Alarcon, Mikko Anthony P.

BSN 406/ Group 21A

I.

Biographic Data

The client Mrs LR, was diagnosed of Hyponatremia, possible 2º dehydration, and. She was admitted because of complaint of epigastric pain.She also stated “naconfine ako dito kase masakit yung tiyan ko pag umuubo”. 2 days before she was admitted she was having multiple episode of vomiting associated with epigastric pain and diarrhea. Client also has type 2 Diabetes mellitus. She was born on April 23, 1951. She is married to Mr MR. She is 62 years old and her husband Mr MR is 69 years old. They are Iglesia ni Cristo. She has no work. They live in Blk 2 Lot 6 East view 2 Antipolo City. Her physician is Dr Soriano.

II.

Nursing History

A. Past health history When asked about her childhood sickness she stated “ Hindi kona maalala e siguro ubo lang at algnat lagi kong sakit noon”. She indicated “Hindi ko na rin maalala kung kumpleto yung bakuna ko hindi ko naman alam na itatanung dito yan”. Client has no known allergies. She also did not have any accidents before. She said that “ naoospital lang ako pag nanganganak ako”. She stop her maintenance on her type 2 Diabetes Mellitus since December 2000. Client did not go to any foreign travel. B. History of Present Illness

According to client, 2 days prior to admission, she always have this feeling of pain in her stomach when she is coughing. Because of that pain she cannot do her daily living activities. She also stated that she was vomiting. And she also stated that had diarrhea during that time.

C. Family History

and symmetric. the skin is intact. The client is very cooperative and response appropriately to the given instruction. D. she has seven siblings and they have a family history of Hypertension. The color is as same as the face. Her husbands and his parents have hypertension. In her family she is the only one with Diabetes mellitus. The client’s eyebrows are evenly distributed. Stains on hands and dirty nails may reflect certain occupations such as mechanic or gardener. it is symmetrically aligned. Pink palpebral conjuctiva. HEENT The head of the patient is rounded.The client stated that her father is deceased. and when eyes are closed there is no sclera visible. Physical Assessment A. The hair of the client is thick and colorered brown with white. General Appearance The clients skin is color brown. Norms: Color is even without obvious lesions: light to dark beige-pink in lighted skinned client. The nose of the patient is straight symmetrical . light tan to dark brown or olive in dark-skinned clients. Clients clothing is appropriate. the eyelids are intact. Client is cooperative and purposeful in his or her interactions with other. The client is clean and groomed appropriately for occasion. Source: Health Assessment in Nursing. The cliet’s eyelashes are equally distributed and is curled slightly outward. Affect is appropriate for the client’s situation. Weber and Kelley. Interpretation: The client’s appearance and her attitude is suitable for her condition. Her nails are clean and neat. and has equal movements. OB history G6 P7 (8 0 0 8) III. Dress is appropriate for the occasion and weather. B. There is no deviation from normal. The pinna recoils after it is folded. Third Edition. The color of the pupil is black. symmetric. The patients ears has minimum amount of cerumen. and blinks bilaterally.

Equal strenght on both sides. no discharge or flaring. silky. pink gums. Third Edition. smooth palate. Nose is symmetric and straight. Norms: Equal size on both sides. and not tender.Mouth: The client’s lips are pale in color. No swelling. smooth shiny white teeth.Ears is mobile. Source: Health Assessment in Nursing. thick hair. Pinna recoils after it is folded. no tenderness. 32 adult teeth. no nodules. Extremities Lower and upper extremities moves symmetrically. resilient hair. Third Edition. Weber and Kelley. Interpretation: The patients head. moist. ears. Firm. skin intact. normocephalic and symmetrical with frontal. equal movements. about 10 degrees from vertical. Joint moves smoothly. Mouth is deviated because of her dentures C. Eyelashes are equally distributed and curled slightly outward. The client wears dentures. Hair is evenly distributed. Color same as facial skin. Joints move smoothly. Smooth skull contour. nose are normal. symmetrical. Eyebrows are evenly distributed. Norms: The skull is rounded. capillaries sometimes evident. parietal. eyebrows symmetrically aligned. Source: Health Assessment in Nursing. . uniform color. auricle aligned with outer canthus of eye. Lips is uniform pink in color. Weber and Kelley. no infection and no infestations. Normally firm Smooth coordinated movement. and occipital prominences. Bulbar conjunctiva is transparent. firm gum texture. No fasciculations/tremors. Smooth coordinated movements. eyes. Light pink. sclera appears white.

But during hospitalization she is always eating health fruits but still no multivitamins to help her more in her current condition.Interpretation: The patients movements are appropriate to her situation. are significant source of carbohydrate. iron. she said that she eats pandesal and egg in the morning with coffee. She eats adequate amount of rice with small amount of the dish being served and drinks only water and sometimes she drinks softdrinks. Rest and Sleep Client is satisfied with her sleep during her stay in the hospital. . B. During hospitalization. because related foods are similar in composition and often have similar nutrient values. all grains. For example. and the B vitamin thiamine. Food group plans emphasize the general types or groups of foods rather than the specific foods. 2008. There are no deviations from normal. Daily food guides that are currently used includes Dietary Guidelines for Americans and the Food Guide Pyramids. Source: Fundamentals of Nursing. Nutrition Before she is hospitalized. the client more on fruits and drinks water but she also said that she drinks juice. But she complained about her sleep during the afternoon because the nurses are always taking her vital signs. Patterns of functioning A. IV. Kozier and Erb. Pp 1246. Client is not taking any muliti vitamins. whether wheat or oats. Interpretation: Patient’s food intake before hospitalization is not so good for health but she said she is aware what are the foods she must eat and not to eat. Norms: Various daily food guides have been developed to help healthy people meet the daily requirements of essential nutrients and to facilitate meal planning.

1326 and 1325). D. and does not have disabilities. Health and Illness Patient’s perception of health is a person who is fat. The frequency of defecation is highly individual. (Fundamentals of Nursing 8th edition by Kozier and Erb pp. Many people believe that “regularity means a bowel movement every day. According to her the amount of urine she excrete when she void is about 150 ml or more that half a cup. Interpretation: The patients elimination patterns are good. (Fundamentals of Nursing 8th edition by Kozier and Erb pp. The clients urine color is yellow and a little foul. However. She said that she is not anymore constipated since she got admitted to the hospital. This occurs when the adult bladder contains between 250 and 450 mL of urine. is not sick. Norms: Voiding or urination all refer to the process of emptying the urinary bladder.Norms: Most healthy adults need 7 to 9 hours of sleep a night. Her perception of the cause of her being in the hospital is because of too much stress and . there is individual variation as some adults may be able to function well with 6 hours of sleep and others may need 10 hours to function optimally. 1168) Interpretation: The patient’ sleeping hours are adequate and she is very satisfied with it. C. varying from several times per day to two or three times per week. Because if she has problems with her sleep her current condition might be affected. Elimination The patient stated that she has no problems with her elimination pattern. She said that she is not healthy now because she is in the hospital. Each person must take 8-10 glasses of water every day.

she immediately go to the nearest hospital but depending on the condition. 1105) Interpretation: The patient’s activity exercise pattern is good.fatigue. 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. . Source: Fundamentals of Nursing. Kozier and Erb. She also said its because of what she eats. 2008. Norms: Make an activity or exercise for at least 30 minutes. at about 2pm she relaxes and watch her noontime shows. E. Pp 295. She wakes at 5 am in them morning to cook for breakfast for her family at 8am she cleans the front of her house. Interpretation: Clients perception of health is proper and very realistic. Activity Exercise Clients stated that her activities and exercise are the same for her. If a member of a family is sick. If the sickness is only mild she would just self prescribe. She relaxes so she doesn’t get fatigue all the time. (Fundamentals of Nursing 8th edition by Kozier and Erb pp. Norms: Health is a highly individual perception.

flushed skin S.” -To prevent diabetes from getting worse and leading to more conditions.V. . Hyperthermia related to illness Ineffective health maintenance related to insufficient resources: finances Risk for unstable blood glucose related to inadequate blood glucose monitoring. medication management -Diabetes if not controlled may lead to more life threatening conditions. Rationale -Clients want to prioritize this first because she does not feel good about it. Problem Prioritization Nursing Diagnosis Cues O – Temperature – 38.“Hindi ko mamaintain yung gamot ko sa diabetes ko kase nauubos lang pera namin dun.2 ºC .

bronchitis. gonorrhea.VI. lower respiratory tract infections. Effectively treats bone and joint infections. causing cell death. otitis media. Nursing resposibilies -Determine history of hypersensitivity reactions to cephalosphorins.penicillins and history of allergies particularly to drugs before therapy is initiated. meningitis. skin and soft tissue infections. Mode of action Bacteriacidal: inhibits synthesis of cell wall of sensitive organisms. reducing or eliminating infection. -Report onselt of loose stools -Absorption of cefuroxime isenhanced by food. -Notify prescriberabout rashes orsuperinfections . pharyngitis/tonsilliti s. urinary tract infections. and is used for surgical prophylaxis. sinusitis. Drug study Name of drug Generic name: Cefuroxime Brand name: Ceftin Indication It is effective for the treatment of penicillinaseproducing Neisseria gonorrhoea(PPNG).

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