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A Case Study On Acute Gastroenteritis

In Partial Fulfillment of the Requirements In NCM103N- Related Learning Experience

Metabolism Concept

Submitted to:

Ms. Trina S. Domanais RN MN MAN Clinical Instructor

Submitted by:

FsCrestine N. Buga-ay St.N Cyrus Jean S. DestorSt.N Marigold Anne Diaz St.N Nada A. PaguitalSt.N Ramon Bien E. PatrataSt.N

July 04, 2013

TABLE OF CONTENTS Introduction Objectives Initial Data Base Biographic Data Clinical Data Family Health History Past Health History History of Present Illness Definition of Diagnosis Physical Assessment Anatomy and Physiology Pathophysiology Etiology Symptomatology Schematic Tracing of the Disease Narrative Medical Management Diagnostic Exam Actual Laboratory Test Diagnostic Exams Possible Laboratory & Diagnosis Therapeutics Drug Study Nursing Care Nursing Care Plan 62 72 80 80 26 27 29 33 33 3 5 7 7 7 8 8 9 10 12 15 26

Discharge Planning Nursing Theory Prognosis References

91 93 94 96

INTRODUCTION Metabolism is an integral part of the physical and chemical processes in the body that convert or use energy for bodily functions such breathing, circulating blood, controlling body

temperature, contracting muscles, digesting food and nutrients, eliminating waste through urine and feces and functioning of the brain and nerves (ADAM, 2011). We students nurses were task to look for a patient with metabolic problem in accordance to our metabolism concept. This task involves having the permission of the client to be a part or our subject for our case study as well as the required consent from the higher authorities. During our exposure on St. Lukes ward which mostly handles patients with metabolic problems, weve seen and known patient experiencing different types of metabolic diseases that gives us the knowledge on what is the actual picture of that certain disease or complication. Also, weve experience alot of complication on that clinical experience because some patient were not cooperating and wants their privacy during their stay on that certain hospital and we have to accept it because it is a part of their privileges being a client of that institution. We, the BSN 3B, group 4 subgroup 1 had our 3 weeks and 1 day experience at St. Lukes Ward of San Pedro Hospital. Our client is Mr. M.Q, 31 years old who is admitted due to fever and LBM on June 19, 2013 at 10:15 PM. We chose him as our client since He is fit to be our subject in our case study for having an Acute Gastroenteritis which is one of the metabolic problems. Also, He is willing and has the cooperation to answer our queries in accordance with his condition. Gastroenteritisis also known asgastro, gastric flu, andstomach flu, although unrelated to influenza. It is the inflammation of the gastrointestinal tract, involving both the stomach and the small intestine and resulting in acutediarrhea. The inflammation is caused most often by infection with certain viruses, less often by bacteria or their toxins, parasites, or adverse reaction to something in the diet or medication.

According to the Centers for Disease Control and Prevention that Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year. The Philippine Health Statistics reported that 971 infants out of 1000 live births died due to Gastroenteritis in the year 2009. And in Davao City, we have 4, 862 numbers in all ages which is rank as 3rd leading cause of morbidity in the year 2011 according to City Health Office of Davao City. Gastroenteritis occurs on individuals in all ages.

This case study aims to gather all necessary data that can help provide useful information for health workers who are interested in learning epilepsy. This study can be used as data for further nursing research on the topic. In nursing education we are given the chance to enhance our knowledge with regards on the disease process and we have also the chance to impart our knowledge on our patient through giving of health teachings. In nursing research, we are oblige to search more about the disease as well as its possible causes, its treatment and some possible modification of lifestyle. And finally in nursing practice, our skills were enhance and guided by our clinical instructor to give the proper medical care that the patient should get to lessen his burdens. Through rendering the appropriate interventions and management to the client.

OBJECTIVES General Objectives: That within our 4 weeks span of duty at St. Lukes Ward, we will be able to present a comprehensive case study and enhance our skills in developing our nursing capabilities. Specific Objectives: The group specifically aims to: o o o o o o o o o o o o o o o find a patient that will serve as our subject for our case study; establish rapport with the patient and his significant others to gain their trust and cooperation; gather all necessary data through conducting an interview and through reviewing the patients chart; perform a thorough cephalocaudal assessment on the client to determine any abnormalities; identify the normal and abnormal findings taken during the cephalocaudal assessment; construct an introduction that will serve as an overview of the rotation, case and client; formulate general, specific, measurable, attainable, realistic and time-bounded objectives to serve as our guide; collect pertinent personal causes of the clients present condition specifically the clients family lineage, family history, past health history and present health illnesses; explain the anatomy and physiology of the affected system of our clients case; trace the pathophysiology of our clients case along with its predisposing factors, precipitating factors, etiology and symptomatology; explain the medical management for our clients case which includes the diagnostic and laboratory examinations, doctors orders and the medications administered; make five nursing care plans composing of three actual problems and two risk problems; render suitable health teachings to the client regarding his conditions; discuss the discharge plan and the prognosis on our clients case; and enumerate all the references that we used during the case study.

INITIAL DATA BASE

PERSONAL DATA NAME: Marvin Quinsaat ADDRESS:B21, L12 Rosalina Village 2, Puan AGE: 31 years old RELIGION: Agnostic NATIONALITY: Filipino MOTHERS NAME: NenitaQuinsaat Live-in partner: Lanee Gonzales SEX: Male BIRTHDAY: August 17, 1981 BIRTHPLACE: Manila CIVIL STATUS: Single OCCUPATION: None FATHERS NAME: Mario Quinsaat

CLINICAL DATA DATE OF ADMISSION: June 19, 2013 HOSPITAL: San Pedro Hospital TIME OF ADMISSION: 10:15PM WARD: Sta. Rosa Ward transferred to St. Lukes Ward ATTENDING PHYSICAIN:Dr. Marjorie B. Guillermo CHIEF COMPLAINT: Fever and LBM ADMITTING DIAGNOSIS: Acute gastroenteritis moderate dehydration with ADMISSION VS: Temp. 38.9C PR- 95 bpm CR- 101 bpm RR- 20 BP-110/70

FAMILY HEALTH HISTORY

Quinsaat - Cruz

Through the interview we had, we were able to get information about the family of our client and their illness. His grandfather on his father side Mr. WQ died because of the complications of hypertension while his grandmother, Mrs. JQ died because of pancreatic cancer. On the other hand his grandfather on his mother side Mr. BC died because of thyroidism while his grandmother, Mrs. AC died because of old age. Both of them had asthma. Meanwhile, his father Mr. MQ has hypertension and migraine then his mother Mrs. NQ has asthma. Our client has 3 siblings; all of them have asthma at the moment. His brother MQ has meningitis. Mr. MQ our client has hyperthyroidism.

PAST HEALTH HISTORY Our client had a history of asthma which started at the age of 3. He also told us that he is a non-alcoholic beverage drinker. But he is a smoker for 15 years with 15-20 sticks/day that probably one of the causes of his hypothyroidism aside, from his genetic history of thyroidism. His hyperthyroidism occur 3-4 years ago. His live in partneer Ms. LG told us that our client doesnt have any allergies from food and drugs.

PRESENT HEALTH HISTORY It started 2 days prior to his admission he has an intermittent fever that riches 39+ 0C. This was associated with loose stools which is 5 episodes/dayLast June 19, . He took paracetamol as a temporary relief. 2013 at 10:15pm, our client was admitted at San Pedro Hospital via wheelchair. Few hours prior to admission our client was having persistent symptoms with body malaise, dizziness and positive smokers cough.

DEFINITION OF DIAGNOSIS Gastroenteritis An acute inflammation of the gastric and intestinal mucosa which is most commonly due to bacterial,viral,protozoal, or parasitic infection. It may also be caused by irritation due to chemical or toxin exposure or allergic response. Viral exposure is more likely in winter; bacterial exposure is more common in summer when food-borne illness exposure is likely.

Reference: DiGuilio, M. et al. (2007). Medical-Surgical Nursing Demystified. New York. McGraw Hill.

Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). An infection may be caused by bacteria or parasites in spoiled food or unclean water. Some foods may irritate your stomach and cause gastroenteritis. Lactose intolerance to dairy products is one example.

Reference: WebMD - Better information. Better health. Gastroenteritis (Stomach Flu) Symptoms, Causes, Treatments. Retrieved July 2, 2013, fromhttp://www.webmd.com/digestive-

disorders/gastroenteritis.

Gastroenteritis (better known as the stomach flu) is an inflammation of the GI tract. Although gastroenteritis can occur at any age, infants and older adults are at risk of having more severe symptoms.

Reference: Hurst, M. (2008). Hurst Reviews: Pathophysiology Reviews. New York. McGraw Hill.

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PHYSICAL ASSESSMENT General Survey During the assessment, the client was wearing a loose t-shirt and baggy pants. He is in anectomorphic body build. He stands to(height in cm) and weighs (weight in kg). And his BMI is (bmi). Level of consciousness is alert and oriented. He was in an appropriate mood and was cooperative during the assessment. He also had and IVF of PNSS 1L @ 140cc/hr infusing well at left metacarpalvein. Vital Signs Vital sign Blood pressure Cardiac Rate Pulse Rate Respiratory Rate Normal range 10/70-120-80 60-100 70-80 16-20 Result 120/80 87 80 20

Skin, Hair, and Nails His hair was evenly distributed and was well groomed. He had silver strands of hair on his head. His skin was warm to touch and had good skin turgor, with no discolorations noted. His finger and toe nails were long and uncut. Capillary bedsrefilledat 2 seconds. Head and Neck His head was symmetrical and round in shape, erect and is midline. And also, neither lesions nor masses were noted upon palpation. His neck was symmetrical with head centered. (add thyroid assessment here). Lymph nodes were not palpable. Eyes His pupils were equally round and reactive to light stimulation and accommodation. His eyes move symmetrically. Visual acuity of 150 - 100, he was wearing glasses.

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Ears His ears had the same color as the facial skin, symmetrical in position, firm and not tender. Pinna recoils after it is folded. Presence swelling or odorous discharges were not noted on both ears. Hearing acuity is normal. Nose and Sinuses The color of the nose is the same with as the rest of the face; nasal structure is smooth and symmetrical; and the client reports no tenderness upon palpation. Sinuses were not tender upon palpation. Mouth and Pharynx His lips appeared dry and pale. He has 28 teeth light yellowish in color with no dental carries. Gums are pink, moist, and firm with tight margins to the teeth. No lesion noted. The buccal area was also pink and moist with no lesion. The tongue was able to move freely, with sublingual frenulum intact and midline. The uvula was fleshy, and hangs freely in midline. Neck? Breasts and Axillae The areolar area and nipples were not inspected due to clients refusal. According to patients verbalization, the nipples were symmetrical with negative inversion, discharges, crusting, and masses. Both axillas were noted to be free from rashes and infections. Thorax and Lungs His anteroposterior transverse ratio was 1:2. He had a (tattoo description here) on his chest. Clear breath sounds upon auscultation of both lung fields with no adventitious sounds noted. Upon palpation, vocal fremitus was symmetrical. Heart No murmurs skip beats, noted upon auscultation. (add other assessment here). Abdomen (add abdominal Assessment here). Hndikokasinakia nag tyannya.:D

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Genitourinary Client refused visualization of the genitalia. Musculoskeletal The muscles on both sides of the body had no contractures and tremors. Muscle weaknesses were not noted on both lower and upper extremities.

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ANATOMY AND PHYSIOLOGY

The GI System

The gastro-intestinal system is essentially a long tube running right through the body, with specialised sections that are capable of digesting material put in at the top end and extracting any useful components from it, then expelling the waste products at the bottom end. The whole system is under hormonal control, with the presence of food in the mouth triggering off a cascade of hormonal actions; when there is food in the stomach, different hormones activate acid secretion, increased gut motility, enzyme release etc. etc. Nutrients from the GI tract are not processed on-site; they are taken to the liver to be broken down further, stored, or distributed.

The Esophagus

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Once food has been chewed and mixed with saliva in the mouth, it is swallowed and passes down the oesophagus. The oesophagus has a stratified squamous epithelial lining (SE) which protects the oesophagus from trauma; the submucosa (SM) secretes mucus from mucous glands(MG) which aid the passage of food down the oesophagus. The lumen of the oesophagus is surrounded by layers of muscle (M)- voluntary in the top third, progressing to involuntary in the bottom third- and food is propelled into the stomach by waves of peristalisis.

The Stomach

The stomach is a 'j'-shaped organ, with two openings- the oesophageal and the duodenal- and four regions- the cardia, fundus, body and pylorus. Each region performs different functions; the fundus collects digestive gases, the body secretes pepsinogen and hydrochloric acid, and the pylorus is responsible for mucus, gastrin and pepsinogen secretion. The stomach has five major functions;

Temporary food storage Control the rate at which food enters the duodenum Acid secretion and antibacterial action

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Fluidisation of stomach contents Preliminary digestion with pepsin, lipases etc.

G- mucosa containing glandular tissue; different areas of the stomach contain different types of cells which secrete compounds to aid digestion. The main types involved are:
o o o

parietal cells which secrete hydrochloric acid chief cells which secrete pepsin enteroendocrine cells which secrete regulatory hormones.

MM- muscularis mucosae SM- submucosa The stomach contains three layers of involuntary smooth muscle which aid digestion by physically breaking up the food particles;
o o o

OM- inner oblique muscle CM- circular muscle LM- outer longitudinal muscle

The Small Intestine

The small intestine is the site where most of the chemical and mechanical digestion is carried out, and where virtually all of the absorption of useful materials is carried out. The whole of the small intestine is lined with an absorptive mucosal type, with certain modifications for each section. The intestine also has a smooth muscle wall with two layers of muscle; rhythmical

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contractions force products of digestion through the intestine (peristalsis). There are three main sections to the small intestine;

Duodenum forms a 'C' shape around the head of the pancreas. Its main function is to neutralize the acidic gastric contents (called 'chyme') and to initiate further digestion; Brunner's glands in the submucosa secrete an alkaline mucus which neutralizes the chyme and protects the surface of the duodenum.

Jejunum where most chemical digestion takes place Ileum. The jejunum and the ileum are the greatly coiled parts of the small intestine, and together are about 4-6 metres long; the junction between the two sections is not welldefined. The mucosa of these sections is highly folded (the folds are called plicae), increasing the surface area available for absorption dramatically. The epithelial surface of the plicae (P) is further folded to form villi(V). These increase the surface area of the small intestine still further, and the surface of each villus is covered in small microvilli to maximise surface area- the area available for absorption is vast. Each villus has its own blood supply- the vessels can be seen in the submucosa (SM)- and blood containing digestive products from the small intestine is taken to the liver via the hepatic portal system. The double muscle layer (M) moves food through the intestine by peristalsis.

The Large Intestine

By the time digestive products reach the large intestine, almost all of the nutritionally useful products have been removed. The large intestine removes water from the remainder, passing semi-solid feces into the rectum to be expelled from the body through the anus. The mucosa (M) is arranged into tightly-packed straight tubular glands (G) which consist of cells specialized for

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water absorption and mucus-secreting goblet cells to aid the passage of feces. The large intestine also contains areas of lymphoid tissue (L); these can be found in the ileum too (called Peyer's patches), and they provide local immunological protection of potential weak-spots in the body's defenses. As the gut is teeming with bacteria, reinforcement of the standard surface defenses seems only sensible.

Ascending Colon - The ascending colon is comprised of strong muscles that motor waste products upward and onward out of the body. As part of the larger gastrointestinal tract, the ascending colon connects and continues the work of the small intestine in moving food along on its journey through the body.

Transverse Colon - helps stabilize fluid levels and prepare the body for the expulsion of waste Descending Colon - to store food that will be emptied into the rectum; its function is primarily the absorption of water from fecal matter Rectum - store your feces and provide force to force feces out of your body through the anus

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PATHOPHYSIOLOGY

PREDISPOSING FACTORS Age Geographical Location

PRECIPITATING FACTORS Unsanitary food handling Poor environmental condition Lifestyle (habitual eating of street foods)

Ingestion of food contaminated with bacteria (Salmonella, Shigella,Campylobacter, Clostridium, E. coli and Aeromonas species), viruses (rotavirus, norovirus, adenovirus) or parasites

Release of enterotoxins and attachment of microorganisms to mucosal epithilium

Decrease intestinal wall integrity

Increase secretion of water and electrolytes

Parasympathetic and sympathetic stimulation

Decrease intestinal absorption

Inhibits Sodium reabsorption

Stimulation of the emetic center

Increase gastrocolic reflex

Increase peristalsis 19

Large amount of CHON-rich in fluids

Nausea and vomiting

Diarrhea

Increase bowel sounds, abdominal cramping and abdominal pain

Deficient fluid volume Fever Poor skin turgor Poor capillary refill Lethargy Weakness Weight loss

Dehydration

Diagnosis: - Stool exam Treatment: - Antibiotics - Antivirals - Antiparasitic - ORS

If not treated

Hypovolemic Shock

Death

Good Prognosis: RECOVERY

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PATHOPHYSIOLOGY OF ACUTE GASTROENTERITIS Viruses and bacteria spread from person to person by means of the fecal-oral route or by direct ingestion of contaminated foods cause gastroenteritis. Some viruses such as the norovirus may be transmitted by an airborne route. Once these microorganisms have been ingested, they will release enterotoxins that may damage and outnumber normal bacteria and attach themselves in the bowel wall causing a decrease in intestinal wall integrity and would cause inflammation in the stomach and intestine. Once this will happen, there would be a stimulation of the emetic center in the brain caused by the parasympathetic and sympathetic stimulation which would eventually lead to vomiting. There would also be a decrease intestinal absorption and increase gastrocolic reflex which would result to an increase peristaltic movement causing abdominal bowel sounds, abdominal pain and cramping. In relation to the release of enterotoxins, there would be an increase secretion of water and electrolytes and Sodium would not reabsorbed back. Proteins would also increase in the lumen and would lead to greater chances of dehydration (proteins also play a vital role in holding fluids intracellularly by oncotic pressure). All of these factors would lead to fluid volume deficiency and dehydration marked by signs and symptoms such as fever, capillary refill, lethargy, weakness and weight loss. If the patient will not be treated, he/she may undergo hypovolemic shock and death. If treated, patient will have a good prognosis and will have a better chance of recovering. poor skin turgor, poor

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LABORATORY EXAMINATION

HEMATOLOGY

TEST Hemoglobin Erythrocytes MCH MCV MCHC Leukocyte Neutrophil Lymphocyte Monocyte Eosinophils Basophils Hematocrit Platelete Count

RESULT 132 g/dL 5.41/L 24.4 pg 74 fl 34.1 g/dL 5.9 g/L 0.33 0.52 0.10 4% 0% 0.41 % 188 g/L

NORMAL 140-180 g/dL 4.5-5.0 L 28-33 pg 82-98 fl 33-36 g/L 4.8-10.8 g/L 0.55-0.65 0.25-0.40 0.02-0.06 2-8 % 0-0.5 % 0.40 0.48 % 150 400 gL

STOOL ANALYSIS COLOR CONSISTENCY ENTAMOEBA HISTOLITICA

Dark brown Brown Brown

Soft Loose Mucoid

No Ova/Parasite No Ova/Parasite No Ova/Parasite

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HORMONE TEST Albumin RESULT 32 LOW NORMAL 34 - 50

CHEMISTY TEST Sodium Potassium Calcium RESULT 144 3.9 2.44 UNIT mmol/L mmol/L mmol/L NORMAL 136-144 3.6-5.1 2.23-2.58

ULTRASOUND THYROID LENGTH WIDTH THICKNESS LEFT 6.9 cm 2.9 cm 2.8 cm RIGHT 5.6 cm 3.0 cm 2.6 cm

THYROID FUNCTION TEST

TEST FT4 THYROID STIM

RESULT > 100 < 0.005

INTERPRITATION HIGH LOW

NORMAL 12-22 0.27-4.2

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HEMATOLOGY DATE COMPONENT DEFINITION RATIONALE NORMAL RESULT VALUES 132 g/dL I NTERPRETATION Low Low hemoglobin can indicate a hidden source of bleeding such as peptic ulcer or inflammatory bowel disease. NURSING RESPONSIBILITIE S Pre-test: 1. Explain the procedure to the patient. 2. Explain to the patient that he will experience discomfort from the needle puncture and the pressure of the tourniquet. 3. Obtain history of known allergens. 4. Obtain results of previously performed test. 5. Obtain a list of medications the patient is taking. 6. Note any recent procedures that can interfere with the result. 7. Tell the patient and the watcher that there are no fluid, food or medication restrictions, unless by medical direction.

Hemoglobin

The oxygen-carrying pigment and predominant protein in the red blood cells. Hemoglobin forms an unstable, reversible bond with oxygen.

Erythrocytes

The most common type of cell in blood. It carries oxygen throughout the circulatory system, from the lungs to the rest of the body, and brings carbon dioxide waste back the other way.

Measure the 140-180 severity of anemia, g/dL or polycythemia; Monitors blood loss and response to blood replacement; Monitors hematologic functions. To test for anemia, 4.5-5.0 L a common condition that occurs when the body has insufficient red blood cells

5.41L

High As the volume of fluid in the blood drops, the count of RBCs per volume of fluid artificially rises that cause dehydration.

MCH

MCV

MCH stands for mean corpuscular hemoglobin. It refers to the quantity of hemoglobin in red corpuscles This is a calculated value derived from the measurement of hemoglobin and the red cell count. Mean corpuscular volume is the average volume of a red blood cell. This is a calculated value derived from the hematocrit and red cell count.

Measures the 27-33pg average amount of hemoglobin in the average red cell.

24.4 pg

Low low levels indicate iron deficiency or anaemia

Measures the 85-96Fl average volume of a red blood cell.

74fL

Low When the number is smaller than normal, the cell is too small and this is a condition that causes microcytic anemia or microcytosis

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MCHC

Mean corpuscular hemoglobin concentration (MCHC) is the average concentration of hemoglobin in red blood cells

Leukocytes

A colorless blood corpuscle capable of ameboid movement, whose chief function is to protect the body against microorganisms causing disease

Neutrophils

Are produced in the bone marrow and circulate in the blood, are a type of white blood cell. Neutrophils are the first type of immune cell to respond to and arrive at the site of infection, often within an hour.

MCHC is used to 33-36 g/L help diagnose the type (cause) and severity of anemia. When MCHC is low, this can mean a person has irondeficiency anemia. This type of anemia can be caused by insufficient iron in the diet or by blood loss. Blood loss, such as what might occur with tumors in the colon and other parts of gastrointestinal tract can cause low iron levels and a low MCHC. To count WBC 4.8present. A high 10.8g/L white blood cell count, called leukocytosis. A low white blood cell count, called leukopenia. To detect the 0.55presence of 0.65% infections since it plays a major role in the immune response system.

34.1 g/dL

Normal If the levels fall between the normal range, the person does not have to worry about being anemic.

Post-test: 1. Observe venipuncture site for bleeding or hematoma formation.

2. Apply pressure at the site of the venipuncture because bleeding may occur. 3. If hematoma develops, apply warm soaks. 4. Evaluate the results in relation to the patients symptoms and other tests performed.

5.9 g/L

Normal

0.33%

Low A condition, neutropenia caused by decreased production of neutrophils.The level of neutrophil

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Neutrophils will respond to infection inside the body, but also on the surface, as in the case of skin infections.

production decreases because they are crowded out of the bone marrow by the early form of WBC. Increased number of lymphocytes indicates infections. Decreased lymphocyte occurs after burns or trauma. 0.250.40% 0.52% High An increase in lymphocyte concentration is usually a sign of a viral infection (in some rare case, leukemias are found through an abnormally raised lymphocyte count in an otherwise normal person). High Monocytes can also increase in response to stress and other factors. A high monocyte count may be referred to as monocytosis.

Lymphocytes

Lymphocytes are an integral component of blood in human beings. They vary in size and shape based on their function in the human body. There are natural killer cells which would locate and destroy potentially harmful cells like virus infected cells.

Monocytes

Eosinophils

Is a mononuclear phagocyte that A high monocyte circulates in the blood. count usually indicates an infection, often caused by bacteria. Decreased monocyte amount indicate hairy cell leukemia. Are white blood cellsthat are one of An increase in the immune system components count is typically responsible for combating seen with those multicellular parasites and people having certain infections in vertebrates. parasitic infestation of the intestine. Decrease in count

0.020.06%

0.10%

2-8%

4%

Normal Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions.

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Basophils

Basophils are a type of white blood cells that are involved in inflammatory reactions in your body, especially those related to allergies and asthma. When stimulated, basophils release histamine and other enzymes that can lead to inflammation, bronchoconstriction and asthma symptoms. Basophils contain anticoagulant heparin, which prevents blood from clotting too quickly. They also contain the vasodilator histamine, which promotes blood flow to tissues N: 0.0000 0.0005%

is seen in the early phase of acute insults, such as shock, major pyogenic infections, trauma, surgery, etc. Determines chronic 0-0.5% inflammation, allergic responses and stress response; Assists in determining the cause of an elevated WBC alone; Detects hematologic disorders and abnormalities

0%

Normal

Hematocrit

The hematocrit is the proportion, by - To determine the volume, of the blood that consists percentage of of red blood cells. RBCs in the plasma.

0.400.48%

0.41

Normal

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STOOL ANALYSIS DATE COMPONENTS ENTAMOEBA HISTOLITICA DEFENITION A protozoan parasite responsible for disease called AMOEBIASIS. It usually occur in the large intestine and causes internal inflammation as its name suggests (histo = tissue, lytic = destroying). RATIONALE RESULT No Ova/Parasite NURSING RESPONSIBILITY procedure and the reason it is required clearly and privately to the patient. Obtain informed consent and document that it has been given.

appropriate, offer the patient the choice of using either a commode at the bedside or a toilet.

CONSISTENCY COLOR

Stool color is generally influenced by what you eat as well as by the amount of bile- yellowgreen fluids that digest fats in the stool. As bile pigments travel through you gastrointestinal tract, they are chemically altered by enzymeschanging the pigments from green to brown.

soft If the stool is bright Dark Brown red or black which may indicate the presence of blood.

bedside are pulled the toilet completely protect the privacy.

curtains tight or door is shut to patients

using a commode ensure toilet paper is available and accessible to the patient, and that the patient also has

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ENTAMOEBA HISTOLITICA

A protozoan parasite responsible for disease called AMOEBIASIS. It usually occur in the large intestine and causes internal inflammation as its name suggests (histo = tissue, lytic = destroying). Stool color is generally influenced by what you eat as well as by the amount of bile- yellowgreen fluids that digest fats in the stool. As bile pigments travel through you gastrointestinal tract, they are chemically altered by enzymeschanging the pigments from green to brown. A protozoan parasite responsible for disease called AMOEBIASIS. It usually occur in the large intestine and causes internal inflammation as its name suggests (histo = tissue, lytic = destroying). If the stool is bright red or black which may indicate the presence of blood.

No Ova/Parasite

access handwashing facilities.

to

CONSISTENCY COLOR

Loose Brown

using the toilet, place a disposable clean bedpan (Fig 1) under the toilet seat to catch the specimen.

put on gloves (Fig 2). the patient has produced the sample, examine the stool for consistency, colour, blood or any other abnormality.

ENTAMOEBA HISTOLITICA

No Ova/Parasite

CONSISTENCY

Mucus in stool can occur with a variety of intestinal infections that cause severe

Mucoid

of the specimen container and collect the sample using the spoon provided (Fig 3). Fill the container about a third full. Secure the lid.

contamination.

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diarrhea. remaining faecal matter according to local policy.

bedpan (if used) according to local policy (Fig 4).

and apron and dispose of them appropriately (Fig 5). ash hands.

specimen container clearly and accurately (Fig 6).

specimen container in a specimen bag with the completed laboratory request form.

cannot be sent to the laboratory immediately, place it in the appropriate refrigerator. In

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some infections, however, especially those caused by parasites such as amoebiasis, the stool should remain fresh and warm. If you are in any doubt ask the laboratory for advice.

findings. Record the date and time that the specimen was obtained.

COLOR

Stool color is generally influenced by what you eat as well as by the amount of bile- yellowgreen fluids that digest fats in the stool. As bile pigments travel through you gastrointestinal tract, they are chemically altered by enzymeschanging the pigments from green to brown.

If the stool is bright red or black which may indicate the presence of blood.

Brown

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COMPONETS Albumin

DEFINITION A protein made by the liver. A serum albumin test measures the amount of this protein in the clear liquid portion of the blood.

HORMONE RATIONALE RESULT Low albumin levels can also be seen in inflammation, shock, and malnutrition 32

NORMAL 34-35

NURSING RESPONSIBILITES Assess for peripheral edema in the lower extremities when the albumin level is decreased. Albumin is the major protein compound responsible for plasma colloid osmotic pressure. With a decreased albumin level, fluid seeps out of the blood vessels into the tissue spaces.

COMPONENTS Sodium

DEFINITION Sodium is the most abundant cation (pronounced cation) in the blood and its chief base. It functions in the body to maintain osmotic pressure, acid-base balance and to transmit nerve impulses.

CHEMISTRY RATIONALE RESULT Your blood sodium 100 level represents a balance between the sodium and water in the food and drinks you consume and the amount in urine

NORMAL 136-144

NURSING RESPONSIBILITIES Pre- Test Usually no special preparation is necessary by the patient. Samples for calcium and phosphorus and for magnesium should be collected following an eighthour fast.

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Post- Test -check for signs of discomfort and bruising at the puncture site - observe for signs of dizziness and fainting - apply pressure at the puncture site to reduce bruising until the bleeding stops apply warm compress at the puncture site to relieve discomfort

Potassium

Calcium

Potassium regulates the heart and function of the muscle. And he major positive ion (cation) found inside of cells. Calcium is bound to the proteins in the bloodstream, so the level of calcium is related to the patient's nutrition as well as the calcium

The proper level of 3.9 potassium is essential for normal cell function.

3.5-5.1

It is important in the 2.44 transmission of nerve impulses across synapses, the clotting of blood and the contraction of muscles

2.23-2.58

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intake in the diet.

COMPONENTS FT4

DEFINITION

THYROID FUNCTION TEST RATIONALE RESULT > 100

NORMAL 12-22

Free T4 measures Free T4 is typically the free, unbound elevated in thyroxine levels in hyperthyroidism your bloodstream

NURSING RESPONSIBILITIES Pre Test *tell patient that there is no need for changes of diet and activities * Venipuncture is performed in the usual manner following standard pre cautions for prevention of exposure to bloodborne pathogens.

THYROID STIMULATING HORMONE (TSH)

A special messenger hormone that stimulate the thyroid to release more thyroid hormone

TSH that is elevated, or above normal, is considered indicative of hypothyroidism.

<0.005

0.27-4.2

Post test *routine care at the area of puncture mark * Pressure is applied for a few seconds, and the wound is covered with a bandage.

34

ULTRASOUND THYROID LENGTH WIDTH LEFT 6.9 cm 2.9 cm RIGHT 5.6 cm 3.0 cm

THICKNESS 2.8 cm 2.6 cm *Both thyroid lobes enlarged. Both show heterogeneous parenchymal echopattern. External outline is smooth. No pathologic classification *Bilateral carotid spaces are intact *No cervical lymphadenopathy demonstrated *Impression: thyromegaly with diffuse thyroid parechymal disease

35

Medical orders

36

DRUGSTUDY

Date Ordered: June 19, 2013


Generic Name: Propylthiouracil (PTU) Brand Name: Classification: Anti-thyroid drug Mechanism of Action: Inhibits conversion of the synthesis of thyroid hormones; partially inhibits the peripheral T4 to T3, the more potent form of thyroid hormone.

Indication: Hyperthyroidism Contraindication: Allergy Pregnancy

Ordered Dose: 50mg tab BID Adverse Effects: CNS: Paresthisias, neuritis, vertigo, neuropaties, depression CV: Vasculitis, periarteritis Dermatologic: Urticaria, pruritus, skin pigmentation, exfoliative dermatitis, lupus-like syndrome GI: Epigastric distress, loss of taste, jaundice, hepatitis GU: Nephritis Hematologic: Agranulocytosis, granulocytopenia, thrombocytopenia, hypoprothrombinemia, aplastic anemia

Side Effects: Nausea Vomiting Skin rash Headache Drowsiness Weakness

37

Drug Interaction: Increased risk of bleeding with oral anticoagulants Alterations in the ophylline, metoprolol, propranolol, digitalis glycoside clearance, serum levels and effects as patient moves from hyperthyroid state to eurothyroid state

Nursing Responsibilities: 1. 2. 3. 4. 5. 6. Observe the 10 rights in giving the drug. Assess allergy to antithyroid products Administer drug in 3 equally divided doses at 8 hour interval Inform patient of the possible side effects of the drug Instruct patient to take drug with meals todecrease risk of adverse GI reactions. Urge patient to report signs and symptomsof infection, such as fever and sorethroat, or signs and symptoms that couldreflect hepatic dysfunction, such as anorexia and right-upper-quadrant pain. 7. Advise patient to notify prescriber immediately if he has fatigue, weakness, and vagueabdominal pain, loss of appetite, itching,easy bruising, or yellowing of eyes or skin. 8. Monitor CBC, PT, and liver and thyroidfunction test results in patientstakingpropylthiouracil. Elevated serum triiodothyronine(T3) level may be the soleindicator of inadequate treatment.

38

Date Ordered: June 19, 2013 Generic Name:Paracetamol Brand Name:Boigesic Classification: Non-opioid analgesics, Antipyretics Mechanism of Action: Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating which helps dissipate heat.

Indication: Mild pain Fever

Contraindication: Hypersensitivity to acetaminophen or its components Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

Ordered Dose:500mg tab every 4 hours for fever Adverse Effects: CV: chest pain, dyspnea, myocardial damage GI: heaptic toxicity and failure, jaundice GU: Acute renal failure, renal tubular necrosis Hematologic: Methemoglobinemia-cyanosis, haemolytic anemia- hematuria, anuria, neutropenia, hypoglycaemia, leukopenia Hypersensitivity: Rash, urticarial

Side Effects: Headache Nausea vomiting

Drug Interactions: Increased toxicity with long term, excessive ethanol ingestion Increased hypoprothrombinemic effect of oral anticoagulants Increased risk of hepatotoxicity

39

Possible decreased therapeutic effects with barbiturates, carbamazepine, hydantoins, rifampin, sulfinpyrazone Possible delayed or decreased effectiveness with anticholinergics Possible reduced absorption of acetaminophen with activated charcoal Possible decreased effectiveness of zidovudine

Nursing Responsibilities: 1. 2. 3. 4. 5. 6. 7. 8. Observe the 10 rights in giving the drug Assess temperature of the patient before giving the medicine. Use liquid form for children and patients who have difficulty swallowing. Administer with water. Give drug with food if GI upset occurs. Discontinue drug if hypersensitivity occurs. Ensure patient is not allergic to Paracetamol Assess allergic reactions: rash, urticaria; if these occur, drug may have to be discontinued.

40

Date Ordered: June 19, 2013 Generic Name: Racecadotril Brand Name:Hidrasec Classification: Antidiarrheal Mechanism of Action: Racecadotril is an antihypersecretory agent. It inhibits the enzyme enkephalinase in the small intestine, thereby reducing the intestinal hypersecretion of water and electrolytes induced by cholera toxin or inflammation. Racecadotril does not affect basal secretory activity and exerts rapid antidiarrhoeal action without modifying intestinal transit time

Indication: Treatment of acute diarrhea Contraindication: Allergy Renal impairment Liver impairment Pregnancy and lactation

Ordered Dose: 100g/ tab BID Side Effects: Drowsiness nausea and vomiting dizziness headaches

Drug Interactions: No interaction with other drugs have been described in humans to date. In humans, the concomitant treatment of racecadotril with loperamide or nifuroxazide does not modify the kinetics of racecadotril.

Nursing Responsibilities: 1. 2. 3. 4. 5. Observe the 10 rights in giving the drug. Assess if patient is hypersensitive to the drug. Advise patient to increase oral fluid intake Instruct patient to eat foods rich in fiber such as green leafy vegetables Instruct to report episodes of loose bowel movement

41

6. Educate about the possible side effects og the drug 7. Observe for the amount & consistency of the stool 8. Instruct patient to report any unusualities

42

Date Ordered: Generic Name:Methimazole Brand Name:Tapdin Classification: Antithyroid agent Mechanism of Action: Inhibits the synthesis of thyroid hormones and thus is effective in the treatment of hyperthyroidism Indication: Management of hyperthyroidism,goiter, Graves disease and psoriasis. It is also used before thyroid surgery or radioactive iodine treatment.

Contraindication:Allergy, pregnancy, lactation Ordered Dose: 5mg/tab Adverse Effects:


CNS: Paresthisisas, neuritis, vertigo, neuropathies Dermatologic: Uricaria, pruritus, lupus-like syndrome, skin pigmentation GI: Epigastric distress, sialadenopathy, jaundice, hepatitis GU: Nephritis Hematologic: Agranulocytosis, granulocytopenia, thrombocytopenia, vasculitits

Side Effects: Nausea & vomiting Gastric discomfort Headache Skin rashes Drowsiness

Drug Interaction: Increased theophylline clearance and decreased effectiveness if given to hyperthyroid patients; clearance will change as patient approaches euthyroid state Altered effects of oral anticoagulants with methamizole Increased therapeutic effectsand toxicity of digitalis glycosides,metoprolol, propranolol when hyperthyroid patients become euthyroid

43

Nursing Responsibilities: 1. Observe the 10 rights in giving the drug 2. Give drug in three equally divided doses at 8 hour interval 3. Inform patient that the drug should be taken for a prolonged period to achieve the desired effects. 4. Educate patient of the possible side effects 5. Instruct patient to take the drug with food 6. Instruct to report if patient experiences fever, sore throat, unusual bleeding or bruising, headache or general malaise.

44

Date Ordered: June 19, 2013 Generic Name: Ciprofloxacin Brand Name:Cipro Classification: Antibacterial Mechanism of Action: Bactericidal; Interferes with DNA replication in susceptible bacteria preventing cell reproduction.

Indication: For treatment of infections Contraindication: Allergies Pregnancy Lactation

Ordered Dose: 500 mg tab BID Adverse Effects: CNS: insomnia, fatigue, somnolence, depression, blurred vision CV:Arrhytmias, hypotension, angina EENT: Dry eye, eye pain, keratopathy GI:diarrhea, abdominal pain Hematologic: Elevated BUN, AST, ALT, serum creatinine and alkaline phosphatase; decreased WBC, neutrophil count, Hct

Side effects: Headache Dizziness Nausea Vomiting dry mouth

Drug Interaction: decreased therapeutic effect with iron salts, sucralfate decreased absorption withantacids, didanosine increased serum levels and toxic effects of theophyllines if taken concurrently with ciprofloxacin

45

increased effects of coumarin or its derivatives

Nursing Responsibilities: 1. 2. 3. 4. 5. 6. 7. 8. Assess allergy to ciprofloxacin. Observe 10 rights in giving the drug. Drink plenty of water when taking the drug. Monitor vital signs. Give antacids at least 2 hours after dosing. Inform about the possible side effects of the drugs. Educate patient about the ways to prevent infection such as handwashing. Advise to eat foods rich in Vitamin C to boost immune system.

46

Date Ordered: June 20, 2013 Generic Name:Propranolol Brand Name:Inderal Classification: Beta-adrenergic blocker Antianginal Antiarrhytmic Antihypertensive

Mechanism of Action: Through beta-blocking action, propranolol: o Prevents arterial dilation and inhibits renin secretion, resulting in decreased blood pressure (in hypertension and pheochromocytoma) and relief of migraine headaches o Decreases heart rate, which helps resolve tachyarrhythmias o Improves myocardial contractility, which helps ease symptoms of hypertrophic cardiomyopathy o Decreases myocardial oxygen demand, which helps prevent anginal pain and death of myocardial tissue.

Indication: To manage hypertension To treat chronic angina To treat supraventricular arrhythmias and ventricular tachycardia To control tremor To prevent vascular migraine headaches As adjunct to treat hypertrophic cardiomyopathy As adjunct to manage pheochromocytoma To prevent MI

Contraindication: Asthma Cardiogenic shock Greater thanfirst-degree AV block Sick sinus syndrome Heart failure (unless secondary totachyarrhythmia responsive to propranolol)

47

Hypersensitivity to propranolol or itscomponents

Ordered Dose: Adverse Effects: Allergic reactions: Pharyngitis, erythematous rash, laryngospasm CNS: Vertigo, tinnitus, paresthesias CV: CHF, cardiac arrhythmias , pulmonary edema Dermatologic: Pruritus EENT: Conjunctivitis GI: Ischemic cholitis, renal and mesenteric arterial thrombosis, retroperitoneal fibrosis, hepatomegaly, acute pancreatitis GU: Impotence, decreased libido, dysuria

Side Effects: Dizziness Headache Nausea Vomiting Eye irritation sweating

Drug Interaction: Increased effects with verapamil Decreased effects with indomethacin, ibuprofen, piroxicam, sulindac, barbiturates Prolonged hypoglycemic effects of insulin Initial hypertensive episode followed by bradycardia with epinephrine Increased first-dose response to prazosin Increased serum levels and toxic effects with lidocaine, cimetidine

Nursing Responsibilities: 1. 2. 3. 4. 5. Observe the 10 rights in giving the drug. Assess if there is allergy to the drug. Take with meals to facilitate absorption. Monitor vital signs. Inform patient about the possible side effects of the drug

48

Date Ordered: June 20, 2013 Generic Name: Probiotics Brand Name:HexBio Classification: Anti-diarrheal Mechanism of Action: Suppressing the growth of pathogens through secretion of antimicrobial substances Competing for attachment sites/nutrients with the pathogens.

Indication:Treatment of diarrhea Contraindication: allergy

Ordered Dose: 1 sachet OD Adverse Effects: Side Effects: Nursing Responsibilities: 1. 2. 3. 4. 5. 6. 7. 8. 9. Observe the 10 rights in giving the drug. Assess if patient is hypersensitive to the drug. Dissolve 1 sachet in cup of water Advise patient to increase oral fluid intake Instruct patient to eat foods rich in fiber such as green leafy vegetables Instruct to report episodes of loose bowel movement Educate about the possible side effects og the drug Observe for the amount & consistency of the stool Instruct patient to report any unusualities

49

Date Ordered: Generic Name: Verapamil hydrochloride Brand Name:Isoptin Classification: Calcium channel blocker Antianginal Antiarrhytmic antihypertensive

Mechanism of Action: Inhibits calcium movement into coronaryand vascular smooth-muscle cells by blockingslow calcium channels in cell membranes.The resulting decrease in intracellularcalcium level has the following effects: o inhibits smooth-muscle cell contractions decreases myocardial oxygen demand by o relaxing coronary and vascular smooth o muscle, reducing peripheral vascular o resistance, and decreasing systolic and o diastolic pressures o slows AV conduction time and prolongs o AV nodal refractoriness o Interrupts reentry circuit in AV nodalreentranttachycardias.

Indication: To treat chronic angina pectoris To manage hypertension To prevent or treat supraventriculartachycardia

Contraindication: Allergy Hypotension Pregnancy & lactation Heart-block Sick sinus syndrome except with ventricular pacemaker

Ordered Dose: 40mg/tab Adverse Effects: CNS: Vertigo CV: Peripheral edema, hypotension, arrhythmias, bradycardia, AV heart block

50

Side Effects: Nausea Constipation Dizziness Headache Sleepiness

Drug Interaction: Risk of serious cardiac effects with IV beta-adrenergic blocking agents; do not give these drugs within 48 hour before or 24 hour after IV verapamil. Increased cardiac depression with beta-adrenergic blocking agents Additive effects of verapamil and digoxin to slow AV conduction Increased serum levels of digoxin carbamazepine, prazosin, quinidine Increased respiratory depression with atracurium, gallamine, pancoronium, tubocurarine, vecuronium Decreased effects with calcium, rifampin

Nursing Responsibilities: 1. Observe the 10 rights 2. Ensure that the patient swallows SR tablets whole; patient should not cut, crush or chew them. 3. Monitor vital signs, especially BP very carefully with concurrent doses of antihypertensives. 4. Administer SR form in the morning with food to decrease GI upset. 5. Do not take the drug with grape or grapefruit. 6. Inform about the possible side effects of the drug.

51

D/T

CUES

NEED

NURSING DIAGNOSIS

OBJECTIVES OF CARE

NURSING INTERVENTIONS

EVALUATION

J U N E 20,

Subjective: Ginakalibanga man gudko. Gahaponnisugodakong kalibanga. Objective:

E L I M I N A T I O N P A T T E R N

Diarrhea r/t infectious processes secondary to acute gastroenteritis

At the end of my 8 hours span of nursing care, the patient will be able to:

1.

Obtain vital signs to have baseline data

June 20, 2013 @ 3pm GOAL MET After the 8 hours span of care, the patient was be able to: 1. Report decrease in frequency of bowel movements as evidenced by: Less than 3 bowel movements during the shift with semiformed stool 2. Learned ways to prevent diarrhea such as ensuring that the food he eats is safe and not spoiled 3. Verbalized understanding of the condition, Muinomnakougdaghanng atubigugmukaonugmgagul ayparamarehydratekougm

2. 1. Diarrhea means loose bowel movements, usually causing to move his or her bowels frequently. Vomiting may bepresent as well. Acute diarrhea means the diarrhea lasts for only a limited time; this is also called gastroenteritis. There are manypossible causes of gastroenteritis, including infections with bacteria, viruses, or parasites. Diarrhea may also be asymptom of other diseases, but this is less common. 5. 4. 3. 2. Learn ways to prevent diarrhea Verbalize understanding of the interventions Demonstrate ways to prevent infection 4. 3. Report decrease in the frequency of bowel movements

Assess the medications being taken by patient some drugs may cause diarrhea
Observe and record number and consistency of stools per day

2 0 1 3 @

Vital signs as taken: -T: 36.6oC -PR: 80 bpm -RR: 20 cpm -CR: 87 bpm -BP: 120/80 mmHg

Documentation of output provides a baseline and helps direct replacement fluid therapy Secure stool sample to test the sample and identify the possible causative agent Emphasize importance of handashing to prevent spread of microorganisms

7am

dry lips sunken eyes loose watery stool history of loose watery stools, 5episode/day with 100cc/episode

IVF of PNSS 1L @ 140cc/hr Drugs as ordered: -Ciprofloxacin 500

52

mg tab BID -Paracetamol 500mg tab q4 PRN for fever -Propylthiouracil 50mg BID -Isoptin 40mg/tab -Tapdin 5mg/tab -Propranolol Anti-diarrheal drugs as ordered: -Hidrasec 100g/tab BID -Hexbio 1 sachet OD 8. Reference: Hurst, M. (2008). Hurst Reviews: Pathophysiology Reviews. New York. McGraw Hill. 7. Administer drugs as ordered (Ciprofloxacin 500 mg tab BID, Paracetamol 500mg tab q4 PRN for fever, Propylthiouracil 50mg BID, Isoptin 40mg/tab, Tapdin 5mg/tab, Propranolol) to promote pharmacological management Instruct to eat fiber rich foods such as green leafy vegetables and fruits These are stool-forming foods 9. Administer anti-diarrheal drugs as ordered (Hidrasec 100g/tab BID and Hexbio 1 sachet OD to promote faster recovery 6. Monitor input and output of the patient Diarrhea can lead to profound dehydration and electrolyte imbalance. 4.

ugahiakonglibang. Demonstrated ways to prevent infection such as handwashing

53

10. Teach patient or caregiver the importance of fluid replacement during diarrheal episodes. to prevent dehydration 11. Method of food preparation Fried food or food contaminated with bacteria during preparation may cause diarrhea 12. Instruct to avoid stimulants such as caffeine and carbonated drinks Stimulants may increase GI motility and worsen diarrhea 13. Encourage fluids; consider nutritional support Fluids compensate for malabsorption and loss of nutrients

Date& Time

Cues

Need

Nursing Diagnosis

Objective of Care
54

Nursing Intervention

Evaluation

J U N E

Subjective:

Fatigue related to After the 8 hours span of 1. hypermetabolic state increased care, the patient will be signs,

Monitor noting

vital pulse

@ 3pm

pakiramdamko, C hinanghina ako, T at madali lang I ako mapagod. V

with able to: energy 1. Show decrease, or absence

rate or cardiac rate at rest and when active.

Goal Met

requirements.

After the 8 hours span

2 2,

Parati lang nga I ako natutulog. T As verbalized Y R: Hyperthyroidism is an over

of R: Pulse or Cardiac of care, the patient will rates are typically be able to:

irritability

elevated, and even at 2. Verbalize increased knowledge regarding and fatigue rest, tachycardia up to 160 bpm may be 1. Showed decrease, absence irritability. or of

2 0 1 3

by the patient. E Objective: Lack energy X of E R C Irritable I S VS taken as E follows: T: 36.6 P: 80 CR: 87 P A T

production of thyroid hormone,

which creates far reaching metabolic effects. Hypertrophy and

noted.

management 2. Note daily energy high energy patterns. 2. Verbalized increased R: Helpful in knowledge regarding fatigue of and management of high energy

of

hyperplasia of the thyroid gland occur with increased vascularity. of the Most clinical

consuming activities.

7 am

determining 3. Verbalize proper pattern/timing of activity.

understanding

manifestations result from

his medical illness and the 3. Advise patient to

consuming activities.

55

BP: 120/80 RR: 20

T E R N

increased metabolic excessive production, increase neuromuscular and cardiovascular activity, and rate, heat

management required.

report development of tachypnea, dyspnea, pallor, and cyanosis. 3. Verbalized proper understanding of R: O2 demand and that consumption are in his medical

4. Demonstrate relaxation techniques

illness and the management required.

can decrease the increased

presence of fatigue hypermetabolic state, such as: massage potentiating risk of

hyperactivity of the sympathetic nervous system.

and cold or hot hypoxia with activity. showers. 4. Provide quiet cool

4. Demonstrated relaxation techniques that

environment, room, sensory

can decrease the presence of

decreased stimuli,

fatigue such as: massage cold or and hot

soothing colors, and quiet music.

showers. R: Reduces stimuli

that may aggravate agitation, hyperactivity, and

56

insomnia.

5. Encourage client to rest in bed as much as possible.

R: Helps counteract effects of increased metabolism.

6.

Provide

comfort like

measures

massages and hot or cold showers.

R:

May

decrease energy,

nervous

promoting relaxation.

7. Provide for calming diversional such as activities reading,

57

listening to the radio, and watch television.

R: Allows for use of nervous energy in a constructive manner, serves as a

distraction, and may reduce anxiety.

8. Avoid topics that irritate or upset client. Discuss respond feelings. ways to to these

R: Increased irritability of the CNS client to may be

cause easily

excited,

agitated, and prone to emotional outbursts.

58

9.

Discuss

with Others

Significant reasons for

fatigue

and emotional ability.

R: Understanding that the behavior is

physically based may enhance coping with current situation and encourage Significant Other to respond

positively and provide support for client.

10.

Administer as as

medications, indicated, such

anti-anxiety agents.

R: May be prescribed

59

to

help

combat

nervousness, hyperactivity, insomnia. and

60

Date and Time J U N E 22, 2013 @ 7 AM

Cues

Need

Nursing Diagnosis

Objectives of Care That within my 8 hours span of care, my patient will be able to: a. Verbalize less pain felt; b. enumerate ways on how to deal with pain during its occurrence ; c. pain scale of 1-2 out of 5.

Nursing Interventions

Evaluation

Subjective: Sakitakongti yanpabalikbal ikunyamagsig esiyaugtingog , as verbalized by the patient.

Objective: Facial grimace Irritability Reduced interaction with people Appears weak Pain scale of 3 out of

C O G N I T I V E / P E R C E P T U A L

Acute pain r/t inflammatory process Rationale: Gastroenteritis is the inflammation of the stomach and the intestinal tracts that primarily affects the bowel. One manifestation of gastroenteritis is abdominal pain. During the course of inflammation, the bodys immune response is to release cytokines and prostaglandin causing an increase in vascular permeability and causes pain in the abdomen. (Black, J.M. 2010)

1. Establish rapport with the patient. Rationale: To gain trust and cooperation. 2. Check vital signs. Rationale: To serve as baseline data. 3. Assess level of pain using pain scale. Rationale: To determine the degree of pain felt by the client. 4. Provide diversional activities such as watching television or listening to music. Rationale: To divert his/her attention from the pain felt.

June 22, 2013 @ 3pm Goal Met a. Okay okaynaman akongpamin awkaysaga niha. Medyoniara ngarangnaako ngpaminaw , as verbalized by the patient. b. Magfacebooknal angkoaniaru nmedyomah uwasanko. Maginompudkog analgesic paramawala

P A T T E R

61

N 5. Instruct client to perform deep breathing exercise. Rationale: Deep breathing exercises may reduce pain sensation/ used in pain management. 6. Provide a calm environment. Rationale: Lessens patients irritability. 7. Administer prescribed analgesics. Rationale: To decrease pain. 8. Monitor effectiveness of pain medications. Rationale: To promote timely intervention.

angsakit, as verbalized by the client.

c. Pain scale of 2 out of 5.

62

Needs Date & Time Cues

Nursing Diagnosis Objectives of Care Evaluation Nursing Interventions

J U N E

Subjective: nag papalpitatesiyakani na miss as verbalized by the watcher

21,

2 0 1 3

Objective: CR: 120 bpm Palpitation Short breathlessness Irritability Irregular heart rate Medication: Propanolol 10g

A C T I V I T Y E X C E R C I S E P A T T

Risk for decrease cardiac output ( systemic) r/t increasing workload of the heart as manifested by hyperthyroidism

1. Establish rapport. That with my 2 hours To gain the trust and span of care, the the cooperation of the patient will be able to client. have normal cardiac 2. Monitor vital signs. output as evidenced For baseline data. by: a. Enumerate causative factors 3. Increase oral fluid intake. affecting his water helps regulate normal breathing. the bodys cardiac rate. 4. Record sounds. the heart

December 21, 2013 @ 11 am GOAL MET Patient was able to have normal Cardiac rate as evidenced by client was able to: a. verbalized angpaggalawgalawkosig uro at pagiisipngsobraangdahila n kaya akohinihingalkokaninaper ongayon okay okayna

R: patients with hyperthyroidism usually have the symptoms of palpitation. With the increasing workload of the heart this may lead to decrease cardiac output due to excessive pumps of the heart.

Know of any changes in heart rhythm. b. Identify situations 5. Limit your activities that would adequately. worsen the level of heart rate. adequate rest is needed to improve the

b. verbalized angdilikopaginomsatam anggamotkopagnasabah ayangdahilan kaya ako nag papalpitate

63

Reference:Smeltzer, 7 AM TO 3PM E R N S. RN, C. EdD, FAAN.

efficiency of cardiac contraction and oxygen consumption and reduce redundant work. 6. Emphasized the importance of c. identify and use adequate rest in elevation of cardiac appropriate output. support system. This will help the client understand ways that could help lower cardiac rate. d. Show signs of 7. improvement on 8. Emphasized importance of his cardiac rate of adherence to 120bpm wo a medical normal range (60management. 100) This will help the client understand ways that could help stabilize his cardiac output. 9. Record intake and output. To have basis in the fluid loss that affects the cardiac rate.

Brunner &Suddarths Textbook Medical Surgical Nursing. Williams Wilkins, Philadelphia. 2010, 12thedition. & of

c. identify his support system and that is his family. ginabadlong man konilalabinaakong partner d. have a cardiac rate of 90bpm after rechecking.

Marigold Anne Diaz, St. N

10. Provide calm, restful surroundings, minimize

64

environmental activity/noise. Limit the number of visitors and length of stay. Helps reduce sympathetic stimulation; promotes relaxation. Reference: Doenges, M.E (8th edition) (2009) Nurses Pocket Guide. USA: F.A Davis Company

D/T

CUES

NEED

NURSING DIAGNOSIS

OBJECTIVES OF CARE

NURSING INTERVENTIONS

EVALUATION

Reference:

Doenges, M.E (8th edition) (2009) Nurses Pocket Guide. USA: F.A Davis Company Gulanick, L.O (7th edition) (2009) Nurses Pocket Guide. Washington, DC: Springfield Weber, J. (2010). Health assessment in nursing. (3rded.) Philadelphia: Lippincott William &wikins 65

J U N E

Subjective: Naga sigarilyo man gudkomaongluspadnia kungngabil as verbalized by the

M E T A B O L

Impaired tissue perfusion r/t decreased hemoglobin in the blood as evidenced by anemia

At the end of my 8 hours span of nursing care, the patient will be able to:

14. Obtain vital signs To have baseline data 15. Assess patients condition

June 20, 2013 @ 3pm GOAL MET

After the 8 hours span of care, the patient was be able to:

20,

patient.

Thyroid gland is responsible for the secretion of the hormones that controls the metabolic rate of the

2 0 1 3

Objective: (+) hyperthyroidism for 3-4 years Consumes 15-20 sticks/ day Vital signs as taken: -T: 36.6 C -PR: 80 bpm -RR: 20 cpm -CR: 87 bpm -BP: 120/80 mmHg With a capillary refill of 2sec. Dry pale lips history of loose watery stools,
o

I C

5. Demonstrates adequate tissue perfusion as evidenced by warm and dry skin, and the absence of respiratory distress 6. Verbalizes knowledge of treatment regimen, including appropriate exercise and medications and their actions and possible side effects

To render appropriate interventions

16. Monitor vital signs, capillary refill and nail beds. Provides information about the degree / adequacy of tissue perfusion and help determine the need for intervention.

5. Demonstrated adequate tissue perfusion as evidenced by skin is warm, in normal skin turgor and respiration is on normal range of 20-25 bpm.

P A T T E R N

body which the body burns energy to maintain the normal functions of life and the rate of growth or replacement of body tissue. Individuals with hyperthyroidism tends to have an overactive thyroid gland which increases the production of hormones that exceeds the normal metabolic rate causing increase peristaltic movement that may

7am

6. Patient verbalize 17. Observe for skin color on the knowledge of treatment regimen as kabalona man kosamgaepektosatambal kaymga 4 kona nah katuigginatumarug kung naa may mgadilinakubationkaynag a pa check-up man dayonko.

7. Identifies changes in lifestyle that are needed to increase tissue perfusion such as gradually stop smoking by consuming at least 2-3 sticks/ day.

sick. The skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations. 18. Check respirations and absence of work of breathing.

66

5episode/day with 100cc/episode Diagnostic and Lab: + Hematology: -hemoglobin 132g/dl (140-180 g/dL) -erthrocytes 5.41L (4.5-5.0 L) -MCH 24.4pg (2733pg) -MCV 74 fl (8596fl) +Thyroid function test: -FT4 > 100(12-22) -Thyroid stimulating hormone(TSH) <0.005 (0.27-4.2)

result to gastroenteritis.

Cardiac pump malfunction and/or 7. Identifies changes in lifestyle that are needed not to provoke the disease process gitestingan man naku mag undangdatiugsigarilyoper o mas nagasakit man 19. Monitor intake and output To replace what is loss. gudko, kabalo man kongabawaljudperoginahi nya-hinayanlangjudnaku 20. Review GI function, noting anorexia, decreased or absent bowel sounds, nausea or vomiting, abdominal distension and constipation. Diminished blood flow to mesentery can turn out to GI dysfunction, loss of

Reference: Timothy Secomb. January 26, 2009. Quantitative Analysis of Peripheral Tissue Perfusion Using Spatiotemporal Molecular Dynamics. University of Arizona, United States of America

ischemic pain may result to respiratory distress. Nevertheless, abrupt or continuous dyspnea may signify thromboembolic pulmonary complications.

IVF of PNSS 1L @ 140cc/hr Drugs as ordered: Anti-thyroid drug

peristalsis, for example. Problems may be potentiated or provoked by utilization of analgesics, diminished activity, and dietary changes.

- Tapdin 5mg/tab - Propylthiouracil (PTU) 50mg tab BID

67

Anti-diarrheal drug

21. Encourage ambulation. To promote venous return.

- Hidrasec 1 g/tab BID - HexBio 1 sachet OD

22. Discourage sitting with legs crossed or standing for long periods of time. With arterial insufficiency, leg elevation decreases arterial blood supply to the legs.

23. Encourage client to walk and perform toe up and point flex exercises. Exercise helps increase venous return, build up collateral circulation, and strengthen the calf muscle pumps

24. Encourage patient to eat rich in iron foods. To help in anemia.

25. Advise for the proper nutrients

68

and vitamins. The balance of a good diet includes protein and adequate hydration, necessary for healing of the sick.

26. Administered medication as ordered: Tapdin 5mg/tab, Propylthiouracil (PTU) 50mg tab BID for hyperthyroidism Hidrasec 1 g/tab BID,HexBio 1 sachet OD for diarrhea To lessen complication through pharmacologic management.

27. If arterial disease is present and client smokes, aggressively encourage smoking cessation. Smoking will aggravate

69

the disease process .

28. Teach client to recognize the signs and symptoms that need to be reported to a physician. To seek for medical assistance.

Collaboration: 29. Keep an eye on the results of laboratory examination. To identify deficiencies and needs treatment / response to therapy.

Reference: Marilynn E. Doenges. 2008. Nursing diagnosis manual: planning, individualizing, and documenting client care. University of Michigan.

70

71

METHOD Medication

Health Teachings Medications should be taken regularly as prescribed, on exact dosage, time and frequency, making sure that the purpose of medications is fully disclosed by the health care provider. Instruct the family to report the occurrence of any adverse effects and refer them immediately to the physician.

Rationale For a better and effective management of the condition which would provide optimum health for the patient and prevent lethal complications that that they would encounter.

To maximize the optimum health of the patient whenever the patient has taken the drugs.

Exercise Exercise should be promoted in a way by stretching hand and feet every morning. Encourage the patient to keep active to adhere to exercise program and to remain as self-sufficient as possible. Comply to the treatment regimen such as taking medications as prescribed by the physician. To promote muscle strength and enhance circulatory processes.

Treatment

It necessary to take the prescribed take home medications and to follow the given instructions exactly as they are told

Discuss to the

To let the patient and

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watcher and significant others the dangers of noncompliance to doctors order Hygiene Instruct patient for proper body hygiene such as routine handwashing. Emphasize the importance of having a clean environment and surroundings. Instruct patient to observe and apply proper food handling.

significant others recognize the possible efffects if compliance to the Doctors order is not attained To deter the spread of microorganisms

Having a clean environment decreases the likelihood of having breeding sites of vectors. To prevent reoccurrence of the illness

Out- patient teaching

Instruct to have a regular consultation with the doctor for cases of emergency and any unusualities that would follow. Encourage patient to take adequate vitamins especially vitamin C-rich foods and increasing of oral fluid intake should be conveyed. Fruits especially banana in the diet is significant. Laxative foods should be avoided such as some fruits,

This is to monitor the condition of our patient and to immediately have interventions advised by the doctor. To strengthen the immune response

Diet

To promote bulky stool.

To avoid passing easily of stool.

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vegetables and cereals.


Where is your nursing theory??

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PROGNOSIS Our patient no longer has fever and LBN and could be discharged the next day; we rated the duration of illness as good prognosis. He eats fruits and vegetables with good appetite, drinks at least 8 glasses of water every day. The patient readily compiled with the treatment regimen, so we therefore conclude that our patient has a good prognosis.

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Deglin, J.H. &m Vallerand, A.H. (2009). Daviss Drug Guide for NURSES (Eleventh

Doenges, M. E., APRN, BCretired Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales.Saunders 2011.10th edition.

Elsevier, M. (2007). Maternity & Womens Health Care (9th Edition). Elsevier Inc. 11 830

Gulanick, M. et al.(2007). Nursing Care Plan. Elsevier Inc. Singapore

James,SRPhd, Ashwill, JW RN, MSN, Medical Disability Advisor, Mosby 2010 Jonas MS: Mosby's Dictionary of Complementary and Alternative Medicine. Elsevier (c) 2009, 6th edition.

Klossner, N. J., MSN, RNC. Introductory Maternity &Pediatric Nursing.Williams & Wilkins, Philadelphia.2010, 2nd edition. Linton, A. D., Phd. Mayo Foundation for Medical Education and Research (MFMER)W.B . Newfield S. A., PhD, RN, APRN. BC.COXS CLINICAL APPLICATIONS OF NURSING DIAGNOSIS: Adult, Child, Womens, Mental Health,Gerontic, and Home Health Considerations F. A. Davis Company. 2009, 7th edition. Smeltzer, S. C. EdD, RN, FAAN. Brunner &Suddarths Textbook of Medical Surgical Nursing.Williams & Wilkins, Philadelphia.2010, 12th edition. Tortora, G. J., Derrickson, B. H. PRINCIPLES OF ANATOMY AND PHYSIOLOGY. John Wiley & Sons, Inc, Hoboken. 2012, 12thedition.Westline Industrial Drive, St.
Louis, Missouri 63146Wilkins. 323 Norristown Road, Suite 200, Ambler, PA 190022756.York: Lippincott, Williams, & Wilkins

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