines FoundationSalinas Drive, Lahug, Cebu CityCOLLEGE OF NURSINGCASE STUDY
8 Months oldSex :
Pagsibungan, Mandaue CityName of Hospital:
Dr. Ignacio Cortes General Hospital 
Date of Admission: January 20,2010Ward & Bed No. :
pedia ward, room 216 CCase No. :
68797Chief Complaint :
Vomitting and DiarrheaMedical diagnosis : Acute GastroentiritisDEVELOPMENTAL TASKERIK ERIKSON'SHope: Trust vs. Mistrust (Infants, 0 to 1 year)Psychosocial Crisis: Trust vs. MistrustVirtue: HopeThe first stage, which corresponds to Freud's oral stage, centersaround the infant's basic needs being met by the parents. The infantdepends on the parents, especially the mother, for food, sustenance,and comfort. The child's relative understanding of world and societycome from the parents and their interaction with the child. If theparents expose the child to warmth, regularity, and dependableaffection, the infant's view of the world will be one of trust. Shouldthe parents fail to provide a secure environment and to meet thechild's basic need a sense of mistrust will result. According toErikson, the major developmental task in infancy is to learn whether or not other people, especially primary caregivers, regularly satisfybasic needs. If caregivers are consistent sources of food, comfort,and affection, an infant learns trust- that others are dependable andreliable. If they are neglectful, or perhaps even abusive, the infantinstead learns mistrust- that the world is in an undependable,unpredictable, and possibly dangerous place.During the first or second year of life, the major emphasis is on the mother and father’s
nurturing ability and care for a child, especially in terms of visualcontact and touch. The child will develop optimism, trust,confidence, and security if properly cared for and handled. If a childdoes not experience trust, he or she may develop insecurity,worthlessness, and general mistrust to the world.
1.History of present illness
A day prior to admission the patient had loose watery stools and fever.No home medicalk remedies done to the patient. Instead they immedietlyadmitted the patient to the hospital for immediate intervention.
2. History of past illness 
Patient M.A had no previous medical/ hospital admission.
Gordon’s Functional Health Patterns
3.1 Health Perception and Health Maintenance-
client claimed that he is a wellbeing and healthy prior to her admission and she is able to take his medications without fail
3.2 Nutrition and Metabolism-
On diet as tolerated with strict aspiration precaution.LDrinks 8 glasses of water, in a soft diet; consumed 100% of meals every serving.nausea and vomiting not noted.
3.3 Elimination-
voids six times a day in a pale yellow urine appx. 1500Cc for 24 hoursand defecates into a well formed stool once a day without fail.
3.4 Activity & Exercise-
able to perform ADL such as grooming bathing, eating andmakes walking as his daily exercise
3.5 Cognition & Perception –
able to maintain quality time for her self and familyand perceived things clearly as it is
3.6 Sleep & Rest Pattern-
sleeps appx 8 hours a day with nap intervals includingtwo pillow on her head in a sidelying position, difficulty of sleeping not noted
3.7 Sexuality & Reproduction-
menarche not yet noted and is still not applicable tothe patient.
3.8 Self-Perception & Self- Concept-
perceived self as a active and cooperativestuednt at school.
3.9 Roles & Relationship-
Has a good realtionship with her parents and sister athome and as well at the staff of the hospital as evidenced by, nteracting with nurses andother personnel in the area. Participates and cooperates with nursing procedures such asvital signs taking and giving of medications. Smiles and maintains eye contact.
3.10 Stress Tolerance & Coping-
Client wants to go home because he find it sadand is worrying about there financial problems, copes by taking all medications andfollowing all remedies so that he would get well soon; able to understand written andspoken words, interpret ideas and concepts, evaluates and compares facts andorganizes her thought. With good mood and affect during interaction; understanding andmoderate speech. Has good judgment ability. Abstract thinking is intact and appropriatewhen asked about the meaning of “no man is an island” it is hard to live when you arealone
3.11 Values & Beliefs-
he is roman catholic and strongly believes in God; he usuallygoes to mass every Sunday
5. Diagnostic and Laboratory Tests
a. HEMATOLOGY TEST – December 14, 2009TEST Results unit Reference rangesCBCWBC H 12.3 10^9/L 4.00~11.30RBC 5.33 10^12/L 4.60~6.00Hgb 147 g/L 140~175Hct 0.48 0.42~0.52Mean corpuscular volume 87 fL 80~96Mean corpuscular Hb 27.00 pg 27~31Mean corpuscular Hb concen. 0.36 0.32~0.36RBC distribution width 13.4 % 11.6~14.6Platelet count 439 10^9/L 150~450Differential countSegmenters 0.69 0.50~0.70Lymphocytes 0.26 0.18~0.42Monocytes H 0.18 0.02~0.11Eosinophils 0.02 0.00~0.06

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