General objectives:

At the end of the case presentation the students will be able to: To develop our sense of unselfish love & empathy in rendering nursing care to our patient so that we may be able to serve future clients with higher level of holistic understanding as well as individualized care. To be able to apply learned knowledge in lecture into actual setting Contribute to the promotion to human health & well being to avoid having Ascites.

Specific objectives:
Establish rapport to the client Formulate & apply nursing care plans utilizing the nursing care process. To learn new clinical skills as well as sharpen our current clinical skills required in the management of the patient with Ascites.

DEMOGRPHIC DATA I. Clients Data Base

Biographical Data
Name: Patient X Address: Room 201 Centinial Village, Taguig City Gender: Female Provider of History: Patient X Birth date: 1967 Place of Birth: Race: Filipino Educational Level: High School Occupation: House Wife Significant to Others: Mr. X Death July 25, 1995 (Aplastic Anemia) Siblings: 4 Children, 3 Girls and 1 Boy with a Complete Immunization

Reasons for Seeking Health Care History of Present Health Concern

Character: Abdominal Cramps Onset: Location: Stomach Duration: 5 minutes Severity: Pain Scale of 7 out of 10 What makes it Worse: When I am sitting down in bed I do not feel any pain but when I stand up I feel the pain.

Associated Factors:

Past Health History

Problems at Birth: None Childhood Illness: Common Illness such as cough and cold Immunization: None Menarch: 15 years Old Adult Illness: Ascites Surgeries: None Accidents: Vehicular Accident Prolonged Pain/Patterns: None Allergies: None

Family Health History

Parents Maternal Side: None Parents Illness: None

Lifestyle and Health Practices

Typical Day: Drinking and Smoking 24 Hour Dietary Allowance: Vegetable Purchase/Prepares Meals: Herself Activities on a Typical Day: Drinking Liquor Exercise Habits/Patterns: Cleaning Sleep and Rest Habits/Patterns: 9 Hours Medications/Other Substances Used: Mefenamic Social Activities Fun/Relaxation: Contributing to Society: None Watching Television

Relationship with Family: Healthy Relationship Values, Religious Affiliation, Spirituality: Past, Current, Future Plans for Education: None Type Work, Job Satisfaction, Work Stressors: Finances: Supported by her sisters and siblings Stressors in Life: Tiredness Residency: 15 years Type of Environment: Condominium Neighborhood: Not Congested Area Environmental Risk: Polluted

PHYSICAL ASSESSMENT
Assessment Normal findings Deviation from normal Actual findings Interpretation and analysis

Body build, height Proportionate, and weight varies with lifestyle Posture, gait, standing, sitting, walking Overall hygiene and grooming Body and breath odor Relaxed, erect posture, coordinated movement Clean, net No body odor or minor body odor relative to work or exercise; no breath odor

Signs of distress in No distress noted posture or facial expression Obvious signs of health or illness Clients attitude Healthy appearance Cooperative, able to follow instruction Appropriate situation

Clients affect/ mood. Appropriateness of clients response.

Quantity of speech Understandable , ( amount and pace) moderate pace, clear tone and Quality (loudness, inflection clarity, inflection) and Exhibits thoughts association Organization (coherence of thought) Relevance and organization of thought Logical sequence makes sense and has sense reality

Assessing the skin

Assessment Inspect the skin color

Inspect uniformity of skin color

Normal findings Deviation from normal Varies from light Pallor, cyanosis, light to brown; jaundice, from ruddy pink erythema to light pink; from yellow overtones to olive Areas of either Centrally hyper uniform pigmentation or hypo pigmentation Edema No edema

Actual findings jaundice

Interpretation and analysis

Within normal range

No edema Assess the edema

Dry skin Observe and palpate skin moisture Palpate skin temperature Moisture in skin folds and the axillae Uniform with normal range Excessive moisture or excessive dryness Generalized hyperthermia, localize hypothermia Skin stays pinched are tended or moves back slowly Within normal range When pinched skin do not springs back to previous state

Note skin turgor When pinched skin springs back to previous state may be slower in elders

Assessing the hair, scalp, cranium, face Assessment Inspect the evenness of growth over the scalp Inspect the hair thickness or thinness Inspect the texture and oiliness Normal findings Evenly distributed hair Deviation from normal Patches of hair loss Actual findings Evenly distributed hair Interpretation and analysis Within normal range

Thick hair

Very thin hair

Thick hair

Within normal range Within normal range Within normal range

Silky, resilient hair

Brittle hair, excessive oily or dry hair Flaking, sore, lice, nits and ringworm

Silky

Note presence of infections by No infection or parting the hair infestation in several areas, checking behind the ears and along the hairline at the neck

No infection or infestation

Inspect the amount of body hair

Vary Vary Hirsutism, in women, naturally absent or spares leg hairs Assessing the nails Deviation from normal Spoon nail, clubbing 180 deg. Actual findings Convex, curvature angle of nail plate

Within normal range

Assessment Inspect the finger nails plate shape to determine its curvature and angle

Normal findings Convex, curvature angle of nail plate; about 160 deg.

Interpretation and analysis Within normal range

Inspect fingernail and toenail Smooth texture texture

Inspect the fingernail and toenail bed color

Excessive thickness or thinness or presence of grooves or furrows Bluish or purplish tint; pallor

Smooth texture

Within normal range

Inspect tissues surrounding nails

Highly vascular and pink in lightskinned clients; dark skinned clients may have brown or black pigmentations in longitudinal strike Intact epidermis

Pallor and cyanotic Within normal range Within normal range

Intact fingernails Hang nails Prompt return of Delayed return of pink or usual pink or usual color color

Perform blanch test of capillary refill. Press two Prompt return of or more nails bet. pink or usual Your thumb and color index finger

Assessing the skull and face Assessment Inspect the skull for size, shape, and symmetry Normal findings Deviation from Actual findings normal Rounded, smooth Lack of Rounded, smooth skull contour symmetry, skull contour increased skull size with more prominent nose and forehead, long mandible growth hormone or increased bone thickness Smooth, uniform Smooth consistency Sebaceous cysts; absence of local deformities nodules and from trauma; masses masses; nodules Interpretation and analysis Within normal range

Palpate the skull for nodules or masses and depression

Within normal range

Inspect the facial features

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size symmetric nasolabial folds

Symmetrical Increased facial hair, thinning of eyebrows, asymmetric features, exophthalmos , myxedema facies, moon face, periorbital edema; sunken eyes Asymmetric facial movements

Within normal range

Note symmetry of facial movements

Symmetric facial movements

Symmetrical facial movements

Within normal range

Distorted features, mask face in Parkinsons disease; tightened; hard face in scleroderma Assessing the eye structures and visual acuity Assessment Inspect the eyebrows for hair distribution and alignment and skin quality and movement Inspect the eye lashes for evenness of distribution and direction of curl Inspect the eyelids for surface characteristics, position in relation to the cornea, ability to blink, and frequency of blinking Inspect the bulbar conjunctiva for color, texture, and presence of lesions Inspect the palpebral Normal findings Hair evenly distributed; skin intact eyebrows symmetrically aligned; equal movement Equally distributed; curled slightly outward Deviation from normal Loss of hair; scaling and flakiness of skin, unequal alignment and movement of eyebrows Turned inward Actual findings Hair evenly distributed; skin intact eyebrows symmetrically aligned; equal movement Equally distributed; curled slightly outward Interpretation and analysis Within normal range

Within normal range

Skin intact; no discharge; no discoloration Lids close symmetrically

Redness, swelling, flaking, crusting, plaques, discharge, nodules, lesions Lids close asymmetrically, incompletely or painfully Jaundiced sclera excessive pale sclera reddened sclera; lesions or nodules Extremely pale; extremely red; nodules or other lesions

Skin intact; no discharge; no discoloration Lids close symmetrically

Within normal range

Transparent; capillaries sometimes evident; sclera appears white Shiny, smooth, and pink

Jaundiced sclera excessive pale sclera reddened sclera; lesions or nodules Dry, rough and pale Within normal range Paleness and cyanotic are

conjunctiva by everting the lids Inspect and palpate the lacrimal gland Inspect and palpate the lacrimal sac and nasolacrimal duct

No edema no tenderness over lacrimal gland No edema or tearing

Swelling or tenderness over lacrimal gland Evidence of increased tearing; regurgitation of fluid on palpation on palpation of lacrimal sac Opaque; surface not smooth Cloudy

No edema no tenderness over lacrimal gland No edema or tearing

cause by bleeding Within normal range

Within normal range Transparent, shiny, and smooth Transparent

Inspect the cornea for clarity and texture Inspect the anterior chamber for transparency and depth

Transparent, shiny, and smooth Transparent

Within normal range

Black in color; equal in size; Inspect the pupils normally 3 to 7 for the color, mm in diameter; shape, and round, smooth symmetry of size border, iris flat and round

Cloudiness, mydriasis, miosis, anicocoria; bulging of iris toward cornea

Black in color; equal in Size; normally 3 to 7 mm in diameter; round smooth border, iris flat and round

Within normal range

Assessing the ears and hearing Assessment Insect the auricles for color, symmetry of size, and position Normal findings Color same as facial skin, symmetrical, auricle aligned outer canthus of eye Deviation from normal Blush color of earlobes excessive redness Asymmetry, lowset ears Actual findings Color same as facial skin symmetrical auricle aligned outer canthus of eye Mobile firm and not tender; pinna recoils after it is folded Interpretation and analysis Within normal range

Palpate the auricles for texture, elasticity, and areas of tenderness

Mobile, firm, and not tender; pinna Lesions; flaky, recoils after it is scaly skin; folded tenderness when moved or pressed

Within normal range

Assessing the nose and sinuses Assessment Inspect the external nose for any deviations in shape, size, or color and flaring or discharge from the nares Normal findings Symmetric and straight, no discharge or flaring, uniform color Deviation from normal Asymmetric, discharge from nares, localized areas of redness or presence of skin lesions Actual findings Symmetric and straight, no discharge or flaring, uniform color Interpretation and analysis Within normal range

Determine patency of both nasal cavities Observe for the presence of redness, swelling, growths, and discharge Inspect the nasal septum bet. The nasal chambers

Air moves freely as the client breaths through the nares Mucosa pink, clear, watery discharge, no lesions

Air movement is restricted in one or both nares Mucosa red, edematous, abnormal discharge, presence of lesions Septum deviated to the right or to the left

Air moves freely as the client breaths through the nares Mucosa pink, clear, watery discharge, no lesions

Within normal range

Within normal range

Nasal septum intact and in midline

Nasal septum intact and in midline

Within normal range

Assessing the mouth and oropharynx Assessment Lips and buccal mucosa: Inspect the outer lips for symmetry of contour, color, and texture Uniform pink color, soft moist, smooth texture, symmetry of contour, ability to purse lips Pallor; generalized or localized swelling; fissures, crust, or scale In ability to purse lips Pallor; leukoplakia, red, bleeding Excessive dryness Mucosal cysts; irritations from dentures; abrasions, ulcerations; nodules Pale in color, soft dry, rough in texture, symmetry of contour, inability to purse lips Pale in color, soft dry, rough in texture, symmetry of contour, inability to purse lips Within normal range Normal findings Deviation from normal Actual findings Interpretation and analysis

Uniform pink Inspect and color, moist palate the inner smooth, soft, lips and buccal glistening, and mucosa for color, elastic texture moisture, texture, and presence of lesions

Teeth and gums: Inspect the teeth and gums while examining the gums and buccal mucosa

32 adult teeth Smooth, white, shiny, tooth enamel Pink gums Moist firm texture to gums No retraction of gums Smooth, intact dentures

Within normal range

Inspect the dentures

Missing teeth Brown or black discoloration of the enamel Excessive red gums Sponge texture; bleeding; tenderness Ill-fitting; irritated and excoriated area

Within normal range Smooth, intact dentures

Tongue/floor of the mouth : Inspect the surface of the tongue for position, color, and texture

under dentures Central position, pink color, moist; slightly rough; thin whitish coating Smooth, lateral margins; no lesions Raised papillae

Inspect tongue movement

Move freely, no tenderness

Smooth tongue Inspect the base base with of the tongue, the prominent veins mouth floor, and the frenulum Smooth with no Palpate the palpable nodules tongue and floor of the mouth for any nodules, lump or excoriated area Palates and uvula: Inspect the hard and soft palate for color, shape, texture, and the presence of bony prominences Inspect the uvula for position and mobility Oropharynx and tonsils: Inspect the oropharynx for color and texture Pink and smooth No discharge Of normal size or not visible

Deviated from center, excessive trembling, smooth red tongue, dry, furry tongue , white coating Nodes, ulcerations, Move freely, no discolorations; tenderness areas of tenderness Smooth tongue base with Restricted prominent veins mobility Swelling, ulcerations

Central position, pink color, moist; slightly rough; thin whitish coating Smooth, lateral margins; no lesions Raised papillae

Within normal range Within normal range

Within normal range

Within normal range

Smooth with no palpable nodules

Swelling nodules

Within normal range Light, pink, smooth, soft, palate Lighter pink hard palate, irregular Within normal texture range

Light, pink, smooth, soft, palate Lighter pink hard palate, irregular texture Discoloration Palate the same color Positioned in Positioned in Irritation middle of soft middle of soft Exostoses palate palate growing from the hard palate Deviation to one side from tumor or trauma; immobility

Within normal range

Pink and smooth posterior wall

Pink and smooth posterior wall

Inspect the tonsils

Reddened or edematous; presence of lesions plaques, or drainage Inflamed Presence of discharge Swollen Assessing the neck

Pink and smooth No discharge Of normal size or not visible

Assessment Neck muscle: Inspect the neck muscles for masses Observe head movement

Normal findings

Deviation from normal Unilateral next swelling; head titled to one side Muscles tremors, spasm or stiffness

Actual findings

Interpretation and analysis Within normal range Within normal range

Muscles equal in size; head centered Coordinated, smooth movements with no discomfort

Muscles equal in size; head centered Coordinated, smooth movements with no discomfort

Assess muscle strength Lymph nodes: Palpate the entire neck for enlarged lymph nodes Trachea:

Equal strength Unequal strength

equal strength Muscles cannot be flexed and extend Not palpable

Muscle weakness and tenderness are present Within normal range

Not palpable Enlarged, palpable, possibly tender

Central Palpate the placement in a trachea for lateral middle of neck; deviation spaces are equal in both sides

Deviation to one side, indicating possible neck tumor; thyroid enlargement; enlarged lymph nodes Visible diffuseness or local enlargement Presence of bruit

Central placement in a middle neck; spaces are equal in both sides

Within normal range

Thyroid gland: Inspect the thyroid gland If enlargement of the gland is suspected, auscultate over the thyroid area for a bruit Not visible on inspection Absence of bruit Absence of bruit Within normal range Not visible on inspection Within normal range

Assessing the thorax and lungs Assessment Posterior Thorax: Inspect the shape and symmetry of the thorax for posterior and lateral views Anteroposterior to transverse diameter in ratio of 1:2 Chest symmetric Barrel chest; increased Anteroposterior to transverse diameter Chest asymmetric Exaggerated Anteroposterior to tranverse diameter in ratio of 1:2 Chest symmetric Spine vertically aligned Within normal range Normal findings Deviation from normal Actual findings Interpretation and analysis

Spine vertically Inspect the spinal aligned

Within normal range

alignment for deformities Percuss the thorax Precaution notes resonate, expect over scapula Lowest point of resonance is at the diaphragm

spinal curvatures Asymmetry in percussion Areas of dullness or flatness over lung tissue Precaution notes resonate, expect over scapula Lowest point of resonance is at the diaphragm Within normal range

Anterior Thorax: Inspect the costal angle and the angle at which ribs enter the spine

Costal angle is less than 90 degrees, and the ribs insert into the spine at approximately a 45 angle Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscles and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach Bronchial and tubular breath sounds

Costal angle widened

Costal angle is less than 90 degrees, and the ribs insert into the spine at approximately a 45 angle Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscles and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach Bronchial and tubular breath sounds

Within normal range

Percuss the anterior chest symmetrically

Asymmetry in percussion notes Areas of dullness or flatness over lungs tissue

Within normal range

Auscultate the trachea

Pale in color, soft dry, rough in texture, symmetry of contour, inability to purse lips

Within normal range

Within normal range

Auscultate the anterior chest

Bronchovesicular Adventitious Bronchovesicular breath sounds breath sound breath sounds Vesicular (low, Breath sounds soft, breezy) are normal with breath sounds no obstruction heard over lung periphery Assessing the abdomen Normal findings Deviation from normal Actual findings Interpretation and analysis

Assessment Inspection the abdomen: Inspect for the skin integrity

Unblemished skin Uniform color Silver-white striae or surgical

Presence of rash or other lesions Tense, glistening skin

No Surgical incision

Inspect for contour and symmetry Auscultation of the abdomen:

scar Flat, rounded, or scaphoid No visible vascular pattern Distended Audible bowel sounds No visible vascular pattern Visible venous pattern associated with liver disease, ascites, and venocaval obstruction Hypoactive Hyperactive / increased Hyperactive sounds indicate increased intestinal motility and are usually associated diarrhea, an era Deviation from normally bowel obstruction, or the use of laxatives. True absence of sounds indicates a cessation of intestinal motility. Visible venous pattern associated with liver disease, ascites, and venocaval obstruction Hypoactive Hyperactive / increased Hyperactive sounds indicate increased intestinal motility and are usually associated diarrhea, an era Deviation from normally bowel obstruction, or the use of laxatives. True absence of sounds indicates a cessation of intestinal motility. Within normal range

Observe the vascular pattern Auscultate the abdomen for bowel sounds

Audible bowel sounds Absence of arterial bruits Absence of frictions rub

percuss the abdomen: percuss several areas in each of the four quadrants to determine the presence of tympany and dullness palpation of the abdomen: perform the light palpitation first to detect areas of No tenderness; tenderness and/or relaxed abdomen muscle guarding with smooth, consistency palpation of the liver:

Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder

Large dull areas

Tenderness and hypersensitivity Superficial masses Localized areas of increased tension

palpate the liver to detect enlargement and tenderness

May not be palpable Border feels smooth

Enlarge, smooth but tender; nodular or hard Assessing the musculoskeletal

Assessment Muscles: Inspect the muscles for size Inspect the muscles and tendons for contractures Inspect the muscles for tremors Palpate muscles at rest to determine muscle tonicity Palpate muscles while the client is active for placidity, plasticity, and smoothness of movement Test the muscle strength Bones: Inspect the skeleton for structure Joints: Inspect the joins for swelling Assessment Heel down opposite shine: ask the client to place the heel of one foot just below the opposite knee

Normal findings

Deviation from normal Atrophy or hypotrophy, asymmetry Malposition of body part Presence of tremors

Actual findings

Interpretation and analysis Within normal range

Equal size on both sides of body No contractures No tremors

Equal size on both sides of body No contractures No tremors

Atonic Normally firm Flaccidity or spasticity Normally firm

Within normal range Within normal range

Smooth coordinated movements

Smooth coordinated movements

25% or less of Equal strength on normal strength each body side No deformities Bones misaligned

Within normal Equal strength on range each body side No deformities Within normal range

No swelling

One or more Leg varicosities swollen joints Assessing the neurologic system Deviation from normal Actual findings Interpretation and analysis

Normal findings

Demonstrate bilateral equal coordination

Has tremors or is awkward; heel moves off shin

Demonstrate bilateral equal coordination

Within normal range

and run the heel down the skin to the foot, repeat with other foot toe or ball of foot to the nurses finger: temperature sensation Able to discriminate bet. hot and cold Areas of dulled or loss sensation Able to discriminate bet. hot and cold Within normal range

DRUG STUDY

DRUGS

CLASSIFICATIO N

INDICATIO N

CONTRAINDICATIO N

INTERACTIO N

SIDE EFFECTS

NURSIN G CONSID ERATIO N

Metoclopr amide

antiemetics

Am N for monitoring, PRN

Nausea and vomiting caused by GI disorder; migraine following surgery; disorder of GI motility.

Stimulation of muscular construction might adversely affect GI condition. Patient with Epilepsy.

Antagonize d by antimuscar nic agents and opinoid analgesics. Incompatibl e with Cephalotin Na and other cephalospo rin

Drowsin ess, restlessn ess, Dizzines s, Headach e, Diarrhea , Hypoten sion, Hypeten sion, depressi on

Advice patent to avoid alcoholi c ingestio n durinag therapy .

Tell patient to avoid activitie s that require alertne sss for 2 hours after doses.

Omeprazol e

Proton pump inhibitor

20 mm/cap O.D. 6 am

Symptom atic gastroeso phageal reflux dsease without esophage al lession

Contraindicated in patient hypersensitivity to drug or its component.

Reduced absorption of ampicillin ester, iron, salt and ketoconazo le, decreased metabolism of anti coagulant, diazepam or phenytoin

Anemia, eosinope nia, leukocyt osis, Neutrop enia, Hematur ia, Proteinu ria, UTI; abdomin al pain, Dizzines s, Headach

Possibili ty of gastric ulcer malign ancy should be conside red.

Tramadol capsule

analgesics

10:30 am, 1 cap

Moderate to severe pain due to mild illness , pain after diagnosis

Acute alcohol intoxication, severe respiratory depression, patient with at risk of stupor due to head injuries.

Antidepress ant, Ritonavir, Linezolid, Moclobemi de.

Respirat ory depressi on, Palpitati on, Chills, Chest pain, Decreas e in BP, arrytmia , vomiting , Nausea, urticaria

Reasse ss patient s level of pain atleast 30 mins. After adminis tration.

Monitor bladder and bowel dysfunc tion

Lactulose

Laxative

30 cc. B.I.D

Constipati on associate d with ped problems; post-op, surgical procedure

Galactosaemia, Bowel obstruction

Flatulenc Show e, home diarrhea care patient how to mix and use drug.

Instruct patient not to

use other laxative drud during lactolus e therapy .

Ampicillin sulbactam

antibiotic

1.5 g.I.V ANST

Treatmen t of resp. GIT and GUT infection

Hypersensitivity to penicillins

Decreases efficacy of OC and anticoagula nt . Probenicid impairs drug excretion. Increased skin rash witl allopurinol

Rashes,, anaphyl axis ,blood Upset, Super infection

History of signific ant allergy f astma. Avoid IV near major periphe ral nerves or blood vessel

Metrodina zole

antibiotic

500 mg. I.V ANST B.I.D

Treatmen t of infection which may be due to anaerobic bacteria

Hypersensitivity to nitroimidazole derivatives..

Alcohol provoke disulfiram like reaction Enhance anticoagula nt effect of warfarin

GI disturba nce, Skin reaction, head ache, vertigo, insomnia , seizures, ataxia

Monitor liver functio n test results carefull y in erderly patient.

Give oral form with meals. Avoid bolus adminis tration or haloge nated hydroc arbon anesth.

Dopamine

Cardiac drugs

Correctio n of cardiac hemodyn amic imbalance present to shock

Ventricular fibrillation,

Effects may be potentiated by MAOIs

GI upset , tachycar dia, anginal pain, hypoten sion, dyspnea, vasocon striction,

azotemi a

INTRODUCTION

Ascites is defined as an abnormal accumulation of the abdomen. Rapidly developing (acute) ascites can occur as a complication of trauma, perforated ulcer, appendicitis, or inflammation of the colon or other tube-shaped organ (diverticulitis). This condition can also develop when intestinal fluids, bile, pancreatic juices, or bacteria invade or inflame the smooth, transparent membrane that lines the inside of the abdomen (peritoneum). However, ascites is more often associated with liver disease and other long-lasting (chronic) conditions. Our patient female, 44 years of age, has been admitted with diagnosis of ascites secondary to 1) pulmonary tuberculosis, 2) Gynecologic Pathology, 3) and maligninacy and anemia secondary to 1)chronic disease, 2)Iron deficiency anemia, 3)Occult blood loss. And also other diagnosis was leukocytosis secondary to malignancy which is not priority. These secondary problems are incidental to our case especially in PTB and should be precautious to these diseases that might have already started to evade the body. Since ascites can rapidly develop in the body, the patient might have signs of difficulty breathing due to abnormal accumulation in the abdomen which can block the airway passage. Our main focus in this research is how ascites leads to anemia. Anemia can be associated with chronic disease, iron deficiency anemia, and occult blood loss. Anemia is reduction below normal of the number of erythrocytes, quantity of

hemoglobin, or the volume of packed red cells in the blood. Our patient was on blood transfusion since the blood level is low.

UNIVERSITY OF PERPETUAL HELP COLLEGE OF MANILA

PRESENTS YOU ASCITES VARIABLE MANIFESTATION GROUP 1

ABELLAR, JUSTINE ANCHETA, MARC APOLONIO, KRISTINE HAZEL AZUCENA, NINA BARACAO, VALERIE BONUS, KALLAH BRAZILENO, JEROME CANTOS, RACHELLE CHAVEZ, ANDREW DEL MONTE, CARMEN DIZON, CJ GENKO, AYA LEAL, JANINE

G. Gordons pattern of Health Functioning

The patients functional health pattern were evaluated prior to hospitalization and during the hospitalization. Health behavior is intended to prevent illness or disease or to provide for early detection of disease.

The patients health perception is not emphasized well, patient ignores whenever she experience unusual things in her health. She doesnt go to the hospital for check-up and is not taking any food supplement. She still believes that the medical team can help her to cure her disease and during her hospitalization her diet is strictly guarded by the doctor. Her actions take to understand her health state, maintain an optimal state of health, prevent illness and injury, and reach her maximum physical and mental potential. When it comes to role relationship, patients relationship with her family plays a major role in her situation right now. Patient has a good and harmonious relationship with her family. Her family stays beside her during her hospitalization to attend her needs. The patient is independent to other people; she can stand on herb own and can have even better relationship. The patients cognitive perceptual patterns were evaluated to assess the ability of the patient in abstract thinking if she can hypothesized and evaluate solution to a problem. She finished high school. She can write legibly but cannot clearly pronounced words; also she uses gestures whenever she cant speak. Being in a complicated state right now her cognitive ability is compromised. Values and belief pattern was assess in patient. She is a Subedits and she goes to their worship center when she has time. The patient sometimes prays at night before sleeping if she can't go to church. Due to her illness the patient cannot go to church that is why she prays a lot. Her illness concern her values and beliefs, she became more religious. All clients have needs that reflect their spirituality. These needs are often brought forward by an illness or other health crisis. Clients who have well defined spiritual beliefs may find that their beliefs are challenged by their health situation; clients who have no defined beliefs may suddenly come face to face with challenging questions related to the meaning and purpose of life. The patient has difficult elimination pattern due to her condition, she cant urinate and defecate well because of her surgery. Patient is having a problem in urination since she was admitted. She is on bed and find it difficult to urinate and defecate. There is a problem in her urination and defecation due to her present condition. Weak abdominal and pelvic muscles are often ineffective in increasing the intra-abdominal pressure during defecation or in controlling defecation. Weak muscles can result from lack of exercise, immobility or impaired neurologic functioning. As to the patients activity and exercise pattern. The patient usually watches television at home doing the household chores. She spends 3hours for 2-3 times a week for relaxation time. Patient now rest most of the time because her condition requires a lot of rest. The patient can no longer engage in heavy exercise because of her surgery. Her activities are limited due to his condition and to help him recover. People define their health and physical fitness by their activity because their mental well being and the effectiveness of body functions depend largely on their mobility status. With her condition, she still manages to have an adequate sleep of 6-8 hours per day with slight awakening. The patient sleeps less than 6 hours because she is uncomfortable due to her condition, she might experience easy fatigability due to lack of sleep and rest. Illness that causes pain or physical distress can result in sleep problem. Environment can promote or hinder sleep and rest. Patients nutritional status was also evaluated. She is an alcohol-drinker but doesnt smoke. The patient wants to eat but she can't due to doctors order (NPO). She slightly loss her appetite due to his condition and she is ordered not to take anything per orem (NPO). An individual reach status greatly affects eating habits and nutritional status. Maintaining a healthy or ideal body weight requires a balance between expenditures of energy and intake of nutrients. The patient sees herself as a normal and active adult. During her stay in the hospital the patient is weak. She barely talks and sometimes she shows interest in her usual activities. A persons self perception is important in health management. An individual with positive self

concept are better able to develop and maintain interpersonal relationships and resist psychological and physical illness. An individual possessing a strong self concept should be better able to accept or adapt to changes that may occur over the lifespan. The patient does not practice sex anymore since she is a widowed. Sexual health is an individual and constantly changing phenomenon falling within the wide range of human sexual thoughts, feelings, needs and desires. Coping and Stress management is also an important thing to assess in a patient. The patient is also the head of the family and she supports her family and gives them their basic needs. She is worried about the financial status due to her condition even though her husband has also work and earning. Coping is an effort of an individual to overcome or handle stress and the patient is slightly worried due to her condition. Every experience stress, individual are bond to cope for them to be capable of understanding and how to handle life challenges.

TABLE OF CONTENTS
I. OBJECTIVES

II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII.

INTRODUCTION DEMOGRAPHIC DATA CHIEF COMPLAINT PRESENT MEDICAL HISTORY PAST MEDICAL HISTORY FAMILY AND SOCIAL HISTORY PHYSICAL ASSESSMENT PATHOPHYSIOLOGY LAB RESULT DRUG STUDY NURSING CARE PLAN DISCHARGE PLAN