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PATIENT’S PROFILE

NAME : Mon Lexter Gacutan Fernandez

AGE : 6 months

GENDER : Male

ADDRESS : Claveria, Cagayan

PLACE OF BIRTH : Enrile, Cagayan

OCCUPATION : N/A

NATIONALITY : Filipino

CIVIL STATUS : Single

RELIGION : Protestant

CHIEF COMPLAINT : LBM


Vomiting

FINAL DIAGNOSIS : Acute Gastroenteritis

ATTENDING PHYSICIAN : Dra. Magdalena Velarde

DATE ADMITTED :

TIME ADMITTED :

ADMITTING
INSTITUTION : Saint Paul Hospital
NURSING HISTORY

Present Health History:

3 days prior to admission, the patient was experiencing loose bowel movement, fever, and
vomiting. He was rushed to a hospital in Claveria, Cagayan for possible medications. He was given
Hydrasec to prevent his watery stools.

Past Health History:

He has been experiencing diarrhea, colds, and cough before.

Family Health History:

According to the SO, hypertension is the detected disease on the both sides of the family.
GORDON'S 11 FUNCTIONAL NEEDS

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Before hospitalization:
According to the SO, the patient was so active at home. He plays frequently with his
cousins. Whenver they would talk or tickle him, he would smile and laugh. He rarely cries at
home.

During hospitalization:
The patient oftenly cries. He feels uneasy because the room was hot. He does not laugh
or smile. When he does, this would just take a short period of time.

NUTRITIONAL-METABOLIC PATTERN

Before hospitalization:
The patient eats soft food. He loves eating lugaws, cereals, and mashed squash. He even
takes his meal almost 4 – 5 times a day. He loves to drink fruit juices.

During hospitalization:
He was advised to just take ISOMIL, a brand of milk, since he is suffering from
diarrhea. They have stopped giving him soft diet.

ELIMINATION PATTERN

Before hospitalization:
The patient does not have any problem on her elimination pattern. They usually change
his diapers 3 to 4 times a day. He defacates twice a day, that is upon waking up in the morning
and before sleeping at night.

During hospitalization:
His SO's change his diapers almost 12 – 15 times a day. They also said that they have
almost consumed 1 and ½ packs of baby diapers because he defacates more than usual. His
stool was watery and soft.

ACTIVITY-EXERCISE PATTERN

Before hospitalization:
He loves playing baby rattles with his cousins. He actively listens to stories. He smiles
and laughs whenever people play with him. He loves to turn around the bed because according
to his mother, this is his way to stretch his arms and feet. He does not like to be carried.

During hospitalization:
He has been rarely smiling and laughing. Whenver the nurses touch or talk to him, he
just cries and hide his head beneath his mother's arm. He just wants to be cuddled.
SLEEP-REST PATTERN

Before hospitalization:
He sleeps almost 12 – 14 hours a day. When people do not come and visit their house,
he just sleeps. He loves sleeping almost every hour.

During hospitalization:
He has difficulty in getting his sleep. He could not get enough sleep because the room
was so hot and the nurses kept on going in and out of the room, giving medications.

COGNITIVE-PERCEPTUAL PATTERN

SELF-PERCEPTION-SELF-CONCEPT PATTERN

ROLE-RELATIONSHIP PATTERN

SEXUALITY-REPRODUCTIVE

COPING-STRESS TOLERANCE PATTERN

Before hospitalization:
They just give him milk or maybe cuddle him whenever he starts to cry. Sometimes,
people play with him with baby rattles to deviate his focus.

During hospitalization:
They have to cuddle him until he stops crying. Whenver they try to give him milk or
anything that he could play with, he refuses to hold it. He just hides on his mother's arm.

VALUE-BELIEF PATTERN
LABORATORY EXAMINATIONS

URINALYSIS REPORT
Date: August 4, 2009

PARAMETER NORMAL ACTUAL FINDINGS ANALYSIS


FINDINGS
Color Yellow Amber Yellow normal
Transparency Clear to slightly Slightly Turbid normal
turbid
Reaction 4.5-8 5 normal
Specific Gravity 1.005-1.030 1.03 normal
Sugar Negative Negative normal
Protein Negative Positive 1
Squamous Few Occasional normal
Epithelial Cells
Red Blood Cells Few 0-2 normal
Pus Cells Few 01/02/09 normal
Amorp. Few Occasional normal
Urates/Phosphates

FECALYSIS REPORT
Date: August 3, 2009

PARAMETER NORMAL ACTUAL FINDINGS ANALYSIS


FINDINGS
Physical Properties
Color Yellow Yellow Light Due to the presence of
bacteria
Consistency Semi-formed Watery Due to presence of
bacteria
Bacteria: Few
Occult Blood: Negative
REMARKS: NO OVA/INTESTINAL PARASITE SEEN
HEMATOLOGY REPORT
Date: August 3, 2009

PARAMETER NORMAL ACTUAL FINDINGS ANALYSIS


FINDINGS
White Blood Cells 5-10 x 10^g/L 9.1 x 10^g/L Normal
Hemoglobin M: 13.0-18.0 g/dL 12.5 g/dL Normal
Hematocrit 39-54 % 38.00% Normal
Segmenters 0.60-0.70 0.33 Normal
Lymphocytes 0.20-0.30 0.62 Increased due to the
body’s increased
immune system
Monocytes 0.02 – 0.06 0.05 Normal
Platelet Count 150-450 x 10^g/L 442 x 10^g/dL Normal
REVIEW OF ANATOMY AND PHYSIOLOGY

If a human adult’s digestive tract were stretched out, it would be 6 to 9 m (20 to 30 ft) long. In
humans, digestion begins in the mouth, where both mechanical and chemical digestion occur. The
mouth quickly converts food into a soft, moist mass. The muscular tongue pushes the food against the
teeth, which cut, chop, and grind the food. Glands in the cheek linings secrete mucus, which lubricates
the food, making it easier to chew and swallow. Three pairs of glands empty saliva into the mouth
through ducts to moisten the food. Saliva contains the enzyme ptyalin, which begins to hydrolyze
(break down) starch—a carbohydrate manufactured by green plants.Once food has been reduced to a
soft mass, it is ready to be swallowed. The tongue pushes this mass—called a bolus—to the back of the
mouth and into the pharynx. This cavity between the mouth and windpipe serves as a passageway both
for food on its way down the alimentary canal and for air passing into the windpipe. The epiglottis, a
flap of cartilage, covers the trachea (windpipe) when a person swallows. This action of the epiglottis
prevents choking by directing food from the windpipe and toward the stomach.

Mouth

The mouth plays a role in digestion, speech, and breathing. Digestion begins when food enters the
mouth. Teeth break down food and the muscular tongue pushes food back toward the pharynx, or
throat. Three salivary glands—the sublingual gland, the submandibular gland, and the parotid gland—
secrete enzymes that partially digest food into a soft, moist, round lump. Muscles in the pharynx
swallow the food, pushing it into the esophagus, a muscular tube that passes food into the stomach. The
epiglottis prevents food from entering the trachea, or windpipe, during swallowing.

Esophagus

The presence of food in the pharynx stimulates swallowing, which squeezes the food into the
esophagus. The esophagus, a muscular tube about 25 cm (10 in) long, passes behind the trachea and
heart and penetrates the diaphragm (muscular wall between the chest and abdomen) before reaching the
stomach. Food advances through the alimentary canal by means of rhythmic muscle contractions
(tightenings) known as peristalsis. The process begins when circular muscles in the esophagus wall
contract and relax (widen) one after the other, squeezing food downward toward the stomach. Food
travels the length of the esophagus in two to three seconds.A circular muscle called the esophageal
sphincter separates the esophagus and the stomach. As food is swallowed, this muscle relaxes, forming
an opening through which the food can pass into the stomach. Then the muscle contracts, closing the
opening to prevent food from moving back into the esophagus. The esophageal sphincter is the first of
several such muscles along the alimentary canal. These muscles act as valves to regulate the passage of
food and keep it from moving backward.

Stomach

The stomach, located in the upper abdomen just below the diaphragm, is a saclike structure with strong,
muscular walls. The stomach can expand significantly to store all the food from a meal for both
mechanical and chemical processing. The stomach contracts about three times per minute, churning the
food and mixing it with gastric juice. This fluid, secreted by thousands of gastric glands in the lining of
the stomach, consists of water, hydrochloric acid, an enzyme called pepsin, and mucin (the main
component of mucus). Hydrochloric acid creates the acidic environment that pepsin needs to begin
breaking down proteins. It also kills microorganisms that may have been ingested in the food. Mucin
coats the stomach, protecting it from the effects of the acid and pepsin. About four hours or less after a
meal, food processed by the stomach, called chyme, begins passing a little at a time through the pyloric
sphincter into the duodenum, the first portion of the small intestine.

Liver

The liver is the largest internal organ in the human body, located at the top of the abdomen on the right
side of the body. A dark red organ with a spongy texture, the liver is divided into right and left lobes by
the falciform ligament. The liver performs more than 500 functions, including the production of a
digestive liquid called bile that plays a role in the breakdown of fats in food. Bile from the liver passes
through the hepatic duct into the gallbladder, where it is stored. During digestion bile passes from the
gallbladder through bile ducts to the small intestine, where it breaks down fatty food so that it can be
absorbed into the body. Nutrient-rich blood passes from the small intestine to the liver, where nutrients
are further processed and stored. Deoxygenated blood leaves the liver via the hepatic vein to return to
the heart.

Small Intestine

Most digestion, as well as absorption of digested food, occurs in the small intestine. This narrow,
twisting tube, about 2.5 cm (1 in) in diameter, fills most of the lower abdomen, extending about 6 m
(20 ft) in length. Over a period of three to six hours, peristalsis moves chyme through the duodenum
into the next portion of the small intestine, the jejunum, and finally into the ileum, the last section of
the small intestine. During this time, the liver secretes bile into the small intestine through the bile duct.
Bile breaks large fat globules into small droplets, which enzymes in the small intestine can act upon.
Pancreatic juice, secreted by the pancreas, enters the small intestine through the pancreatic duct.
Pancreatic juice contains enzymes that break down sugars and starches into simple sugars, fats into
fatty acids and glycerol, and proteins into amino acids. Glands in the intestinal walls secrete additional
enzymes that break down starches and complex sugars into nutrients that the intestine absorbs.
Structures called Brunner’s glands secrete mucus to protect the intestinal walls from the acid effects of
digestive juices
The small intestine’s capacity for absorption is increased by millions of fingerlike projections called
villi, which line the inner walls of the small intestine. Each villus is about 0.5 to 1.5 mm (0.02 to 0.06
in) long and covered with a single layer of cells. Even tinier fingerlike projections called microvilli
cover the cell surfaces. This combination of villi and microvilli increases the surface area of the small
intestine’s lining by about 150 times, multiplying its capacity for absorption. Beneath the villi’s single
layer of cells are
capillaries
(tiny vessels) of the bloodstream and the lymphatic system. These capillaries allow nutrients produced
by digestion to travel to the cells of the body. Simple sugars and amino acids pass through the
capillaries to enter the bloodstream. Fatty acids and glycerol pass through to the lymphatic system.Most
digestion, as well as absorption of digested food, occurs in the small intestine. This narrow, twisting
tube, about 2.5 cm (1 in) in diameter, fills most of the lower abdomen, extending about 6 m (20 ft) in
length. Over a period of three to six hours, peristalsis moves chyme through the duodenum into the
next portion of the small intestine, the jejunum, and finally into the ileum, the last section of the small
intestine. During this time, the liver secretes bile into the small intestine through the bile duct. Bile
breaks large fat globules into small droplets, which enzymes in the small intestine can act upon.
Pancreatic juice, secreted by the pancreas, enters the small intestine through the pancreatic duct.
Pancreatic juice contains enzymes that break down sugars and starches into simple sugars, fats into
fatty acids and glycerol, and proteins into amino acids. Glands in the intestinal walls secrete additional
enzymes that break down starches and complex sugars into nutrients that the intestine absorbs.
Structures called Brunner’s glands secrete mucus to protect the intestinal walls from the acid effects of
digestive juices
The small intestine’s capacity for absorption is increased by millions of fingerlike projections called
villi, which line the inner walls of the small intestine. Each villus is about 0.5 to 1.5 mm (0.02 to 0.06
in) long and covered with a single layer of cells. Even tinier fingerlike projections called microvilli
cover the cell surfaces. This combination of villi and microvilli increases the surface area of the small
intestine’s lining by about 150 times, multiplying its capacity for absorption. Beneath the villi’s single
layer of cells are
capillaries
(tiny vessels) of the bloodstream and the lymphatic system. These capillaries allow nutrients produced
by digestion to travel to the cells of the body. Simple sugars and amino acids pass through the
capillaries to enter the bloodstream. Fatty acids and glycerol pass through to the lymphatic system.

Large Intestine

A watery residue of indigestible food and digestive juices remains unabsorbed. This residue leaves the
ileum of the small intestine and moves by peristalsis into the large intestine, where it spends 12 to 24
hours. The large intestine forms an inverted U over the coils of the small intestine. It starts on the lower
right-hand side of the body and ends on the lower left-hand side. The large intestine is 1.5 to 1.8 m (5
to 6 ft) long and about 6 cm (2.5 in) in diameter.The large intestine serves several important functions.
It absorbs water—about 6 liters (1.6 gallons) daily—as well as dissolved salts from the residue passed
on by the small intestine. In addition, bacteria in the large intestine promote the breakdown of
undigested materials and make several vitamins, notably vitamin K, which the body needs for blood
clotting. The large intestine moves its remaining contents toward the rectum, which makes up the final
15 to 20 cm (6 to 8 in) of the alimentary canal. The rectum stores the feces—waste material that
consists largely of undigested food, digestive juices, bacteria, and mucus—until elimination. Then,
muscle contractions in the walls of the rectum push the feces toward the anus. When sphincters
between the rectum and anus relax, the feces pass out of the bod.
PHYSICAL
Area
ASSESSMENT
Technique Normal Findings Actual Findings Evaluation
Assessed
Skin
Color Inspection Light brown, Light brown skin Normal
tanned skin (vary
according to race)
Soles and Inspection Lighter colored Lighter colored Normal
palms palms, soles palms, soles
Moisture Inspection/ Skin normally dry Skin normally dry Normal
Palpation
Temperature Palpation Normally warm Normally warm Normal
Texture Palpation Smooth and soft Smooth and soft Normal
Turgor Palpation Skin snaps back Skin does not snap Dehydrated
immediately back immediately
Skin
appendages
a. Nails Inspection Transparent, Transparent, Normal
smooth and convex smooth and convex
Nail beds Inspection Pinkish Pale Due to
decreased
blood flow
Nail base Inspection Firm Firm Normal
White color of nail Returns within 2-3 Normal
bed under pressure seconds
Capillary Inspection/ should return to
refill Palpation pink within 2-3
seconds
b. Hair
Distribution Inspection Evenly distributed Evenly distributed Normal
Color Inspection Black Black Normal
Texture Inspection/ Smooth Smooth Normal
Palpation
Eyes
Eyes Inspection Parallel to each Parallel to each Normal
other other
Visual Acuity Inspection PERRLA- Pupils PERRLA- Pupils Normal
(penlight) equally round react equally round react
to light and to light and
accommodation accommodation
Eyebrows Inspection Symmetrical in Symmetrical in Normal
size, extension, hair size, extension, hair
texture and texture and
movement movement
Eyelashes Inspection Distributed evenly Distributed evenly Normal
and curved outward and curved outward
Eyelids Inspection Same color as the Same color as the Normal
skin skin

Blinks Blinks involuntarily


involuntarily and and bilaterally up to Normal
bilaterally up to 20 18 times per minute
times per minute
Do not cover the
Do not cover the pupil and the sclera, Normal
pupil and the lids normally close
sclera, lids symmetrically
normally close
symmetrically
Conjunctiva Inspection Transparent with Transparent with Normal
light pink color light pink color
Sclera Inspection Color is white Color is white Normal
Cornea Inspection Transparent, shiny Transparent, shiny Normal
Pupils Inspection Black, constrict Black, constrict Normal
briskly briskly
Iris Inspection Clearly visible Clearly visible Normal
Ears
Ear canal Inspection Free of lesions, Free of lesions, Normal
opening discharge of discharge of
inflammation inflammation

Canal walls pink Canal walls pink Normal


Hearing Inspection Client normally Client normally
Acuity hears words when hears words when Normal
whispered whispered
Nose
Shape, size Inspection Smooth, symmetric Smooth, symmetric
and skin with same color as with same color as Normal
color the face the face

Nares Inspection Oval, symmetric Oval, symmetric


and without and without Normal
discharge discharge

Mouth and
Pharynx
Lips Inspection Pink, moist Light pink, dry, Lack of fluid
symmetric symmetric intake
Buccal Inspection Glistening pink soft Glistening pink soft Normal
mucosa moist moist
Gums Inspection Slightly pink color, Slightly pink color,
moist and tightly fit moist and tightly fit Normal
against each tooth against each tooth
Tongue Inspection Moist, slightly Moist, slightly
rough on dorsal rough on dorsal Normal
surface medium or surface medium or
dull red dull red
Teeth Inspection Firmly set, shiny Firmly set, shiny Normal
With tooth decay
Hard and soft Inspection Hard palate- dome- Hard palate- dome-
palate shaped shaped Normal
Soft Palate- light Soft Palate- light
pink pink
Neck
Symmetry of Neck is slightly Neck is slightly
neck muscles, Inspection hyper extended, hyper extended, Normal
alignment of without masses or without masses or
trachea asymmetry asymmetry
Neck ROM Inspection Neck moves freely, Neck moves freely, Normal
without discomfort without discomfort
Thyroid Palpation Rises freely with Rises freely with Normal
gland swallowing swallowing
Thorax and Auscultation Clear breath sounds Clear breath sounds Normal
Lungs
Abdomen Inspection Skin same color Skin same color Normal
with the rest of the with the rest of the
body body

Bowel Auscultation Clicks or gurling Clicks or gurling Normal


sounds sounds occur sounds occur
irregularly and irregularly and
range from 5-35 range from 20 per
per minute minute

Extremities

Symmetry Inspection Symmetrical Symmetrical Normal

Skin color Inspection Same with the Same with the color Normal
color of other parts of other parts of the
of the body body

Hair Inspection Evenly distributed Evenly distributed Normal


distribution

Skin
Temperature Palpation Warm to touch Warm to touch Normal

Presence of
lesion Inspection No lesions No lesions Normal

ROM Inspection Moves freely Able to move but Due to body


without discomfort with assistance weakness

Neurology
system
Level of Inspection Fully conscious, Fully conscious,
consciousness respond to respond to Normal
questions quickly, questions quickly
perceptive of perceptive of events
events

Behavior and Inspection Makes eye contact Makes eye contact


appearance with examiner, with examiner,
hyperactive hyperactive Normal
expresses feelings expresses feelings
with response to with response to the
the situation situation