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Name: E.V.E Age: 11 years old Gender: Male Address: Sitio Ibabaw Dulumbayan, Teresa, Rizal Civil Status: Single Date of Birth: Septemr 14, 2001 Place of Birth: Taytay, Rizal Nationality: Filipino Ethnic Group: None Primary Language Spoken: Tagalog Highest Educational Attainment: Grade 4 Occupation: N/A Religious Orientation: Roman Catholic Health Care Financing: Family
A. PRESENT HEALTH HISTORY The patient was admitted last April 16 at around 8:00 pm due to chief complains of vomiting and episodes of loose stools, specifically 5 times. His admitting diagnosis is Acute Gastroenteritis with mild dehydration due to Amoebiasis. According to the patient’s mother, they went on swimming last April 7 which she thought her son got the infectious agent. Moreover, the patient had been hospitalized for 4 days from now and so he is already in possible discharge. B. PAST HEALTH HISTORY According to the patient’s mother, E.V.E have had Amoebiasis before when he was still 6 years old and he was also been hospitalized for 3 days due to it. “Hindi ko na kasi matandaan kung pano siya nagka-Amoebiasis noon, per siguro dahil sa pagkain,” the patient’s mother verbalized. Also, the patient had pneumonia when he was still on his neonatal period but according to his mother, he was no longer manifesting the condition today. The patient has
complete vaccinations. He usually got colds and fever at approximately 2-3 times a year and over the counter medications is their way of treating it. He had also childhood diseases such as chicken pox and mumps. His chicken pox just happened last May 2012 at lasted for more than a week. He had mumps when he was still on Grade 2. He was breastfed up to 2 years of age as his mother stated. Also, he is not taking any vitamins or supplements. C. FAMILY HEALTH HISTORY GENOGRAM
D.V (-) old age
G.V arthritis D.B (-) DM W.E (-) HPN
E.R.E (A/W) E.L.E (A/W) E.M.E (DM)
The patient’s father is Edmundo 48 years old and his mother, Leah rose is 39 years old. They are both alive and well with no present illnesses according to the patient’s mother. He has 4 siblings. The eldest is Junro, 16 years old male, the 2nd is Edrolyn, 15 years old female, who has asthma, the patient is the 3rd child and the youngest is Edmund Jun, 4 years old. All are alive and well aside from her sister who has asthma. The patient’s grandmother from his mother’s side was already deceased and her gradmother has arthritis. E.V.E’s mother has 3 siblings, she is the youngest and all of them are alive and well. However, his grandparents from his father’s side were already both deceased. Her grandmother died due to Diabetes Mellitus and his grandfather passed away due to Hypertension. His father has also 3 siblings; he is the eldest and the only male in the family and all of them are all alive and well.
He had several medications. “Hindi naman sila namimili ng ulam. They seldom eat out on fast foods or restaurants. whether wheat or oats.” the patient’s mother verbalized. During the hospitalization: The patient’s appetite is becoming better compared to 2 days prior his hospitalization according to her mother. the patient had difficulty eating. They do not eat on fast food chains often.5ml q4 if with fever. He also drinks water every time he eats. He lost appetite and had vomited several times. iron. the patient drinks 2 glasses of water. He only had lugaw each meal time. Metronidazole 500mg tablet TID and Zithromax 500mg tablet daily. he eats bread and drink milo. However. For lunch and dinner they often have vegetable dish and sometimes with meat and fish according to the patient’s mother. the patient does not have any food allergies noted. Also.II. ceftriaxone 500mg TIV q8. as like other kids of his age he loves eating junk foods and sweets for snacks. Nutrition Before Hospitalization: The patient eats 3 times daily. His sister often cooks food for them as a family. Erceflora 1 tube daily. For example. In every meal. Usually for breakfast. all grains.) Interpretation: The patient usually eats vegetables and is not picky. because related foods are similar in composition and often have similar nutrient values. He loves to eat sweets and salty foods. Paracetamol 7. Kozier and Erb. Daily food guides that are currently used includes Dietary Guidelines for Americans and the Food Guide Pyramids (Source: Fundamentals of Nursing. and the B vitamin thiamine. 2008. Pp 1246. which is better compared to commercially prepared ones. these are as follows. . He eats a lot more compared to the past 2 days before he was admitted. they prepare their own food. He is not nauseated and doesn’t suffer from any gastric upset. So. Food group plans emphasize the general types or groups of foods rather than the specific foods. Norms:Various daily food guides have been developed to help healthy people meet the daily requirements of essential nutrients and to facilitate meal planning. Kahit anong ihain kinakain naman nila. However. In the past 2 days prior to hospital admission. episodes of vomiting were still noted during the first 2 days of hospitalization. are significant source of carbohydrate. Sometimes he eats junkfoods and soda for snacks. He usually drinks up to 700ml of water daily. In the morning he consumes mainly carbohydrates which is good in order to keep him active during the day considering his age where in he is at playful stage. Buscupan ½ ampoule TIV. GORDON’S FUNCTIONAL HEALTH PATTERNS A.
because it’s summer break. He often sleeps at 9:00 pm and wakes up at 8:00am making it up to 11 hours of sleep in total. he does not have any difficulty sleeping in the hospital. also whenever he has to take medications. He does not have any difficulty sleeping. Rest and Sleep Before Hospitalization: The patient has average hours of sleep. (Source: Fundamentals of Nursing 8th edition by Kozier and Erb pp. he has minimal disturbances which is appropriate because due medications have to be taken within the time prescribed and nurses’ checking them at the ward from time to time is inevitable and it is on purpose of their stay in the hospital. the patient’s mother said that by 8:00 pm he was already asleep and wakes up at 5:00am. 1168) Interpretation: The patient has adequate sleep and rest because he has a total of 11 hours of sleep at night and also he mentioned that he also sleeps during noontime. sometimes when the doctors or nurses checks them in the ward he wakes up. there are no classes the patient also takes a nap at noontime.E also mentioned that he is satisfied with his sleeps and does not have any disturbances during his resting period. he has to wake up. Usually around 1:00 to 3:00pm. Also. Usually he urinates 3 times a day and the color of the urine is often slightly turbid with no foul odor. he has slight sleep disturbances as he said. Elimination Before Hospitalization: 2 days prior to hospital admission the patient had several episodes of loose bowel movement. He still sleeps at 9:00pm and wakes up at 7 or 8:00am. when he has school. E. He is refreshed during the day and does not sleepy. Norms: Most healthy children need 10 to 12 hours of sleep a night to function optimally. . However. During his hospital admission. At present. However. he does not have any difficulty urinating.V. He described his stools as black and tarry according to his mother. 5 times during the day of April 16 to be exact. During Hospitalization: According to the patient.B.
he no longer has problems regarding his bowel movement and urination pattern. “Syempre kapag wala kang sakit. kelangan kumain ng maraming gulay. The frequency of defecation is highly individual. He is not picky when it comes to food. Kozier and Erb. 1326 and 1325. “Para po maging malusog.During Hospitalization: In the first 2 days of hospital admission the patient still have episodes of loose stools though the frequency is decreasing day by day. Many people believe that “regularity” means a bowel movement every day. Health and Illness The patient describes a healthy individual as a person who is active. Many people define and describe health as the following: • • • Being free from symptoms of disease and pain as much as possible Being able to be active and to do what they want or must Being in good spirits most of the time These characteristics indicate that health is not something that a person achieves suddenly. From having loose stools. (Source: Fundamentals of Nursing. This occurs when the adult bladder contains between 250 and 450 mL of urine. C. Each person must take 8-10 glasses of water every day. (Source: Fundamentals of Nursing 8th edition by Kozier and Erb pp. he said that his stools become better than before and that he only moves his bowel once a day already. nakakapaglaro ka at masaya ka. Norms: Voiding or urination all refer to the process of emptying the urinary bladder.” the patient verbalized.” He said that he likes all vegetables.) Interpretation: The patient was able to void without any discomfort as reported by him. 2008. He stated. So. Pp 295). happy and does not have any sickness. During the day assessed. He does not have any difficulty moving his bowel and the consistency is not loose anymore. playful. he does not have any problems urinating. . Norms: Health is a highly individual perception. He urinates 4 to 5 times daily and describes the color of his urine as yellowish with no foul smell. varying from several times per day to two or three times per week. he is already for discharge and he had his bowel movement once. Also.
He said he plays basketball and other outdoor games. Norms: Make an activity or exercise for at least 30 minutes. 1105) Interpretation: The patient is active. (Source: Health Assessment in Nursing. eating a lot will give him energy to sustain in his activities during the day. III.5°C and 37. Activity/ Exercise The patient’s daily activities are mainly outside playing with his playmates. he is outside all day often and so his lifestyle is not sedentary. He also plays computer games but not usually because he said his mother does not give him money sometimes to pay in the computer shop.0°C / Axillary PR: 92 beats/minute= regular. 2013 Temp: 36. PHYSICAL ASSESSMENT A.7°C must be maintained. Thus.shallow BP: 90/60 mmHg Norms: For the body to function on a cellular level. He is active and quite playful.) . Weber and Kelley. strong RR: 21 cycles/minute= regular.Interpretation: Observing the patient’s response. Third Edition. (Fundamentals of Nursing 8th edition by Kozier and Erb pp. Parents with school aged children do have a hard time having their child eat vegetables because they prefer processed foods such as hotdogs and sausages but the patient said that he eats vegetables and that he is not picky which is again appropriate in having a proper balanced diet. a core body temperature between 36. he is right that he should eat a lot because considering his age. He often goes biking with his playmates around the vicinity of their place during the afternoon. Initial Vital Signs Time: 8:00am Date: April 20.
he never took a bath just sponge bath. Thus. His nails on toes are a bit long. 2008.pp. Dress is appropriate for the occasion and weather. Malinaw ang mga mata ko. Nevertheless. A normal adult inspiration lasts 1 to 1. Stains on hands and dirty nails may reflect certain occupations such as mechanic or gardener. Affect is appropriate for the client’s situation. He is also aware of person. (Source: Health Assessment in Nursing. “Hindi naman po sumasakit ang ulo ko. A typical blood pressure for a healthy adult is 120/80. His hair is evenly distributed.5 seconds and an expiration lasts 2 to 3 seconds. B. naririnig naman kita ng maayos. (Source: Fundamentals of Nursing. His thoughts are appropriate to the situation and he is in a good mood because he knew he is on possible discharge. light tan to dark brown or olive in dark-skinned clients. the patient is somewhat aware and oriented to person. the patient looks not properly groomed because he didn’t take a bath for days.Pulse rate of adults ranges from 60. Third Edition. He wears appropriate clothing to situation and weather. However. ) Interpretation: The patient’s vital signs are within the normal range and are stable. dyed in brown color. he does not have any foul odor. The client is clean and groomed appropriately for occasion. Weber and Kelley. General Appearance Actual Findings: The patient has a dark even complexion with no presence of hyperpigmentation and lesions on skin. His face is uniform in color . Kozier and Erb. place and time.) Interpretation: In general appearance. place and time C. Since his hospital admission. Norms: Color is even without obvious lesions: light to dark beige-pink in lighted skinned client. he is very cooperative in participating during the interview. He is conscious. Hindi din po ako bingi. cooperative and coherent.HEENT Actual Findings: S: The patient stated. He responds to my questions promptly during the interview. The scalp is lighter in color than the skin color. round and symmetrical.100 beats/minute. Client is cooperative and purposeful in his or her interactions with other.” O: The patient’s head is normocephalic.
uniform color. transparent and equal in size. However. Though he doesn’t have missing tooth or tooth decays. Hair is evenly distributed. the patient’s hair for instance is not. Chest and Back Actual Findings: S: E. Hindi rin ako nahihirapang huminga. pinna moves back when palpated. moves freely with no tenderness. Weber and Kelley. no lesions.) Interpretation: In the HEENT assessment. no missing teeth and tooth decays noted. moist. sclera appears white. and occipital prominences. Both ears have the same color with the patient’s face and aligned to the outer canthus of the eye. normocephalic and symmetrical with frontal. pink conjunctiva. the eyelids blink bilateral. and it is yellowish in color. His nose is at the center and is symmetrical. eyebrows symmetrically aligned. about 10 degrees from vertical. skin intact. The patient can breathe freely on both nares. soft and hard palate. there is a presence of cerumen on both ears. Lips is uniform pink in color. pati na din ang likod ko hindi naman nangangalay o sumasakit. his teeth are not all permanent some are temporary. symmetrical. 32 adult teeth. The lips is pinkish in color. uvula. firm gum texture. Bulbar conjunctiva is transparent. raised papillae. resilient hair. pink color. Eyelashes are equally distributed and curled slightly outward. for the patient admitted he dyed his hair making it brown in color. Norms: The skull is round. “Hindi naman po sumasakit ang dibdib ko. Tongue in central position. Eyebrows are evenly distributed. C. eye lashes are curled outward. Nose is symmetric and straight. Third Edition. pupils are black in color. no discharge or flaring. He can hear well because he responds to my questions attentively during the interview. auricle aligned with outer canthus of eye. no infection and no infestations.” . equal movements. silky. Pinna recoils after it is folded. the teeth are white. Firm. His eyebrows are black in color and aligned. thick hair.E verbalized. the cornea is shiny. and has patent airways. he can move his eyes without any discomfort.V. Ears are mobile. Color same as facial skin. and not tender. (Source: Health Assessment in Nursing. Light pink. most of the results are considered to be normal based on the norms. Smooth skull contour. smooth shiny white teeth. capillaries sometimes evident. pink gums. parietal. uniform in color. the tongue is also pinkish in color as well as the gums. Lighter pink hard palate and more irregular in texture. smooth palate.and temperature with a scar on the forehead.
No evidence of liver/spleen enlargement. Extremities Actual Findings: S: “Hindi naman po masakit at nangangalay ang mga binti at braso ko. 2008. rounded or scaphoid. The skin’s temperature and color are uniform. Full and symmetric chest. E. Norms: Unblemished skin.” O: The patient’s abdomen is round. uniform in color with no lesions noted. Norms and Standards: Chest is symmetric. Visible peristalsis in very lean client.) Interpretation: The patient’s abdomen has no deviation from normal findings noted. (Source: Fundamentals of Nursing. Weber and Kelley. Breasts are not tender when palapated. Symmetric movements caused by respiration. Symmetric contour. Kozier and Erb. Fremitus is heard most clearly at the apex of the lungs. he can move his extremities without any discomfort. slightly unequal with no presence of mass and/or lesions. Percussion notes resonate. effortless and has 21 cycles in one full minute. (Source: Health Assessment in Nursing. Skin intact and uniform temperature. no lesions.O: The chest is symmetric and expands as he breathes. Third Edition. Nakakakain ako ng marami at hindi na ko nagsusuka buhat nung isang araw pa. His respiration is quiet rhythmic. uniform color. silver-white striae or surgical scars. The skin is intact and the temperature is even. . Abdomen Actual Findings: S: “Hindi na po sumasakit ang aking tyan. His muscle tone is equal in both upper and lower extremities. except over scapula lowest point of resonance is at the diaphragm and vesicular and bronchovesicualr breath sounds. Flat.” O: The patient has smooth coordinated movements.) Interpretation: There are no deviations from normal noted. D.
60 0. no nodules. there are no deviations from normal noted. Joint moves smoothly.2(M) 4. IV. (Source: Health Assessment in Nursing. Third Edition.79x10/L Ref.1 0. Values 125-160 0.5(F) Leukocyte Stab Neutrophil Eosinophil Basophil Lymphocyte Monocyte ESR Platelet count Reticulocyte Bleeding Time x10/L x10/L 150-350 5-15 2-4 minutes 0.5-6.40-0.40 4.20-0.50 4.01-0. Thus. Normally firm.06 0. Equal strength on both sides.) Interpretation: The client can move his extremities without any discomfort.40 . LABORATORY RESULTS Hematology Examination: Hemoglobin Hematocrit RBC 133gll 0. Weber and Kelley.06 0-0.20-0. No fasciculation/tremors.01 0.3 x10/L 5-10 0-0.5-5.38-0.Norms and Standards: Equal size on both sides. no tenderness.84 21. Smooth coordinated movement. No swelling.40 0.
65 ◊ stress ◊ acute infection Lymphocytes 0.250.Clotting Time Clot ret.07 16. Time Protime Patient Control % Activity INR APTT Control Secs Secs secs secs % 2-6 minutes 12-14 secs 70-100% Norms Hematology Result 04.07 ◊ Parasitic infections ◊ Allergic reactions ◊ Increased Adrenosteroid production .01 0.13.35 ◊Chronic infection ◊ Viral Infection ◊Mononucleosis ◊ Leukemia ◊ Sepsis ◊Immunodeficiency\ diseases Eosinophils 0.62 0.550.03 x 109/L Normal Values 5–10 x 109/L Interpretation Increased Decreased WBC ◊ Infection ◊ Inflammation ◊ Trauma ◊ Autoimmune disease ◊ Drug toxicity ◊ Bone marrow failure ◊ aplastic anemia ◊ dietary deficiency Neutrophil 0.020.20.03 0.07 14.43 x 109/L Result 04.31 0.01 0.83 0.
p df) FECALYSIS COLOR: CONSISTENCY: PARASITES: AMOEBA: positive for E.32 0. Histolytica cyst.0x 1012/L ◊ Dehydration ◊ Pulmonary fibrosis ◊ Hemorrhage ◊ Anemia ◊ Dietary deficiency (Source:http://cdn. Greenish yellow mucoid .350.1 g/L 110.7 g/L 116-140 g/L ◊ Polycythemia ◊ Dehydration ◊ COPD ◊ Hemorrhage ◊ Anemia ◊ Cancer ◊ Kidney disease ◊ Sickle Cell Anemia Hematocrit 0.0 -5.41 ◊ Polycythemia ◊ Dehydration ◊ COPD ◊ Hemorrhage ◊ Anemia ◊ Hyperthyroidism ◊ Dietary deficiency ◊ Hemorrhage ◊ Leukemia ◊ Pernicious anemia ◊ Hemolytic anemia ◊ Chemotherapy Platelet 365 x 109/L 615 x 109/L 150-350 x 109/L ◊ Malignant disorder ◊ Polycythemia ◊ Rheumatoid Arthritis ◊ Iron Deficiency Anemia RBC 4.34 0.28 3.nursingcrib.◊ Leukemia Hemoglobin 101.76 x 1012/L 5.com/wpcontent/uploads/case%20study/labhypertension.
5-5.CYST: TROPHOZOITE: PUS CELLS: RBC: OTHERS: 35-40/rpf 3-6/rpf bacteria: many Norms: Normal Findings Color Consistency brown soft and bulky.htm) ELECTROLYTES RESULTS SODIUM POTASSIUM CHLORIDE 136.5 98-107 . small and dry.6 UNIT mmol/L mmol/L REF. VALUE 135-140 3.5 3. depending on the diet Parasite Pus Cells Bacteria Red Cells none none none 0-3 (+)infection (-)normal (+)infection (-)normal (+)infection (-)normal normal Interpretation normal normal (Source: http://healcon.com/health-book/health-condition/fecalysis-norms_AQZ5AGquLGLjKmVjAwRmAmL=.
This occurs with diseases of the liver. This occurs when there is an increase in the amount of body water in relation to sodium. Chloride 98-107 <107 mmol/L: hyperchloremia .Norms: Normal Findings Sodium 135-145 Interpretation <145 mmol/L: Hypernatremia An excess in sodium levels in the blood in relation to water is called 'hypernatremia'.5mmol/L: hypokalemia >5 mmol/L: hyperkalemia An abnormal increase in potassium (hyperkalemia) or a decrease in potassium (hypokalemia) can seriously affect the nervous system and increases the chance of arrhythmias. Causes of hypernatremia may include kidney disease.5-5 <3. Potassium 3. >135 mmol/L: Hyponatremia A decrease in sodium levels in the blood in relation to water is called 'hyponatremia'. lack or little water intake or loss of water due to diarrhea and/or vomiting. kidney. burn victims and those who suffer from congestive heart failure and other conditions.
some kidney disease and sometimes in overactive parathyroid glands. Elevated levels are seen in diarrhea. >98 mmol/L: hypochloremia Decreased chloride levels is 'hypochloremia'. Chloride is normally lost in the urine.5: hypocalcemia HIGH: muscle weakness fatigue abdominal cramps loss of appetite nausea and /or vomiting constipation .5-5.5: hypercalcemia LOW: muscle twitching and cramping seizures varying degrees of depression hair loss cataracts conjunctivitus (inflammation of the mucuos membrane of inner eyelid) >4. sweat and stomach secretions but an excessive loss can happen from heavy sweating. Calcium(ionized) 4.Increased chloride levels is 'hyperchloremia'. vomiting and adrenal gland or kidney disease.5 <5.
5 <2. and hyperparathyroidism Signs and Symptoms: Decrease cardiac respiratory function Muscle weakness .6mmol/L: hyperphosphatemia Causes of increased phosphate leves are due to excess vitamin D.5: hypomagnesemia Signs and symptoms associated with abnormal levels: decreased mental function ranging from drowsiness to coma in severe states decreased tendon reflex leading to paralysis Nausea / vomiting hypotension due to dilated blood vessels Phosphate 1. hypoparathyroidism.5-2.possible coma if left untreated Magnesium 1.6 <2.5: hypermagnesemia >1. addisons disease and increased intake of phosphate foods >1. impaired colon motility.7-2.7 mmol/L: hypophosphatemia Causes of decreased phosphate are due to malnutrition. cushing syndrome. excess use of antacids.
Side Effects Generic: Azithromy cin Brand name: Zithromax Drug Class: Macrolide antibiotic 500 mg/1 tab OD for 3 days Azithromyc in is an antibiotic (macrolidetype) used to treat a wide variety of bacterial infections.htm) V. rash.. angioedema. difficile associated diarrhea. DRUG STUDY Home Medications Name Dosage Action Indication Contraindic ation Ketolide or related allergy. It will not work for viral infections (e.Fatigue Confusion Seizures Bone pain (Source: http://www. Metronidaz Indicated for the treatment of patients with mild to moderate infections caused by susceptibl e strains of the designate d microorga nisms. Nursing Responsibilitie s Inform patient not to share medications Do not take drug with food or antacids Take antacids 2h before or after taking the drug Direct sunlight (UV) exposure should be minimized during therapy with drug or patient might use sunblock Report immediately if onset of diarrhea occurs Generic: 500 mg 1 Acute History of GI Take full .org/Blood-Tests-Electrolytes.Th is antibiotic treats only bacterial infections. hepatotoxicit y. C. chest pain. abdominal pain. common cold. GI upset.g. flu). It works by stopping the growth of bacteria. cholestatic jaundice). allergy (eg.mdhealthnetwork.
Giardia. Thrombophle bitis (IV). epileptic form seizures (high doses or prolonged treatment). It is effective against a wide range of organisms including E. You may experience these side effects: Dry mouth with strange . cholestatic hepatitis. Raised liver enzyme values. Cosmetics may be applied to the area after application. vaginalis. severe reactions may occur. and stomatitis due to overgrowth of Candida. Weakness. unless partner wears a condom. anaerobes e. Transient leucopenia and thrombocyto penia. and erythema of rosacea hypersensit ivity to metronidaz ole or other nitroimidaz ole derivatives. ataxia. changes in mood or mental state. glossitis. Bacterioide s sp. disturbances Furred tongue. Pregnancy (1st trimester) and lactation. Urethral discomfort and darkening of urine. drowsiness. headache. Numbness or tingling in the extremities. course of drug therapy. histolytica. intraoperat ive. dizziness. Peptococc us sp and Peptostrep tococcus sp. T.Metronida zole Brand name: Flagyl Drug Class: Antiinfectives.g. take the drug with food if GI upset occurs. cough syrups). Avoid contact with the eyes. Do not drink alcohol (beverages or preparations containing alcohol. pustules. Your urine may be a darker color than usual. Apply the topical preparation by cleansing the area and then rubbing a thin film into the affected area. Antiprotozoals tab for 7 days ole is converted to reduction products that interact with DNA to cause destruction of helical DNA structure and strand leading to a protein synthesis inhibition and cell death in susceptible organisms. jaundice. Clostridium sp. this is expected. insomnia. Hypersensiti vity reactions. Refrain from sexual intercourse during treatment for trichomoniasis . and moderately active against Gardnerell infection with susceptibl e anaerobic bacteria Acute intestinal amebiasis Amebic liver abscess Trichomon iasis (acute and partners of patients with acute infection) Preoperati ve. postoperat ive prophylaxi s for patients undergoin g colorectal surgery Topical application : Treatment of inflammat ory papules. Fusobacter ium sp.
drugs or poisons. Chronic or persistent diarrhea with duration of >14 days. vomiting.a sp and Campyloba cter sp. diarrhea (eat frequent small meals). sucking sugarless candies may help). . It produces various vitamins. fever. dizziness. unusual fatigue or weakness. Report severe GI upset. metallic taste (frequent mouth care. nausea. Not for use in immunoco mpromised patients (cancer patients on chemother apy. patients takingimmu nosuppres sant meds) No known side effects Shake drug well before administration Administer drug within 30 minutes after opening Dilute drug with sweetened milk or fruit juice Administer per orem Monitor patient for any unusual effects from drug Generic: Bacillus Clausii Brand name: Erceflora Drug class: Antidiarrh eals 1 vial of 2 billion/ 5 ml suspensi on Contribute s to the recovery of the intestinal microbial flora altered during the course of microbialdi sorders of diverse origin. chills. particularly group B vitamins thus contributin gto correction of vitamin disorders caused by antibiotics & chemother apeutic agents. Acute diarrhea with duration of ≤14 days due to infection.
the parasite can cause abscesses. intestinal lumen. VI. Here they kill epithelial cells. In the pathogenic phase. the trophozoites extrude all . forming a motile trophozoite. or the brain. After feeding. In the process. and sometimes the mucosa. excystation occurs. Occasionally they manage to enter the capillaries. It then travels to the large intestine and colon. The cysts travel through the digestive track until the small intestine. and produce colitis. they destroy tissues and cells. and lymphocytes. Here the infection can follow either of two phases: pathogenic and non-pathogenic. There. The abscesses may subsequently burst.Promotesn ormalizatio n of intestinal flora. neutrophils. lungs. releasing many trophozoites which can re-enter the lumen. Once in those organs. the virulent trophozoite invades the gut. where they can be transported to the liver. PATHOPHYSIOLOGY Infective cysts are ingested through water or food contaminated with infected feces.
They do not invade the membrane. After feeding. -to maintain general health and regarding current and physical well being -to remain free of preventable complications -to control feelings of anxiety and help patient manage the situation . They “round up” and form cysts. PRIORITIZED LIST OF PROBLEMS Cues Rationale Nursing Diagnoses Readiness for enhanced S: “Gusto ko na pong maligo pero -to assist client in maintaining sabi ng nanay ko sa bahay na self-care responsibility for planning and lang daw namin kase uuwi na achieving self-care goals/general well naman daw kami. they round up and form cysts. the trophozoites feed on bacteria and detritus from the outer lining of the gut. -to provide accurate and relevant information future needs. waiting for a new host. they can live anywhere from2-5 weeks. The cysts pass through the digestive system and are contained in the feces. In the non-pathogenic phase.ingested material and binary fission occurs. where they areresistant to the environment. (Source: http://nursingcrib. as in the pathogenic phase. and do not form ulcers or abscesses. In feces.” being -to support client in making healhrelated decisions and pursuit of selfcare practices that promote helth to foster self-esteem and support positive self-concept. -to encourage communication among those who are involved in client’s health promotion.com/case-study/amoebiasis-amebiasis-amoebic-dysentery-casestudy/) VII.
Risk for Infection Risk factors: Immunosuppression Antibiotic Therapy Increased environmental exposure to pathogens Insufficient knowledge to avoid exposure to pathogens -to identify etiology/precipitating factors -to note signs and symptoms of sepsis -to demonstrate behaviors or lifestyle changes to prevent development of infection -to avoid reoccurrences of the condition Risk for deficient fluid Risk factors: Excessive losses through normal routes (e.g Diarrhea) Oral fluid intake of 6 glasses per day -to identify risk factors and appropriate interventions -to demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit volume (Source: NANDA 11th edition) .
com/case-study/amoebiasis-amebiasis-amoebic-dysentery-casestudy/ .pdf Source:http://healcon.htm Source: http://www.REFERENCES: Weber and Kelly: Health Assessment in Nursing 3rd Edition Kozier and Erb (2008): Fundamentals of Nursing 8th Edition) Doenges.htm Source: http://nursingcrib.mdhealthnetwork.com/health-book/health-condition/fecalysis-norms_ AQZ5AGquLGLjKmVjAwRmAmL.com/wpcontent/uploads/case%20study/labhypertension.nursingcrib.org/Blood-Tests-Electrolytes. Moorhouse and Murr: Nurse’s Pocket Guide 11th edition Source:http://cdn.
the client’s condition will be monitored Nursing Intervention Rationale Evaluation Subjective: The patient verbalized.” Goal was met as evidenced by healing of the skin rashes as evidenced by visual disappearance of the rashes and a rate of 0 in itchiness from a scale of 1-10. the client will be able to identify the importance of . “Gusto ko na pong maligo pero sabi ng nanay ko sa bahay na lang daw namin kase uuwi na naman daw kami. Administer medications as ordered Vital signs taken and recorded Performed initial thorough assessment Discuss to the client the importance of maintaining To promote faster healing To note any changes in the vital signs To obtain baseline data To promote maintenanc e of good proper After 5 minutes of nursing intervention. the client will be able to maintain responsibility in achieving proper self-care Objectives: After 30 minutes of nursing intervention. NURSING CARE PLAN Nursing Diagnosis Readiness for enhanced selfcare Analysis Goal and Objectives Goal: After 8 hours of nursing interventions.VIII.
maintaining good proper hygiene good proper hygiene Provide ways to the client on how to achieve good proper hygiene Initiate daily bathing and good grooming Promote handwashing before and after eating and voiding hygiene After 10 minutes of nursing interventions. the client will be able to demonstrate ways in achieving proper hygiene To help the client learn ways on how to achieve good proper hygiene To promote comfort To remove dirt and prevent contaminati on and transmissio n of microorgani sms To prevent transmissio n of microorgani sms into the body To prevent re- Encourage client to keep nails clean and short After 15 minutes of nursing Assist patient in developing .
the client will be able to participate in prevention measures and treatment program programs for preventive care occurence of the condition and further complicatio ns To avoid ingestion of infectious agents Encourage client to avoid consumption of such food and water if in doubt of its preparation Instruct the client’s guardian to report in cases of vomiting and diarrhea Inform the medications to be taken at home and its specific considerations Promote the importance of compliance to home To monitor signs and symptoms of Amoebiasis To promote timely healing To enhance effect of treatment program .intervention.
optimizing better outcomes To enhance understandi ng and cooperation In another 10 minutes of nursing interventions.medications Inform the client’s guardian the importance of follow up visits Encourage client that maintaining good proper hygiene is a key role in health promotion Offer support To promote commitment . the client will be able to show willingness to participate in health promotion To reduce anxiety and boost selfesteem .