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FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING
AY 2010-2011

In partial fulfilment
Of the requirements in
Nursing Care Management 103

Submitted to
Irene Latosa

Submitted by

Santos, Arizza Jane L.


Sison, Joanna Christie C.
Tan, Alyssa Joanna M.
Tizon, John Bernard
Tuazon, Raymund
Ubay, Justin
Ujano, Cristine Joy T.
Urban, Xavier Norbert C.
Valdecantos, Alejandro King
Valdenor, April Joy F.
Verdillo, Rachel Anne F.
Zapata, Molly Mae O.

9 August 2010

I. Biographic Data
Name: H.L.C.
Address: Taguig City
Age: 50 years old Gender: Male
Marital Status: Married Occupation: Fish Ball Vendor
Religious Affiliation: Roman Catholic
Chief Complaint: Carbuncle back at the right shoulder
Provisional Diagnosis: Carbuncle back at the right shoulder

II. Nursing History


A. Past Health History
The client had his hypertension at age of 42 and was
confined for a week; he has also myocardial infarction, and
stroke. No medications were administered after the diagnosis. It
was his 2nd time to be hospitalized this year. He is a smoker for
almost 6 years and an alcoholic drinker every after work. He has
no known allergy and completely immunized.
B. History of Present Illness
1 week prior to confinement: started to a single small
pimple and became enlarged, (-) fever, (+) chills, (+) pain and no
self medicated for his hypertension.

C. Family History
The mother side of the client has a history of hypertension.

III. Patterns of Functioning


A. Psychological Health
1. Coping Patterns
The client was asked to describe stressors around him, he said
that “Dati trabaho sa pabrika. Dami kasi ginagawa doon dati. Ngayon,
Sa Bicutan Subd. ako. 2pm ako napunta lagi doon para magtinda.”
When asked about his coping mechanisms, he said that, “Naninigarilyo
ako. 1 kaha nauubos ko araw-araw. Katabi ko din ang sigarilyo
hanggang sa pagtulog.” He also added that “Pagkatapos ko magtinda
ay umiinom ako mag-isa o kaya minsan kasama ko panganay ko.
Nakakalimutan ko din maghapunan dahil sa gin.” He also verbalized,
“Mahilig kasi talaga ako sa matatamis, tapos mahilig din ako sa
softdrinks, yun yung madalas kong kainin sa bahay.” The client
stated, “Pag ako ang may problema, minsan sinasarili ko, kasi
nga masikreto talaga akong tao pero kung pag problemang
pampamilya naman pinaguusapan namin.” When asked what he
feels for being confined in the hospital, he verbalized, “Siyempre
hindi maganda, sa totoo lang gusting gusto kong umuwi. Ayoko
talaga ditto hindi ako komportable. Nag-aadjust na langako kaya
iniisip ko na lang para to sa ikabubuti ko at ng pamilya ko kaya
pumayag na lang akong magpahospital.”

INTERPRETATION:Mature persons are open to new experiences


and continued growth; they can tolerate ambiguity, are flexible,
and can adapt to change. ( Kozier and Erb’s. Fundamentals of
Nursing 8th edition.Volume 1. P. 398)

ANALYSIS: Lifestyle patterns in combination with aging, family


history and developmental stressor sare often related to health
problems to arise, For example smoking and excessive alcohol
consumption place an individual at greater risk of developing
chronic respiratory problems,lung cancer,diabetes mellitus and
liver disease (Kozier and Erb’s. Fundamentals of Nursing 8th
edition.Volume 1. P.400)

2. Interaction Pattern
The client stated that sometimes he has a hard time
dealing with other people. He verbalized, “Hirap akong
makisama sa ibang tao, pag umiinom nga ako mag-isako lang at
sa bahay lang ako. Minsan nakakainum man ko rin yung anak ko,
sila at sila din lang.” Interaction in their family is good as they
usually spend time with each other. He verbalized, “Minsan kasi
nagbobonding din naman kami nagkakantahan kasi may player
sa bahay.” His wife also stated, “Saka kung may hindi kami
pagkakaintindihan pinaguusapan namin ng maayos kaso minsan
yung asawa ko medyo masikreto o malihim kumbaga.”

INTERPRETATION:Middle-aged person should interact effectively


and share companionable activities with life partner. ( Kozier and
Erb’s. Fundamentals of Nursing 8th edition.Volume 1. P. 401)

ANALYSIS: Family members support one another and have the


ability to listen, empathize and reach out to one another in times
of crisis. When the needs of family members are met, they are
more able to reach out to meet the needs of others in society.
(FUNDAMENTALS OF NURSING BY BARBARA KOZIER, et al
pp.193,SEVENTH EDITION)
3. Cognitive Pattern
The client as well as his family knows how to read and
write as he verbally said, “Marunung naman akong magbasa pati
mga anak ko at yung asawa ko.” The client stated, “Ako kasi
hanggang high school lang yung natapos ko, salat na kasi kami
sa pampaaral kaya di na ako nakapagpatuloy sa kolehiyo kaya
mas pinili kong magtrabaho na lang.” When it comes to his
visuals, he said, “Medyo malabo na yung mata ko, minsan di ko
na makita yung binabasa ko lalo na pagpagkaliit-liit.” When
asked about his hearing capabilities, the stated that he can still
hear sounds the way he used to hear them. He stated,
“Nakakarinig pa rin naman ako gaya ng dati, malakas pa naman
yung pandinig ko, hindi naman ako yung tipo ng kailangan mung
sigawan para lang marinig yung sasabihin mo.”

INTERPRETATION:Cognitive processes include reaction time,


memory, perception, learning, problem-solving, and creativity.
Reaction time during the middle years stays much the same or
diminishes during the later part of the middle years. Memory and
problem solving are maintained through middle adulthood.
Learning continues and can be enhanced by increased
motivation at this time in life. ( Kozier and Erb’s. Fundamentals
of Nursing 8th edition.Volume 1. P. 400)

ANALYSIS: The diminishing of sensory perception that may come


with chronic disease or aging is generally gradual. For example,
hearing loss is the third most common condition reported by the
elderly (Kozier and Erb’s. Fundamentals of Nursing 8th
edition.Volume 2. P. 983)

4. Self-Concept
The client stated, “Wala pa naman nagbago sa pagtingin
ko sa sarili ko, kaso nga lang kinakabahan ako baka pag umuwi
ko may ilang bagay na akong hindi puwedeng gawin yung mga
ipagbabawal ng doctor.” The client also feels that he is no longer
young. He stated, “Tumatanda naman na ako kaya may mga
pagbabago din tulad ng paningin ko nang hihinana, pero ganun
naman talaga, tanggap ko naman.”
INTERPRETATION:The middle-aged person does not make
comparisons with others, often no longer fears aging or death,
relaxes the sense of competitiveness, and enjoys the
independence and freedom of middle age. ( Kozier and Erb’s.
Fundamentals of Nursing 8th edition.Volume 1. P. 399)

ANALYSIS: Midlifers begin to recognize that time is at a premium


and that time is at a premium and that life is finite. Youthfulness
and physical strength can no longer be taken for granted( Kozier
and Erb’s. Fundamentals of Nursing 8th edition.Volume 1. P. 399)

5. Emotional Patterns
The patient stated, “Kung anu yung nararamdaman ko,
siyempre gustong gusto kong umuwi, matagal na ako dito sa
hospital at hindi ko yun gusto.” The client feels sad for being
confined in the hospital for quite a long time. He stated, “Gaya
nga ng sabi ko kanina, hindi talaga ako komportable dito kaya
medyo nakakalungkot na matagal na ako dito at saka ayoko na
problemahin masiyadong pamilya ko yung gastusin kasi nga
malaki ang mga bayarin sa hospital.” The client also thinks that
staying in the hospital too long is a burden to his family. He also
said that it is saddening for him to have such kind of illness. The
client said that it is really painful. When asked how painful
through the use of pain scale, the client verbalized, “Kung
lalagyan ko ng score mga 7 siguro, medyo makirot lalo na kapag
nahihigan ko yung sugat ko.”

INTERPRETATION: The prevalence of pain in older people is


generally higher due to both acute and chronic disease
conditions. (Kozier and Erb’s. Fundamentals of Nursing 8th
edition.Volume 2. P. 1194)

ANALYSIS: Pain tolerance does vary considerably from person to


person even within the same person at different times and in
different circumstances (Kozier and Erb’s. Fundamentals of
Nursing 8th edition.Volume 2. P. 1189)

6. Sexuality
The client verbalized, “Gumagamit kami ng family
planning, pero yung asawa ko ha. Gumagamit siya ng pills, pero
tinigil na niya ata.” When his wife was asked why she stopped
using pills, she answered, “Tumigil na ako sa paggamit ng pills
kasi pakiramdam ko naninikip yung dibdib ko.” The wife also said
that when she was still using pills, the pills were effective and
she never missed taking it. The patient had no doubts in his
sexual preference and also said, “Lalaking-lalaki ata ‘to, may
pamilya nga ako di ba. Hindi ko naman pinagdudahan yung
pagkalalaki ko.”

INTERPRETATION: The middle-aged adult should exhibit


appropriate knowledge and attitudes about sexuality (e.g., about
andropause). ( Kozier and Erb’s. Fundamentals of Nursing 8th
edition.Volume 1. P. 401)

ANALYSIS: Gender identity is the result of a long series of


developmental events that may or may not conform to one’s
apparent biologic sex. Once gender identity is established, it
cannot be easily changed(Kozier and Erb’s. Fundamentals of
Nursing 8th edition.Volume 2. P. 1023)

7. Family Coping Patterns


The client stated, “pag may problema, gaya nga ng sinabi
ng asawa ko kanina, pinaguusapan talaga namin, tuladngayon
na nandito ako sa hospital. Salitan silang pagbabantay sa akin,
yung asawa ko at yung anak kong lalake, yung panganay.”
Sometimes most of their problems were due to financial
constraints. “Uutang sa 5/6 tapos utang ulit o kaya hulug-hulugan
para makabayad. The client was also asked about their family income
and said that “Sa benta namin na fish ball kami kumukuha ng pera.
250 lang kita tapos pinagkakasya na lang namin. 2 beses lang din
kami nakakakain.Almusal at hapunan lang. When asked if there are
still other problems, the client said that “Minsan nag-aaway kami dahil
nga sa pera.” The client also added that “Hindi na nga-aaral yung 4
namin na anak.” He stated, “minsan nag-away kami ng anak
kong lalake, kasi ayaw sumunud sa akin.” When asked what was
done to fix the problem between him and his son, he stated,
“ako pinalipas ko muna yung init ng ulo ko, saka ko siya
kinausap ulit at nagpaliwanag. Medyo ang hirap kasi halos lalake
lahat ng anak ko, iisa lang yung babae yung bunso.” Their
youngest which is their only daughter is their problem right now,
for she is already a mother at the age of 16. “Medyo masakit sa
loob kasi nag-iisang babae siya tapos may anak na siya sa edad
niya, ang hirap pa man din bumuhay ng pamilya ngayon, pero
tanggap na naming, pinagtutulungan na lang naming yung
gastusin sa bata.”

INTERPRETATION:Mature persons are open to new experiences


and continued growth; they can tolerate ambiguity, are flexible,
and can adapt to change. ( Kozier and Erb’s. Fundamentals of
Nursing 8th edition.Volume 1. P. 398)

ANALYSIS: Family members support one another and have the


ability to listen, empathize and reach out to one another in times
of crisis. When the needs of family members are met, they are
more able to reach out to meet the needs of others in society.
(FUNDAMENTALS OF NURSING BY BARBARA KOZIER, et al
pp.193,SEVENTH EDITION)

B. Socio-Cultural Patterns
1. Cultural Patterns
The client came from Misamis Oriental. He stated, “hindi kasi
talaga magandang maggupit ng kuko sa gabi yun naman ang
pinaniniwalaan ko.” The client verbalized, “hindi naman ako
masiyadong mapamahiin, may mga pinaniniwalaan ako pero
hindi naman lahat.”

INTERPRETATION: Nursing involves the identification of


cultural traits and the integration of such cultural elements in
the delivery of care. . ( Kozier and Erb’s. Fundamentals of
Nursing 8th edition.Volume 1. P. 315)

ANALYSIS: Identify measures that will assist the client to


develop or maintain healthy nail practices. Kozier and Erb’s.
Fundamentals of Nursing 8th edition.Volume 1. P. 763)

2. Significant Relationships
The client said that his family is really important to him. He
stated, “yung pamilya ko talaga ang importante sa akin,
kaya nga ako nagtratrabaho ng maiigi.” The client
verbalized that his parents are important and as well as his
siblings. “Importante talaga yung parents ko sa akin, pati
yung mga kapatid ko, kasi kung nangangailangan man
minsan,sila at sila yung una kong malalapitan.” For the
client, it is important to value those people for they are
necessary for you to survive and face the problems.

INTERPRETATION:In middle age, the individual is “linked to


the welfare of others” (Lachman, 2004, p. 306). Reference:
( Kozier and Erb’s. Fundamentals of Nursing 8th
edition.Volume 1. P. 399)

ANALYSIS: Family members support one another and have


the ability to listen, empathize and reach out to one
another in times of crisis. When the needs of family
members are met, they are more able to reach out to meet
the needs of others in society. (FUNDAMENTALS OF
NURSING BY BARBARA KOZIER, et al pp.193,SEVENTH
EDITION)

3. Recreation Patterns
The client stated, “every morning naman nag-eexercise
naman ako kaso mabilis ako mapagod, may dumbbells
kasi sa bahay, mga at least 15 minutes araw-araw.” The
client with his family sometimes spends time together
through having sound trip or listening to music. One of
their recreational activities is that they watch television all
together. He stated, “eto talaga yung madalas naming
gawin na kumpleto kami yung manood ng T.V.”

INTERPRETATION:The middle-aged adult should be


developing adult leisure time activities. Marriage partners
have more time for companionship and recreation, thus
marriage may be more satisfying in the middle years of
life. Generative middle-aged persons are able to feel a
sense of comfort in their lifestyle and receive gratification
from charitable endeavors. ( Kozier and Erb’s.
Fundamentals of Nursing 8th edition.Volume 1. P. 399)
ANALYSIS: In elders, health promotion and illness
prevention are important, but often the focus is on learning
to adapt and live with increasing changes and
limitations( Kozier and Erb’s. Fundamentals of Nursing 8th
edition.Volume 1. P. 285)

4. Environment
The client was asked to describe their home and
community environment. When the client was asked to
describe the materials used for their house he said “Sa
semento gawa yung bahay namin.” The client also said
that “May electric fan yung bahay namin. Isa sa baba para
sa aming mag-asawa at yung isa ay para sa mga anak
namin.” The client described if there is an electrical supply
to their house and he said “Meron kaming supply ng
kuryente.” When asked to describe their garbage disposal,
the client said “Isa lang ang basurahan namin, plastic siya.
Nasa labas ng bahay yung basurahan namin. May
kumukuha din ng basura namin araw-araw.” When asked
about their water source, the client said that “NAWASA yun
supplyer ng tubig sa lugar namin.” The client also
described their source of drinking water as “Pinapakuluan
nmain yung tubig bago namin inumin tapos nilalagay
namin sa pitchel o garapon na may takip. Kada 2 araw din
nmain nililinis yung mga lalagyan na yun.” When asked to
describe about their food storage, the client said that
“Nilalagay namin sa Tupperware na may takip tapos nasa
ibabaw ng lamesa. Wala kasi kaming ref kaya mahirap din.
Pag panis na, tinatapon na namin agad. Pag hindi pa panis,
iniinit na lang namin sa kaldero.” When the client was
asked to describe their sleeping environment, the client
said “Semento na may sapin at karton tapos tag-isang
unan lang kaming mag-asawa. Yung mga anak nmain ay
natutlog sa taas. May katol din kami gabi-gabi.” When
asked about their community communication system, the
client described that “Nakakarating naman sa amin pag
may gagawin sa barangay tsaka yung health center lalo na
pag may bagyo o kaya minsan nalalaman na lang din
namin sa mga kapitbahay.Binabaha din yung lugar namin
kaya minsan namimigay din ng de lata yung barangay pag
may bagyo.

INTERPRETATION: The environment of the client is vital to


the health of middle-aged adults as they are more prone to
health problems.

ANALYSIS: Because each if the agent-host environment


factors constantly interacts with others, health is an ever-
changing state. When the variables are in balance, health
is maintained; when variables are not in balance, disease
occurs (Kozier and Erb’s. Fundamentals of Nursing 8th
edition.Volume 1. P. 298)

5. Economic
The client stated, “kasi hindi talaga sapat yung kinikita
naming mag-asawa kahit pa dalawa kami nagtratrabaho.”
His wife gains 100 pesos from her everyday work and the
client gains 150 pesos per day. He verbalized, “yang 250
na yan pinagkakasya talaga namin, pag kinulang gaya ng
pagkakaroon ng emergency talagang nang-uutang na lang
kami sa 5-6 saka naming babayaran araw-araw.” They also
said that sometimes they just eat 2 times a day. The client
stated, “ang hirap kasi talaga ng buhay ditto sa pilipinas,
hirap kami ng asawa ko maghanap ng trabaho may sapat
na kita kasi nga hindi rin naman kami nakapagtapos ng
kolehiyo.” His wife stated, “minsan dagdag pa sa gastusin
niyang magyosi, nakakaisang kaha kasi siya kada araw.”

INTERPRETATION: The middle-aged adult should be


establishing and maintaining an economic standard of
living. ( Kozier and Erb’s. Fundamentals of Nursing 8th
edition.Volume 1. P. 399)

C. Spiritual Patterns
1. Religious Beliefs and Practices
The client stated, “ako kasi hindi madalas magsimba kasi nga
trabaho talaga inaaatupag ko, misis ko ang nagsisimba
kasama yung iba kong anak.” The client believes in God
though he doesn’t visit the church frequently. The client
prefers to pray at home before sleeping. He verbalized, “mas
maganda pa nga magdasal minsan sa bahay lang kasi mag-
isa mo lang, mas payapa. Minsan pinagdadasal ko na lang
talaga yung kalagayan ko, pinagpapasadiyos ko na lang,”
stated by the client.

INTERPRETATION: In middle age, people tend to be less


dogmatic about religious belief, and religion often offers more
comfort to the middle-aged person than it did previously.
People in this age group often rely on spiritual beliefs to help
them deal with illness, death, and tradegy.. ( Kozier and Erb’s.
Fundamentals of Nursing 8th edition.Volume 1. P. 400)

ANALYSIS: Spirituality refers to that part of being human that


seeks meaningfulness through intra-, inter-, and transpersonal
connection (Reed, 1992). Spirituality generally involves a
belief in a relationship with some higher power, creative force,
divine being, or infinite source of energy. For example, a
person may believe in “God”, “Allah”, the “Great Spirit” or a
“Higher Power”. (Kozier and Erb’s Fundamental’s of Nursing p.
1042)

2. Values and Valuing


The client stated, “kasi ayaw talaga ng misis ko yung pagiging
malihim ko minsan, kasi nga mas gusto ko talagang sarilinin
kung ako lang naman may problema. Ayoko kasi idamay sila
baka lalo lang maging pabigat sa kanila.” As stated by the client
earlier it is important for him to value other people for they are
important in facing problems.

INTERPRETATION: The person establishes ethical and moral


standards that are independent of the standards of others. The
focus shifts from inner self and being to others and doing.
Religious and philosophical concerns become important. ( Kozier
and Erb’s. Fundamentals of Nursing 8th edition.Volume 1. P. 399)

ANALYSIS: Emotional health depends on a social environment


that is free of excessive tension and does not isolate the persons
from others. A climate of open communication, sharing, and love
fosters the fulfillment of the person’s optimum potential
IV. Activities of Daily Living:

ADL BEFORE DURING INTERPRETATION


HOSPITALIZATION HOSPITALIZATIO AND ANALYSIS
N

Nutrition Before his During Mr. HLC‘s Mr. HLC’s food


hospitalization, Mr. hospitalization, he intake was
HLC had eaten one said that his food decreased and
cup of rice and his intake is controlled during
viand, chicken adobo. controlled. his hospitalization.
He ate one match box Food intakes
sized chicken and during
three potatoes. He hospitalization are
drank a glass of closely monitored.
water. During lunch, There are different
since he was busy kinds of diet that is
selling fish balls, he ordered by the
was only able to eat a physician and it
pack of sky flakes and must be strictly
drank a glass of implemented.
water. During dinner,
he ate one pack of
lucky me noodles and
two slices of bread.
He also drank a glass
of water.

Elimination Before his Since he got to the Mr. HLC’s


hospitalization, Mr. hospital, Mr. HLC elimination pattern
HLC usually has bowel still hasn’t has been changed
movement every day. defecated yet. He since he went to
He said that he only also urinates less. hospital. Since his
defecates once a day. food and liquid
His stool varies light intake is
to dark brown, decreased, Mr. HC
formed, soft, was not able
semisolid, moist, and defecate yet and
aromatic. There is no his urine output is
signs of bleeding or decreased.
change in color. He
doesn’t feel any pain
or discomfort during
defecation. He
urinates about ten
times a day. He
doesn’t feel any pain
or discomforts when
urinating.

Exercise Before, Mr. HLC But since he got to Mr. HLC’s activity
usually wakes up the hospital, Mr. level has
early in the morning HLC wasn’t able to decreased since he
to prepare for his perform any is at bed most of
work, which is selling exercise at all. the time. Patients
fish balls. After that on the hospital are
he performs dumbbell kept rested for
exercises for about 15 timely healing.
minutes. In the
afternoon, Mr. HLC
walks a lot to sell his
fish balls.

Hygiene Prior to During his Mr. HLC wasn’t


hospitalization, Mr. hospitalization, Mr. able to take a bath
HLC takes care of his HLC wasn’t able to or brush his teeth
hygiene by taking a take a shower or during his
bath and brushing his brush his teeth. hospitalization
teeth once a day. He because most of
said that he rarely the time he’s in his
wash his hands bed in the ward.
because he is usually
busy working.

Substance Use Prior to During his Mr. HLC is not able


hospitalization, Mr. hospitalization, of to smoke and drink
HLC is a smoker and a course, the patient in the hospital.
drinker. He said that wasn’t able to These things are
he smokes one pack smoke and drink. not allowed in the
of cigarette a day and hospital premises
he drinks gin when he and it can
arrives from work. aggravate his
condition.

Sleep and Rest The patient sleeps His sleep during His sleep and rest
late at night when at his hospitalization during
home. He drinks gin was intermittent. hospitalization
to be able to fall He sleeps for 30 were intermittent
asleep. He usually minutes or for an because of
sleeps for almost 6-8 hour and he will frequent vital signs
hours. wake up to take taking and
his medications administering of
and other stuffs. medications.

Sexual Activity Mr. HLC said that Since he got to the Mr. HLC’s sexual
because both of them hospital, Mr. HLC activity was absent
are busy working, and his wife can’t when he went to
they rarely perform have sexual the hospital.
sexual activities. activities.

V. Physical Assessment:

A. GENERAL NORMS ACTUAL INTERPRETATIO


APPEARANCE FINDINGS N AND
ANALYSIS

1. POSTURE Relaxed, Leans Normal


AND GAIT erect forward due
posture; to carbuncle
coordinated back.
movements.
Needs
assistance
when
walking

2. SKIN COLOR Healthy Brown skin Deviation from


appearance color with normal
carbuncle on
the back

3. PERSONAL Clean, neat Dirty in Deviation from


HYGIENE/ appearance normal
GROOMING No body
odor or With body
minor body odor or
odor relative minor body
to work or odor related
exercise; no to poor
breath odor. hygiene; no
breath odor.

4. AGE Acts Acts Normal


APPROPRIATEN according to according to
ESS age. age.

5. VERBAL Understanda Understanda Normal


BEHAVIOR ble ble
moderate moderate
phase; clear phase; clear
tone and tone and
inflection; inflection;
exhibits exhibits
thought thought
organization organization
. .

Logical Logical
sequence; sequence;
makes makes
sense; has sense; has
sense of sense of
reality. reality.

6. NON Cooperative, Elicits Deviation from


VERBAL able to protective normal
BEHAVIOR follow behavior in
instructions, IV infusion
appropriate site.
to situation.
Irritable
No distress
noted. Follows
instructions.

B.
MEASUREMENT
S

1. (Axillary) 36.2°C Normal


TEMPERATURE 35.9-36.9°C

2. PULSE RATE 60-100 bpm 92 bpm Normal

3. 12-20bpm 15 bpm Normal


RESPIRATORY
RATE
4. BLOOD (systole) 90- 100/70 Normal
PRESSURE 140 mmHg mmHg

(diastole)
60-100
mmHg

VI. Laboratory and Examinations Results:

Result Normal Range Analysis


Hemoglobin 101 130-170 Low hemoglobin means
(Hgb) having an anemia
Hematocrit (Hct) 0.295 0.40-0.54 Low hematocrit may be
due to:

•AnemiaAnemia
•Bleeding
•Destruction of red
blood cells
•Leukemia
•MalnutritionMalnutritio
n
•Nutritional deficiencies
of iron, folate, vitamin
B12, and vitamin B6
•Overhydration
HBA1C 12% 3.90-6.20 This means that the
patient is in greater risk
of the different
complications of having
diabetes.
Glucose 19.86 3.88-6.38 An indication of risk in
heart diseases.
Cholesterol 3.91 <=5.20 Normal
HDL direct 0.58 0.91-1.29 A low HDL cholesterol
level is thought to
accelerate the
development of
atherosclerosis.
Triglycerides 2.29 0.45-1.81 High triglyceride levels
are associated with an
increased risk of
developing heart
disease.
LDL Cholesterol 2.29 3.20-4.10 LDL less than 100 mg/dL
(2.59 mmol/L) if you
have heart disease or
diabetes
VLDL 1.04 0.20-0.90 High levels may be
associated with a higher
risk for heart disease
and stroke.
LDL/HDL Rate 1.54 1.60-6.60 Lower than the normal
range.
Chole/HDL Rate 6.74 2.70-8.90 Within normal range.
DRUG CLASSIFICATIO INDICATION ACTION AND CONTRAINDICA ADVERSE
N DRUGPHARMACOKIN TION EFFECT
ETICS

Drug name: Anti-infective Treatment of Action: Hypersensitivity Body as a


infections due to to penicillins; whole:
Ampicillin Antibiotic susceptible Antibiotic agent mononucleosis
Sulbactam organism in skin with broad Hypersensitivity
Aminopenicillin spectrum of (rash, itching,
and skin
structure (e.g., activity resulting anaphylactoid
klebsiella from beta- reaction), fatigue,
Dose:
pneumonia, lactamase malaise, chills,
750mg TIV q8 staphylococcus inhibition. headache,
aureus) and Sulbactam edema.
intraabdominal inhibits beta-
lactamases most GI:
infections (e.g.,
Escherichia coli) frequently
Diarrhea,
and for responsible for
nausea ,
gynaecologic transferred drug
vomitting,
infections (e.g., resistance.
abdominal
Bacteroides sp. Because of this
distention,
Including B. action, a wide
candidiasis.
fragilis). Also range of
used for betalactamases Hematologic:
infections caused found in
by ampicillin- organisms Neutropenia,
susceptible resistant to thrombocytopeni
organism. penicillins and a.
cephalosporins
are inhibited. Urogenital:

Dysuria

Pharmakonecti CNS:
cs:
Seizure
Peak:
Other:
Immediate after
the IV. Local pain at
injection site;
Duration: thrombophlebitis.

6-8hours

Distribution:

Most body
tissues; high CNS
concentrations
DRUG CLASSIFICATIO INDICATION ACTION AND CONTRAINDICA ADVERSE
N PHARMACOKIN TION EFFECT
ETICS

Drug name: Central Nervous Effective agent Action: Hypersensitivity Body as a


System agent; for control of to tramadol or whole:
Tramadol moderate to Centrally acting other opioid
Hydrochloride Opiate Agonist; moderately opiate receptore analgesics; Sweating,
severe pain. agonist that patients on MAO anaphylactic
Dose: Narcotic inhibits the reaction
inhibitors;
Analgesic uptake of
100mg TIV q8 x 3 patients acutely
norepinephrine GI:
doses intoxicated with
and serotonin, alcohol, Nausea,
suggesting both hypnotics constipation,
opioid and centrally acting vomiting,
nonopioid analgesics, xerostomia,
mechanisms of opioids, or dyspepsia,
pain relief. May psychotrophic diarrhea,
produce opoid drugs abdominal
like effects, but
distetntion,anore
causes less
xia, flatulence
respiratory
depression than Urogenital:
morphine
Urinary retention/
frequency
Pharmakonecti CNS:
cs:
Drowsiness,
Absorption: dizziness, vertigo,
fatigue,
Rapidly absorbed
headache,
from GI tract,
somnomlence,
75% reaches
restlessness,
systemic
euphoria,
circulation
confusion,
Onset: anxiety,
coordination
30-60 minutes disturbance,
sleep
Peak:
disturbance,
2 hours seizures

Distribution: Special Senses:

Approximately Visual
20% bound to Disturbances
plasma proteins,
probably crosses
blood-brain
barrier

Metabolic:

Metabolized
extensively
inliver by
cytochrome

Elimination:

Excreted
primarily in urine

Half life:

6-7 hours

DRUG CLASSIFICATIO INDICATION ACTION AND CONTRAINDICA ADVERSE


N PHARMACOKIN
ETICS TION EFFECT

Drug name: Central nervous Short term Action: Hypersensitivity GI:


system agent; management of to ketorolac;
Keterolac pain It inhibits individuals with Nausea,
Tromethamine NSAID synthesis of complete or dyspepsia, GI
analgesics; prostaglandins partial syndrome pain, hemorrhage
Dose: and is of nasal polyps,
Antipyretic peripherally CNS:
30mg TIV q6 x angioedema, and
acting analgesics. bronchospastic
4doses Drowsiness,
Ketorolac does reaction to dizziness,
not have any aspirin or other headache
known effects on NSAIDS; patients
opiate receptors with severe renal Other:
impairments or at
Pharmakonecti Edema, sweating,
risk for renal
cs: pain at the
failure due to
volume injection site.
Peak:
depletion;
45-60 minutes patients with risk
of bleeding;
Metabolic: active peptic
ulcer disease;
Metabolized in pre- or intra-
the liver operatively;
intrathecal or
Elimination:
epidural
Excreted in urine administration; in
combination with
Half life: other NSAIDS.

4-6hour
DRUG CLASSIFICATIO INDICATION ACTION AND CONTRAINDICA ADVERSE
N PHARMACOKIN TION EFFECT
ETICS

Drug name: Gastrointestinal Blocks daytime Action: Safe use during Body as a
agent and nocturnal pregnancy or whole:
Ranitidine HCL basal gastric acid Potent anti-ulcer lactation is
Antisecretory secretion drug that established. Hypersensitivity
Dose: competitively reaction,
stimulated by
histamine and and reversibly anaphylaxis
50mg q8
reduces gastric inhibits histamine
action at H2- GI:
acid release in
response to food, receptor sites on
Constipation,
pentagastrin and parietal cells,
nausea,
insulin. Shown to thus blocking
abdominal pain,
inhibit 50% of the gastric acid
diarrhea
stimulated secretion.
gastric acid Indirectly reduces Hematologic:
secretion. pepsin secretion
but appears to Reversible
have minimal decrease in WBC
effect on fasting count,
and postprandial thrombocytopeni
serum gastrin a
concentrations or
secretions of CNS:
gastric intrinsic
factors or mucus. Headache,
malaise,
Pharmakonecti dizziness,
cs: somnolence,
insomnia, vertigo,
Peak: mental confusion,
agitation,
2-3 hours depression,
hallucinations in
Duration: older adult

8-12 hours CV:

Distribution: Bradycardia

Distributed into Skin:


breastmilk
Rash
Metabolic:

Metabolized in
the liver

Elimination:

Excreted in urine
with some
excreted in feces

Half life:

2-3hours

Paracetamol Adult: Analgesics Mild to Not recommended in severe renal


200mg q4 (Non-Opioid) moderate impairment (CrCl <10 ml/min), severe
& pain and respiratory insufficiency, liver disease or
Antipyretics fever opioid dependent patients. Increased
intracranial pressure or head injury,
patients at risk of seizures or on drugs
that may lower the seizure threshold (e.g.
SSRI, TCA, antipsychotics, centrally acting
analgesics or local anaesthesia), biliary
tract disorders, in a state of shock or
unconsciousness. May impair ability to
drive or operate machinery. Avoid abrupt
withdrawal. May cause withdrawal
symptoms, dependence and abuse.
Elderly. Pregnancy, lactation.
I. Prioritized List of Nursing Problems

Diagnosis Rank Justification

Acute pain r/t 1 According to Maslow’s


debridement of upper Hierarchy of needs, a
Right back as evidence person cannot do
by verbal Report of pain certain task when pain
is present. Pain is a
factor in which it may
cause disturbances to a
client. Nurse has
resources such as
teaching the client on
how to decrease pain
level. This is also done
by reinforcing client to
take pain medications
as needed.

Risk for infection r/t 2 According to Maslow’s


delayed healing of Hierarchy of Needs,
wounds since it is only a risk it is
secondary to the pain
that is feeling by the
client , but must be
entertained to prevent
further complication.

Deficient knowledge r/t 3 Since knowledge is


unfamiliarity of important, the patient
information should involve in his
treatment process that
may lead to other
disease. Also, if the
client is involved he/she
will be less anxious
there for he will be more
cooperative.
Nursing Care Plan

Nursing Goal and Nursing Rationale Evaluation


Diagnosis Objectives Intervention

Acute pain related Goal:


to debridement of After 8 hours of The client
right upper back as nursing verbalized a
evidenced by intervention, client decrease level of
verbal report of will demonstrate pain. From the pain
pain. decreased level of scale of 7 it
pain. becomes 5. The
Subjective: goal was achieved.
Objectives:
 Client rated INDEPENDENT:
his pain as 7 1. After the
out of 10 discussion,
using the client will be Provide an ample Providing an
pain scale (1 able to: time for the client enough time for the
is the lowest to verbalize her client to verbalize The client
and 10 is the a. Describ feelings. her feelings verbalized the
highest) e the promotes characteristic of
 “ Medyo characteristic individualized plan pain and his other
makirot lalo s of pain she of care. complaints.
na kapag feels in 3
nahihigaan ko mins.
yung sugat Discuss the proper
ko.” breathing (deep Discussing proper
breathing) exercise. breathing exercise The client was able
Objective: gives information to demonstrate the
 Appears b. Return for the client. proper breathing
weak. demonstrate Discuss the exercise in 2 mins.
proper advantages of deep Discussing the
 Grimace was breathing breathing exercise. advantages of deep
noted. exercise breathing exercise
 Positioning to (deep enhances
avoid pain. breathing) in participation of the
 Stain of blood 2 mins Demonstrate the client.
on his clothes proper technique of
on the site of deep breathing Demonstrating the
the wounds. exercise. deep breathing
 Redness and exercise promotes
swelling was proper exhibition of
noted on the the technique.
affected site.
Discuss what is all
about guided Discussion provides The client was able
imagery. information for the to participate in the
client regarding discussion and
Guided Imagery. demonstration of
c. Perfor guided imagery.
m and
participate Discuss the Discussion of the The client was able
with the importance and importance of return demonstrate
nurse in benefits of Guided Guided Imagery it in 2 mins.
guided Imagery. promotes
imagery as a participation of the
form of client.
relaxation for
2 mins.
Return Demonstration
demonstrate how promotes proper
to perform proper technique of guided
Guided Imagery as imagery as one
a form of form of relaxation.
relaxation.
Reduces muscle
fatigue and
Encourage client to maximizes
change position circulation to
frequently. tissues.

Monitor vital signs Monitoring is done


to know whether
nursing
interventions were
effective.

For baseline data

COLLABORATIVE:

Reinforce the use


of pain medication To relieve pain.
(Tramadol).
Reinforcing the use
of pain medications
promotes
compliance to take
the medicines.
Discharge Plan

Medications:
a. Paracetamol
b. Ranitidine
c. Tramadol

Exercise:

Avoid strenuous exercise until wound at the back has been fully
healed.

Treatments:

Wound debridement was done in the hospital to remove pus and


abscess from the carbuncle back.
Continuous blood glucose monitoring is done for the patient with
suspected Diabetes Mellitus.

Health Teachings:
a. Reduce carbohydrate consumption.
b. Avoid sweets
c. Blood glucose monitoring
d. Clean wound site regularly

Out-patient follow-up:

Check-up every 3 months


Diet:
Diabetic Diet
- Avoid sweets and carbohydrates.