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Saint Louis University School of Nursing Baguio City, Philippines

In Partial Fulfillment of Subject Intensive Nursing Practicum (Case Analysis)

Submitted by: Cabais, Aristotel C. Kallikrein 2 January 20, 2012

Submitted to: Maam Jackielyn Ramirez

Table of Contents Introduction1 Nursing Assessment..1-5 Pathophysiology.6-7 Medications.8-9 Prioritization10 NCP proper.11-19

Introduction Hepatitis B is one of the major diseases that inflicts many Filipinos in the Philippines today and have social stigma similar to HIV virus or AIDS. Thus, anyone who is diagnosed to be a Hepatitis B positive is already cast as someone that is dirty, denied of medical attention from a medical practitioner, and rejected for employment. Thus, adding more burdens to the disease carried by the Hepatitis B carriers; not only to them but also to their respective families or beloved ones as well. The presenter chose this specific case to be presented to his fellow students and instructor because Hepatitis B has increasing prevalence in the Philippines. The Department of Health reported last 2008 high prevalence of hepatitis B cases in the country with around 500 to 700 cases reported every year. It is very unusual to have opportunity to present such case with the consent and cooperation of the patient. Like HIV patient, patients with Hepatitis B felt the stigma casted by people in the society against their existence. The social isolation felt by the patient with Hepatitis B is more painful than the effect of disease itself. The patient was admitted for 4 days from January 13, 2012 to January 16, 2012. The presenter assessed the patient for 2 consecutive meeting only (January 13, 2012 and January 14, 2012) because of the limited opportunity since the presenter is assigned at the Emergency Room. The patient was diagnosed of Hepatitis B infection, hematuria, and hemorrhagic cystitis of UTI. Hepatitis B is an infectious inflammatory illness of the liver caused by the hepatitis B virus (HBV) that affects hominoidea, including humans. Originally known as "serum hepatitis", the disease has caused epidemics in parts of Asia and Africa, and it is endemic in China. About a third of the world population has been infected at one point in their lives, including 350 million who are chronic carriers. Hematuria, or haematuria, is the presence of red blood cells (erythrocytes) in the urine. It may be idiopathic and/or benign, or it can be a sign that there is a kidney stone or a tumor in the urinary tract (kidneys, ureters, urinary bladder, prostate-(In males only), and urethra), ranging from trivial to lethal. If white blood cells are found in addition to red blood cells, then it is a signal of urinary tract infection. Hemorrhagic cystitis, can occur as a side effect of cyclophosphamide, ifosfamide, and radiation therapy. Radiation cystitis, one form of hemorrhagic cystitis is a rare consequence of patients undergoing radiation therapy for the treatment of cancer. Several adenovirus serotypes have been associated with an acute, self-limited hemorrhagic cystitis, which occurs primarily in boys. It is characterized by hematuria, and virus can usually be recovered from the urine. Nursing Assessment Patients Profile Name: Patient T. Address: Binalonan, Pangasinan Age: 21 years old Birthday: Sepatember 6, 1990 Religion: Roman Catholic Educational attainment: College undergraduate 1

Occupation: Fish vendor Dialect: Tagalog and Ilocano Admission Details Date admitted: January 13, 2012 Ward and Room: Medical Ward Chief complaints: Jaundice and hematuria Medical diagnosis: Hepatitis B infection, hematuria, hemorrhagic cystitis of UTI A.) History of Present Illness Condition started 1 month prior to admission, patient noted yellowish discoloration on his eyes and skin with associated abdominal pain, nausea and vomiting aggravated by food and fluid intake. No other associated signs and symptoms like fever and diarrhea. 2 weeks prior to admission, patient sought consult to a private physician laboratory test were done revealing mild diffused fatty liver infiltration and consider a calculous cholecystitis. Patient was given unrecalled medications but provided no relief of symptom. 1 week prior to admission, patient sought consult to another physician for second opinion. Ultrasound was done and shows mild hepatomegaly. Patient was given unrecalled medications which provided slight relief. Patient was then advised by her aunt to seek consult at this institution, hence admitted. 1.) Past Medical History

Patient was admitted last 2008 due to typhoid fever. Other than that he has no previous hospitalization and surgery. He has no history of asthma, CAD, CVD. He cant recall anymore his immunization status. 2.) Socio Cultural History Patient is currently living in a concrete and non-congested house with her parent and two sisters at Binalonan, Pangasinan. He is a Pangalatoc but he often used Tagalog and Ilocano as a dialect. He is non-smoker and non-alcoholic drinker. He verbalized that after he got sick, he feels isolated because some people kept away from him. 3.) Heredofamilial History Patient has a family history of hypertension and diabetes mellitus in both side of his parent. Other than that he has no history of other diseases anymore. B.) Assessment Health History Condition started 1 month PTA, patient noted yellowish discoloration on his eyes 2

and skin with associated abdominal pain, nausea and vomiting aggravated by food or fluid intake. No other associated signs and symptoms like fever and LBM. No consult was done. 2 weeks PTA patient sought consult to a private doctor. Lab test was done revealing Hepatitis B positive. Ultrasound was done revealing mild diffused fatty liver infiltration and considers acalculous cholecystitis. Patient was given unrecalled medication but provided no relief of symptom. 1 week PTA, patient sought consult to another doctor for second opinion. Ultrasound was also done revealing Mild hepatomegaly. Patient was also given unrecalled medication which provided slight relief. Patient was then advised by her aunt to seek opinion to this instution and was advised to be admitted. Activity and Rest Patient was a fish vendor. Patient was not able to participate in usual activities and hobbies due to hospitalization. His leisure time is watching television. Hes ambulatory, stands erect and with normal gait. His usual exercise was walking and has an active lifestyle. Weakness and fatigue was one of the limitations imposed by condition. Pain was also felt in the abdominal area. He sleeps for about 6-8 hours per night and he naps for about 1 hour in the afternoon. Patient has no insomnia. He is rested on awakening. Excessive grogginess is manifested if patient has inadequate hours of sleep. His bedtime ritual is hygiene. Has good muscle strength of 5/5 in both upper and lower extremities. There are no limitations in the ROM of his both upper and lower extremities. He has a normal muscle mass and tone. He is coherent and alert. Circulation Patient verbalized that he has no history of High Blood Pressure, Head injury, Stroke, Hemoptysis, Heart Problem, Syncope, Spinal cord injury, Palpitations, Bleeding tendencies, Varicosities and Pain in legs with activity. No numbness and tingling in the extremities. Patient has a moist and slightly yellowish in color skin. Mucous membrane is pinkish but has yellowish hard palate. Lips are slightly moist. Sclera is icteric. Skin is moist.He has a blood pressure of 150/90 mmHg. Carotid, temporal, brachial, radial ulnar and dorsalis pedis pulses are all present, deep regular +1. Patient has no thrills or heaves, friction rub and murmurs. No jugular vein distention. He has clear breath sound on both lung fields. Has a temperature of 36.4 C, afebrile. He has a capillary refill of 1-2 secs. He has no nail abnormalities like clubbing and has no koilonychias. Ego Integrity Patient is single. His usual way of handling stress is by sleeping. He expressed his feelings like anger, anxiety, fear and grief through verbalization. Patient is Roman Catholic. Hes not that active in practicing religion. He is sometimes visiting the church and prays. He has a good interpersonal relationship. He is calm and no observed body language such as pacing or fidgeting. No observed physiological response such as pallor or flushing. Elimination According to the patient, his usual bowel elimination is 1x a day. Character of stool is usually formed or semi formed and brown in color. No history of bleeding involve when it comes to elimination. No constipation and diarrhea at the moment. He also verbalized that his usual voiding pattern is 5-6 times a day, yellowish in color urine. He 3

He has no difficulty of voiding, no retention, no urgency and no frequency. His abdomen is soft upon palpation and no associated tenderness or pain. Food/Fluid His usual food intake is 3 meals and 1-2 snacks in a day. The usual content of his meal includes the following: Breakfast-rice + meat/veggies or coffee/milo and bread & Lunch and Dinner: Rice + meat/veggies. He was able to consume food given about 95%. No usual change in appetite when he was confine. His snacks include juice and biscuits. His food preferences are those that are fried. He doesnt like saluyot at all. He has no food allergies. No problems in swallowing. There is a presence of gag reflex. Hygiene Patient needs minimal assistance in carrying out activities of daily living. No use of prosthetic devices. He doesnt need assistance in feeding and eating with utensils. He can get supplies and able to wash body and body parts. He can get in out alone the bathroom but sometimes assistance is needed due to the presence of IV. His usual preferred time of personal care or bathing is in the morning. His dressing is appropriate to time, place and situation. He can select clothes independently and dress self with minimal assistance still due to the presence of IV. His general appearance is neat and clean and well groomed. Hair is equally distributed, no presence of vermin. Neurosensory Patient has no history of brain injury, trauma and stroke. No history of seizures. But sometimes experience headache. No changes in smell and hearing. No visual difficulty. He is oriented to time, place, situation, person and time. No hallucinations and delusions. There is a presence of deep tendon reflexes: ++ on both upper and lower extremities. Pain/discomfort Patient verbalizes that he has abdominal pain. He rated pain as 5/10, localized at right lower quadrant non radiating Aggravated by sudden movement and palpation and relieved by proper positioning. Pain felt has no associated symptom. There is slow movement upon performing an activity. Grimacing noted upon sudden movement and holds on the abdominal area. Respirations Patient has no difficulty of breathing and no shortness of breath. No history of asthma, tuberculosis, emphysema and bronchitis. Patient is a non smoker and non alcoholic drinker. His respiratory rate is about 20 cpm. There is no use of accessory muscles and nasal flaring. Has clear breath sounds on both lung fields. No assisted devices involved during breathing. Safety Patient has no allergies to food and medications. Client is somehow exposed to pollution. He is currently living with his family in a concrete house which is not congested. He has unrecalled history of immunizations. No history of accidental injuries. Skin problem involved is jaundice. No lesions, lacerations, enlarged nodes and lumps. No impairment in vision, hearing, detecting hot or cold, smell and touch. No use of prostheses and ambulatory devices. Body temperature is about 36.4 C. 4

Sexuality Patient is circumcised. He does not practice testicular examination. He has no prostate disorder. Patient is sexually active and has sexually transmitted disease (Hepatitis B). Social Interactions Patient is single. He has good relationship with family members and relatives. Patient has concern on presence of illness. His role to the family is son and he also helps in the need of his family. Client is Ilocano, able to speak dialect properly. Teaching/Learning Patient is a college undergrad. With regard to decision making which involves his health, he is the one who decide but still seeks advice to his parents and other relatives like aunt. No presence of advance directives. Familial history involved are the following: Hypertension and DM. Discharge plan considerations Patient was discharged last January 16, 2012. His resources available were his family, relatives and friends. Areas that may require alteration includes food preparation, food may not be frequently fried, less intake of fatty foods and compliance to medications must be take in consideration. Diagnostic Results Hepato Biliary Tree Sonogram done last January 3, 2012 shows mild diffuse fatty liver infiltration with probable focal fatty sparring in segment IV; consider acalculous cholecystitis. Ultrasound done last January 6, 2012 shows mild hepatomegaly; normal sonogram of the gallbladder, kidney, pancreas, spleen, urinary bladder and prostate gland. Urinalysis done last January 14, 2012 shows pus cell of 15-20. CBC done January 14, 2012 shows elevated erythrocyte of 10.8% (0.00-8.00%) which is indicative of ongoing infectious process . Bilirubin test done last January 14, 2012 shows elevated bilirubin of 5.02 mg/dl (0.2-1.3 mg/dl); elevated direct bilirubin 4.17 mg/dl (0.0-0.4 mg/dl); normal indirect bilirubin of 0.85 mg/dl (0.0-1.1 mg/dl) which is indicative of malfunctioning of the liver.