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CHAPTER 2

PATIENT'S DATA

A. PATIENT'S PROFILE

Name of Patient: Hermenia


Age/Sex: 78 years old/female
Civil Status: Widow
Date of birth: April 2, 1932
Birthplace: Cotabato City
Address: Glodo subd. San Francisco, Panabo City, Davao del Norte
Religion: Roman Catholic
Nationality: Filipino
Origin( Hometown): Panabo City
Educational Attainment: High School Graduate
Occupation: None
Weight: 42 kg.
Height: 5'1
Date of Admission: November 16, 2010
Date of discharge: November 27, 2010
Attending Physician:
Chief Complaint: Abdominal pain
Impression: Community Acquired Pneumonia High Risk, Upper
Gastrointestinal Bleeding secondary to Bleeding Ulcer Disease
Final Diagnosis: Anemia secondary to Upper Gastrointestinal Bleeding
secondary to Bleeding Ulcer Disease
Procedure: Insertion of NGT

B. Family Background

Patient Hernia was born on April 2, 1932, she was married to Apolinario
has 4 children namely Alberto (married) with 2 children, Juliana (married) 1
child, Ricardo (married) 2 children, Lourdes (single parent) 1 child. Mrs.
Herminia is unemployed according to her they have hypotension as their
hereditery, while on her husband side was hypertension. Their only means to
subdue it, if not eradicate, was to avoid nutriments that can heighten the
disease. Their family experienced minor illnesses such as cough, colds and
fever. Taking Paracetamol tablet is their only remedy for these illnesses.

C. EFFECTS OF PRESENT DISEASE TO SELF/ FAMILY


Patient Herminia said that she has accepted her condition and that she
had no regrets of not going to the doctor cause “ makaya pa ang sakit og gasto
ra kung muadto pa ko sa doctor”. Sha passed the stages of denial, anger and
bargaining and is currently on the stage of acceptance. Besides what ever she
said will be done because for she is the mother, so her children will just follow
her. Since the patient manifest the disease she can't do simple house chores
she is always in the bed.
Watcher Chary said that she has accepted the condition of her mother
and regrets that they did not go to the doctor in time “ unta niadto nalang ko diri
tong una pa para mabal-an unta kung asa ang sakit sa akong mama”.

D. HISTORY OF PAST ILLNESS


Patient Herminia said that her past illness were fever, cough, flu, mild and
severe headaches. She never experienced admitted to hospital because if she
is not feeling well she will just go the a “quack doctor” or “manghihilot'.She only
take herbal medicines to relieve her cough. Her fever and flu her remedy on it is
Paracetamol tablet. She has a small garden which she always pay her attention
that results to forget her meal. Patient is a smoker (tobacco) and occasionally
alcohol drinker. She likes to eat salty foods.

E. HISTORY OF PRESENT ILLNESS


Patient experienced 3 months(August 2010) ago prior to admission
abdominal pain at the right upper quadrant every midnight specially if she is very
full. She put liniment oil to relieve the pain and it slightly relief. She go
immediately to a “quack doctor” and give her a herbal plants as an advise to
relieve her pain. After 2 weeks she experienced chest pain, difficulty in breathing
and non productive cough. She go again to a quack doctor and take the herbal
medicine(extract of Lagundi) given by the quack doctor. November 16, 2010 at 1
pm patient experienced another episode of severe abdominal pain at right upper
quadrant. She take herbal medication but her pain cannot be relieve anymore
that's why decided to go to a doctor at 5:30 pm.

F. ASSESSMENT
PHYSICAL ASSESSMENT
A. VITAL SIGNS
11/16/10 TEMPERATURE PULSE RATE RESPIRATORY BLOOD
RATE PRESSURE
04:00:00 PM 35.8ºc 62bpm 21cpm 140/90 mmHg
08:00:00 PM 36 ºc 61bpm 21cpm
12:00:00 PM 37.3ºc 70bpm 20cpm
11/17/10
04:00:00 AM 36.2ºc 65bpm 18cpm 120/80 mmHg
08:00:00 AM 36ºc 70bpm 19cpm 120/80 mmHg
12:00:00 AM 36.5ºc
04:00:00 PM 36.6ºc 70bpm
08:00:00 PM 36.6ºc 18cpm 120/70 mmHg
12:00:00 PM 36.2ºc 21cpm 120/90 mmHg
11/18/10
04:00:00 AM 36.2ºc 60bpm 19cpm 130/80 mmHg
08:00:00 AM 36.6ºc
12:00:00 AM 36.4ºc 110/80 mmHg
04:00:00 PM 36.2ºc
08:00:00 PM 36.4ºc
12:00:00 PM 36.3ºc
11/19/10
04:00:00 AM 36.3ºc 70 bpm 19cpm 120/80 mmHg
08:00:00 AM 36.4ºc 75bpm 20cpm 120/80 mmHg
12:00:00 AM 36.1ºc
04:00:00 PM 37.6ºc 78bpm 21cpm 120/80 mmHg
08:00:00 PM 37ºc 120/90 mmHg
12:00:00 PM 36.2ºc
11/20/10
04:00:00 AM 36.7ºc 75bpm 20cpm 120/80 mmHg
08:00:00 AM 37.3ºc 140/80 mmHg
12:00:00 AM 38ºc 76bpm 23cpm 130/80 mmHg
04:00:00 PM 36.6ºc 75bpm 20cpm 130/80 mmHg
08:00:00 PM 36.8ºc
12:00:00 PM 36.4ºc 80bpm 20cpm 110/70 mmHg
11/21/10
04:00:00 AM 37ºc 80bpm 20cpm 110/80 mmHg
08:00:00 AM 36.6ºc 80bpm 20cpm 140/90 mmHg
12:00:00 AM 36.3ºc
04:00:00 PM 36.5ºc 80bpm 20cpm 130/80 mmHg
08:00:00 PM 36.2ºc
12:00:00 PM 36.4ºc 130/90 mmHg
11/22/10
04:00:00 AM 36.7ºc 80bpm 20cpm 130/90 mmHg
120/90 mmHg
08:00:00 AM 36.2ºc
12:00:00 AM 36.6ºc 90bpm 20cpm 140/90 mmHg
130/90 mmHg
04:00:00 PM 37.4ºc 96bpm 25cpm 130/80 mmHg
140/100 mmHg
08:00:00 PM 37ºc
12:00:00 PM 36.8ºc 130/90 mmHg
130/80 mmHg
11/23/10
04:00:00 AM 36.7ºc 90bpm 23cpm 140/100 mmHg
08:00:00 AM 36.5ºc 80bpm 20cpm 140/80 mmHg
140/80 mmHg
12:00:00 AM 36.4ºc
04:00:00 PM 36.5ºc
08:00:00 PM 37.2ºc 90bpm 25cpm 130/90 mmHg
12:00:00 PM 36.6ºc 140/90 mmHg
11/24/10
04:00:00 AM 37.8ºc
08:00:00 AM 36.8ºc 90bpm 26cpm 160/80 mmHg
12:00:00 AM 36.8ºc 85bpm 140/90 mmHg
04:00:00 PM 37.2ºc 85bpm 25cpm 140/90 mmHg
08:00:00 PM 36ºc 130/90 mmHg
12:00:00 PM 36.8ºc

11/25/10 TEMPERATURE PULSE RATE RESPIRATORY BLOOD


RATE PRESSURE
08:00:00 AM 36.5ºc 101bpm 30cpm 130/80mmHg
09:00:00 AM 36.8ºc 110bpm 32cpm 130/80mmHg
10:00:00 AM 36.6ºc 105bpm 29cpm 130/80mmHg
11:00:00 AM 36.9ºc 105bpm 33cpm 140/80mmHg
12:00:00 PM 36.6ºc 108bpm 33cpm 130/80mmHg
01:00:00 PM 36.6ºc 105bpm 32cpm 130/80mmHg
02:00:00 PM 36.6ºc 103bpm 32cpm 130/80mmHg
03:00:00 PM 36.7ºc 103bpm 32cpm 130/80mmHg

B. Neurologic Status
Patient is responsive,coherent and cooperative. Oriented in name or
person, time, date and place.

C. Cardiovascular System
Patient has increase heart rate 108 bpm .Abnormal blood pressure
140/80 mmHg . She experienced chest pain with no heart murmurs upon
auscultation.

D. Respiratory system
Patient respiratory rate 33 cpm which evidenced she experienced
difficulty in breathing and shortness of breath. And rule out she has a community
aquired pnuemonia high risk.
E. Gastrointestinal System
Patient experienced abdominal pain in the right upper quadrant with
hematochezia and melena. In a soft diet and no dark colored foods. With
nasogastric tubing attached to nose.

F. Genito- urinary System


Patient has a foley catheter attached to uro bag with yellow out put. In
intake and output monitoring q shift.

G. Musculoskeletal System
Patient needs assistance in activity in daily living because of muscle
weakness with limited range of motion. Without any deformities.

H. Integumentary System
Patient has a poor skin turgor , pallor noted and dry skin. Hair is evenly
distributed all over the body. With bed sore moist, red color at the back with
unpleasant odor.

11/26/10 TEMPERATURE PULSE RATE RESPIRATORY BLOOD


RATE PRESSURE
08:00:00 AM 36.1ºc 102bpm 32cpm 130/90mmHg
09:00:00 AM 36.3ºc 100bpm 30cpm 130/90mmHg
10:00:00 AM 36.6ºc 110bpm 31cpm 130/80mmHg
11:00:00 AM 36ºc 110bpm 32cpm 130/80mmHg
12:00:00 PM 36.5ºc 108bpm 32cpm 130/90mmHg
01:00:00 PM 36.3ºc 107bpm 32cpm 130/90mmHg
02:00:00 PM 36.5ºc 112bpm 32cpm 130/90mmHg
03:00:00 PM 36.5ºc 108bpm 33cpm 130/90mmHg

B. Neurologic Status
Patient is responsive,coherent and cooperative. Oriented in name or
person, time, date and place.

C. Cardiovascular System
Patient has increase heart rate 110 bpm. Abnormal blood pressure
130/90mmHg.She experienced chest pain with no heart murmurs upon
auscultation.

D. Respiratory system
Patient respiratory rate 33 cpm which evidenced she experienced
difficulty in breathing and shortness of breath. And rule out she has a community
aquired pnuemonia high risk.

E. Gastrointestinal System
Patient experienced abdominal pain in the right upper quadrant with
hematochezia and melena. In a soft diet and no dark colored foods. With
nasogastric tubing attached to nose.

F. Genito- urinary System


Patient has a foley catheter attached to uro bag with yellow out put. In
intake and output monitoring q shift.

G. Musculoskeletal System
Patient needs assistance in activity in daily living because of muscle
weakness with limited range of motion. Without any deformities.

H. Integumentary System
Patient has a poor skin turgor , pallor noted and dry skin. Hair is evenly
distributed all over the body. With bed sore moist, red color at the back with
unpleasant odor.

11/27/10 TEMPERATURE PULSE RATE RESPIRATORY BLOOD


RATE PRESSURE
08:00:00 AM 36.3ºc 100bpm 38cpm 130/90 mmHg
09:00:00 AM 36.1ºc 102bpm 32cpm 130/90 mmHg
10:00:00 AM 36.4ºc 99bpm 32cpm 120/60 mmHg
11:00:00 AM 36.4ºc 96bpm 32cpm 110/60 mmHg
12:00:00 PM 36.3ºc 92bpm 29cpm 90/60 mmHg
01:00:00 PM 36.7ºc 92bpm 25cpm 90/60 mmHg
02:00:00 PM 36.2ºc 80bpm 20cpm 70/50 mmHg

B. Neurologic Status
Patient is responsive,coherent and cooperative. Oriented in name or
person, time, date and place.

C. Cardiovascular System
Patient has increase heart rate 102bpm. Abnormal blood pressure
130/90 mmHg. She experienced chest pain with no heart murmurs upon
auscultation.
D. Respiratory system
Patient respiratory rate 38cpm. which evidenced she experienced
difficulty in breathing and shortness of breath. And rule out she has a community
aquired pnuemonia high risk.

E. Gastrointestinal System
Patient experienced abdominal pain in the right upper quadrant with
hematochezia and melena. In a soft diet and no dark colored foods. Patient
removed the NGT without any supervision of the doctor or nurse.
F. Genito- urinary System
Patient has a foley catheter attached to uro bag with yellow out put. In
intake and output monitoring q shift.

G. Musculoskeletal System
Patient needs assistance in activity in daily living because of muscle
weakness with limited range of motion. Without any deformities.

H. Integumentary System
Patient has a poor skin turgor , pallor noted and dry skin. Hair is evenly
distributed all over the body. With bed sore moist, red color at the back with
unpleasant odor.

PSYCHOSOCIAL ASSESSMENT
Patient is friendly and always cooperating. According to patient she has
no enemy in her neighbor and she is not a strict type of mother. She likes to stay
in home and manage her little garden.
CHAPTER 9
DISCHAGE PLAN

M-edication
E-xercise
T-reatment
H-ygiene
O-ut patient
D-iet
S-piritual

MEDICATION
Instruct to continue the medication as prescribed by the doctor.

EXERCISE
Encouraged patient to demonstrate exercise such as turning side to side every 2
hours.

TREATMENT

HYGIENE
Encouraged to do proper hygiene. Advised to clean the bed sore everyday or as
indicated.

OUT-PATIENT
Instruct patient to continue medical care as ordered. Follow up check up for
proper intervention for continue healing progress.

DIET
Instructed to eat in exact time. Advised to eat nutritious foods rich in vitamins,
protein, and minerals to help strengthen the immune system. Advised not eat
dark colored foods and avoid alcohol beverages. Instructed to increase oral fluid
intake.

SPIRITUAL
Given emotional support as well as advised to pray to strengthen spiritual needs.
Family advised to support patient emotional, spiritual, physical, and psychosocial
needs.