Nursing Process

I. ASSESSMENT A. General Data Patient’s initials: LA Address: Pandacan, Manila Age: 35 years old Date of birth: March 17, 1974 Date of Admission: November 9, 2009 Date of history Taking: Nov 11, 2009

Sex: F Civil Status: Married Number of Days in the Hospital: 3 Place of birth: Ilo-ilo Order of Admission: wheelchair Informant: FB

B. Chief Complaints Abdominal cramping, diarrhea and vomiting C. History of Present Illness 5 days prior to confinement, patient experienced abdominal cramping w/ severe diarrhea and vomiting. She also added that she doesn’t take any medications before confinement. She was rushed at the ER around 9pm of November 9, 2009. And was prescribed meds such as hydrite 2 tabs and ciprofloxacin 500mg, BID x 7 days. She was positive of diarrhea for 10x and vomiting of 2x. D. 1. 2. 3. 4. 5. 6. 7. 8. Past History Childhood Illness/es: none Adult Illness/es: none Immunization: complete (cannot recall year) Previous Hospitalization: none Operation/s: cholestectomy Injury/ies: none Medication/s taken prior to confinement: Allergy/ies: none

II: Systems Reviews- Gordon’s Eleven Functional Areas A. Health Perception-Health Management Pattern Prior to confinement, the client’s general health has been good for the past few years. She did not have any colds before. She eats fruits and vegetables to keep her healthy but doesn’t take any vitamins. She does smoke nor drink alcohol. She did not experience any accidents for the past few years. During hospitalization, she is able to ambulate. Her skin is pale. B. Nutritional Metabolic Pattern Prior to confinement client has a good appetite. She eats four meals a day which consist of meat and vegetables as verbalized by the client. Her usual breakfast is macaroni soup as said by the client. Her lunch consists of vegetables, breaded pork and a cup of rice. Her dinner consists of rice and vegetables like chopsuey. She likes junk foods. She drinks 8-10 glasses of fluid a day, especially water. She maintains her weight. She did not have any hair loss. Her wounds heal up easily.

The 4th of November, she ate a food that comes from the “turo-turo” for her lunch. And suddenly at that night she experience diarrhea but she doesn't mind it because she knew that its just a normal diarrhea that she frequently have. During confinement, she is in soft liquid diet. C. Elimination Pattern Prior to hospitalization, she eliminates once a day with solid, brownish or yellowish stools. She experiences no discomfort when defecating and uses no laxatives. She voids three times a day with yellowish urine in an amount of approximately 850ml a day. No discomfort is present and no problems in controlling when she voids. The client does not experience any excessive perspiration and no problems about odor. During hospitalization, she defecates 10 times per day with soft liquid and greenish stool. She had a decreased urination of 450mL/day. D. Activity and Exercise pattern Prior to confinement, the client has sedentary lifestyle. The client’s form of exercise is by walking on their stairs every morning. She does not have problems in taking care of herself. “hindi talaga ako nageexercise, paglalakad lang paakyat at pagbaba ng hagdanan ang pinakaexercise ko.” As the client said. Once a week she is watching over her sari-sari store. “minsan binabantayan ko yung tindahan naming pag wala yung katulong namin.” As the client said. During hospitalization, her form of exercise is by ambulation, and deep breathing exercise. E. Sleep- Rest pattern Prior to hospitalization, the client usually sleeps at 8pm and wakes up at 5am. She does not have any problems falling asleep. She doesn’t have nightmares. The client falls asleep quickly whenever she reads books. If she has time in the afternoon she takes a nap. During hospitalization, the client has difficulty falling asleep. Patient verbalized, “nahihirapan na akong makatulog mula ng maospital ako”. F. Cognitive- Perception pattern Prior to hospitalization, the client does not wears eye glasses. “Minsan may nakakalimutan akong mga bagay”, as verbalized by the client. .When there are important decisions to make she addresses it to her mom and her husband. She has no difficulty learning new things During hospitalization, the client is oriented and attentive. The client does not have difficulty in speaking, she can use to languages, English and tagalong.

G. Self perception- Self concept pattern Prior to hospitalization, the client stated that she is confident, moody and feels good about herself. “ Masaya naman ako kahit hindi ko makuha ang gusto ko basta alam kong masaya ang mga anak ko”, as verbalized by the client. During confinement, client is attentive. Her tone of voice is low and calm. Client is relaxed most of the time and is attentive while sitting on the chair.

H. Roles- Relationship pattern Prior to confinement, Client is married for 10 years. She has 4 children. She and her husband decide if a problem or any situation occurs. “Give and take kami ng asawa ko”, as verbalized by the client... “Pag nagaaway kami pumupunta ako sa nanay ko”, as verbalized by the client. She does not belong to any affiliation. She has some close friends. “Masaya naman kami g asawa ko kahit di naman kasama ung 4 naming anak”, as stated by the client. During hospitalization, patient had no longer fulfill her role as a housewife because of being sick. I. Sexuality- Reproductive pattern Prior to confinement, the client started her menstrual period at the age of 13 with a 3-4 days duration, with no accompanying symptoms. She is satisfied with her sexual pattern or life. “Hindi ako nagcocontraceptive kasi may mga side effects yun”, as verbalized by the client. She is having sex with her husband almost every night. She uses 3 pads of napkin per day. She has been pregnant for 4 times, and labored for 4 times. She has never undergone to abortion. During confinement, patient remains the same as stated above. J. Coping Stress Tolerance Pattern Prior to hospitalization, the client has no changes in life for the past year. She eats junk foods, smoke, wonder when she’s stressed out. She sometimes talks with her husband when there are problems. “Pag nahihirapan na talaga ako pumupunta na ako sa nanay ko.”, as stated by the client. During confinement, patient stated that she copes with stress through the help of his husband. K. Values-Beliefs Pattern Prior to hospitalization, the client does not go to mass. “Malapit lang naman ung simbahan kaya naririnig ko ung pari kaya din na ako pumupunta.” As verbalized by the client. “Pinakikinggan ko na lang ung radio” as verbalized by the client. The client is a Roman Catholic. During hospitalization, “Nagdasal ako sa Diyos kasi di naman ako makapunta sa simbahan kasi madami akong ginagawa sa bahay. F. Family Assessment Name N.L L.M R.M O.M M.L Relation husband cousin Cousin’s wife niece patient Age 35 22 22 2mons. 35 Sex M M F F F Occupation student Salon employee -------------Gov’t employee Educational Attainment College Highschool grad. Highschool grad. ---------College grad.

G. Heredo – Family Illness Maternal: hypertension Paternal: DM H. Developmental History Theorist Freud Age 35 Task Genital Patient Description Begins at puberty involves the development of the genitals, and libido begins to be used in its sexual role. The patient is attracted with the opposite sex and has a satisfying sexual relationship with her husband. In the initial stage of being an adult we seek one or more companions and love. She is a happily married woman and has a good relationship with her family. It is characterized by acquisition of the ability to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations. The patient considers her experiences as her guide and best teacher in life. Rules of law are important for maintaining a society, but members of the society should agree upon these standards. The patient is aware about the things that are happening in the society. The self, previously sustained in its identity and faith compositions by an interpersonal circle of significant others, now claims an identity no longer defined by the composite of one's roles or meanings to others. She doesn't easily confide with what others says and is serious in taking responsibility of her beliefs in life



Intimacy and Solidarity vs. Isolation Formal Operational Stage





Stage 5 - Social Contract Orientation



Individuative -Reflective Faith

I. Physical Examination Regional Examination (March 7, 2009; 2pm) Height: 5’ 2” Actual height: 157 cm Vital Signs: Temperature: 35°C Blood Pressure: 100/70mmHg Respiratory Rate: 10bpm Pulse Rate: 55bpm SKIN Inspection: • fair complexion • pale • no discolorations • no lesions Palpation: • rough • dry • warm to touch • poor skin turgor NAILS Inspection: • All fingers are clean • Pinkish nail beds • Intact epidermis • Well trimmed Palpation: • Capillary refill of one second • brittle HEAD AND FACE Hair and scalp Inspection: • Black hair • Strands are thin and fine • Wavy, shiny and smooth • No flakes and dandruff Palpation: • Scalp is white • (-) tenderness • (-) no contour Face Inspection: • Fair in color • Color of face symmetrical to the body • Symmetric facial features Palpation: • Warm Weight: 55kg BMI: 22-normal


EYES Inspection: • Iris is black • Pinkish sclera • Eyebrows symmetrically aligned; equal movement • Eyelashes equally distributed; curled slightly forward • Eyelids close symmetrically EARS Inspection: • Color same as facial skin • Symmetrical • No hearing aid • Palpation: • Mobile • Easily to recoil NOSE and SINUSES Inspection: • Straight without deformities • Symmetrical to the face • Air moves freely as the patient breaths through the nares • Mucosa is pink • Nasal septum intact and in the midline • (-) inflammation Palpation: • (-) tenderness in the frontal and maxillary sinuses MOUTH and PHARYNX • Tongue is color pink • Hard and soft palate is color pink • Absence of 3 molars in lower right • (-) inflammation • Dry lips NECK Inspection: • No discolorations • Symmetrical • Coordinated, smooth movements with no discomfort • Patient able to flex, hyperextend, lateral flex • (-) swelling Palpation: • Trachea in midline • (-) tenderness and enlargement SPINE • Spine is in midline and vertically aligned • No lateral deviations • Right and Left shoulders and hips are at the same height THORAX AND LUNGS

Inspection: • Symmetrical • No deformities • Retraction of the intercostals spaces during inspiration Palpation: • No lumps, masses and pulsations • No areas of tenderness • Chest excursion is symmetrical and separating the thumbs • (+) vibrations during tactile / vocal fremitus Auscultation: • (+) wheezes CARDIOVASCULAR/HEART Inspection: • Absence of pulsations Palpation: • Pulse sites have good thrusting quality • Carotid arteries have symmetric pulsations and thrusting quality Auscultation • Aortic, pulmonic, tricuspid and apical have good S1 and S2 BREAST Inspection: • Breast is pendulous • No dimpling • Skin uniform in color • (-) nodules • Areola round and bilaterally the same, dark brown • Nipples round, everted and equal size, similar in color, both point in the same direction Palpation: • (-) tenderness ABDOMEN Inspection: • Umbilicus at the middle • Presence of striae (pink in color) about 3cm Palpation: • Bladder is not distended EXTREMITIES Inspection: • Equal in size on both sides of the body • No deformities • Patient stand with assistance • Hips and knees somewhat flexed • Arms bent at the elbows, raising the level of the arms • Extremities are symmetrically aligned Palpations: • (-) tenderness, edema • Able to resist to the pressure • No discomfort • Muscles are firm

GENITALS • Patient refused RECTUM AND ANUS • Patient refused I. PERSONAL/SOCIAL HISTORY Habits: cleaning, watching television, cooking Vices: none Lifestyle: sedentary lifestyle Social affiliation: none Client’s day like: The client’s day like is going to work from 8am to 5pm then she would go to her mother’s house to visit her kids. After visiting her kids she goes home to rest. She waits for her husband so that they will eat supper together. After eating she watches T.V for a while and then goes to sleep. Rank in the Family: eldest child Travel: none Educational Attainment: college graduate Occupation: government employee II. ENVIRONMENTAL HISTORY M.L. lives in Pandacan, Manila in a concrete type, 4-story house with her live-in partner and her cousin’s family. They have clean surroundings and sufficient space to move around. They maintain the cleanliness of their surroundings by tidying up every day and proper garbage disposal. Garbage is collected every day. Lighting of the house and ventilation is adequate. The ambiance of their neighbor was solemn most of the time and there are street lights at night to lighten up the area where people pass by. Their house is near the church, market and a school.



Menarche: 13 years old Amount and Characteristics: Uses 3 pads a day. Has solid formation of the blood with a fluid appearance. Duration: 5-6 days Associated Symptoms: dizziness and stomach cramps V. PEDIATRIC HISTORY- N/A


LABORATORY RESULT/FINDINGS NORMAL VALUE Male- 13.5-18 g/dl 5-10x10 9/l 0.55-0.65 0.22-0.04 RESULT 83.3 INTERPRETATION This shows that the hemoglobin level is very low than normal that indicates decrease tissue pefusion. This indicates low level of sodium in the blood or hyponatremia Neutrophils is lower than normal which indicatates risk for infection. The eusinophils is higher than normal range which involved in allergic reactions(neutralizes histamine; digest foreign proteins). Lymphocytes is higher than normal range which may help in fighting against infection. This indicates that the level of sodium is slightly lower than normal. The potassium level is slightly below than normal range. This indicates that the level of calcium is lower than normal range. The RBS is just within the normal range. This shows that the erythrocyte volume fraction level is just within the normal range.

LABORATORY EXAM Hemoglobin mass concentration Leukocyte number concentration Neutrophils Eusinophils

17.9 0.35 0.79

Lymphocytes Sodium Potassium Calcium RBS Erythrocytes volume fraction Erythrocyte number concentration Stool exam Thrombocytes (Platelet)

volume0.22 1.35-148 mmol/L 3.5-5 mmol/L 1.13-1.32 mmol/L 3.9-6 mmol/L 0.25

0.79 130.4 mmol/L 3.15 mmol/L 0.84 mmol/L 0.84 mmol/L 0,25 7.5 mmol/L No ova found

150,000450,000 /mm3


Predisposing Factors:  Environment  Hygiene  Stress

Precipitating Factors: ~ Age(35 Months) ~ Gender(Female)

Ingestion of E. Coli Invasion of gastric mucosa Penetration of Gastric mucosa Toxins producing pathogens cause watery, large volume diarrhea Signs & Symptoms: Watery stool Fever

Irritation of the Gastric Lining

Signs & Symptoms: Vomiting

Fluid and Electrolyte imbalance too much Na+ and H2O are expelled from the body

Increased fluid loss Signs & Symptoms: Decrease skin turgor Sunken Eyes



2. 3. 4. Potential: 5.

Deficient fluid volume Knowledge deficit Disturbed sleep pattern Risk for infection

X: B. ONGOING APPRAISAL  admitted to 3C female ward in clear liquid diet  Start D5 0.3NaCL 500ml @ 100cc/hr  Labs: • CBC • Urinalysis • Serum Electrolytes  I & O q shift  v/s q4H  IVF with D5 0.3NaCl 500ml @ 100cc/hr  Continue medications X: C. DISCHARGE PLAN

M- prevacid 300mg OD
- hydrite 2 tabs in 200cc water

E- Encourage brisk walking everyday
- Provide clean and comfortable environment. - Maintain a quite, pleasant environment to promote relaxation

T- Continue home meds.
-Cook food properly and stored food.

H- Bath regularly
- wash hands frequently - Bleach soiled laundry.

O- Patient may not be able to eat a regular diet.
- Avoid dairy products for several weeks after the disease has run its course. - The patient should continue to advance slowly from bland nondairy soups and grain products to a solid diet.

D- soft liquid diet
- Eat properly prepared and stored food.

S-igns and Symptoms
 Go back to the hospital if these signs and symptoms occur:  Blood in vomit or stool    Vomiting more than 48 hours Fever higher than 101°F (40°C) Swollen abdomen or abdominal pain


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