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Far Eastern University Institute of Nursing School year 2009-2013 A Case Study Presented to the faculty of Far Eastern University In partial fulfillment of the Requirements in Nursing care management 102 March 09, 2011 Clinical instructor: Professor. Calpatura, Luisa RN, MSN Prepared By: Bautista, Princess Alyssa S. . BSN 307 Group 1-B
INITIAL DATA BASE
I. Demographic Data Name: Mariflor Gavaran (MG) Address: 2920 M Santos Ext. Brgy San Jose Antipolo City Age: 37years old Gender: Female Date of birth: sept 19, 1973 Place of birth: calumpit Bulacan Ethnic group: none Primary dialect spoken: Tagalog Marital status: Married Educational: College Graduate Occupation: Teacher Religious orientation: Roman Catholic Health care financing: couple has their budget for health care Income: 9,000-15,000 a month I. History of Present Illness Client has an chicken pox when she was a kid. Her immunization was complete and also the immunization of their children. She has an allergy in alaxan ³lumalaki ang mata ko pag nakakainom ako ng alaxan´ as verbalized by the client. She has no history of accidents and injuries. She has no past history of hospitalization. she has a history of foreign travel in Korea on 1998 and in Japan on 2002 ± 2005. Obstetric history LMP: July 20 AOG:
y
July20 August September October November December January February
11 31 30 31 30 31 31 15 210/7 = 30 weeks
EDD 7 -3 4 G4P3 The client said that she was hospitalized because of diarrhea. ³noong Friday ng gabi kumain lang naman ako mango, banana, rice, milk, rice sumakit na yung tiyan ko at nagtatae na ako´ as client stated. She came to the hospital as a chief complaint of loose bowel movement but ³kaya lang naman ako nag pa ospital kasi hindi ko na kinaya at inaalala ko yung magiging kalagayan ng baby ko´ as client stated. The client feels weak and lethargic because of her condition. She is in under medication of metronidazole through IV, ampicillin 500g, and diatabs 1 capsule 20 +7 27 10 1 11
>April 27, 2011
Analysis: Tetanus toxoid vaccination for women is important to prevent tetanus in both mother and baby. Completing the 5 doses following the schedule provide lifetime immunity Public Health Nursing in the Philippines pg. 150
Interpretation: The clients went to hospital because she is concerned about her baby¶s condition.
III.Physical Assessment Norms Findings Analysis
General Survey y Body built and height and weight in relation to clients age, lifestyle and behavior
y
y
Proportionate,varies in lifestyle
y
Proportionate
y
The client body built is proportionate to her body The client posture is relaxed and coordinated movement The clients has good overall hygiene
y
y
Posture and gait, standing, sitting, and walking Overall hygiene and grooming Body and breath odor Obvious signs of illness Attitude Affect, mood ; appropriateness of response Quantity and quality of speech
Relaxed;erect posture coordinated movement
y
Relaxed;erect posture coordinated movement
y
y
y y
y
y y y
y y y y
y
y
Clean, neat No body odor or minor body odor relative to work or exercise; no breath odor Healthy appearance Cooperative, able to follow instructions Appropriate to situation Understandable, moderate pace; clear tone and inflection; exhibits thoughts association Logical sequence; makes sense; has sense of reality
y y y
y
y y
Clean, neat No body and breath odors Signs of illness Answers the question seriously questions still cooperative Appropriate to the situation and responds to the question correctly Has moderate voice and understandable Sensible, realistic and
y
y
The clients has Signs of illness she Answers the question seriously questions still cooperative The client is Appropriate to the situation
y
Relevance and organization of thoughts
has sense
y
y
and responds to the question correctly The client Has moderate voice and understandable The client has Sensible, realistic and has sense
Norms Head to Toe examination
Findings
Analysis
PHYSICAL ASSESSMENT Normal findings Head to Toe examination A. Head 1. Skull a. Size, shape or symmetry
b. Presence of nodules,
Actual findings
Remarks
Rounded smooth skull contour (kozier, p.585) Smooth, uniform consistency; absence of nodules or masses (kozier, p.585) No depressions No tenderness, nodules, masses and edema (kozier, p.582) Evenly distributed hair; thick hair (kozier, p.582) Silky, resilient hair (kozier, p.582) Symmetric or slightly asymmetrical facial features; symmetrical facial movements (kozier, p.585)
Rounded, normocephalic and symmetrical No masses, nodules and depressions
masses and depressions 2. Scalp a. Color and appearance b. Areas of tenderness
My client¶s skull is rounded, symmetrical and normocephalic My client¶s skull has no masses, nodules and depressions My client¶s scalp has no depression There are no areas of tenderness in my client¶s scalp Her hair is evenly distributed and thick My client has a dry hair My client has symmetrical features and facial movements
No depressions No tenderness
3. Hair a. Evenness of growth; thickness or thinness b. Texture and oiliness over the scalp 4. Face a. Facial features; symmetry of facial movement B. Eyes 1. Eyebrows a. Hair distribution, alignment, skin quality and movement
Thick ,Curly hair , Dry hair
Symmetric facial features; symmetrical facial movements
Hair evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement (kozier, p.588)
Hair evenly distributed, skin intact, symmetrically aligned, equal movement
My client¶s eyebrows are equally distributed, intact, symmetrically aligned and has an equal movement
2. Eyelashes
a. Evenness of distribution and direction of curl 3. Eyelids a. Surface characteristics , position in relation to the cornea, ability to blink and frequency of blinking
Equally distributed; curved pointing outward (kozier, p.588) Skin intact; no discharge; no discoloration; lids close symmetrically; approximately 15-20 involuntary blinks per minute; bilateral blinking; when lids open, no visible sclera above cornea, and upper and lower borders of cornea are slightly covered (kozier, p.588)
Equally distributed and the hair turned outward
My client¶s eyelashes is equally distributed and turned outward My client has an Intact skin; no discharge; no discoloration; lids close symmetrically; 17 involuntary blinks in 1 minute ; bilateral blinking; when lids open, no visible sclera above cornea and upper and lower borders of cornea are slightly covered My client¶s bulbar conjunctiva is transparent; smooth; no lesions and capillaries are visible My client¶s palpebral conjunctiva is shiny smooth and light pink
Intact skin; no discharge; no discoloration; lids close symmetrically; 17 involuntary blinks in 1 minute ; bilateral blinking; when lids open, no visible sclera above cornea and upper and lower borders of cornea are slightly covered
4. Conjunctiva a. Color, texture, and presence of lesions in the bulbar conjunctiva
Transparent capillaries sometimes evident; sclera appears white (yellowish in dark-skinned clients) (kozier, p.588) Shiny, smooth, pink red (kozier, p.588)
Transparent; smooth; no lesions and capillaries are visible
b. Color, texture, and presence of lesions in the palpebral conjunctiva 5. Lacrimal gland, lacrimal sac and nasolacrimal duct
a.
Shiny, smooth, light pink
Presence of edema or tearing
No edema; no tearing (kozier, p.589)
No edema or tearing
There is no presence of tearing and edema on my client¶s lacrimal sac.
6. Cornea
a. Clarity and texture 7. Pupils a. Color, shape and symmetry of size b. Light reaction and accommodation
Transparent, shiny and smooth (kozier, p.589) Black; equal in size; 3-7 mm in diameter; round; smooth border (kozier, p.590) Pupils constrict when looking at near objects; pupils dilate when looking at far objects; pupils converge when near object is moved towards the nose (kozier, p.590)
Transparent and shiny; smooth
My client¶s cornea is transparent and shiny My client¶s pupil is black, round and equal in size My client¶s eyes is Constrict as light passes through it; it constricts when looking at near objects and dilates when looking at far objects; converge as it moves towards the nose My client can see the object in his peripheral vision
Black; round; same size
Constrict as light passes through it; it constricts when looking at near objects and dilates when looking at far objects; converge as it moves towards the nose
8. Visual fields a. Peripheral visual fields
When looking straight ahead , the client can see object in his periphery (kozier, p.591) Both eyes coordinated, move in unison, with parallel alignment (kozier, p.592) Able to read newsprint (kozier, p.592)
The client can see the object in his periphery
9. Extraocular Muscles a. Alignment and coordination of the eye 10. Visual acuity a. Near vision
Both eyes are coordinated
My client¶s both eyes are coordinated.
Cannot read newsprint
b. Distance vision C. Ears 1. Auricles a. Color, symmetry of size and position
20/20 vision on snellen chart (kozier, p.592)
farsighted
My client¶s cannot read newspaper because her eyes is blured in near vision My client¶s can read through far
Color same as facial skin; symmetrical ; auricle aligned with outer canthus of eye, about
Same with the color of the face; auricles are symmetrically aligned with outer canthus of eye
My client¶s auricle is same with the color of the face; auricles are
10 degrees from vertical (kozier, p.596) b. Palpate for texture, elasticity and areas of tenderness Mobile, firm and not tender; pinna recoils back after it is folded (kozier, p.596) Elastic, firm, no tenderness; pinna recoils back after it is folded
symmetrically aligned with outer canthus of eye My clients auricle is elastic, firm, no tenderness; pinna recoils back after it is folded My client¶s external ear has a dry cerumen, brown in color. There are no lesions, pus and blood My client can hear normal voice tones My client can hear the ticking sounds My client can hear the sound on both ears My client can hear the sound on both ears
2. External Ear canal a. Presence of cerumen, skin lesions, pus and blood
Distal third contains hair follicle and glands: (dry cerumengrayish tan in color, wet cerumen ± various of brown) (kozier, p.596) Normal voice tones audible (kozier, p.597) Able to hear ticking in both ears (kozier, p.597) Able to hear ticking in both ears (kozier, p.597) Air conducted hearing is greater than the bone conducted hearing (kozier, p.598) Symmetric; no discharge; no flaring; uniform color (kozier, p.600) Mucosa is pink; clear, watery; no discharge; no lesions (kozier, p.600) Air moves freely as the client breathes through the nares
There is dry cerumen brown in color; no lesions, pus and blood
3. Hearing Acuity Test a. Normal voice tones b. Watch tick test c. Weber¶s test d. Rinne¶s test
Normal voice tones heard Can hear the ticking sounds Sound is heard on both ears Air conducted hearing is greater than the bone conducted hearing
D. Nose and Sinuses a. Shape, size , color, flaring or discharge from the nose b. Presence of redness, swelling, growths and discharge of the nasal cavity c. Patency of both nasal cavities
Symmetric, straight, uniform in color; no discharge or flaring
Paled pink; clear and watery; no discharge, lesions and swelling
Air moves freely as the client breath out
My client¶s nose is symmetric, uniform color and has no discharge or flaring My clients nose is Paled pink; clear and watery; no discharge, lesions and swelling The air moves freely as my client breathe
(kozier, p.600) d. Nasal septum Nasal septum is intact and at the midline (kozier, p.600) Intact and at the midline
out. My client¶s nasal septum is Intact and at the midline
E. Mouth 1. Lips and Buccal Mucosa a. Symmetry of contour, color and texture 2. Teeth and Gums a. Color, number and condition and presence of dentures
Uniform pink color; moist, soft, glistening, and elastic texture (kozier, p.602) 32 adult teeth; smooth, white, shiny tooth enamel (kozier, p.602)
Slightly Pink in color; soft. It is moist, smooth texture; symmetry of contour; ability to purse lips 28 teeth with dental carries; 4 severely damaged
My client¶s lips are pale because of possible dehydration My client has dental caries and she only has 28 teeth which are supposed to be 32 because of poor dental hygiene and lack of dental checkup
3. Tongue/floor of the mouth a. Color, shape, texture and the presence of bony prominences
Light, pink hard palate, more regular texture (kozier, p.604)
Light pink hard palate; pink rough or lumpy soft palate
a. Position, color, and Smooth; moves freely; no texture; movement and tenderness base of the tongue (kozier, p.603)
Central position; pink color; moist; slightly rough; thin whitish coating; smooth lateral margins; no lesions with raised papillae
b. Any nodules, lumps or
Smooth; no palpable nodules
Smooth; no palpable nodules
My client¶s tongue is slightly pale hard palate because of possible dehydration My client¶s tongue is in central position; slightly pale in color; because of possible dehydration moist; thin whitish coating; smooth lateral margins; no lesions with raised papillae l My client¶s tongue has
excoriated areas 4. Palates and uvula b. Color, shape, texture and the presence of bony prominences c. Position and mobility of uvula F. Neck and lymph nodes 1. Neck Muscle
(kozier, p.604) Light, pink hard palate, more regular texture (kozier, p.604) Positioned in midline of the soft palate (kozier, p.604) Slightly pink hard palate; pink smooth soft palate
no nodules My client¶s palate is Slightly pink in color because possible dehydration Her uvula is positioned in the midline
Uvula is at the middle of the soft palate
Muscle equal in size ; head centered (kozier, p. 607)
Muscle equal in size; head centered
There is an equal size in the muscle of her neck and her head is positioned in center
2. Lymph nodes 3. Trachea a. Placement
Central placement in the midline the of neck; spaces are equal on both sides (kozier, p.608) Not visible (kozier, p.608) Lobes may not be palpated. If palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing (kozier, p.608)
Placed at the midline and spaces equal on both sides
Trachea is placed in the midline and has equal space on both sides Her thyroid gland is not visible upon palpation Her lobes are not palpable upon palpation
4. Thyroid gland a. Symmetry and visible masses b. Smoothness and areas of enlargement, masses or nodules
Not visible on inspection
lobes not palpable; no enlargement, masses or nodules
G. Thorax 1. Posterior Thorax a. Shape, symmetry, diameter of
Anteroposterior to transverse diameter in ratio of 1:2; chest
1:2 diameter symmetric with chest
She has 1:2 diameter symmetric with chest
anteroposterior thorax to transverse diameter; color; lesions b. Temperature, tenderness, masses
symmetric (kozier, p.614) Uniform temperature; no tenderness; no masses (kozier, p.614) Full and symmetric chest expansion; thumbs separate 35 cm (1.5-2 inches) as the client takes a deep breath (kozier, p. 615) Bilateral symmetry of vocal fremitus; fremitus is heard most clearly in the apex of the lungs (kozier, p.615) It has uniform temperature, no tenderness, and no masses she has uniform temperature, no tenderness, and no masses She hasFull and symmetric chest expansion; thumbs separate 3-5 cm as the client takes deep breath She has a bilateral symmetry of the vocal fremitus; fremitus is heard most clearly in the apex of the lungs The client breath quiet, rhythmic and effortless respiration The client temperature is uniform and there is no any tenderness and masses She has a Full and symmetric chest expansion when the client takes a deep breath Normal
c. Respiratory excursion
Full and symmetric chest expansion; thumbs separate 3-5 cm as the client takes deep breath
d. Vocal fremitus
There is bilateral symmetry of the vocal fremitus; fremitus is heard most clearly in the apex of the lungs
2. Anterior Thorax a. Breathing patterns
b. Temperature, tenderness, masses
Quiet, rhythmic and effortless respiration (kozier, p.617) Uniform temperature; no tenderness; no masses (kozier, p.617)
The client breath quiet, rhythmic and effortless respiration The temperature is uniform and there is no any tenderness and masses
c. Respiratory excursion
d. Tactile fremitus
Full and symmetric chest expansion; thumbs separate 35 cm (1.5-2 inches) as the client takes a deep breath (kozier, p.617) Same as the posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue
Full and symmetric chest expansion when the client takes a deep breath
Vocal fremitus is decreased it sound when it became near the heart ad breast
e. Auscultation of the trachea
(kozier, p.617) Bronchial and tubular breath sounds (kozier, p. 618) Bronchovesicular and vesicular breath sounds (kozier, p.618)
Bronchial and tubular breath sound are easily heard
f.
Auscultation of the anterior thorax
Bronchovesicular and vesicular breath sounds are easily be heard
My client Bronchial and tubular breath sound are easily heard Bronchovesicular and vesicular breath sounds are easily be heard Her Pulse can be easily felt Normal
1. Carotid Arteries a. Palpation of carotid artery b. Auscultation of carotid areas 1. Bones a. Normal structure and deformities b. Areas of edema or tenderness A. Assess Joints range of motion a. Upper extremities (shoulder and scapula) b. Upper extremities (elbows) c. Upper extremities (hands) d. Lower extremities (acetabulum/ inguinal area) e. Lower extremities (popliteal)
Symmetry pulse volumes; full pulsations, thrusting quality (kozier, p.622) No sounds heard on auscultation (kozier,p.623) No deformities (kozier, p.641) No tenderness or swelling (kozier, p.641)
Pulse can be easily felt
No sounds heard upon auscultation
No any bones deformities and structure No tenderness and swelling
She has No any bones deformities and structure No tenderness and swelling upon palpation
Smooth coordinate movements (kozier, p.641) Smooth coordinate movements (kozier, p.641) Smooth coordinate movements (kozier, p.641) Smooth coordinate movements (kozier, p.641) Smooth coordinate movements (kozier, p.641)
Limited range of motion Limited range of motion Limited range of motion Limited range of motion Limited range of motion
f.
Lower extremities (ankle)
Smooth coordinate movements (kozier, p.641)
Limited range of motion
C.Patterns of Functioning According to Gordon FUNCTIONAL HEALTH PATTERN A. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN The patient perceived her health in the state of good condition she considered healthy about her is ³masigla ako, hindi ako mapakali pag wala akong gingawa at pag konting sakit naman hindi ko iniinda saka pag feeling ko hindi ko na kaya saka lang ako pupunta sa ospital.. She manages his health by practicing proper hygiene and eating nutritious food .the client does not drink, smoke or use any vices. Her environment is well ventilated and has an adequate lightning. During hospitalization she sees herself as a total ill person because she cannot do anymore the things she usually does like going to work, taking care of her children. She rely her present condition with the help of the therapeutic personnel and by following the prescribed medications. The patient perceived that he is not healthy because of his condition. ANALYSIS The World Health Organization takes a more holistic vie of health. Its constitution defines a state of complete physical, mental and social well being and not merely the absence of disease. (WHO 1948) (Fundamentals of Nursing, Barbara Kozier, 2004p.171) INTERPRETATION She perceives health as wealth and she values his health a lot.
B. NUTRITIONAL AND METABOLIC PATTERN
3 DAY DIET RECALL SUNDAY BREAKFAST SUNDAY SANDWICH 2 CUP OF WATER
LUNCH
DINNER
FRIED CHICKEN 1 CUP OF RICE 3 CUP OF WATER
LUGAW 2 CAP OF WATER
MONDAY ARROZCALDO W/ BREAD TUESDAY LUGAW W/ EGG AND BREAD MANOK W/ SABAW SAGING SAGING SABAW 1 CUP OF RICE SAGING TILAPIA 1 CUP OF RICE SAGING
The patient eats 3 times a day with her family at their house and an afternoon snacks after coming from work. According to her, she eats meat, fish and also vegetables and some dry foods she doesn¶t like smelly food. Her food preparation is more on fried, steaming and w/ soup. Her appetite is moderate and usually depends on the food being served. She didn¶t complain any difficulty in swallowing. During hospitalization pag kumakaen ako pinupupu ko rin,´as client stated. The doctor recommends having a banana rice apple tea (BRAT) diet .
Analysis There are profound changes in maternal metabolism during pregnancy, and successful adaptation to these changes is necessary for favorable pregnancy outcome. There are alterations in the maternal metabolism of protein, carbohydrate and fat. Changes occur in maternal metabolism to accommodate these needs of the fetus. Increased macronutrient and micronutrient intake by the mother during pregnancy ensures that these increased metabolic needs are met (Foundations and Clinical Application of Nutrition A Nursing Approach, Furth Edition , Michele Grodner, EdD, cHes, 2004 pp. 238.)
Interpretation The client knows the proper nutrition¶s food to be eaten during pregnancy.
C. ELIMINATION PATTERN The client has a discomfort in deficating her stool is yellowish and watery ³isang labasan at onti lang´ as verbalized by the client she deficates 3 time a day ³kapag pumupupu ako humihilab yung tiyan ko pero pag nalabas ko na malaking ginhawa As client stated. The client has no discomfort in urinating her urine is yellowish she urinates 10x a day. The client always eats banana and increasing fluid intake to achieve a proper normal elimination. The client has no odor problems Analysis The factors that affect defecation are diet and activity. Sufficient bulk in the diet is necessary to provide fecal volume. Activity stimulates peristalsis, thus facilitating movement of byme along colon. Weak abdominal and pelvic muscles are often ineffective in increasing the intra abdominal pressure during defecation or in controlling defecation. (Fundamentals of Nursing 7th edition, Barbara kozier, 2004 pp. 1223-1229)
INTERPRETATION The client does not defecate within the normal bowel elimination. She has a problem with defecating her stool is watery and yellowish she feels abdominal pain when she is defecating.
D. ACTIVITY EXERCISE PATTERN
The client usually activities in a day are praying, cooking, and cleaning the house,and going to work. She usually walks 500 meters going to school and going home she takes about 5 mins of walking. She is satisfied with the amount of exercise that she can get. During hospitalization her activity was limited lying on bed ³ngayon naka hospital ako hindi ko nagagawa ang dapat kong gawin kasi buntis ako at sa kalagayn ng sakit ko´as client verbalized. But the patient is given his bathroom privileges
Analysis Individuals who have inactive lifestyles or who are faced with inactivity because of illness or injury are at risk for many problems that can affect major body systems. Immobility adversely affects the cardiovascular, respiratory, metabolic, urinary and psychoneurologic systems. ± Fundamentals of Nursing by Kozier, 7th ed
Interpretation The client¶s has a routine physical activity but there is a restriction of activities because of her present condition.
E. SLEEP REST PATTERN The client¶s usually time of sleep is 10pm-5am she is taking a nap for 2 hours in office just to take a rest for a while. She is not satisfied with the amount of hours of her sleep. ³Kung meron pang time gusto ko pa sana matulog kaso wala na eh´ as verbalized by the client. She always wakes up by night ³nagigising ako ng alanganing tapat pag gumagalaw si baby´ as verbalized by the client. Sometimes she feels refreshing when she wakes up. Her sleeping environment is quiet but when her baby is crying she interrupt her sleeping. The client always watches TV for her relaxation, doing her chores and after that she is going to sleep as her bed time routine. By closing her eyes it is help to make her asleep. During hospitalization she doesn¶t have the adequate time of sleep since she is disturbed with the nurses that enter the room every now and then, and because of the environmental changes of her surroundings. Analysis Environment can promote or hinder sleep. Any change for example, noise in the environment can inhibit sleep. The absence of usual stimuli or the presence of unfamiliar stimuli can prevent people from sleeping. ± Fundamentals of Nursing by Kozier 7th Ed. Interpretation The pattern of sleep for her it¶s not satisfying because of some disturbance to her surroundings. Because environment can promote or hinder sleep. F. COGNITIVE-PERCEPTUAL PATTERN INTERPRETATION The client can read, write, and speak. She has no difficulty in hearing, but her vision is nearsighted she wears eye glasses last year and her last checked up was last year also. She is sensitive in smell when she is in the stage of first trimester period. And also she is doing fine in work.
ANALYSIS Young adults are able to use formal operation characterized by the ability to think abstractly and employ logic. Young adults are able to generate hypothesis what will happen given a set of circumstances and do not have engaged in trial and error behavior. (fundamentals of nursing kozier pp.394-395)
INTERPRETATION She is normal in terms of his cognitive abilities. She has good memory and reasoning skills. He can easily comprehend on things. In terms of her perceptual pattern, she has no problems with his senses except with her vision
G. SELF PERCEPTION AND SELF-CONCEPT PATTERN She sees herself as a person with a good personality. She has been a good friend, sister and a mother. She said she has to be a good person in order not to hurt others. She also describes herself as ³masigla, walang problema´ as verbalized by the client. She expresses her thoughts by telling her problem especially to her husband. Her next goal after five years is to finish her masteral degree, to ensure that their children are finishing their study and she will work hard to pursue her dreams. The client wants to be with a happy person and open to her. Her type of mood was ³tawa nalang ako kahit may problema tawa parin´ as verbalized by the client. ANALYSIS Is one¶s mental age of oneself. A positive self concept is essential to a person¶s mental and physical health individuals with a positive self concept are better able to develop and maintain interpersonal relationship and resist psychologic and physical illness.-Fundamentals of nursing Kozier 8th edition p.1003 INTERPRETATION The client has no problem with her personality. She is doing well in everything just to give a good future for her family and she has in a positive outlook.
H. ROLE RELATIONSHIP PATTERN The client lives with her family and she has a close relationship with her family. She is fulfilling her role as a full time mom. Their usually activities when there is no work are going to church every Sunday, eating together in fast food , and going to the mall to buy grocery. They are expressing their thoughts or opinion by talking to one another. She thinks that her work is being affected by her health status because of so much stress. Her income is sufficient for her family¶s need. During hospitalization she had more time to bond with her family. She said that it was a nice feeling to know that your family is so supportaive to him. She learned to appreciate the beauty of having a family that gives you strength and support no matter what.
ANALYSIS Throughout life people undergo numerous role changes. A role is expectation about how the person occupying one position behaves. Role relationship relates what a person in particular role does to the behaviors expected of that rolefundamentals of nursing kozier 8th edition p.1006
INTERPRETATION My client is close to her family. And also I observed that they are open to each other. They have a good family bonding.
I.
SEXUALITY-REPRODUCTIVE PATTERN The client uses calendar method as their contraceptives. Her last menstrual period was on July 20, 2010.
ANALYSIS According to Erikson the danger of this stage is role confusion. The inability to settle on an occupational identity commonly disturbs adolescent. The adolescent needs to establish a self concept that accepts both personal strength and weaknesses. The milestone of female puberty is menarche. INTERPRETATION They are not using any contraceptives except calendar method. The couple had planned to have a family planning as well J. COPING STRESS TOLERANCE PATTERN According to the client her stressful event is having no money she handle her stress by praying. Her husband is always there to help and talk the most whenever if they have a problem. The client has big changes in her life such as she didn¶t do things that she does before. Whenever she has a big problem she will talk to her husband to ask for advice. During hospitalization she shares her problems to his family. She verbalizes her feelings and condition.
ANALYSIS Stress is a condition in which the person experience changes during the normal balance state-fundamentals of nursing kozier 8th edition p.1061 INTERPRETATION The client experience stress but she handled it by expressing her feelings by someone close to her. K. VALUE-BELIEF PATTERN The client defines a healthy person as mentally, physically, spiritually, and absence of diseases she is belongs to Roman Catholic the most important things being a catholic is by praying to god because as she said ³siya talaga pedeng mapagsabihan ng problema´. According to her health is important because health is wealth.
ANALYSIS Religion is an organized system beliefs and practices. It offers a way of spiritual expression that provides guidance for believers in life¶s question and challenges.-fundamentals of nursing kozier 8th edition p.1004
INTERPRETATION My client has her own definition of heath. Religion is also important to her. She has faith in God.
D. significant laboratory findings FECALYSIS (feb15, 2011) YELLOW WATERY NO OVA OR PARASITES SEEN 1-3/HPT 0-1/HPT 132.9mmol/L 3.60
COLOR
CONSISTENCY AMOEBA PLUS CELLS RBC SODIUM POTASSIUM
INTERPRETATION: The color of her fecalysis is yellow which is an indication that she has a problem in her GI tract. The consistency is watery. There is an absence of amoeba.
Hematology report (feb15, 2011) FINDINGS Hemoglobin Hematocrit Erythrocyte Leukocytes Lymphocytes Platelet count Blood type B rh+
REFERENCE VALUE 125-160 0.38-0.800 4.5-5.5 (F) 5-10 0.20-0.40 120-350
ACTUAL FINDINGS 148 g/L 0.44 5.08x10/ul 12.0 0.18 320 x10/L
INTERPRETATION The client¶s hemoglobin, hematocrit and erythrocytes, is within in a normal range but her leukocytes is higher within the normal range which indicates that she has a leukocytosis. Her white blood cells are increase than red blood cell. Another is lymphocytes that have low value within in a normal which means that her body's resistance to fight infection has been substantially lost and one may become more susceptible to certain types of infection. Her platelet count is within in a normal range and her blood type B rh(+) it means that her plasma is contains antibodies and it has no effect to her baby.
IV.pathophysiology She ate mango, banana, rice, milk, rice that can be the cause of diarrhea
Ingestion of bacteria
Invading and killing of the intestinal villi
Foods cannot be digested
Disturbing the structural integrity of the region
Food molecules acts as osmotic agent Large amounts of water,electrolytes, and intestinal fluids were pulled Inflammation of the lining of the stomach
Watery stool, Abdominal pain, malaise, ,
I.
List of prioritized problems *not less than 5, nanda based Cues S: ³mga 3days na ako nagtatae isang labasan lahat yun at puro tubig walang buo´ O: - watery stool -slighly dehydrated -yellowish rationale When fluid loss exceeds intake, a fluid volume deficit exists. A fluid volume deficit is a physiological situation in which fluids are lost in an isotonic fashion (both fluid and electrolytes Are lost together).
DIAGNOSIS 1. Deficient Fluid volume related to excessive looses
2 risk. Imbalance nutrition less than bodily requirements
S: ³pag kumakaen ako pinupupu ko rin,´ O: -brat diet only
Poor nutrition can be a cause of low infant birth weight.
3.acute pain related to abdmoninal cramping
S: kapag pumupupu ako humihilab yung tiyan ko pero pag nalabas ko na malaking ginhawa O: -abdominal pain -facial grimace -weak
4.risk for dehydration
S:´nagtatae ako ng tubig 3 araw na´ 0: -weak
Because more electrolytes and fluids that being expelled it can be a cause of dehydration
- slightly poor skin turgor 5.Activity intolerance r/to weakness S:´ngayon naka hospital ako hindi ko nagagawa ang dapat kong gawin kasi buntis ako at sa kalagayn ng sakit ko´ O: -weak -malaise -lethargic According to Maslow¶s hierarchy of needs, activity intolerance is in the physiologic needs and it must be prioritized. In ABC¶s of life activity intolerance has something to do with the energy and it is categorized as B stands for breathing.
VI. DRUG STUDY Name of the Drug
Indications
Mode of Action
Specific Nursing Responsibility ASSESSMENT History: CNS or Hepatic disease, candidiasis, blood dyscarias, pregnancy, lactation. Physical: Reflexes, affect; skin lesions, color (with topical application); abdominal examination, liver palpitation, urinalysis, CBC, LFTs INTERVENTIONS: WARNING:do not use unless needed. Metronidazole may be carcinogenic. - Administer oral doses with food. - Apply topically after cleansing the area. Advise patient that cosmetic may be used over the area after application. - Reduce dosage in hepatic disease. TEACHING POINTS: take full course of drug therapy; take the drug
Metronidazole 500 mg
-
acute infection with susceptible anaerobic bacteria Acute intestinal amebiasis Amebic liver abcess Trichomoniasis
- BACTERICIDAL: inhibits DNA synthesis in specific(obligate) anaerobes, causing cell death; antiprotozoal-trichomonacidal, amebicidal: Bio-chemical mechanism is unknown.
-
-
-
-
-
-
with food if GI upset occurs. Do not drink alcohol (beverages or preparations containing alcohol, cough syrups) for 48-72 hr of drug use; severe reactions may occur. Your urine may be a darker color than usual; this is expected. Refrain form sexual intercourse during treatment for trichomoniasis, unless partner wears a condom. Apply the topical preparation by cleansing the area and then rubbing a thin film into the affected area. Avoid contact with the eyes. Cosmetics may be applied to the area after medication is dry. You may experience these side effects: Dry mouth with strange metallic taste; nausea, vomiting, diarrhea. Report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills.
Name of Drug
Indications
Mode of Action
Specific Nursing Responsibility Assessment HISTORY: allergy to penicillins, cephalosporins, or other allergens; renal disorders; lactation PHYSICAL: culture infected area; skin color; lesion; R, adventitious sounds; bowel sounds, CBC, LFTs, renal function tests, serum electrolytes, Hct, Urinalysis culture infected area before treatment; reculture area if response is not as expected. Check IV site carefully for signs of thrombosis or drug reaction. Do Not give IM injections on the same site; athropy can occur. Monitor injection sites. Administer oral drug on an empty stomach, 1 hr before or 2 hrs after meals with a full glass of water, do not give fruit juice or soft drinks.
Ampicillin 500 mg
Treatment of infections caused by susceptible strains of Shigella, Salmonella, S. typhosa Haemohilius Influenzae, Proteus mirabilis, enterococci, gram ± positive organisms
Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death
-
-
Teaching Points Take this drug around-theclock Take the full course of therapy; do not stop taking the drug if you feel better. This anti-biotic is specific in your problem and should not be used to self-treat other infections. If you are a woman and you use a hormonal contraceptive, you should use a second form of birth control for 1-2 weeks while taking this drug. You may experience this side effects: Nausea, Vomiting, GI upset(eat small frequent meals), diarrhea Report pain or discomfort at sites, unusual bleeding or bruising, mouth sores, rash, hives, fever, itching, severe diarrhea, difficulty breathing.
-
-
-
Name of Drug
Indications
Mode of Action
Specific Nursing Responsibility Assessment: HISTORY: allergy to lomustine, radiation therapy, chemotherapy, hematopoietic depression, impaired renal or hepatic function, pregnancy, lactation PHYSICAL: T; weight, mucous membranes, liver evaluation; CBC , differential; urinalysis; LFTs, renal function tests WARNING: Do not give full dosage within 2-3 weeks after a full course of radiation therapy or chemotherapy due to risk of severe bone marrow depression; reduced dosage may be needed. advise patient that this drug cannot be taken during pregnancy
Loperamide 1 capsule
-
-
Control and symptomatic relief of acute non ±specific diarrhea and chronic diarrhea associated with inflammatory bowel disease Reduction of volume of discharge from ileostomies. OTC use: control of diarrhea including traveler¶s diarrhea.
- slows intestinal motility and affects water and electrolyte movement through the bowel by inhibiting peristalsis through direct effects on the circular and longitudinal muscles of the intestinal wall.
INTERVENTIONS Monitor for response. If improvement is not seen within 48 hrs, discontinue treatment and notify health care provider.
-
Give drug after each unformed stool. Keep track of amount given to avoid exceeding the recommended daily dosage unless directed by a physician. WARNING: Have the opoid antagonist naloxone readily available in case of overdose and CNS depression. TEACHING POINTS Take drug as prescripted. Do not exceed prescribed dosage or recommended daily dosage. Drink clear fluids to prevent dehydration You may experience these side effects: Abdominal fullness, nausea, vomiting, dry mouth, dizziness. Report abdominal pain or distention, fever and diarrhea that does not stop after a few days.
-
-
VII.NCP (7 COLUMNS)
ASSESSMENT
NURSING DIAGNOSIS Deficient Fluid volume related to loose bowel movement
ANALYSIS
GOALS AND OBJETIVE GOALS: After 5 hours of nursing intervention the client will be able to minimized loose bowel movement OBJECTIVES 1. After 20mins of discussion, .the client will be able to discuss the 2 disadvantages of diarrhea 2.After 20mins of discussion, the mother will be able to define diarrhea 3. After 20mins of discussion,
NURSING INTERVENTION
RATIONALE
EVALUATION
S: ³mga 3days na ako nagtatae isang labasan lahat yun at puro tubig walang buo´ O: - watery stool -yellowish -3X BM
When fluid loss exceeds intake, a fluid volume deficit exists. A fluid volume deficit is a physiological situation in which fluids are lost in an isotonic fashion (both fluid and electrolytes are lost together).
>Determine effects of age
Very young and extremely elderly ind. Are quickly affected by fluid volume deficit To know the current status of her vital signs To determine if there is a dehydration >these signs
>Assess vitals
>note any presence of physical signs >note change in
the mother will be able to state 3 out of 5 causes of diarrhea 4. After 20mins of discussion, the mother will be able to state 3 out of 5 causes of diarrhea
usual mentation
indicate sufficient dehydration to electrolytes imbalance >to more accurately determine replacement needs >fluid use for replacement >that lend to exert diuretic effect >early identification of risk factors can decrease occurrence and severity of complications associated with hypovolemia
>observe I and O
>administer IV >limit intake of alcohol >discuss factor related to occurrence of deficit as individually appropriate
VIIi DISCHARGE PLAN DISCHARGE PLAN Learning content Medication y y y Take iron supplement once a day Take vitamin C Be sure to get adequate amounts of rest Take naps during the day Rest when the neonate is resting Begin exercising when allowed by health care provider; starts slowly and gradually increase the amount done. Increased fluid intake Exercise daily and eat more nutritious food
Exercise
y
Treatment
y y
Hygiene
y y
Wash perineum from front to back with the use of betadine feminine wash and warm water Take a bath 3x a day y y y Increase protein and calorie intake to restore body tissues If breast-feeding drink at least ten 8 oz (237mL) glasses of water per day Drink plenty of fluids specially water and eat foods that are high in fiber to prevent constipation
Diet
INITIAL DATA BASE
I. Demographic Data Name: Mariflor Gavaran (MG) Address: 2920 M Santos Ext. Brgy San Jose Antipolo City Age: 37years old Gender: Female Date of birth: sept 19, 1973 Place of birth: calumpit Bulacan Ethnic group: none Primary dialect spoken: Tagalog Marital status: Married Educational: College Graduate Occupation: Teacher Religious orientation: Roman Catholic Health care financing: couple has their budget for health care Income: 9,000-15,000 a month I. History of Present Illness Client has an chicken pox when she was a kid. Her immunization was complete and also the immunization of their children. She has an allergy in alaxan ³lumalaki ang mata ko pag nakakainom ako ng alaxan´ as verbalized by the client. She has no history of accidents and injuries. She has no past history of hospitalization. she has a history of foreign travel in Korea on 1998 and in Japan on 2002 ± 2005. Obstetric history LMP: July 20 AOG:
y
July20 August September October November December January February
11 31 30 31 30 31 31 15 210/7 = 30 weeks
EDD 7 -3 4 G4P3 The client said that she was hospitalized because of diarrhea. ³noong Friday ng gabi kumain lang naman ako mango, banana, rice, milk, rice sumakit na yung tiyan ko at nagtatae na ako´ as client stated. She came to the hospital as a chief complaint of loose bowel movement but ³kaya lang naman ako nag pa ospital kasi hindi ko na kinaya at inaalala ko yung magiging kalagayan ng baby ko´ as client stated. The client feels weak and lethargic because of her condition. She is in under medication of metronidazole through IV, ampicillin 500g, and diatabs 1 capsule 20 +7 27 10 1 11
>April 27, 2011
Analysis: Tetanus toxoid vaccination for women is important to prevent tetanus in both mother and baby. Completing the 5 doses following the schedule provide lifetime immunity Public Health Nursing in the Philippines pg. 150
Interpretation: The clients went to hospital because she is concerned about her baby¶s condition.
III.Physical Assessment Norms Findings Analysis
General Survey y Body built and height and weight in relation to clients age, lifestyle and behavior
y
y
Proportionate,varies in lifestyle
y
Proportionate
y
The client body built is proportionate to her body The client posture is relaxed and coordinated movement The clients has good overall hygiene
y
y
Posture and gait, standing, sitting, and walking Overall hygiene and grooming Body and breath odor Obvious signs of illness Attitude Affect, mood ; appropriateness of response Quantity and quality of speech
Relaxed;erect posture coordinated movement
y
Relaxed;erect posture coordinated movement
y
y
y y
y
y y y
y y y y
y
y
Clean, neat No body odor or minor body odor relative to work or exercise; no breath odor Healthy appearance Cooperative, able to follow instructions Appropriate to situation Understandable, moderate pace; clear tone and inflection; exhibits thoughts association Logical sequence; makes sense; has sense of reality
y y y
y
y y
Clean, neat No body and breath odors Signs of illness Answers the question seriously questions still cooperative Appropriate to the situation and responds to the question correctly Has moderate voice and understandable Sensible, realistic and
y
y
The clients has Signs of illness she Answers the question seriously questions still cooperative The client is Appropriate to the situation
y
Relevance and organization of thoughts
has sense
y
y
and responds to the question correctly The client Has moderate voice and understandable The client has Sensible, realistic and has sense
Norms Head to Toe examination
Findings
Analysis
PHYSICAL ASSESSMENT Normal findings Head to Toe examination A. Head 1. Skull a. Size, shape or symmetry
b. Presence of nodules,
Actual findings
Remarks
Rounded smooth skull contour (kozier, p.585) Smooth, uniform consistency; absence of nodules or masses (kozier, p.585) No depressions No tenderness, nodules, masses and edema (kozier, p.582) Evenly distributed hair; thick hair (kozier, p.582) Silky, resilient hair (kozier, p.582) Symmetric or slightly asymmetrical facial features; symmetrical facial movements (kozier, p.585)
Rounded, normocephalic and symmetrical No masses, nodules and depressions
masses and depressions 2. Scalp a. Color and appearance b. Areas of tenderness
My client¶s skull is rounded, symmetrical and normocephalic My client¶s skull has no masses, nodules and depressions My client¶s scalp has no depression There are no areas of tenderness in my client¶s scalp Her hair is evenly distributed and thick My client has a dry hair My client has symmetrical features and facial movements
No depressions No tenderness
3. Hair a. Evenness of growth; thickness or thinness b. Texture and oiliness over the scalp 4. Face a. Facial features; symmetry of facial movement B. Eyes 1. Eyebrows a. Hair distribution, alignment, skin quality and movement
Thick ,Curly hair , Dry hair
Symmetric facial features; symmetrical facial movements
Hair evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement (kozier, p.588)
Hair evenly distributed, skin intact, symmetrically aligned, equal movement
My client¶s eyebrows are equally distributed, intact, symmetrically aligned and has an equal movement
2. Eyelashes
a. Evenness of distribution and direction of curl 3. Eyelids a. Surface characteristics , position in relation to the cornea, ability to blink and frequency of blinking
Equally distributed; curved pointing outward (kozier, p.588) Skin intact; no discharge; no discoloration; lids close symmetrically; approximately 15-20 involuntary blinks per minute; bilateral blinking; when lids open, no visible sclera above cornea, and upper and lower borders of cornea are slightly covered (kozier, p.588)
Equally distributed and the hair turned outward
My client¶s eyelashes is equally distributed and turned outward My client has an Intact skin; no discharge; no discoloration; lids close symmetrically; 17 involuntary blinks in 1 minute ; bilateral blinking; when lids open, no visible sclera above cornea and upper and lower borders of cornea are slightly covered My client¶s bulbar conjunctiva is transparent; smooth; no lesions and capillaries are visible My client¶s palpebral conjunctiva is shiny smooth and light pink
Intact skin; no discharge; no discoloration; lids close symmetrically; 17 involuntary blinks in 1 minute ; bilateral blinking; when lids open, no visible sclera above cornea and upper and lower borders of cornea are slightly covered
4. Conjunctiva a. Color, texture, and presence of lesions in the bulbar conjunctiva
Transparent capillaries sometimes evident; sclera appears white (yellowish in dark-skinned clients) (kozier, p.588) Shiny, smooth, pink red (kozier, p.588)
Transparent; smooth; no lesions and capillaries are visible
b. Color, texture, and presence of lesions in the palpebral conjunctiva 5. Lacrimal gland, lacrimal sac and nasolacrimal duct
a.
Shiny, smooth, light pink
Presence of edema or tearing
No edema; no tearing (kozier, p.589)
No edema or tearing
There is no presence of tearing and edema on my client¶s lacrimal sac.
6. Cornea
a. Clarity and texture 7. Pupils a. Color, shape and symmetry of size b. Light reaction and accommodation
Transparent, shiny and smooth (kozier, p.589) Black; equal in size; 3-7 mm in diameter; round; smooth border (kozier, p.590) Pupils constrict when looking at near objects; pupils dilate when looking at far objects; pupils converge when near object is moved towards the nose (kozier, p.590)
Transparent and shiny; smooth
My client¶s cornea is transparent and shiny My client¶s pupil is black, round and equal in size My client¶s eyes is Constrict as light passes through it; it constricts when looking at near objects and dilates when looking at far objects; converge as it moves towards the nose My client can see the object in his peripheral vision
Black; round; same size
Constrict as light passes through it; it constricts when looking at near objects and dilates when looking at far objects; converge as it moves towards the nose
8. Visual fields a. Peripheral visual fields
When looking straight ahead , the client can see object in his periphery (kozier, p.591) Both eyes coordinated, move in unison, with parallel alignment (kozier, p.592) Able to read newsprint (kozier, p.592)
The client can see the object in his periphery
9. Extraocular Muscles a. Alignment and coordination of the eye 10. Visual acuity a. Near vision
Both eyes are coordinated
My client¶s both eyes are coordinated.
Cannot read newsprint
b. Distance vision C. Ears 1. Auricles a. Color, symmetry of size and position
20/20 vision on snellen chart (kozier, p.592)
farsighted
My client¶s cannot read newspaper because her eyes is blured in near vision My client¶s can read through far
Color same as facial skin; symmetrical ; auricle aligned with outer canthus of eye, about
Same with the color of the face; auricles are symmetrically aligned with outer canthus of eye
My client¶s auricle is same with the color of the face; auricles are
10 degrees from vertical (kozier, p.596) b. Palpate for texture, elasticity and areas of tenderness Mobile, firm and not tender; pinna recoils back after it is folded (kozier, p.596) Elastic, firm, no tenderness; pinna recoils back after it is folded
symmetrically aligned with outer canthus of eye My clients auricle is elastic, firm, no tenderness; pinna recoils back after it is folded My client¶s external ear has a dry cerumen, brown in color. There are no lesions, pus and blood My client can hear normal voice tones My client can hear the ticking sounds My client can hear the sound on both ears My client can hear the sound on both ears
2. External Ear canal a. Presence of cerumen, skin lesions, pus and blood
Distal third contains hair follicle and glands: (dry cerumengrayish tan in color, wet cerumen ± various of brown) (kozier, p.596) Normal voice tones audible (kozier, p.597) Able to hear ticking in both ears (kozier, p.597) Able to hear ticking in both ears (kozier, p.597) Air conducted hearing is greater than the bone conducted hearing (kozier, p.598) Symmetric; no discharge; no flaring; uniform color (kozier, p.600) Mucosa is pink; clear, watery; no discharge; no lesions (kozier, p.600) Air moves freely as the client breathes through the nares
There is dry cerumen brown in color; no lesions, pus and blood
3. Hearing Acuity Test a. Normal voice tones b. Watch tick test c. Weber¶s test d. Rinne¶s test
Normal voice tones heard Can hear the ticking sounds Sound is heard on both ears Air conducted hearing is greater than the bone conducted hearing
D. Nose and Sinuses a. Shape, size , color, flaring or discharge from the nose b. Presence of redness, swelling, growths and discharge of the nasal cavity c. Patency of both nasal cavities
Symmetric, straight, uniform in color; no discharge or flaring
Paled pink; clear and watery; no discharge, lesions and swelling
Air moves freely as the client breath out
My client¶s nose is symmetric, uniform color and has no discharge or flaring My clients nose is Paled pink; clear and watery; no discharge, lesions and swelling The air moves freely as my client breathe
(kozier, p.600) d. Nasal septum Nasal septum is intact and at the midline (kozier, p.600) Intact and at the midline
out. My client¶s nasal septum is Intact and at the midline
E. Mouth 1. Lips and Buccal Mucosa a. Symmetry of contour, color and texture 2. Teeth and Gums a. Color, number and condition and presence of dentures
Uniform pink color; moist, soft, glistening, and elastic texture (kozier, p.602) 32 adult teeth; smooth, white, shiny tooth enamel (kozier, p.602)
Slightly Pink in color; soft. It is moist, smooth texture; symmetry of contour; ability to purse lips 28 teeth with dental carries; 4 severely damaged
My client¶s lips are pale because of possible dehydration My client has dental caries and she only has 28 teeth which are supposed to be 32 because of poor dental hygiene and lack of dental checkup
3. Tongue/floor of the mouth a. Color, shape, texture and the presence of bony prominences
Light, pink hard palate, more regular texture (kozier, p.604)
Light pink hard palate; pink rough or lumpy soft palate
a. Position, color, and Smooth; moves freely; no texture; movement and tenderness base of the tongue (kozier, p.603)
Central position; pink color; moist; slightly rough; thin whitish coating; smooth lateral margins; no lesions with raised papillae
b. Any nodules, lumps or
Smooth; no palpable nodules
Smooth; no palpable nodules
My client¶s tongue is slightly pale hard palate because of possible dehydration My client¶s tongue is in central position; slightly pale in color; because of possible dehydration moist; thin whitish coating; smooth lateral margins; no lesions with raised papillae l My client¶s tongue has
excoriated areas 4. Palates and uvula b. Color, shape, texture and the presence of bony prominences c. Position and mobility of uvula F. Neck and lymph nodes 1. Neck Muscle
(kozier, p.604) Light, pink hard palate, more regular texture (kozier, p.604) Positioned in midline of the soft palate (kozier, p.604) Slightly pink hard palate; pink smooth soft palate
no nodules My client¶s palate is Slightly pink in color because possible dehydration Her uvula is positioned in the midline
Uvula is at the middle of the soft palate
Muscle equal in size ; head centered (kozier, p. 607)
Muscle equal in size; head centered
There is an equal size in the muscle of her neck and her head is positioned in center
2. Lymph nodes 3. Trachea a. Placement
Central placement in the midline the of neck; spaces are equal on both sides (kozier, p.608) Not visible (kozier, p.608) Lobes may not be palpated. If palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing (kozier, p.608)
Placed at the midline and spaces equal on both sides
Trachea is placed in the midline and has equal space on both sides Her thyroid gland is not visible upon palpation Her lobes are not palpable upon palpation
4. Thyroid gland a. Symmetry and visible masses b. Smoothness and areas of enlargement, masses or nodules
Not visible on inspection
lobes not palpable; no enlargement, masses or nodules
G. Thorax 1. Posterior Thorax a. Shape, symmetry, diameter of
Anteroposterior to transverse diameter in ratio of 1:2; chest
1:2 diameter symmetric with chest
She has 1:2 diameter symmetric with chest
anteroposterior thorax to transverse diameter; color; lesions b. Temperature, tenderness, masses
symmetric (kozier, p.614) Uniform temperature; no tenderness; no masses (kozier, p.614) Full and symmetric chest expansion; thumbs separate 35 cm (1.5-2 inches) as the client takes a deep breath (kozier, p. 615) Bilateral symmetry of vocal fremitus; fremitus is heard most clearly in the apex of the lungs (kozier, p.615) It has uniform temperature, no tenderness, and no masses she has uniform temperature, no tenderness, and no masses She hasFull and symmetric chest expansion; thumbs separate 3-5 cm as the client takes deep breath She has a bilateral symmetry of the vocal fremitus; fremitus is heard most clearly in the apex of the lungs The client breath quiet, rhythmic and effortless respiration The client temperature is uniform and there is no any tenderness and masses She has a Full and symmetric chest expansion when the client takes a deep breath Normal
c. Respiratory excursion
Full and symmetric chest expansion; thumbs separate 3-5 cm as the client takes deep breath
d. Vocal fremitus
There is bilateral symmetry of the vocal fremitus; fremitus is heard most clearly in the apex of the lungs
2. Anterior Thorax a. Breathing patterns
b. Temperature, tenderness, masses
Quiet, rhythmic and effortless respiration (kozier, p.617) Uniform temperature; no tenderness; no masses (kozier, p.617)
The client breath quiet, rhythmic and effortless respiration The temperature is uniform and there is no any tenderness and masses
c. Respiratory excursion
d. Tactile fremitus
Full and symmetric chest expansion; thumbs separate 35 cm (1.5-2 inches) as the client takes a deep breath (kozier, p.617) Same as the posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue
Full and symmetric chest expansion when the client takes a deep breath
Vocal fremitus is decreased it sound when it became near the heart ad breast
e. Auscultation of the trachea
(kozier, p.617) Bronchial and tubular breath sounds (kozier, p. 618) Bronchovesicular and vesicular breath sounds (kozier, p.618)
Bronchial and tubular breath sound are easily heard
f.
Auscultation of the anterior thorax
Bronchovesicular and vesicular breath sounds are easily be heard
My client Bronchial and tubular breath sound are easily heard Bronchovesicular and vesicular breath sounds are easily be heard Her Pulse can be easily felt Normal
1. Carotid Arteries a. Palpation of carotid artery b. Auscultation of carotid areas 1. Bones a. Normal structure and deformities b. Areas of edema or tenderness A. Assess Joints range of motion a. Upper extremities (shoulder and scapula) b. Upper extremities (elbows) c. Upper extremities (hands) d. Lower extremities (acetabulum/ inguinal area) e. Lower extremities (popliteal)
Symmetry pulse volumes; full pulsations, thrusting quality (kozier, p.622) No sounds heard on auscultation (kozier,p.623) No deformities (kozier, p.641) No tenderness or swelling (kozier, p.641)
Pulse can be easily felt
No sounds heard upon auscultation
No any bones deformities and structure No tenderness and swelling
She has No any bones deformities and structure No tenderness and swelling upon palpation
Smooth coordinate movements (kozier, p.641) Smooth coordinate movements (kozier, p.641) Smooth coordinate movements (kozier, p.641) Smooth coordinate movements (kozier, p.641) Smooth coordinate movements (kozier, p.641)
Limited range of motion Limited range of motion Limited range of motion Limited range of motion Limited range of motion
f.
Lower extremities (ankle)
Smooth coordinate movements (kozier, p.641)
Limited range of motion
C.Patterns of Functioning According to Gordon FUNCTIONAL HEALTH PATTERN A. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN The patient perceived her health in the state of good condition she considered healthy about her is ³masigla ako, hindi ako mapakali pag wala akong gingawa at pag konting sakit naman hindi ko iniinda saka pag feeling ko hindi ko na kaya saka lang ako pupunta sa ospital.. She manages his health by practicing proper hygiene and eating nutritious food .the client does not drink, smoke or use any vices. Her environment is well ventilated and has an adequate lightning. During hospitalization she sees herself as a total ill person because she cannot do anymore the things she usually does like going to work, taking care of her children. She rely her present condition with the help of the therapeutic personnel and by following the prescribed medications. The patient perceived that he is not healthy because of his condition. ANALYSIS The World Health Organization takes a more holistic vie of health. Its constitution defines a state of complete physical, mental and social well being and not merely the absence of disease. (WHO 1948) (Fundamentals of Nursing, Barbara Kozier, 2004p.171) INTERPRETATION She perceives health as wealth and she values his health a lot.
B. NUTRITIONAL AND METABOLIC PATTERN
3 DAY DIET RECALL SUNDAY BREAKFAST SUNDAY SANDWICH 2 CUP OF WATER
LUNCH
DINNER
FRIED CHICKEN 1 CUP OF RICE 3 CUP OF WATER
LUGAW 2 CAP OF WATER
MONDAY ARROZCALDO W/ BREAD TUESDAY LUGAW W/ EGG AND BREAD MANOK W/ SABAW SAGING SAGING SABAW 1 CUP OF RICE SAGING TILAPIA 1 CUP OF RICE SAGING
The patient eats 3 times a day with her family at their house and an afternoon snacks after coming from work. According to her, she eats meat, fish and also vegetables and some dry foods she doesn¶t like smelly food. Her food preparation is more on fried, steaming and w/ soup. Her appetite is moderate and usually depends on the food being served. She didn¶t complain any difficulty in swallowing. During hospitalization pag kumakaen ako pinupupu ko rin,´as client stated. The doctor recommends having a banana rice apple tea (BRAT) diet .
Analysis There are profound changes in maternal metabolism during pregnancy, and successful adaptation to these changes is necessary for favorable pregnancy outcome. There are alterations in the maternal metabolism of protein, carbohydrate and fat. Changes occur in maternal metabolism to accommodate these needs of the fetus. Increased macronutrient and micronutrient intake by the mother during pregnancy ensures that these increased metabolic needs are met (Foundations and Clinical Application of Nutrition A Nursing Approach, Furth Edition , Michele Grodner, EdD, cHes, 2004 pp. 238.)
Interpretation The client knows the proper nutrition¶s food to be eaten during pregnancy.
C. ELIMINATION PATTERN The client has a discomfort in deficating her stool is yellowish and watery ³isang labasan at onti lang´ as verbalized by the client she deficates 3 time a day ³kapag pumupupu ako humihilab yung tiyan ko pero pag nalabas ko na malaking ginhawa As client stated. The client has no discomfort in urinating her urine is yellowish she urinates 10x a day. The client always eats banana and increasing fluid intake to achieve a proper normal elimination. The client has no odor problems Analysis The factors that affect defecation are diet and activity. Sufficient bulk in the diet is necessary to provide fecal volume. Activity stimulates peristalsis, thus facilitating movement of byme along colon. Weak abdominal and pelvic muscles are often ineffective in increasing the intra abdominal pressure during defecation or in controlling defecation. (Fundamentals of Nursing 7th edition, Barbara kozier, 2004 pp. 1223-1229)
INTERPRETATION The client does not defecate within the normal bowel elimination. She has a problem with defecating her stool is watery and yellowish she feels abdominal pain when she is defecating.
D. ACTIVITY EXERCISE PATTERN
The client usually activities in a day are praying, cooking, and cleaning the house,and going to work. She usually walks 500 meters going to school and going home she takes about 5 mins of walking. She is satisfied with the amount of exercise that she can get. During hospitalization her activity was limited lying on bed ³ngayon naka hospital ako hindi ko nagagawa ang dapat kong gawin kasi buntis ako at sa kalagayn ng sakit ko´as client verbalized. But the patient is given his bathroom privileges
Analysis Individuals who have inactive lifestyles or who are faced with inactivity because of illness or injury are at risk for many problems that can affect major body systems. Immobility adversely affects the cardiovascular, respiratory, metabolic, urinary and psychoneurologic systems. ± Fundamentals of Nursing by Kozier, 7th ed
Interpretation The client¶s has a routine physical activity but there is a restriction of activities because of her present condition.
E. SLEEP REST PATTERN The client¶s usually time of sleep is 10pm-5am she is taking a nap for 2 hours in office just to take a rest for a while. She is not satisfied with the amount of hours of her sleep. ³Kung meron pang time gusto ko pa sana matulog kaso wala na eh´ as verbalized by the client. She always wakes up by night ³nagigising ako ng alanganing tapat pag gumagalaw si baby´ as verbalized by the client. Sometimes she feels refreshing when she wakes up. Her sleeping environment is quiet but when her baby is crying she interrupt her sleeping. The client always watches TV for her relaxation, doing her chores and after that she is going to sleep as her bed time routine. By closing her eyes it is help to make her asleep. During hospitalization she doesn¶t have the adequate time of sleep since she is disturbed with the nurses that enter the room every now and then, and because of the environmental changes of her surroundings. Analysis Environment can promote or hinder sleep. Any change for example, noise in the environment can inhibit sleep. The absence of usual stimuli or the presence of unfamiliar stimuli can prevent people from sleeping. ± Fundamentals of Nursing by Kozier 7th Ed. Interpretation The pattern of sleep for her it¶s not satisfying because of some disturbance to her surroundings. Because environment can promote or hinder sleep. F. COGNITIVE-PERCEPTUAL PATTERN INTERPRETATION The client can read, write, and speak. She has no difficulty in hearing, but her vision is nearsighted she wears eye glasses last year and her last checked up was last year also. She is sensitive in smell when she is in the stage of first trimester period. And also she is doing fine in work.
ANALYSIS Young adults are able to use formal operation characterized by the ability to think abstractly and employ logic. Young adults are able to generate hypothesis what will happen given a set of circumstances and do not have engaged in trial and error behavior. (fundamentals of nursing kozier pp.394-395)
INTERPRETATION She is normal in terms of his cognitive abilities. She has good memory and reasoning skills. He can easily comprehend on things. In terms of her perceptual pattern, she has no problems with his senses except with her vision
G. SELF PERCEPTION AND SELF-CONCEPT PATTERN She sees herself as a person with a good personality. She has been a good friend, sister and a mother. She said she has to be a good person in order not to hurt others. She also describes herself as ³masigla, walang problema´ as verbalized by the client. She expresses her thoughts by telling her problem especially to her husband. Her next goal after five years is to finish her masteral degree, to ensure that their children are finishing their study and she will work hard to pursue her dreams. The client wants to be with a happy person and open to her. Her type of mood was ³tawa nalang ako kahit may problema tawa parin´ as verbalized by the client. ANALYSIS Is one¶s mental age of oneself. A positive self concept is essential to a person¶s mental and physical health individuals with a positive self concept are better able to develop and maintain interpersonal relationship and resist psychologic and physical illness.-Fundamentals of nursing Kozier 8th edition p.1003 INTERPRETATION The client has no problem with her personality. She is doing well in everything just to give a good future for her family and she has in a positive outlook.
H. ROLE RELATIONSHIP PATTERN The client lives with her family and she has a close relationship with her family. She is fulfilling her role as a full time mom. Their usually activities when there is no work are going to church every Sunday, eating together in fast food , and going to the mall to buy grocery. They are expressing their thoughts or opinion by talking to one another. She thinks that her work is being affected by her health status because of so much stress. Her income is sufficient for her family¶s need. During hospitalization she had more time to bond with her family. She said that it was a nice feeling to know that your family is so supportaive to him. She learned to appreciate the beauty of having a family that gives you strength and support no matter what.
ANALYSIS Throughout life people undergo numerous role changes. A role is expectation about how the person occupying one position behaves. Role relationship relates what a person in particular role does to the behaviors expected of that rolefundamentals of nursing kozier 8th edition p.1006
INTERPRETATION My client is close to her family. And also I observed that they are open to each other. They have a good family bonding.
I.
SEXUALITY-REPRODUCTIVE PATTERN The client uses calendar method as their contraceptives. Her last menstrual period was on July 20, 2010.
ANALYSIS According to Erikson the danger of this stage is role confusion. The inability to settle on an occupational identity commonly disturbs adolescent. The adolescent needs to establish a self concept that accepts both personal strength and weaknesses. The milestone of female puberty is menarche. INTERPRETATION They are not using any contraceptives except calendar method. The couple had planned to have a family planning as well J. COPING STRESS TOLERANCE PATTERN According to the client her stressful event is having no money she handle her stress by praying. Her husband is always there to help and talk the most whenever if they have a problem. The client has big changes in her life such as she didn¶t do things that she does before. Whenever she has a big problem she will talk to her husband to ask for advice. During hospitalization she shares her problems to his family. She verbalizes her feelings and condition.
ANALYSIS Stress is a condition in which the person experience changes during the normal balance state-fundamentals of nursing kozier 8th edition p.1061 INTERPRETATION The client experience stress but she handled it by expressing her feelings by someone close to her. K. VALUE-BELIEF PATTERN The client defines a healthy person as mentally, physically, spiritually, and absence of diseases she is belongs to Roman Catholic the most important things being a catholic is by praying to god because as she said ³siya talaga pedeng mapagsabihan ng problema´. According to her health is important because health is wealth.
ANALYSIS Religion is an organized system beliefs and practices. It offers a way of spiritual expression that provides guidance for believers in life¶s question and challenges.-fundamentals of nursing kozier 8th edition p.1004
INTERPRETATION My client has her own definition of heath. Religion is also important to her. She has faith in God.
D. significant laboratory findings FECALYSIS (feb15, 2011) YELLOW WATERY NO OVA OR PARASITES SEEN 1-3/HPT 0-1/HPT 132.9mmol/L 3.60
COLOR
CONSISTENCY AMOEBA PLUS CELLS RBC SODIUM POTASSIUM
INTERPRETATION: The color of her fecalysis is yellow which is an indication that she has a problem in her GI tract. The consistency is watery. There is an absence of amoeba.
Hematology report (feb15, 2011) FINDINGS Hemoglobin Hematocrit Erythrocyte Leukocytes Lymphocytes Platelet count Blood type B rh+
REFERENCE VALUE 125-160 0.38-0.800 4.5-5.5 (F) 5-10 0.20-0.40 120-350
ACTUAL FINDINGS 148 g/L 0.44 5.08x10/ul 12.0 0.18 320 x10/L
INTERPRETATION The client¶s hemoglobin, hematocrit and erythrocytes, is within in a normal range but her leukocytes is higher within the normal range which indicates that she has a leukocytosis. Her white blood cells are increase than red blood cell. Another is lymphocytes that have low value within in a normal which means that her body's resistance to fight infection has been substantially lost and one may become more susceptible to certain types of infection. Her platelet count is within in a normal range and her blood type B rh(+) it means that her plasma is contains antibodies and it has no effect to her baby.
IV.pathophysiology She ate mango, banana, rice, milk, rice that can be the cause of diarrhea
Ingestion of bacteria
Invading and killing of the intestinal villi
Foods cannot be digested
Disturbing the structural integrity of the region
Food molecules acts as osmotic agent Large amounts of water,electrolytes, and intestinal fluids were pulled Inflammation of the lining of the stomach
Watery stool, Abdominal pain, malaise, ,
I.
List of prioritized problems *not less than 5, nanda based Cues S: ³mga 3days na ako nagtatae isang labasan lahat yun at puro tubig walang buo´ O: - watery stool -slighly dehydrated -yellowish rationale When fluid loss exceeds intake, a fluid volume deficit exists. A fluid volume deficit is a physiological situation in which fluids are lost in an isotonic fashion (both fluid and electrolytes Are lost together).
DIAGNOSIS 1. Deficient Fluid volume related to excessive looses
2 risk. Imbalance nutrition less than bodily requirements
S: ³pag kumakaen ako pinupupu ko rin,´ O: -brat diet only
Poor nutrition can be a cause of low infant birth weight.
3.acute pain related to abdmoninal cramping
S: kapag pumupupu ako humihilab yung tiyan ko pero pag nalabas ko na malaking ginhawa O: -abdominal pain -facial grimace -weak
4.risk for dehydration
S:´nagtatae ako ng tubig 3 araw na´ 0: -weak
Because more electrolytes and fluids that being expelled it can be a cause of dehydration
- slightly poor skin turgor 5.Activity intolerance r/to weakness S:´ngayon naka hospital ako hindi ko nagagawa ang dapat kong gawin kasi buntis ako at sa kalagayn ng sakit ko´ O: -weak -malaise -lethargic According to Maslow¶s hierarchy of needs, activity intolerance is in the physiologic needs and it must be prioritized. In ABC¶s of life activity intolerance has something to do with the energy and it is categorized as B stands for breathing.
VI. DRUG STUDY Name of the Drug
Indications
Mode of Action
Specific Nursing Responsibility ASSESSMENT History: CNS or Hepatic disease, candidiasis, blood dyscarias, pregnancy, lactation. Physical: Reflexes, affect; skin lesions, color (with topical application); abdominal examination, liver palpitation, urinalysis, CBC, LFTs INTERVENTIONS: WARNING:do not use unless needed. Metronidazole may be carcinogenic. - Administer oral doses with food. - Apply topically after cleansing the area. Advise patient that cosmetic may be used over the area after application. - Reduce dosage in hepatic disease. TEACHING POINTS: take full course of drug therapy; take the drug
Metronidazole 500 mg
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acute infection with susceptible anaerobic bacteria Acute intestinal amebiasis Amebic liver abcess Trichomoniasis
- BACTERICIDAL: inhibits DNA synthesis in specific(obligate) anaerobes, causing cell death; antiprotozoal-trichomonacidal, amebicidal: Bio-chemical mechanism is unknown.
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with food if GI upset occurs. Do not drink alcohol (beverages or preparations containing alcohol, cough syrups) for 48-72 hr of drug use; severe reactions may occur. Your urine may be a darker color than usual; this is expected. Refrain form sexual intercourse during treatment for trichomoniasis, unless partner wears a condom. Apply the topical preparation by cleansing the area and then rubbing a thin film into the affected area. Avoid contact with the eyes. Cosmetics may be applied to the area after medication is dry. You may experience these side effects: Dry mouth with strange metallic taste; nausea, vomiting, diarrhea. Report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills.
Name of Drug
Indications
Mode of Action
Specific Nursing Responsibility Assessment HISTORY: allergy to penicillins, cephalosporins, or other allergens; renal disorders; lactation PHYSICAL: culture infected area; skin color; lesion; R, adventitious sounds; bowel sounds, CBC, LFTs, renal function tests, serum electrolytes, Hct, Urinalysis culture infected area before treatment; reculture area if response is not as expected. Check IV site carefully for signs of thrombosis or drug reaction. Do Not give IM injections on the same site; athropy can occur. Monitor injection sites. Administer oral drug on an empty stomach, 1 hr before or 2 hrs after meals with a full glass of water, do not give fruit juice or soft drinks.
Ampicillin 500 mg
Treatment of infections caused by susceptible strains of Shigella, Salmonella, S. typhosa Haemohilius Influenzae, Proteus mirabilis, enterococci, gram ± positive organisms
Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death
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Teaching Points Take this drug around-theclock Take the full course of therapy; do not stop taking the drug if you feel better. This anti-biotic is specific in your problem and should not be used to self-treat other infections. If you are a woman and you use a hormonal contraceptive, you should use a second form of birth control for 1-2 weeks while taking this drug. You may experience this side effects: Nausea, Vomiting, GI upset(eat small frequent meals), diarrhea Report pain or discomfort at sites, unusual bleeding or bruising, mouth sores, rash, hives, fever, itching, severe diarrhea, difficulty breathing.
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Name of Drug
Indications
Mode of Action
Specific Nursing Responsibility Assessment: HISTORY: allergy to lomustine, radiation therapy, chemotherapy, hematopoietic depression, impaired renal or hepatic function, pregnancy, lactation PHYSICAL: T; weight, mucous membranes, liver evaluation; CBC , differential; urinalysis; LFTs, renal function tests WARNING: Do not give full dosage within 2-3 weeks after a full course of radiation therapy or chemotherapy due to risk of severe bone marrow depression; reduced dosage may be needed. advise patient that this drug cannot be taken during pregnancy
Loperamide 1 capsule
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Control and symptomatic relief of acute non ±specific diarrhea and chronic diarrhea associated with inflammatory bowel disease Reduction of volume of discharge from ileostomies. OTC use: control of diarrhea including traveler¶s diarrhea.
- slows intestinal motility and affects water and electrolyte movement through the bowel by inhibiting peristalsis through direct effects on the circular and longitudinal muscles of the intestinal wall.
INTERVENTIONS Monitor for response. If improvement is not seen within 48 hrs, discontinue treatment and notify health care provider.
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Give drug after each unformed stool. Keep track of amount given to avoid exceeding the recommended daily dosage unless directed by a physician. WARNING: Have the opoid antagonist naloxone readily available in case of overdose and CNS depression. TEACHING POINTS Take drug as prescripted. Do not exceed prescribed dosage or recommended daily dosage. Drink clear fluids to prevent dehydration You may experience these side effects: Abdominal fullness, nausea, vomiting, dry mouth, dizziness. Report abdominal pain or distention, fever and diarrhea that does not stop after a few days.
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VII.NCP (7 COLUMNS)
ASSESSMENT
NURSING DIAGNOSIS Deficient Fluid volume related to loose bowel movement
ANALYSIS
GOALS AND OBJETIVE GOALS: After 5 hours of nursing intervention the client will be able to minimized loose bowel movement OBJECTIVES 1. After 20mins of discussion, .the client will be able to discuss the 2 disadvantages of diarrhea 2.After 20mins of discussion, the mother will be able to define diarrhea 3. After 20mins of discussion,
NURSING INTERVENTION
RATIONALE
EVALUATION
S: ³mga 3days na ako nagtatae isang labasan lahat yun at puro tubig walang buo´ O: - watery stool -yellowish -3X BM
When fluid loss exceeds intake, a fluid volume deficit exists. A fluid volume deficit is a physiological situation in which fluids are lost in an isotonic fashion (both fluid and electrolytes are lost together).
>Determine effects of age
Very young and extremely elderly ind. Are quickly affected by fluid volume deficit To know the current status of her vital signs To determine if there is a dehydration >these signs
>Assess vitals
>note any presence of physical signs >note change in
the mother will be able to state 3 out of 5 causes of diarrhea 4. After 20mins of discussion, the mother will be able to state 3 out of 5 causes of diarrhea
usual mentation
indicate sufficient dehydration to electrolytes imbalance >to more accurately determine replacement needs >fluid use for replacement >that lend to exert diuretic effect >early identification of risk factors can decrease occurrence and severity of complications associated with hypovolemia
>observe I and O
>administer IV >limit intake of alcohol >discuss factor related to occurrence of deficit as individually appropriate
VIIi DISCHARGE PLAN DISCHARGE PLAN Learning content Medication y y y Take iron supplement once a day Take vitamin C Be sure to get adequate amounts of rest Take naps during the day Rest when the neonate is resting Begin exercising when allowed by health care provider; starts slowly and gradually increase the amount done. Increased fluid intake Exercise daily and eat more nutritious food
Exercise
y
Treatment
y y
Hygiene
y y
Wash perineum from front to back with the use of betadine feminine wash and warm water Take a bath 3x a day y y y Increase protein and calorie intake to restore body tissues If breast-feeding drink at least ten 8 oz (237mL) glasses of water per day Drink plenty of fluids specially water and eat foods that are high in fiber to prevent constipation
Diet
