DEMOGRAPHIC DATA: Name: VALANTES, Leonard Chester Quines Age: 1 yr. 8 mos.

Birthday: May 22, 2008 Address: 72 Tram Ucab, Itogon, Benguet 09212728712 Religion: Roman Catholic Next of Kin: Occupation: Latest Hospitalization Date: Attending Physician: Dra. Bautista Date of admission: January 28, 2010 2 :30 pm CHIEF COMPLAINT VOMITING WITH LOOSE BOWEL MOVEMENT HISTORY OF PRESENT CONDITION The onset of the present condition was about 8 hours prior to admission when the patient had 10 episodes of vomiting of previously ingested food and 2 episodes of loose bowel movement. There were no associated signs or symptoms such as fever or diarrhea. The patient was noted to have poor oral intake. The persistence of the child’s symptoms prompted the mother to seek consult from the child’s pediatrician. The mother was advised admission so the child was brought to this institution and was admitted. GROWTH AND DEVELOPMENT PHYSICAL GROWTH: birth weight: 3.75 kg present weight: 11.5 kg DEVELOPMENTAL MILESTONES The developmental milestones are at par with the child’s age. SOCIAL – DEVELOPMENTAL BACKGROUND The patient usually sleeps at 9 PM and wakes at 9 AM. He also takes short afternoon naps. The patient interacts with all family members. The mother claims that he has no disciplinary problems. He is not toilet-trained.

IMMUNIZATIONS According to the child’s parents, he has had all necessary immunizations. The dates were unrecalled and no records were available. PAST MEDICAL HISTORY

The patient was hospitalized at 3 days old for jaundice at SLU HSH. There were no other childhood illnesses such as mumps, measles, or chickenpox. He has no known allergy to any foods or drugs. FAMILY HISTORY The patient is the first and only child. The parents are well and appear to be healthy. There is no history of asthma, hypertension, arthritis or any cardiovascular disease. SOCIAL – ENVIRONMENTAL HISTORY The father is 28 years old, a Criminology graduate, and works as a laborer. The mother is 22 years old, a Criminology graduate, and is a housewife. They live in a non-congested neighborhood in a house made of wood, cement and galvanized iron. Their house has 4 rooms with 6 occupants. Their source of water for washing and cleaning comes from a spring. Their drinking water is boiled for 10 minutes. Their garbage is burned. Their toilet is flush type. PAST PERSONAL HISTORY PRENATAL HISTORY The mother is 20 years old. Her OB score is G1P1 (1-0-0-1). She had delayed menstrual cycle at 1 month age of gestation. She had a positive pregnancy test result. She had her prenatal care at 2 months AOG with total prenatal check up of 7 visits to the OPD. Given ferrous sulfate, Calcium supplement, and multivitamins. At 6 months AOG, mother underwent ultrasound revealing live, singleton, intrauterine pregnancy. She had her CBC and Urinalysis is normal. There are negative exposure to VED’s , smoking, radiation and had no alcohol intake during the pregnancy. NATAL HISTORY The patient was born via NSVD at Benguet General Hospital by an obstetrician. Birth weight was 3.75 kg and birth length was unrecalled. Patient had pink body, good cry and active limb movements upon birth. No congenital malformations noted. No resuscitation done. AS and BS are unrecalled. NEONATAL HISTORY Patient was breastfed after birth with good suck. There was no paleness, negative cyanosis, negative jaundice noted on the 24th of life. Umbilical stump fell off after 1 week without signs of infection.

REVIEW OF SYSTEMS General: (-) febrile episodes, (-) weight loss, (-) weakness, (+) poor oral intake, (-) easy fatigability, (-) incessant crying, (-) irritability

Skin: (-) dryness, (-) circumoral pallor, (-) pallor, no jaundice, no bruising, no bleeding, (-) pruritus Ears: no discharges, no hearing difficulty, (-) ear pains Nose: no bleeding, (-) congestion, (-) cold, (-) nasal discharge Head: no lesions, no trauma Eyes: no tearing, no itching, no redness, no discharges, GUT: (-) dysuria Musculoskeletal: no trauma, no stiffening of extremities, able to ambulate Hematologic: no hematomas, capillary refill of 1-2 seconds, no bruises Nervous system: (-) convulsions Endocrine system: (-) diaphoresis, (-) polydipsia, (-) polyuria Respiratory: (-) cough, (-) cold, (-) posttussive vomiting, (-) shortness of breath, (-) orthopnea Cardiac: (-) edema, (-) easy fatigability, (-) cyanosis GIT: (-) abdominal pain, (-) vomiting, (-) diarrhea, (-) constipation, (-) flatulence, (-) loss of appetite Mouth: lips and buccal mucosa are moist Chest: symmetrical, no lesions Lungs: symmetrical chest expansion, no lagging, (-) bibasal crackles, (-) wheezes Heart: normal late, regular rhythm Abdomen: direct tenderness, no masses palpated Genitalia: grossly male Extremities: no gross deformities, pink nail beds, full and equal pulses, good capillary refill Motor: active limb movements Sensory: Reacts to soft touch Reacts to pain PHYSICAL EXAMINATION General Appearance: awake, afebrile, not in cardiorespiratory distress

Vital Signs: PR: 113 bpm RR: 26 cpm

TEMP. : 37 C Skin: no pallor, no cyanosis, no jaundice, warm to touch with good skin turgor Anthropometric measurements: weight > 11.5 kgs Head: normocephalic, no trauma, normal hair distribution, no gross deformities Eyes: pink palpebral conjunctiva, no abnormal discharges, no sunken eyeballs Ears: normally set, no lesions or deformities, no abnormal discharges Nares: patent with no nasal flaring, no nasal discharge Neurological: Cerebral function: Patient is conscious. Cerebellar function: no nystagmus GORDON’S FUNCTIONAL PATTERNS • Health Perception-Health Management The mother understands the advantages of breastfeeding to the nutrition of the child. She addressed the child’s condition by feeding the child to replenish lost nutrients. • Nutritional-Metabolic Pattern The patient’s present weight is 11.5 kgs. He has no known allergies to any food or drug. The patient is breastfed and is able to tolerate solid food. He has not taken supplements before being admitted at this institution. • Elimination The patient is not toilet trained. The patient does not experience any kind of discomfort when urinating or defecating. • Activity- Exercise Patient is able to ambulate and perform ADLs such as eating, going to the bathroom, standing or sitting without assistance. There is a splint placed on the left hand to avoid strain on the insertion site to prevent dislodging the needle. Cognitive- Perceptual The patient is alert and no irritability was noted. He is aware of the time, place and the people around him. He is able to alert his mother with regards to his condition such as thirst, pain or when needs to have his diaper changed. The child’s developmental milestones are at par with age. Sleep-Rest The patient is fully awake and active. The mother’s has no complaints with regards to whether the child experiences lack of sleep or rest. The child takes afternoon naps.

Sexuality- Reproductive Pattern The patient’s mother has an OB score of G1P1(1001). She and her husband are currently using no family planning method but are trying to put a space of 2-3 years between children.

Coping Stress Tolerance The patient has a stable support system of family members and helper.

Value Belief The patient is baptized as a Roman Catholic. His parents are also Roman Catholics. They are active members in the Church.






Color: light yellow Reaction: acidic Appearance: slightly turbid Specific gravity: 1.010 (-) albumin (-) sugar Pus cells: 0-1/ hpf Red blood cells: 0-1/ hpf Mucus threads: occasional Epithelial cells: occasional (-) crystals (-) cysts Bacteria : occasional

>clear to yellow > > >1.006- 1.030 >(-) albumin > (-) sugar >(-) pus cells >0-2/ hpf >0-2/ hpf >0-2 /hpf >(-) crystals >(-) crystals >(-) bacteria >(-) amorphous urates >(-) yeast cells

The results are indicative urinary tract infection.

Amorphous urates: occasional (-) yeast cells

Erythrocytes: 0.36 Hemoglobin: 121 Leukocytes: 8.47 Segmenters: 0.79 Lymphocytes: 0.21 Normocytic Normochromic

>0.37 – 0.47 > 110 - 150

The results does not indicate any presence of excess of deficiency in blood volume or components.


Color: green brown Consistency: soft (-) pus cells (-) red blood cells (-) yeast cells

> dark brown >semi formed and soft >(-) pus cells >(-) red blood cells >(-) yeast cells

The results do not indicate any abnormalities in the patient’s stool.

A. GENERIC NAME: Bacillus Clausii

BRAND NAME: Erceflora CLASSIFICATION: anti-diarrheal MECHANISM OF ACTION: replaces lost normal flora in the GIT SIDE EFFECTS: may cause constipation when taken in excess NURSING CONSIDERATIONS: this drug may be given even if patient has not eaten. May be mixed with milk or water when administered B. GENERIC NAME: Ascorbic Acid BRAND NAME: Ceelin Plus CLASSIFICATION: vitamis, water- soluble vitamins MECHANISM OF ACTION: used in biochemical reactions in the body SIDE EFFECTS: CNS> drowsiness, nausea and vomiting, headache NURSING CONSIDERATIONS: Best if taken with juices.
C. GENERIC NAME: Amikacin sulfate


MECHANISM OF ACTION: bacteriostatic; binds to the bacterial 30S ribosomal subunit, causing misreading of mRNA and leaving the bacterium unable to synthesize proteins vital to its growth. SIDE EFFECTS: Kidney damage and hearing loss NURSING CONSIDERATIONS: serum creatinine levels should be monitored. Monitor for hypersensitivity. Report immediately any change in hearing acuity, ringing or roaring in ears, alteration in balance, vertigo, feeling of fullness in head; pain, tingling, or numbness of any body part; or change in urinary pattern or decrease in urine

➢ “ Pwede na daw kaming umuwi sabi ng doktor.” as verbalized by the ➢

➢ ➢ ➢ ➢

mother. With initial vital signs of T: 37C ; RR: 26 cpm ; PR: 113 bpm patient able to ambulate without assistance no episode of vomiting noted with good oral intake and good appetite; on breastfeeding with good suck able to tolerate solid foods with good skin turgor and moist capillary refill excitement noted on patient and significant others

Goal: The client will be not experience any recurrence of the condition. LTO: After 8 hours of nursing interventions, the client’s significant other/s will be able to verbalize desire for wellness and how to prevent any recurrence of the condition. STO: After 4 hours of nursing interventions, the client will signs indicative of his readiness for an improved condition and discharge.


Gastric irritation

Acid reflux
Risk for fluid and electrolyte imbalance r/t fluid loss Risk for fluid volume deficit r/t episodes of vomiting


Ingestion of Ingestion of Bacillus Clausi (Erceflora) Ascorbic Acid & Zinc

Ingestion of Amikacin (Aminoglycoside)

Return of Normal Flora in Boosting of the

Destruction of

the GIT Immune System

Infectious Bacteria in the body


Saint Louis university College of nursing Baguio city

Nursing care plan
Patient: valantes, leonard chester

Submitted by: Milar, krizza s. Ocampo, ira kei B. Bsn ii-18 a

Sir lee nino Lagarto
Clinical instructor

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