Name: Patient JJG Age: 2 years old Gender: Male Birthday: October 7, 2009 Birthplace: Bitas, Cabanatuan City
Marital status: Single Address: Mabini Homesite, Cabanatuan City Phone number: 09202835545 Educational level: not applicable Occupation: not applicable Race or ethnic background: not applicable Religion: Roman Catholic Nationality: Filipino Citizenship: Filipino Language spoken: tagalong Source of information: mother Reliability: not applicable
ALL Pre-B - June 6 2012 ALL Pre-B - June 15 2012 ALL Anemia leucopenia thrombocytopenia secondary to chemotherapy – June 5 2012
July 08 2012July 09 2012
.June 15 2012-June 17 2012 ALL Pre b. SP IV chemotherapy day 48 .Final Diagnosis
ALL Pre-B -June 6 2012-June 7 2012 ALL Pre B S/P Chemotherapy . SP PRBC transfusion.July 06 2012 ALL Pre B S/P PRBC and platelet transfusion .July 05 2012.
History of present illness
June 6 2012 With chief complaint: for chemotherapy 2 times diagnosed ALL pre-B Patient came in for 3rd cycle of chemo treatment June 15 2012 With chief complaint : swelling of lower extremities July 5 2012 Diagnosed with ALL on methotrexote intrathecally on if up today. repeat CBC anemia leucopenia thrombocyte Admitted add for blood transfusion.
. packed RBC 2 days ago discharged insert fully. patient was noted with hematoma on lower lip. July 8 2012 Chief complaint: hematoma. Few hours PA. Advised ad. lower lip Diagnosed case of ALL on methotrexate treatment.
AS(anicteric sclerae) Chest and lungs: SCE(symmetrical chest expansion). irritable EENT: pink PC(pink conjunctiva). CBS(clear breath sounds) Heart: Ap(adynamic precordium). NABS Extremities: pulses full and equal Clinical impression: ALL pre B
6 2012 General Appearance: ambulatory. NRRR(normoactive bowel sounds) Abdomen: Soft.
15 2012 General Appearance: F/N. EUE Extremities: (-) swelling
. F/P EENT: (-) CLAD(cenical lymphadenopathy) Chest and Lungs: CBS.
AB Abdomen: Soft NABS
5 2012 General appearance: ambulatory Skin: (+) Pallor Chest and lungs: SCE. CBS Heart: AP.
8 2012 General Appearance: Ambulatory. ARRR Abdomen: non-distended. coherent EENT: pale PC AS (+) hematoma lower lip Chest and lungs: SCE and CBS Heart: Ap. non-intended Extremities: pulses full and equal Clinical impression: ALL
consent was signed.5 0. To ward per wheelchair cuddled by the mother with on going IV fluid of D. 2012 Received a 2 year old boy brought by her mother. The patient was seen and examined by Dr. For intrathecal chemotherapy by Dr.
.COURSE in the WARD
June 1. The patient is pale in appearance and irritable when approached. Intrathecal chemotherapy done. Mendoza with orders made and carried out. Mendoza.3 NaCL 500ml. Vital signs monitored and recorded. Present IV fluid was consumed and shifted to a heplock aseptically.
L.R. rest and comfort promoted.
.3 NaCL 500ml connected to volumetric tube/chamber. Uy with on going IV fluid of D5 0. Added L-aspanagenase 3525 unit in 100ml of D5 was started. instructed to the mother and went home with relatives. The patient was weak in appearance. Encouraged mother to avoid environmental hazanious.aspanegenase 3525 unit in 100ml of D5 consumed and removed aseptically. Attended by ROD Dr.COURSE in the WARD
June 6 2012 Admitted to E. the patient was cuddled by the mother conscious and coherent. Take home instructions.
Discharge instruction instructed to the patient relative well understood as claimed. No complaints of any discomfort as claimed by the mother. Health teachings done and instructed to mother/relatives. Mendoza. All chemo drugs ended with no reactions noted.COURSE in the WARD
June 8 2012 Patient was admitted to the emergency room. Went home per wheelchair accompanied by the patient’s
. ambulatory. conscious and coherent. with heplock and removed aseptically and replaced with IV fluid of D5 0.3 NaCL connected to microset. Seen by Dr. Chemo drugs started as ordered with precautions noted.
with no complaints of any discomfort as claimed. alert and afebrile. went home with relatives. Above IV fluid shifted to L. Mendoza with orders made and carried.
.3 Nacl 500ml. Health teachings done.asparagenase 3525 units 100ml 125 water and regulated at drip 100 gtts/min. currently saved set on sitting position. Examined by Dr.COURSE in the WARD
June 15 2012 Received with dislodged IV fluid of D5 0. Remove IV fluid aseptically.
Present IV fluid removed and shifted with D5 0. cuddled by relative with admitting orders from Dr.3 NaCL 500ml incorporated with 5ml potassium chloride regulated for 58-59 mgtts/min with health teachings done to relatives. In to ward per wheelchair. Went home per wheelchair.COURSE in the WARD
June 23 2012 2 year old boy admitted.3 NaCL inserted aseptically connected to microset. weak in appearance and afebrile. reversed isolation precaution observe Take home instructions instructed to mother/relatives. awake D5 0. Rest and comfort promoted.
Consent for blood transfusion signed and health teachings done. BT was consumed and removed aseptically. conscious. no signs of reactions. vital signs are stable with no complaints of discomfort. Health teachings done/ home instructions instructed to relatives. went home. Present IV fluid changed to PNSS as ordered. Started BT mgtts/min. BT of PRBC 170ml with serial number 062912-003 properly types and cross matched. weak and pale in appearance. Examined by Dr.3 NaCL 500ml. Transferred to room with on going IV fluid of D5 0. Puno-Mendoza. BT regulated at 10 mgtts/min.COURSE in the WARD
July 5 2012 In from ER per wheelchair.
typeB-RH positive. BT was consumed and ended. Mendoza. Uy with orders. Weak in appearance. BT meds given. laboratory result secured and relayed to Dra. Pre-BT meds given. transferred with no transfusion reaction noted. removed aseptically. went home per wheelchair with relatives
. with no reactions.COURSE in the WARD
July 8 2012 Admitted a 2 year male cuddled by mother with complaint of hematoma 1 day PTA. discharge instructions instructed to the relatives. Transfusion ended. Inserted PNSS 500ml and regulated to 10mgtts/min. Examined by Dr. For BT of 160cc PRBC BT with serial number 070312002 properly typed and cross matched and regulated 10gtts/min. Mendoza. 2 units of platelet concentrate with serial number of B-12-1303 and B-12-1304. Attended by Dr.
With Attending Physician Dr.3 Nacl 100ml dose Blood extraction done by NOD Brought to 4th floor General ward by wheelchair accompanied by NOD with aid. Thanexamic acid 110 mg given as stat dose. Intravenous Fluid of D5 0. Paracetamol 110mg given as stat dose.Borja with orders made and carried out. Puno-Mendoza. Metoclopramide 0.3 NaCL 500ml connected to microset insolution using a gauge of 24 on left arm and regulated at 55mgtts/min.COURSE in the WARD
July 18 2012 (Emergency Room) Received a 2 year old cuddled by mother with chief complaint of blooding gum for hours prior to admission attended by Physician on Duty Dr.
.8 mg given as stat dose. fast drop of d5 0.
present IV fluid change to Plain NSS 500ml and regulated as same rate.BT meds given. weak in appearance with swelling at left cheek transfer to bed and room safety oriented to room and hospital policies well understood as claimed by the mother. Blood transfusion of IV platelet. Skin sensitivity testing of Ceftrizidine on right forearm done. hematocrit done Latest temperature 38. Blood Transfusion ended and removed aseptically. Received SMS order from Dr. Skin sensitivity testing of Amikacin on Left forearm done.4C RR-28. type B Rh positive properly typed and crossmatched with initial vital signs of temperature 38. Check after 30 minutes and revealed as negative. Mendoza. concentrate started with blood bag serial number 071812-001.9C
. check after 30 minutes and revealed negative. PR-130 and relayed to Dr. awake and alert. With on-going IV fluid of D5 NaCL 500ml on around 400ml level and regulated at 5mgtts/min.COURSE in the WARD
(General Ward) In from ER per wheelchair accompanied by NOD. Mendoza and carried out. Consent for blood transfusion signed Pre.
Puno-Mendoza and carried out. Received SMS order from Dr. alert and awake.COURSE in the WARD
July 19 2012 Received with on-going IV fluid of Plain NSS 500ml on around 350ml level and regulated at 10mgtts/min. Examined by Dr.
. Puno-Mendoza and carried out. watch out hematoma on Left cheek noted with bleeding on mouth noted.
that causes the patient’s relatives to be more careful on the patient’s health and needs. Rationalization The child undergoes chemotherapy. During Hospitalization The patient’s relative becomes more careful about their patient’s needs. the child can be immune compromised.
ORGANIZING DATA ACCORDING TO GORDON’S 11 FUNCTIONAL HEALTH PROBLEMS
Functional Health Pattern Health Perception/ Health Management Prior The patient has a normal lifestyle.
sometimes the patient’s suffers diarrhea.GORDONS
•NutritionalMetabolic •The patient has a very consumption of food especially on vegetables and fluids. poornutrition. •During the course of chemotherapy the patient’s appetite decreases and as verbalized by the mother the weight of the patient also decreased.
•Patient’s frequency of bowel movement and urine elimination is within normal. •One of the common side effects of chemo-drugs is loss of appetite and weight loss. it is one to the response or induced response to the condition or treatment of the patient. •Diarrhea is one of the side effects of chemo-drugs. also accompanied by nausea and vomiting.
. •Irregularity of the patient’s elimination occurs.
the patient has decreased activity pattern and play. prior to medication. lowcoping mechanism. chemotherapy destroys the good cells and it decreases the patient’s energy and mobility range. •Being a child he is not aware of its disease. the patient is received chemotherapy. • •Upon hospitalization.GORDONS
•ActivityExercise •The patient is active on many activities.
•Becomes irritable and restless during the course of the treatment. •Fatigue and exhaustion.
•The patient’s physical and mental development is normal.
•Being the only son of his family and his present condition. the patient has a normal sleep pattern. etc. •It is due to the hormonal imbalance of the patient.
. the patient has no clue or perception about the disease.
•Self Perception/ Self Concept
•Before hospitalization. he becomes the concern and priority of his family.
• The child still doesn’t know his disease and still has a childish perception.GORDONS
•Sleep-Rest •Prior to hospitalization.
•The patient is the only son of his family.
•There has been a prioritization of care by the family members. uncomfortable of having side effects such as pain. •The mentality of a child cannot conceive his present condition of having a disease. fatigue. the patient now has late sleep and wakes up early. nausea and vomiting.
•Values and Beliefs Spiritual
•The patient has a normal pattern of hygiene. •Daily prayers are done by the family members for their belief that the patient’s disease will be cured.GORDONS
•The patient has a strong belief that his disease will be cured.
•Having some alternations on physical and hormonal state. the patient cannot do his normal routine. •Because of their strong belief that God can answer their prayers and makes miracle about it and boost their self esteem through faith.
•There are no changes on the patient’s hygiene pattern/ the patient is now completely assisted in doing his routine hygiene. he is completely assisted.