In Partial Fulfillment of the Requirements on Related Learning Experience

Submitted By:

Submitted To: Ms. Joan Guzman Clinical Instructor

July 2010

Nationality: 7. CHIEF COMPLAINT: C. The patient could no longer remember any immunization given during his childhood days. . There are also no interventions done at home. One day prior to admission. the client had manifested the same signs and symptoms. Upon admission. Order of Admission: 10. No consultation done and no medications were taken. HISTORY OF PRESENT ILLNESS: Patient¶s condition started 7 months prior to admission. EBDC had manifested progressive epigastric pain and he was weak and pale in appearance and nurses started an Intravenous Line. D. Attending Physician: B.I. Age: 4. Patient¶s Name: 2. Sex: 5. Address: 3. She had no major illness. Civil Status: 8. Birth Date: 6. PATIENT ASSESSMENT DATA BASE A. PAST HEALTH HISTORY/STATUS Patient had chicken pox and mumps when she was still young. GENEARAL DATA 1. Mrs. Date of Admission: 9. patient complained of epigastric pain including to the back with no other sign and symptoms.

ELIMINATION PATTERN  Bowel habits:  Color ±  Odor ±  Consistency  Laxative use if any . being healthy does not only depend on being physically capable but also emotional and mentally sound. NUTRITIONAL-METABOLIC PATTERN     Usual Daily Menu Food ± Water ± Beverages - 3. She complied with any prescribed medication and treatment given to her. FAMILY ASSESSMENT NAME RELATION AGE SEX OCCUPATION EDU¶L ATTAINMENT F. SYSTEM REVIEW 1. 2. she doesn¶t consult the health center in maintaining her health rather she do what she wants.E. EBDC perceived health as a very important aspect of human existence. Illness for him is inability to do activities of daily living. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN Mrs. In health maintenance and habit. For her.

COGNITIVE-PERCEPTUAL PATTERN y Subjective:  Hearing. doesn¶t participate 5.full care I .requires assistance or supervision from another.requires use of equipment II .client doesn¶t have any hearing problem and doesn¶t need any hearing aids. .dependent.requires assistance or supervision from others III . ACTIVITY-EXERCISE PATTERN  Self-care ability ___Feeding ___Bathing ___Bed mobility ___Dressing ___Toileting ___Home maintenance ___Grooming ___Cooking ___Others LEGEND: 0 . and equipment and devise IV .    Bladder: Color ± Odor ± Alterations if any 4.

7. She copes by praying with the presence of his ever supportive family. She can do household chores. the client knows well about her responsibilities. Stress is one that affects health of an individual. She doesn¶t use any sleeping aid in order to sleep. She can easily understand simple things.  Sensory perception. ROLE RELATIONSHIP PATTERN Being the light of the family. 10.  Learning styles. According to her as this time of her confinement she is a burden. SLEEP-REST PATTERN Client sleeps for at least 8 hours with some interrupting wakefulness related to abdominal pain.client learns by experience and is involved in familial decision makings. though some think that sex is lessen as someone gets old. Vision. problem can also have effect the health. COPING-STRESS TOLERANCE PATTERN Such situations normally produce anxiety and stress. 9. She doesn¶t use any visual aid such as eyeglass or contact lenses. She views self as a dependent person because of his state. SEXUALITY-REPRODUCTIVE PATTERN People are actually sexual beings throughout their lives. She said that. as stated by the client. and threaten his self esteem. . There is no problem with sense of taste and smell. 6.client didn¶t complaint of having blurred vision.client is responsive and is able to perceive stimuli. 8. Same with stress. she is supposed to be working in order to earn a living for his family but no matter how she wants to she really can¶t because of his condition and she knows also that her husband is also working for them. SELF-PERCEPTION AND SELF-CONCEPT PATTERN The life events that the client is experiencing at this time served to decrease his self control.

She has good values and right conduct. other traditions) in order to complement and/or correct one's own. deepening of post-conventional morality. General Survey Client is conscious and coherent. with cold and clammy skin. Weak and pale in appearance. characterized by a "radical openness" to other viewpoints.e. HEREDO-FAMILIAR ILLNESS MATERNAL PATERNAL H. Client is well dressed. symbols. and teachings of one's tradition are inherently partial and incomplete. while failure results in shallow involvement in the world. Stagnation Work and Parenthood Adults need to create or nurture things that will outlast them. begin to distinguish between what is true and what one believes.DEVELOPMENTAL HISTORY Erikson¶s Theory (psychosocial development) Generativity vs. James Fowler¶s (faith development theory) Conjunctive Faith Typically found at midlife and beyond.. I.PHYSICAL ASSESSMENT A. VALUE BELIEF PATTERN The client strongly believes and fears God. B. Success leads to feelings of usefulness and accomplishment.11. often by having children or creating a positive change that benefits other people. G. seeks truth/wisdom from a multitude of sources (i. and use of paradox for understanding.Vital Signs BP: CR: RR: TEMP: . realizes the stories. acceptance of pluralistic views.

C.Regional Exam AREA ASSESSED 1. Neck and Lymph nodes inspection inspection inspection inspection palpation symmetrical. Eyes >eyebrows >eyelashes >ability to blink >size 3. smooth brownish normal and pinkish elongated and symmetrical non-tender during palpation inspection inspection inspection inspection symmetrically aligned. symmetrical. Nose >symmetry. shape >size and color >mucosa color >nasal sputum >sinuses 4. Ears 5. Mouth and Throat >lips >sublingual area >tongue >teeth >throat 6. Hair. moist no swelling noted 30 teeth no pain when palpated . dry pinkish. head and face >color >distribution >moisture >texture Techniques Used inspection inspection inspection inspection Findings Black evenly distributed oily fine 2. equal movement slightly straight blinks voluntarily and bilaterally round reactive to light inspection inspection inspection inspection palpation red.

Breast and Axilla 12. Cardiovascular >heart rate >heart sounds 11. no abnormal breath sound no extra sounds noted inspection palpation auscultation flat burborygmus inspection inspection inspection brown in color equal and appropriate symmetrical . Abdomen >contour >texture >frequency and character 12. Thorax and Lungs >symmetry >respiratory rate >breathing pattern 10.7. Nails >color of nail bed >texture >shape >nail base inspection palpation palpation palpation inspection palpation inspection inspection brown pinkish smooth convex curvature firm 9. Skin >color >texture >temperature >moisture 8. Extremities Upper Extremities >skin color >size >symmetry inspection inspection auscultation auscultation auscultation symmetry clear.

none Rank in the family. Habits/Vices The client had no bad vices. Rectum and Anus N/A 15. Genitals N/A 14. f. Drugs.none b.none c.none e.none d. PERSONAL/SOCIAL HISTORY a. TravelEducational attainment. a.inspection interview inspection.She is the light of the family.She is college graduate . Neurological/Cranial nerves >level of consciousness >behavior and appearance >mood and affect >thought process inspection inspection inspection brown in color equal and appropriate symmetrical interview. d. Tea. Caffeine . c.Lower Extremities >skin color >size >Symmetry 13.none b. Smoking.interview interview respond quickly good eye contact not irritable question are all answer II. Lifestyle Social affiliation. Alcohol. e.

III. Maternal and Birth History  Date of Birth  Birth Weight  Type of Delivery  Condition after birth  Hospital b. Neonates  Neonatal history  Enwind history  Type of feeding . ENVIRONMENTAL HISTORY (LIVING/NEIGHBORHOOD/CIRCUMSTANCES) IV. Mother  Complications of delivery  Anesthesia  Exposure to teratogens c. PEDIATRIC HISTORY(for neonates/infants and mothers) a.


The gallbladder (or cholecyst) is a pear-shaped organ that stores bile (or "gall") until the body needs it for digestion. . It is connected to the liver and the duodenum by the biliary tract.

VII. bilirubin Jaundice Pruritus Tea-colored urine Infection Cholecystitis . PATHOPHYSIOLOGY Gallstones Pressure Obstruction Bile Stasis Fat emulsification Fat intolerance Anorexia Flatulence Inflammation Pain (RUQ) Fever Leukocytosis Bile flow in the colon Alcoholic stool Vit K absorption s.


Drug Name: Ketorolac Brand Name: Toradol Dosage: 30 mg every 6 hours Indication: short term management of pain Mechanism of Classificatio Contraindication Action n Adverse Reaction Nursing Consideration .

y y y CNS:Drowsine ss insomnia dizzinesss headache GI: nausea.Analgesic. diarrhea CV: edema hypertension .in those with advance renal impairment.palpitation : >Assess pt before starting therapy >Be alert for adverse reaction and drug interaction > assess patient and family knowledge of drug therapy Drug Name: Celecoxib Brand Name: ceebrex Dosage: 400mg one a day Indication: relief of S/Sx of osteo-arthritis and to reduce the number of edenomatous colorectal poplyps Mechanism of Action Classification Contraindication Adverse Reaction Nursing . angioedema. bronchospatic reactivity or allergic reaction to aspirin or other NSAIDS. Contraindicate d in patient hypersensitive to drug in those with a history of nasal polyps. Possesses antianti inflammatory inflammatory . analgesic. GI pain. and anti fyretic effect. dyspepsia.

rhini tis sinusitis: >Assess pt before starting therapy >Be alert for adverse reaction and drug interaction > assess patient and family knowledge of drug therapy Drug Name: Dexamethasone Brand Name: Dexasine Dosage: 4mg every 6 hours Indication: treatment and management of inflammatory condition. nausea EENT pharyngitis. headache.Consideration Anti-inflammatory Decreasing prostaglandin synthesis relieves pain and inflammation in joints and smooth muscle tissue Contraindicated to patient hypersensitive to drug sulphonamides or aspirin or other NSAIDS and in patients with severe hepatic or renal impairment y y y CNS: dizziness. dyspepsia. allergic reaction . insomnia GI: abdominal pain diarrhea.

peptic ulceration CV: hypertension edema thromboembolis m I. NURSING CARE PLAN Assessment Nursing Planning Nursing Rationale Evaluation . increased appetite.Mechanism of Action Classification Anti-inflammatory Contraindication Adverse Reaction y y Nursing Consideration >obtain history of patient¶s underlying condition before therapy >Monitor patients bp glucose level and electrolyte levels >Look for adverse reaction and drug interaction >assess patient and family knowledge about the drug therapy Relieves cerebral edema reduces inflammation and immune response and reverse shock Contraindicated with patients hypersensitive to drug and in those with systemic fungal infection y CNS: insomnia seizures GI: GI irritation.

sign and .Diagnosis CUES S> O> > Vital taken recorded BP: RR: PR: Temp: Intervention ‡Assess the vital sign.

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