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A Case Study On

Acute Gastroenteritis

In Partial Fulfillment of the Requirements

In NCM103N- Related Learning Experience

Metabolism Concept

Submitted to:

Ms. Trina S. Domanais RN MN MAN

Clinical Instructor

Submitted by:

FsCrestine N. Buga-ay St.N

Cyrus Jean S. DestorSt.N

Marigold Anne Diaz St.N

Nada A. PaguitalSt.N

Ramon Bien E. PatrataSt.N

July 04, 2013

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TABLE OF CONTENTS

Introduction 3

Objectives 5

Initial Data Base 7

Biographic Data 7

Clinical Data 7

Family Health History 8

Past Health History 8

History of Present Illness 9

Definition of Diagnosis 10

Physical Assessment 12

Anatomy and Physiology 15

Pathophysiology 26

Etiology

Symptomatology 26

Schematic Tracing of the Disease 27

Narrative 29

Medical Management 33

Diagnostic Exam 33

Actual

Laboratory Test

Diagnostic Exams

Possible Laboratory & Diagnosis

Therapeutics 62

Drug Study 72

Nursing Care 80

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Nursing Care Plan 80

Discharge Planning 91

Nursing Theory 93

Prognosis 94

References 96

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INTRODUCTION

Metabolism is an integral part of the physical and chemical processes in the body that convert

or use energy for bodily functions such breathing, circulating blood, controlling body

temperature, contracting muscles, digesting food and nutrients, eliminating waste through urine

and feces and functioning of the brain and nerves (ADAM, 2011).

We students nurses were task to look for a patient with metabolic problem in accordance to our

metabolism concept. This task involves having the permission of the client to be a part or our

subject for our case study as well as the required consent from the higher authorities. During

our exposure on St. Luke’s ward which mostly handles patients with metabolic problems, we’ve

seen and known patient experiencing different types of metabolic diseases that gives us the

knowledge on what is the actual picture of that certain disease or complication. Also, we’ve

experience alot of complication on that clinical experience because some patient we’re not

cooperating and wants their privacy during their stay on that certain hospital and we have to

accept it because it is a part of their privileges being a client of that institution.

We, the BSN 3B, group 4 subgroup 1 had our 3 weeks and 1 day experience at St. Luke’s Ward

of San Pedro Hospital. Our client is Mr. M.Q, 31 years old who is admitted due to fever and LBM

on June 19, 2013 at 10:15 PM. We chose him as our client since He is fit to be our subject in

our case study for having an Acute Gastroenteritis which is one of the metabolic problems. Also,

He is willing and has the cooperation to answer our queries in accordance with his condition.

Gastroenteritisis also known asgastro, gastric flu, andstomach flu, although unrelated to

influenza.  It is the inflammation of the gastrointestinal tract, involving both the stomach and the

small intestine and resulting in acute diarrhea . The inflammation is caused most often by

infection with certain viruses, less often by bacteria or their toxins, parasites, or adverse reaction

to something in the diet or medication.

According to the Centers for Disease Control and Prevention that Worldwide, inadequate

treatment of gastroenteritis kills 5 to 8 million people per year. The Philippine Health Statistics

reported that 971 infants out of 1000 live births died due to Gastroenteritis in the year 2009. And

in Davao City, we have 4, 862 numbers in all ages which is rank as 3rd leading cause of

morbidity in the year 2011 according to City Health Office of Davao City. Gastroenteritis occurs

on individuals in all ages.

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This case study aims to gather all necessary data that can help provide useful

information for health workers who are interested in learning epilepsy. This study can be used

as data for further nursing research on the topic.

In nursing education we are given the chance to enhance our knowledge with regards on the

disease process and we have also the chance to impart our knowledge on our patient through

giving of health teachings. In nursing research, we are oblige to search more about the disease

as well as its possible causes, it’s treatment and some possible modification of lifestyle. And

finally in nursing practice, our skills were enhance and guided by our clinical instructor to give

the proper medical care that the patient should get to lessen his burdens. Through rendering the

appropriate interventions and management to the client.

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OBJECTIVES

General Objectives:

That within our 4 weeks span of duty at St. Luke’s Ward, we will be able to present a

comprehensive case study and enhance our skills in developing our nursing capabilities.

Specific Objectives:

The group specifically aims to:

o find a patient that will serve as our subject for our case study;

o establish rapport with the patient and his significant others to gain their trust and

cooperation;

o gather all necessary data through conducting an interview and through reviewing the

patient’s chart;

o perform a thorough cephalocaudal assessment on the client to determine any

abnormalities;

o identify the normal and abnormal findings taken during the cephalocaudal assessment;

o construct an introduction that will serve as an overview of the rotation, case and client;

o formulate general, specific, measurable, attainable, realistic and time-bounded

objectives to serve as our guide;

o collect pertinent personal causes of the client’s present condition specifically the client’s

family lineage, family history, past health history and present health illnesses;

o explain the anatomy and physiology of the affected system of our client’s case;

o trace the pathophysiology of our client’s case along with its predisposing factors,

precipitating factors, etiology and symptomatology;

o explain the medical management for our client’s case which includes the diagnostic and

laboratory examinations, doctor’s orders and the medications administered;

o make five nursing care plans composing of three actual problems and two risk problems;

o render suitable health teachings to the client regarding his conditions;

o discuss the discharge plan and the prognosis on our client’s case; and

o enumerate all the references that we used during the case study.

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INITIAL DATA BASE

PERSONAL DATA

NAME: Marvin Quinsaat SEX: Male

ADDRESS:B21, L12 Rosalina Village 2, Puan BIRTHDAY: August 17, 1981

AGE: 31 years old BIRTHPLACE: Manila

RELIGION: Agnostic CIVIL STATUS: Single

NATIONALITY: Filipino OCCUPATION: None

MOTHER’S NAME: NenitaQuinsaat FATHER’S NAME: Mario Quinsaat

Live-in partner: Lanee Gonzales

CLINICAL DATA

DATE OF ADMISSION: June 19, 2013 TIME OF ADMISSION: 10:15PM

HOSPITAL: San Pedro Hospital WARD: Sta. Rosa Ward transferred

to St. Luke’s Ward

ATTENDING PHYSICAIN:Dr. Marjorie B. Guillermo CHIEF COMPLAINT: Fever and

LBM

ADMITTING DIAGNOSIS: ADMISSION VS:

Temp. – 38.9˚C

PR- 95 bpm

CR- 101 bpm

RR- 20

BP-110/70

Acute gastroenteritis with moderate dehydration

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FAMILY HEALTH HISTORY

Through the interview we had, we were able to get information about the family of our

client and their illness. His grandfather on his father side Mr. WQ died because of the

complications of hypertension while his grandmother, Mrs. JQ died because of pancreatic

cancer. On the other hand his grandfather on his mother side Mr. BC died because of

thyroidism while his grandmother, Mrs. AC died because of old age. Both of them had asthma.

Meanwhile, his father Mr. MQ has hypertension and migraine then his mother Mrs. NQ

has asthma. Our client has 3 siblings; all of them have asthma at the moment. His brother MQ

has meningitis. Mr. MQ our client has hyperthyroidism.

PAST HEALTH HISTORY

Quinsaat - Cruz

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Our client had a history of asthma which started at the age of 3. He also told us that he

is a non-alcoholic beverage drinker. But he is a smoker for 15 years with 15-20 sticks/day that

probably one of the causes of his hypothyroidism aside, from his genetic history of thyroidism.

His hyperthyroidism occur 3-4 years ago. His live in partneer Ms. LG told us that our client

doesn’t have any allergies from food and drugs.

PRESENT HEALTH HISTORY

It started 2 days prior to his admission he has an intermittent fever that riches 39+0C.

This was associated with loose stools which is 5 episodes/dayLast June 19, . He took

paracetamol as a temporary relief. 2013 at 10:15pm, our client was admitted at San Pedro

Hospital via wheelchair. Few hours prior to admission our client was having persistent

symptoms with body malaise, dizziness and positive smoker’s cough.

DEFINITION OF DIAGNOSIS

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Gastroenteritis

An acute inflammation of the gastric and intestinal mucosa which is most commonly due

to bacterial,viral,protozoal, or parasitic infection. It may also be caused by irritation due to

chemical or toxin exposure or allergic response. Viral exposure is more likely in winter; bacterial

exposure is more common in summer when food-borne illness exposure is likely.

Reference:

DiGuilio, M. et al. (2007). Medical-Surgical Nursing Demystified. New York. McGraw Hill.

Gastroenteritis is a condition that causes irritation and inflammation of the stomach and

intestines (the gastrointestinal tract). An infection may be caused by bacteria or parasites in

spoiled food or unclean water. Some foods may irritate your stomach and cause gastroenteritis.

Lactose intolerance to dairy products is one example.

Reference:

WebMD - Better information. Better health. Gastroenteritis (Stomach Flu) Symptoms, Causes,

Treatments. Retrieved July 2, 2013,

fromhttp://www.webmd.com/digestive-disorders/gastroenteritis.

Gastroenteritis (better known as the stomach flu) is an inflammation of the GI tract.

Although gastroenteritis can occur at any age, infants and older adults are at risk of having more

severe symptoms.

Reference:

Hurst, M. (2008). Hurst Reviews: Pathophysiology Reviews. New York. McGraw Hill.

PHYSICAL ASSESSMENT

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General Survey

During the assessment, the client was wearing a loose t-shirt and baggy pants.

He is in anectomorphic body build. He stands to(height in cm) and weighs (weight in kg). And

his BMI is (bmi). Level of consciousness is alert and oriented. He was in an appropriate mood

and was cooperative during the assessment. He also had and IVF of PNSS 1L @ 140cc/hr

infusing well at left metacarpalvein.

Vital Signs

Vital sign Normal range Result

Blood pressure 10/70-120-80 120/80

Cardiac Rate 60-100 87

Pulse Rate 70-80 80

Respiratory Rate 16-20 20

Skin, Hair, and Nails

His hair was evenly distributed and was well groomed. He had silver strands of hair on

his head. His skin was warm to touch and had good skin turgor, with no discolorations noted.

His finger and toe nails were long and uncut. Capillary bedsrefilledat 2 seconds.

Head and Neck

His head was symmetrical and round in shape, erect and is midline. And also, neither

lesions nor masses were noted upon palpation. His neck was symmetrical with head centered.

(add thyroid assessment here). Lymph nodes were not palpable.

Eyes

His pupils were equally round and reactive to light stimulation and accommodation. His

eyes move symmetrically. Visual acuity of 150 - 100, he was wearing glasses.

Ears

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His ears had the same color as the facial skin, symmetrical in position, firm and

not tender. Pinna recoils after it is folded. Presence swelling or odorous discharges were not

noted on both ears. Hearing acuity is normal.

Nose and Sinuses

The color of the nose is the same with as the rest of the face; nasal structure is

smooth and symmetrical; and the client reports no tenderness upon palpation. Sinuses were not

tender upon palpation.

Mouth and Pharynx

His lips appeared dry and pale. He has 28 teeth light yellowish in color with no

dental carries. Gums are pink, moist, and firm with tight margins to the teeth. No lesion noted.

The buccal area was also pink and moist with no lesion. The tongue was able to move freely,

with sublingual frenulum intact and midline. The uvula was fleshy, and hangs freely in midline.

Neck?

Breasts and Axillae

The areolar area and nipples were not inspected due to client’s refusal. According to

patient’s verbalization, the nipples were symmetrical with negative inversion, discharges,

crusting, and masses. Both axillas were noted to be free from rashes and infections.

Thorax and Lungs

His anteroposterior transverse ratio was 1:2. He had a (tattoo description here) on his

chest. Clear breath sounds upon auscultation of both lung fields with no adventitious sounds

noted. Upon palpation, vocal fremitus was symmetrical.

Heart

No murmurs skip beats, noted upon auscultation. (add other assessment here).

Abdomen

(add abdominal Assessment here). Hndikokasinakia nag tyannya.:D

Genitourinary

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Client refused visualization of the genitalia.

Musculoskeletal

The muscles on both sides of the body had no contractures and tremors. Muscle

weaknesses were not noted on both lower and upper extremities.

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ANATOMY AND PHYSIOLOGY

The GI System

The gastro-intestinal system is essentially a long tube running right through the body, with

specialised sections that are capable of digesting material put in at the top end and extracting

any useful components from it, then expelling the waste products at the bottom end. The whole

system is under hormonal control, with the presence of food in the mouth triggering off a

cascade of hormonal actions; when there is food in the stomach, different hormones activate

acid secretion, increased gut motility, enzyme release etc. etc.

Nutrients from the GI tract are not processed on-site; they are taken to the liver to be broken

down further, stored, or distributed.

The Esophagus

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Once food has been chewed and mixed with saliva in the mouth, it is swallowed and

passes down the oesophagus. The oesophagus has a stratified squamous epithelial

lining (SE) which protects the oesophagus from trauma; the submucosa (SM) secretes

mucus from mucous glands(MG) which aid the passage of food down the oesophagus.

The lumen of the oesophagus is surrounded by layers of muscle (M)- voluntary in the top

third, progressing to involuntary in the bottom third- and food is propelled into the

stomach by waves of peristalisis.

The Stomach

The stomach is a 'j'-shaped organ, with two openings- the oesophageal and the duodenal- and

four regions- the cardia, fundus, body and pylorus. Each region performs different functions; the

fundus collects digestive gases, the body secretes pepsinogen and hydrochloric acid, and the

pylorus is responsible for mucus, gastrin and pepsinogen secretion.

The stomach has five major functions;

Temporary food storage

Control the rate at which food enters the duodenum

Acid secretion and antibacterial action

Fluidisation of stomach contents

Preliminary digestion with pepsin, lipases etc.

G- mucosa containing glandular tissue; different areas of the stomach contain different

types of cells which secrete compounds to aid digestion. The main types involved are:

o parietal cells which secrete hydrochloric acid

o chief cells which secrete pepsin

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o enteroendocrine cells which secrete regulatory hormones.

MM- muscularis mucosae

SM- submucosa

The stomach contains three layers of involuntary smooth muscle which aid

digestion by physically breaking up the food particles;

o OM- inner oblique muscle

o CM- circular muscle

o LM- outer longitudinal muscle

The Small Intestine

The small intestine is the site where most of the chemical and mechanical digestion is carried

out, and where virtually all of the absorption of useful materials is carried out. The whole of the

small intestine is lined with an absorptive mucosal type, with certain modifications for each

section. The intestine also has a smooth muscle wall with two layers of muscle; rhythmical

contractions force products of digestion through the intestine (peristalsis). There are three main

sections to the small intestine;

Duodenum forms a 'C' shape around the head of the pancreas. Its main function is to

neutralize the acidic gastric contents (called 'chyme') and to initiate further

digestion; Brunner's glands in the submucosa secrete an alkaline mucus which

neutralizes the chyme and protects the surface of the duodenum.

Jejunum where most chemical digestion takes place

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Ileum. The jejunum and the ileum are the greatly coiled parts of the small intestine, and

together are about 4-6 metres long; the junction between the two sections is not well-

defined. The mucosa of these sections is highly folded (the folds are called plicae),

increasing the surface area available for absorption dramatically.

The epithelial surface of the plicae (P) is further folded to form villi(V). These increase

the surface area of the small intestine still further, and the surface of each villus is

covered in small microvilli to maximise surface area- the area available for absorption is

vast. Each villus has its own blood supply- the vessels can be seen in the

submucosa (SM)- and blood containing digestive products from the small intestine is

taken to the liver via the hepatic portal system. The double muscle layer (M) moves food

through the intestine by peristalsis. 

The Large Intestine

By the time digestive products reach the large intestine, almost all of the

nutritionally useful products have been removed. The large intestine removes

water from the remainder, passing semi-solid feces into the rectum to be

expelled from the body through the anus. The mucosa (M) is arranged into

tightly-packed straight tubular glands (G) which consist of cells specialized for

water absorption and mucus-secreting goblet cells to aid the passage of feces.

The large intestine also contains areas of lymphoid tissue (L); these can be

found in the ileum too (called Peyer's patches), and they provide local

immunological protection of potential weak-spots in the body's defenses. As the

gut is teeming with bacteria, reinforcement of the standard surface defenses

seems only sensible.

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Ascending Colon - The ascending colon is comprised of strong muscles that

motor waste products upward and onward out of the body. As part of the larger

gastrointestinal tract, the ascending colon connects and continues the work of

the small intestine in moving food along on its journey through the body. 

Transverse Colon - helps stabilize fluid levels and prepare the body for the

expulsion of waste

Descending Colon - to store food that will be emptied into the rectum;

its function is primarily the absorption of water from fecal matter

Rectum - store your feces and provide force to force feces out of your body

through the anus

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Release of enterotoxins and attachment of microorganisms to mucosal epithilium

Increase secretion of water and electrolytes

Inhibits Sodium reabsorption

Large amount of CHON-rich in fluids

Diarrhea

Decrease intestinal wall integrity

Parasympathetic and sympathetic stimulation

Decrease intestinal absorption

Stimulation of the emetic center

Nausea and vomiting

Increase gastrocolic reflex

Increase peristalsis

Increase bowel sounds, abdominal cramping and abdominal pain

PREDISPOSING FACTORS

- Age- Geographical Location

PRECIPITATING FACTORS

- Unsanitary food handling - Poor environmental condition- Lifestyle (habitual eating of street

foods)

PATHOPHYSIOLOGY

Ingestion of food contaminated with bacteria (Salmonella, Shigella,Campylobacter, Clostridium, E. coli and Aeromonas species), viruses (rotavirus, norovirus, adenovirus) or parasites

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PATHOPHYSIOLOGY OF ACUTE GASTROENTERITIS

Viruses and bacteria spread from person to person by means of the fecal-oral route or

by direct ingestion of contaminated foods cause gastroenteritis. Some viruses such as

the norovirus may be transmitted by an airborne route. Once these microorganisms have

been ingested, they will release enterotoxins that may damage and outnumber normal

bacteria and attach themselves in the bowel wall causing a decrease in intestinal wall

integrity and would cause inflammation in the stomach and intestine. Once this will

Dehydration

Good Prognosis:

RECOVERY

If not treated

Hypovolemic Shock

Death

Deficient fluid volume

- Fever- Poor skin turgor- Poor capillary

refill- Lethargy- Weakness- Weight loss

Diagnosis:- Stool exam

Treatment:- Antibiotics- Antivirals- Antiparasitic- ORS

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happen, there would be a stimulation of the emetic center in the brain caused by the

parasympathetic and sympathetic stimulation which would eventually lead to vomiting.

There would also be a decrease intestinal absorption and increase gastrocolic reflex

which would result to an increase peristaltic movement causing abdominal bowel

sounds, abdominal pain and cramping. In relation to the release of enterotoxins, there

would be an increase secretion of water and electrolytes and Sodium would not

reabsorbed back. Proteins would also increase in the lumen and would lead to greater

chances of dehydration (proteins also play a vital role in holding fluids intracellularly by

oncotic pressure). All of these factors would lead to fluid volume deficiency and

dehydration marked by signs and symptoms such as fever, poor skin turgor, poor

capillary refill, lethargy, weakness and weight loss.

If the patient will not be treated, he/she may undergo hypovolemic shock and

death. If treated, patient will have a good prognosis and will have a better chance of

recovering.

LABORATORY EXAMINATION

HEMATOLOGY

TEST RESULT NORMAL

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Hemoglobin ↓132 g/dL 140-180 g/dL

Erythrocytes 5.41/L 4.5-5.0 L

MCH ↓ 24.4 pg 28-33 pg

MCV ↓ 74 fl 82-98 fl

MCHC 34.1 g/dL 33-36 g/L

Leukocyte 5.9 g/L 4.8-10.8 g/L

Neutrophil ↓ 0.33 0.55-0.65

Lymphocyte ↑ 0.52 0.25-0.40

Monocyte ↑ 0.10 0.02-0.06

Eosinophils 4 % 2-8 %

Basophils 0 % 0-0.5 %

Hematocrit 0.41 % 0.40 – 0.48 %

Platelete Count 188 g/L 150 – 400 gL

STOOL ANALYSIS

COLOR CONSISTENCY ENTAMOEBA HISTOLITICA

Dark brown Soft No Ova/Parasite

Brown Loose No Ova/Parasite

Brown Mucoid No Ova/Parasite

HORMONE

TEST RESULT NORMAL

Albumin 32 LOW 34 - 50

CHEMISTY

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TEST RESULT UNIT NORMAL

Sodium 144 mmol/L 136-144

Potassium 3.9 mmol/L 3.6-5.1

Calcium 2.44 mmol/L 2.23-2.58

ULTRASOUND

THYROID LEFT RIGHT

LENGTH 6.9 cm 5.6 cm

WIDTH 2.9 cm 3.0 cm

THICKNESS 2.8 cm 2.6 cm

THYROID FUNCTION TEST

TEST RESULT INTERPRITATION NORMAL

FT4 > 100 HIGH 12-22

THYROID STIM < 0.005 LOW 0.27-4.2

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STOOL ANALYSIS

DATE COMPONENTS DEFENITION RATIONALE RESULTNURSING

RESPONSIBILITYENTAMOEBA HISTOLITICA

A protozoan parasite responsible for disease called AMOEBIASIS. It usually occur in the large intestine and causes internal inflammation as its name suggests (histo = tissue, lytic = destroying).

No Ova/Parasite Explain the procedure and the reason it is required clearly and privately to the patient. Obtain informed consent and document that it has been given.

Where appropriate, offer the patient the choice of using either a commode at the bedside or a toilet.

Ensure the bedside curtains are pulled tight or the toilet door is completely shut to protect the patient’s privacy.

If the patient is using a commode ensure toilet paper is available and accessible to the patient, and that the patient also has access to handwashing facilities.

If the patient is using the toilet, place a disposable clean bedpan (Fig 1) under the toilet seat to catch the specimen.

Wash hands and put on gloves (Fig 2).

When the patient has produced the sample, examine the stool for consistency, colour, blood or any other abnormality.

Unscrew the top of the specimen

CONSISTENCY softCOLOR Stool color is generally

influenced by what you eat as well as by the amount of bile- yellow-green fluids that digest fats in the stool. As bile pigments travel through you gastrointestinal tract, they are chemically altered by enzymes- changing the pigments from green to brown.

If the stool is bright red or black which may indicate the presence of blood.

Dark Brown

ENTAMOEBA HISTOLITICA

A protozoan parasite responsible for disease called AMOEBIASIS. It usually occur in the large intestine and causes internal inflammation as its name suggests (histo = tissue, lytic = destroying).

No Ova/Parasite

CONSISTENCY LooseCOLOR Stool color is generally

influenced by what you eat as well as by the amount of bile- yellow-green fluids that digest fats in the stool. As bile pigments travel through you gastrointestinal tract, they are chemically altered by enzymes- changing the pigments from green to brown.

If the stool is bright red or black which may indicate the presence of blood.

Brown

ENTAMOEBA HISTOLITICA

A protozoan parasite responsible for disease called AMOEBIASIS. It usually occur in the large

No Ova/Parasite

HEMATOLOGY

COMPONENT DEFINITION RATIONALE NORMAL VALUES

RESULTI

NTER-PRETATION

NURSING RESPONSIBILITIE

Hemoglobin The oxygen-carrying pigment and predominant protein in the red blood cells. Hemoglobin forms an unstable, reversible bond with oxygen.

Measure the severity of anemia, or polycythemia; Monitors blood loss and response to blood replacement; Monitors hematologic functions.

140-180 g/dL

132 g/dL LowLow hemoglobin can indicate a hidden source of bleeding such as peptic ulcer or inflammatory bowel disease.

Pre-test: 1. Explain the procedure to the patient. 2. Explain to the patient that he will experience discomfort from the needle puncture and the pressure of the tourniquet. 3. Obtain history of known allergens. 4. Obtain results of previously performed test. 5. Obtain a list of medications the patient is taking. 6. Note any recent procedures that can interfere with the result. 7. Tell the patient and the watcher that there are no fluid, food or medication restrictions, unless by medical direction.

Post-test: 1. Observe venipuncture site for bleeding or hematoma formation.

2. Apply pressure at the site of the venipuncture because bleeding may occur.

3. If hematoma develops, apply warm soaks.

4. Evaluate the results in relation to the patient’s symptoms and

Erythrocytes The most common type of cell in blood. It carries oxygen throughout the circulatory system, from the lungs to the rest of the body, and brings carbon dioxide waste back the other way.

To test for anemia, a common condition that occurs when the body has insufficient red blood cells

4.5-5.0 L 5.41L High As the volume of fluid in the blood drops, the count of RBCs per volume of fluid artificially rises that cause dehydration.

MCH MCH stands for mean corpuscular hemoglobin. It refers to the quantity of hemoglobin in red corpuscles This is a calculated value derived from the measurement of hemoglobin and the red cell count.

Measures the average amount of hemoglobin in the average red cell.

27-33pg 24.4 pg Low low levels indicate iron deficiency or anaemia

MCV Mean corpuscular volume is the average volume of a red blood cell. This is a calculated value derived from the hematocrit and red cell count.

Measures the average volume of a red blood cell.

85-96Fl 74fL LowWhen the number is smaller than normal, the cell is too small and this is a condition that causes microcytic anemia or microcytosis

MCHC Mean corpuscular hemoglobin concentration (MCHC) is the average concentration of hemoglobin in  red blood cells

.

MCHC is used to help diagnose the type (cause) and severity of anemia. When MCHC is low, this can mean a person has iron-deficiency anemia. This type of anemia can be caused by insufficient iron in the diet or by blood loss. Blood loss, such as what might occur with tumors in the colon and other parts of gastrointestinal tract can cause low iron levels and a low MCHC.

33-36 g/L 34.1 g/dL

NormalIf the levels fall

between the normal range, the person

does not have to worry about being anemic.

Leukocytes A colorless blood corpuscle capable To count WBC 4.8- 5.9 g/L Normal

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COLOR Stool color is generally influenced by what you eat as well as by the amount of bile- yellow-green fluids that digest fats in the stool. As bile pigments travel through you gastrointestinal tract, they are chemically altered by enzymes- changing the pigments from green to brown.

If the stool is bright red or black which may indicate the presence of blood.

Brown

CHEMISTRYCOMPONENTS DEFINITION RATIONALE RESULT NORMAL

Sodium Sodium is the most abundant cation (pronounced cat-ion) in the blood and its chief base. It functions in the body to maintain osmotic pressure, acid-base balance and to transmit nerve impulses.

Your blood sodium level represents a balance between the sodium and water in the food and drinks you consume and the amount in urine

100 136-144

HORMONECOMPONETS DEFINITION RATIONALE RESULT NORMAL NURSING

RESPONSIBILITESAlbumin A protein made by

the liver. A serum albumin test

measures the amount of this

protein in the clear liquid portion of the

blood.

Low albumin levels can also be seen in inflammation, shock, and malnutrition

32 34-35 Assess for peripheral edema in

the lower extremities when

the albumin level is decreased. Albumin is the major protein

compound responsible for plasma colloid

osmotic pressure. With a decreased albumin level, fluid

seeps out of the blood vessels into the tissue spaces.

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Potassium Potassium regulates the heart and function of the muscle. And he major positive ion (cation) found inside of cells.

The proper level of potassium is essential for normal cell function.

3.9 3.5-5.1

Calcium Calcium is bound to the proteins in the bloodstream, so the level of calcium is related to the patient's nutrition as well as the calcium intake in the diet.

It is important in the transmission of nerve impulses across synapses, the clotting of blood and the contraction of muscles

2.44 2.23-2.58

THYROID FUNCTION TESTCOMPONENTS DEFINITION RATIONALE RESULT NORMAL

FT4 Free T4 measures the free, unbound thyroxine levels in your bloodstream

Free T4 is typically elevated in hyperthyroidism

> 100 12-22

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THYROID STIMULATING

HORMONE (TSH)

A special messenger hormone that stimulate the thyroid to release more thyroid hormone

TSH that is elevated, or above normal, is considered indicative of hypothyroidism.

<0.005 0.27-4.2

ULTRASOUND

THYROID LEFT RIGHT

LENGTH 6.9 cm 5.6 cm

WIDTH 2.9 cm 3.0 cm

THICKNESS 2.8 cm 2.6 cm*Both thyroid lobes enlarged. Both show heterogeneous parenchymal echopattern. External outline is smooth. No pathologic classification

*Bilateral carotid spaces are intact

*No cervical lymphadenopathy demonstrated

*Impression: thyromegaly with diffuse thyroid parechymal disease

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Medical orders

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DRUGSTUDY

Date Ordered: June 19, 2013

Generic Name: Propylthiouracil (PTU)

Brand Name:

Classification: Anti-thyroid drug

Mechanism of Action:

Inhibits conversion of the synthesis of thyroid hormones; partially inhibits the peripheral T4 to T3, the more potent form of thyroid hormone.

Indication: Hyperthyroidism

Contraindication:

Allergy Pregnancy

Ordered Dose: 50mg tab BID

Adverse Effects:

CNS: Paresthisias, neuritis, vertigo, neuropaties, depression CV: Vasculitis, periarteritis Dermatologic: Urticaria, pruritus, skin pigmentation, exfoliative dermatitis, lupus-like

syndrome GI: Epigastric distress, loss of taste, jaundice, hepatitis GU: Nephritis Hematologic: Agranulocytosis, granulocytopenia, thrombocytopenia,

hypoprothrombinemia, aplastic anemia

Side Effects:

Nausea Vomiting Skin rash Headache Drowsiness Weakness

Drug Interaction:

31

Increased risk of bleeding with oral anticoagulants Alterations in the ophylline, metoprolol, propranolol, digitalis glycoside clearance, serum

levels and effects as patient moves from hyperthyroid state to eurothyroid state

Nursing Responsibilities:

1. Observe the 10 rights in giving the drug.2. Assess allergy to antithyroid products3. Administer drug in 3 equally divided doses at 8 hour interval 4. Inform patient of the possible side effects of the drug5. Instruct patient to take drug with meals todecrease risk of adverse GI reactions.6. Urge patient to report signs and symptomsof infection, such as fever and

sorethroat, or signs and symptoms that couldreflect hepatic dysfunction, such as anorexia and right-upper-quadrant pain.

7. Advise patient to notify prescriber immediately if he has fatigue, weakness, and vagueabdominal pain, loss of appetite, itching,easy bruising, or yellowing of eyes or skin.

8. Monitor CBC, PT, and liver and thyroidfunction test results in patientstakingpropylthiouracil. Elevated serum triiodothyronine(T3) level may be the soleindicator of inadequate treatment.

Date Ordered: June 19, 2013

32

Generic Name:Paracetamol

Brand Name:Boigesic

Classification: Non-opioid analgesics, Antipyretics

Mechanism of Action:

Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS.

Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating which helps dissipate heat.

Indication:

Mild pain Fever

Contraindication:

Hypersensitivity to acetaminophen or its components Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

Ordered Dose:500mg tab every 4 hours for fever

Adverse Effects:

CV: chest pain, dyspnea, myocardial damage GI: heaptic toxicity and failure, jaundice GU: Acute renal failure, renal tubular necrosis Hematologic: Methemoglobinemia-cyanosis, haemolytic anemia- hematuria, anuria,

neutropenia, hypoglycaemia, leukopenia Hypersensitivity: Rash, urticarial

Side Effects:

Headache Nausea vomiting

Drug Interactions:

Increased toxicity with long term, excessive ethanol ingestion Increased hypoprothrombinemic effect of oral anticoagulants Increased risk of hepatotoxicity Possible decreased therapeutic effects with barbiturates, carbamazepine, hydantoins, rifampin,

sulfinpyrazone

33

Possible delayed or decreased effectiveness with anticholinergics Possible reduced absorption of acetaminophen with activated charcoal Possible decreased effectiveness of zidovudine

Nursing Responsibilities:

1. Observe the 10 rights in giving the drug2. Assess temperature of the patient before giving the medicine.3. Use liquid form for children and patients who have difficulty swallowing.4. Administer with water. 5. Give drug with food if GI upset occurs.6. Discontinue drug if hypersensitivity occurs.7. Ensure patient is not allergic to Paracetamol8. Assess allergic reactions: rash, urticaria; if these occur, drug may have to be discontinued.

Date Ordered: June 19, 2013

Generic Name: Racecadotril

34

Brand Name:Hidrasec

Classification: Antidiarrheal

Mechanism of Action:

Racecadotril is an antihypersecretory agent. It inhibits the enzyme enkephalinase in the small intestine, thereby reducing the intestinal hypersecretion of water and electrolytes induced by cholera toxin or inflammation. Racecadotril does not affect basal secretory activity and exerts rapid antidiarrhoeal action without modifying intestinal transit time

Indication: Treatment of acute diarrhea

Contraindication:

Allergy Renal impairment Liver impairment Pregnancy and lactation

Ordered Dose: 100g/ tab BID

Side Effects:

Drowsiness nausea and vomiting dizziness headaches

Drug Interactions:

No interaction with other drugs have been described in humans to date. In humans, the concomitant treatment of racecadotril with loperamide or nifuroxazide does not modify the kinetics of racecadotril.

Nursing Responsibilities:

1. Observe the 10 rights in giving the drug.2. Assess if patient is hypersensitive to the drug.3. Advise patient to increase oral fluid intake4. Instruct patient to eat foods rich in fiber such as green leafy vegetables5. Instruct to report episodes of loose bowel movement6. Educate about the possible side effects og the drug7. Observe for the amount & consistency of the stool8. Instruct patient to report any unusualities

35

Date Ordered:

Generic Name:Methimazole

36

Brand Name:Tapdin

Classification: Antithyroid agent

Mechanism of Action: Inhibits the synthesis of thyroid hormones and thus is effective in the treatment of hyperthyroidism

Indication:

Management of hyperthyroidism,goiter, Graves’ disease and psoriasis. It is also used before thyroid surgery or radioactive iodine treatment.

Contraindication:Allergy, pregnancy, lactation

Ordered Dose: 5mg/tab

Adverse Effects:

CNS: Paresthisisas, neuritis, vertigo, neuropathies Dermatologic: Uricaria, pruritus, lupus-like syndrome, skin pigmentation GI: Epigastric distress, sialadenopathy, jaundice, hepatitis GU: Nephritis Hematologic: Agranulocytosis, granulocytopenia, thrombocytopenia, vasculitits

Side Effects:

Nausea & vomiting Gastric discomfort Headache Skin rashes Drowsiness

Drug Interaction:

Increased theophylline clearance and decreased effectiveness if given to hyperthyroid patients; clearance will change as patient approaches euthyroid state

Altered effects of oral anticoagulants with methamizole Increased therapeutic effectsand toxicity of digitalis glycosides,metoprolol, propranolol

when hyperthyroid patients become euthyroid

Nursing Responsibilities:

1. Observe the 10 rights in giving the drug2. Give drug in three equally divided doses at 8 hour interval

37

3. Inform patient that the drug should be taken for a prolonged period to achieve the desired effects.

4. Educate patient of the possible side effects5. Instruct patient to take the drug with food6. Instruct to report if patient experiences fever, sore throat, unusual bleeding or bruising,

headache or general malaise.

Date Ordered: June 19, 2013

Generic Name: Ciprofloxacin

38

Brand Name:Cipro

Classification: Antibacterial

Mechanism of Action:

Bactericidal; Interferes with DNA replication in susceptible bacteria preventing cell reproduction.

Indication: For treatment of infections

Contraindication:

Allergies Pregnancy Lactation

Ordered Dose: 500 mg tab BID

Adverse Effects:

CNS: insomnia, fatigue, somnolence, depression, blurred vision CV:Arrhytmias, hypotension, angina EENT: Dry eye, eye pain, keratopathy GI:diarrhea, abdominal pain Hematologic: Elevated BUN, AST, ALT, serum creatinine and alkaline phosphatase;

decreased WBC, neutrophil count, Hct

Side effects:

Headache Dizziness Nausea Vomiting dry mouth

Drug Interaction:

decreased therapeutic effect with iron salts, sucralfate decreased absorption withantacids, didanosine increased serum levels and toxic effects of theophyllines if taken concurrently with

ciprofloxacin increased effects of coumarin or its derivatives

Nursing Responsibilities:

1. Assess allergy to ciprofloxacin.2. Observe 10 rights in giving the drug.3. Drink plenty of water when taking the drug.

39

4. Monitor vital signs.5. Give antacids at least 2 hours after dosing.6. Inform about the possible side effects of the drugs.7. Educate patient about the ways to prevent infection such as handwashing.8. Advise to eat foods rich in Vitamin C to boost immune system.

Date Ordered: June 20, 2013

Generic Name:Propranolol

40

Brand Name:Inderal

Classification:

Beta-adrenergic blocker Antianginal Antiarrhytmic Antihypertensive

Mechanism of Action:

Through beta-blocking action, propranolol:o Prevents arterial dilation and inhibits renin secretion, resulting in decreased blood pressure

(in hypertension and pheochromocytoma) and relief of migraine headacheso Decreases heart rate, which helps resolve tachyarrhythmiaso Improves myocardial contractility, which helps ease symptoms of hypertrophic

cardiomyopathyo Decreases myocardial oxygen demand, which helps prevent anginal pain and death of

myocardial tissue.

Indication:

To manage hypertension To treat chronic angina To treat supraventricular arrhythmias and ventricular tachycardia To control tremor To prevent vascular migraine headaches As adjunct to treat hypertrophic cardiomyopathy As adjunct to manage pheochromocytoma To prevent MI

Contraindication:

Asthma Cardiogenic shock Greater thanfirst-degree AV block Sick sinus syndrome Heart failure (unless secondary totachyarrhythmia responsive to propranolol) Hypersensitivity to propranolol or itscomponents

Ordered Dose:

Adverse Effects:

41

Allergic reactions: Pharyngitis, erythematous rash, laryngospasm CNS: Vertigo, tinnitus, paresthesias CV: CHF, cardiac arrhythmias , pulmonary edema Dermatologic: Pruritus EENT: Conjunctivitis GI: Ischemic cholitis, renal and mesenteric arterial thrombosis, retroperitoneal fibrosis,

hepatomegaly, acute pancreatitis GU: Impotence, decreased libido, dysuria

Side Effects:

Dizziness Headache Nausea Vomiting Eye irritation sweating

Drug Interaction:

Increased effects with verapamil Decreased effects with indomethacin, ibuprofen, piroxicam, sulindac, barbiturates Prolonged hypoglycemic effects of insulin Initial hypertensive episode followed by bradycardia with epinephrine Increased first-dose response to prazosin Increased serum levels and toxic effects with lidocaine, cimetidine

Nursing Responsibilities:

1. Observe the 10 rights in giving the drug.2. Assess if there is allergy to the drug.3. Take with meals to facilitate absorption.4. Monitor vital signs.5. Inform patient about the possible side effects of the drug

Date Ordered: June 20, 2013

Generic Name: Probiotics

42

Brand Name:HexBio

Classification: Anti-diarrheal

Mechanism of Action:

Suppressing the growth of pathogens through secretion of antimicrobial substances Competing for attachment sites/nutrients with the pathogens.

Indication:Treatment of diarrhea

Contraindication:

allergy

Ordered Dose: 1 sachet OD

Adverse Effects:

Side Effects:

Nursing Responsibilities:

1. Observe the 10 rights in giving the drug.2. Assess if patient is hypersensitive to the drug.3. Dissolve 1 sachet in ½ cup of water4. Advise patient to increase oral fluid intake5. Instruct patient to eat foods rich in fiber such as green leafy vegetables6. Instruct to report episodes of loose bowel movement7. Educate about the possible side effects og the drug8. Observe for the amount & consistency of the stool9. Instruct patient to report any unusualities

Date Ordered:

Generic Name: Verapamil hydrochloride

Brand Name:Isoptin

Classification:

43

Calcium channel blocker Antianginal Antiarrhytmic antihypertensive

Mechanism of Action:

Inhibits calcium movement into coronaryand vascular smooth-muscle cells by blockingslow calcium channels in cell membranes.The resulting decrease in intracellularcalcium level has the following effects:o inhibits smooth-muscle cell contractions decreases myocardial oxygen demand byo relaxing coronary and vascular smootho muscle, reducing peripheral vascularo resistance, and decreasing systolic ando diastolic pressureso slows AV conduction time and prolongso AV nodal refractorinesso Interrupts reentry circuit in AV nodalreentranttachycardias.

Indication:

To treat chronic angina pectoris To manage hypertension To prevent or treat supraventriculartachycardia

Contraindication:

Allergy Hypotension Pregnancy & lactation Heart-block Sick sinus syndrome except with ventricular pacemaker

Ordered Dose: 40mg/tab

Adverse Effects:

CNS: Vertigo CV: Peripheral edema, hypotension, arrhythmias, bradycardia, AV heart block

Side Effects:

Nausea Constipation Dizziness Headache

44

Sleepiness

Drug Interaction:

Risk of serious cardiac effects with IV beta-adrenergic blocking agents; do not give these drugs within 48 hour before or 24 hour after IV verapamil.

Increased cardiac depression with beta-adrenergic blocking agents Additive effects of verapamil and digoxin to slow AV conduction Increased serum levels of digoxin carbamazepine, prazosin, quinidine Increased respiratory depression with atracurium, gallamine, pancoronium, tubocurarine,

vecuronium Decreased effects with calcium, rifampin

Nursing Responsibilities:

1. Observe the 10 rights2. Ensure that the patient swallows SR tablets whole; patient should not cut, crush or chew

them.3. Monitor vital signs, especially BP very carefully with concurrent doses of antihypertensives.4. Administer SR form in the morning with food to decrease GI upset.5. Do not take the drug with grape or grapefruit.6. Inform about the possible side effects of the drug.

45

Cues Need Nursing Diagnosis Objective of Care Nursing Intervention Evaluation

D/T CUES NEED NURSING DIAGNOSIS OBJECTIVES OF CARE NURSING INTERVENTIONS EVALUATION

J

U

N

E

20,

2

0

1

3

@

7am

Subjective:

“Ginakalibanga man

gudko. “

“Gahaponnisugodakong

kalibanga.”

Objective:

Vital signs as taken:

-T: 36.6oC

-PR: 80 bpm

-RR: 20 cpm

-CR: 87 bpm

-BP: 120/80 mmHg

dry lips

sunken eyes

loose watery stool

history of loose

watery stools,

5episode/day with

100cc/episode

IVF of PNSS 1L @

140cc/hr

Drugs as ordered:

-Ciprofloxacin 500

mg tab BID

-Paracetamol

500mg tab q4 PRN

for fever

-Propylthiouracil

50mg BID

-Isoptin 40mg/tab

-Tapdin 5mg/tab

-Propranolol

E

L

I

M

I

N

A

T

I

O

N

P

A

T

T

E

R

N

Diarrhea r/t infectious

processes secondary to

acute gastroenteritis

®Diarrhea means loose

bowel movements,

usually causing to move

his or her bowels

frequently. Vomiting

may bepresent as well.

Acute diarrhea means

the diarrhea lasts for

only a limited time; this

is also called

gastroenteritis. There

are manypossible causes

of gastroenteritis,

including infections with

bacteria, viruses, or

parasites. Diarrhea may

also be asymptom of

other diseases, but this is

less common.

Reference:

Hurst, M. (2008). Hurst

Reviews:

Pathophysiology

Reviews. New York.

McGraw Hill.

At the end of my 8 hours span

of nursing care, the patient

will be able to:

1. Report decrease in the

frequency of bowel

movements

2. Learn ways to prevent

diarrhea

3. Verbalize

understanding of the

interventions

4. Demonstrate ways to

prevent infection

1. Obtain vital signs

® to have baseline data

2. Assess the medications being

taken by patient

® some drugs may cause

diarrhea

3. Observe and record number

and consistency of stools per

day

®Documentation of output

provides a baseline and helps

direct replacement fluid

therapy

4. Secure stool sample

® to test the sample and

identify the possible causative

agent

5. Emphasize importance of

handashing

® to prevent spread of

microorganisms

6. Monitor input and output of the

patient

®Diarrhea can lead to

profound dehydration and

electrolyte imbalance.

7. Administer drugs as ordered

June 20, 2013 @ 3pm

GOAL MET

After the 8 hours span of care, the

patient was be able to:

1. Report decrease in

frequency of bowel

movements as evidenced

by:

Less than 3 bowel

movements during the

shift with semi-

formed stool

2. Learned ways to prevent

diarrhea such as ensuring

that the food he eats is

safe and not spoiled

3. Verbalized understanding

of the condition,

“Muinomnakougdaghanng

atubigugmukaonugmgagul

ayparamarehydratekougm

ugahiakonglibang”.

4. Demonstrated ways to

prevent infection such as

handwashing

46

Date&

Time

J

U

N

E

2

2,

2

0

1

3

@

7

am

Subjective:

“pakiramdamko

, hinanghina

ako, at madali

lang ako

mapagod.

Parati lang nga

ako natutulog.”

As verbalized

by the patient.

Objective:

- Lack of

energy

- Irritable

- VS taken as

follows:

A

C

T

I

V

I

T

Y

E

X

E

R

C

I

S

E

P

Fatigue related to

hypermetabolic

state with

increased energy

requirements.

R: Hyperthyroidism

is an over

production of

thyroid hormone,

which creates far

reaching metabolic

effects.

Hypertrophy and

hyperplasia of the

thyroid gland occur

with increased

vascularity. Most

of the clinical

After the 8 hours span of

care, the patient will be

able to:

1. Show decrease, or

absence of

irritability

2. Verbalize

increased

knowledge

regarding fatigue

and management

of high energy

consuming

activities.

3. Verbalize proper

understanding of

1. Monitor vital

signs, noting pulse

rate or cardiac rate at

rest and when active.

R: Pulse or Cardiac

rates are typically

elevated, and even at

rest, tachycardia up to

160 bpm may be

noted.

2. Note daily energy

patterns.

R: Helpful in

determining

pattern/timing of

activity.

@ 3pm

Goal Met

After the 8 hours span

of care, the patient will

be able to:

1. Showed

decrease, or

absence of

irritability.

2. Verbalized

increased

knowledge

regarding fatigue

and

management of

47

T: 36.6

P: 80

CR: 87

BP: 120/80

RR: 20

A

T

T

E

R

N

manifestations

result from

increased

metabolic rate,

excessive heat

production,

increase

neuromuscular

and cardiovascular

activity, and

hyperactivity of the

sympathetic

nervous system.

his medical illness

and the

management

required.

4. Demonstrate

relaxation

techniques that

can decrease the

presence of fatigue

such as: massage

and cold or hot

showers.

3. Advise patient to

report development of

tachypnea, dyspnea,

pallor, and cyanosis.

R: O2 demand and

consumption are

increased in

hypermetabolic state,

potentiating risk of

hypoxia with activity.

4. Provide quiet

environment, cool

room, decreased

sensory stimuli,

soothing colors, and

quiet music.

R: Reduces stimuli

that may aggravate

high energy

consuming

activities.

3. Verbalized

proper

understanding of

his medical

illness and the

management

required.

4. Demonstrated

relaxation

techniques that

can decrease the

presence of

fatigue such as:

massage and

cold or hot

showers.

48

agitation,

hyperactivity, and

insomnia.

5. Encourage client to

rest in bed as much

as possible.

R: Helps counteract

effects of increased

metabolism.

6. Provide comfort

measures like

massages and hot or

cold showers.

R: May decrease

nervous energy,

promoting relaxation.

7. Provide for calming

49

diversional activities

such as reading,

listening to the radio,

and watch television.

R: Allows for use of

nervous energy in a

constructive manner,

serves as a

distraction, and may

reduce anxiety.

8. Avoid topics that

irritate or upset client.

Discuss ways to

respond to these

feelings.

R: Increased irritability

of the CNS may

cause client to be

easily excited,

50

agitated, and prone to

emotional outbursts.

9. Discuss with

Significant Others

reasons for fatigue

and emotional ability.

R: Understanding that

the behavior is

physically based may

enhance coping with

current situation and

encourage Significant

Other to respond

positively and provide

support for client.

10. Administer

medications, as

indicated, such as

anti-anxiety agents.

51

R: May be prescribed

to help combat

nervousness,

hyperactivity, and

insomnia.

Date and Time

Cues Need Nursing Diagnosis Objectives of Care

Nursing Interventions Evaluation

52

JUNE

22,

2013

@

7 AM

Subjective:

“Sakitakongtiyanpabalikbalikunyamagsigesiyaugtingog”, as verbalized by the patient.

Objective:

Facial grimace

Irritability

Reduced interaction with people

Appears weak

Pain scale of 3 out of 5

COGNITIVE/PERCEPTUAL

PATTERN

Acute pain r/t inflammatory

process

Rationale:Gastroenteritis is the inflammation of the stomach and the intestinal tracts that primarily affects the bowel. One manifestation of gastroenteritis is abdominal pain. During the course of inflammation, the body’s immune response is to release cytokines and prostaglandin causing an increase in vascular permeability and causes pain in the abdomen.(Black, J.M. 2010)

That within my 8 hours span of

care, my patient will be able to:

a. Verbalize less pain felt;

b. enumerate ways on how to deal with pain during its occurrence;

c. pain scale of 1-2 out of 5.

1. Establish rapport with the patient.Rationale: To gain trust and cooperation.

2. Check vital signs.Rationale: To serve as baseline data.

3. Assess level of pain using pain scale.Rationale: To determine the degree of pain felt by the client.

4. Provide diversional activities such as watching television or listening to music.Rationale: To divert his/her attention from the pain felt.

5. Instruct client to perform deep breathing exercise.

June 22, 2013@ 3pm

“Goal Met”

a. “Okay okaynamanakongpaminawkaysaganiha. Medyoniarang-arangnaakongpaminaw”, as verbalized by the patient.

b. “Mag-facebooknalangkoaniarunmedyomahuwasanko. Mag-inompudkoganalgesic paramawalaangsakit”, as verbalized by the

53

Rationale:  Deep breathing exercises may reduce pain sensation/ used in pain management.

6. Provide a calm environment.Rationale: Lessens patient’s irritability.

7. Administer prescribed analgesics.Rationale: To decrease pain.

8. Monitor effectiveness of pain medications.Rationale: To promote timely intervention.

client.

c. Pain scale of 2 out of 5.

54

Reference:

Date &

Time

Cues

Needs Nursing DiagnosisObjectives

of Care

Nursing Interventions

Evaluation

J

U

N

E

21,

2

0

1

3

@

7 AM

TO

3PM

Subjective:“nag papalpitatesiyakanina miss” as verbalized by the watcher

Objective: CR: 120 bpm Palpitation Short

breathlessness Irritability Irregular heart rate Medication:

Propanolol 10g

ACTIVITY-EXCERCISE

PATT

ERN

Risk for decrease cardiac output ( systemic) r/t increasing workload of the heart as manifested by hyperthyroidism

R: patients with hyperthyroidism usually have the symptoms of palpitation. With the increasing workload of the heart this may lead to decrease cardiac output due to excessive pumps of the heart.

Reference:Smeltzer,

S. C. EdD,

RN, FAAN.

Brunner

&Suddarth’s

Textbook of

Medical –

Surgical

Nursing.

That with my 2 hours span of care, the patient will be able to have normal cardiac output as evidenced by:

a. Enumerate causative factors affecting his normal breathing.

b. Identify situations that would worsen the level of heart rate.

c. identify and use appropriate support system.

1. Establish rapport.®To gain the trust and the cooperation of the client.

2. Monitor vital signs.®For baseline data.

3. Increase oral fluid intake.

®water helps regulate the body’s cardiac rate.

4.  Record the heart sounds.

® Know of any changes in heart rhythm.

5. Limit your activities adequately.

®adequate rest is needed to improve the efficiency of cardiac contraction and oxygen consumption and reduce redundant work.

6. Emphasized the importance of adequate rest in elevation of cardiac output.

®This will help the client understand ways

December 21, 2013@ 11 am

“GOAL MET”Patient was able to have normal Cardiac rate as evidenced by client was able to:

a. verbalized “angpaggalawgalawkosiguro at pagiisipngsobraangdahilan kaya akohinihingalkokaninaperongayon okay okayna”

b. verbalized “angdilikopaginomsatamanggamotkopagnasabahayangdahilan kaya ako nag papalpitate”

c. identify his support system and that is his family. “ginabadlong man konilalabinaakong partner”

d. have a cardiac rate of 90bpm after rechecking.

55

56

D/T CUES NEED NURSING DIAGNOSIS OBJECTIVES OF CARE NURSING INTERVENTIONS EVALUATION

J

U

N

E

20,

2

0

1

3

@

7am

Subjective:

“Naga sigarilyo man

gudkomaongluspadnia

kungngabil” as

verbalized by the

patient.

Objective:

(+)

hyperthyroidism

for 3-4 years

Consumes 15-20

sticks/ day

Vital signs as

taken:

-T: 36.6oC

-PR: 80 bpm

-RR: 20 cpm

-CR: 87 bpm

-BP: 120/80

mmHg

With a capillary

refill of 2sec.

Dry pale lips

history of loose

watery stools,

5episode/day with

100cc/episode

Diagnostic and

Lab:

+ Hematology:

-hemoglobin

132g/dl (140-180

M

E

T

A

B

O

L

I

C

P

A

T

T

E

R

N

Impaired tissue

perfusion r/t decreased

hemoglobin in the blood

as evidenced by anemia

® Thyroid gland is

responsible for the

secretion of the

hormones that controls

the metabolic rate of the

body which the body

burns energy to

maintain the normal

functions of life and the

rate of growth or

replacement of body

tissue. Individuals with

hyperthyroidism tends

to have an overactive

thyroid gland which

increases the

production of hormones

that exceeds the normal

metabolic rate causing

increase peristaltic

movement that may

result to gastroenteritis.

Reference:

Timothy Secomb.

January 26, 2009.

Quantitative

Analysis of

At the end of my 8 hours

span of nursing care, the

patient will be able to:

5. Demonstrates adequate tissue perfusion as evidenced by warm and dry skin, and the absence of respiratory distress

6. Verbalizes knowledge

of treatment regimen,

including appropriate

exercise and

medications and their

actions and possible

side effects

7. Identifies changes in

lifestyle that are

needed to increase

tissue perfusion such

as gradually stop

smoking by consuming

at least 2-3 sticks/ day.

14. Obtain vital signs

® To have baseline data

15. Assess patient’s condition

® To render appropriate

interventions

16. Monitor vital signs, capillary

refill and nail beds.

® Provides information

about the degree /

adequacy of tissue

perfusion and help

determine the need for

intervention.

17. Observe for skin color on the

sick.

® The skin color typically

occurs when cyanosis,

cold skin. During the

color change, the sick to

be cool then throbbing

and tingling sensations.

18. Check respirations and

absence of work of breathing.

® Cardiac pump

malfunction and/or

ischemic pain may result

to respiratory distress.

Nevertheless, abrupt or

continuous dyspnea may

signify thromboembolic

June 20, 2013 @ 3pm

GOAL MET

After the 8 hours span of care,

the patient was be able to:

5. Demonstrated adequate

tissue perfusion as

evidenced by skin is

warm, in normal skin

turgor and respiration is

on normal range of 20-25

bpm.

6. Patient verbalize

knowledge of treatment

regimen as “kabalona

man

kosamgaepektosatambal

kaymga 4 kona nah

katuigginatumarug kung

naa may

mgadilinakubationkaynag

a pa check-up man

dayonko”.

7. Identifies changes in

lifestyle that are needed

not to provoke the

disease process

“gitestingan man naku

mag

undangdatiugsigarilyoper

57

58

59

METHOD Health Teachings RationaleMedication Medications should

be taken regularly as prescribed, on exact dosage, time and frequency, making sure that the purpose of medications is fully disclosed by the health care provider.

Instruct the family to report the occurrence of any adverse effects and refer them immediately to the physician.

For a better and effective management of the condition which would provide optimum health for the patient and prevent lethal complications that that they would encounter.

To maximize the optimum health of the patient whenever the patient has taken the drugs.

Exercise Exercise should be

promoted in a way by stretching hand and feet every morning.

Encourage the patient to keep active to adhere to exercise program and to remain as self-sufficient as possible.

To promote muscle strength and enhance circulatory processes.

Treatment Comply to the treatment regimen such as taking medications as prescribed by the physician.

Discuss to the watcher and significant others the dangers of noncompliance to doctor’s order

It necessary to take the prescribed take home medications and to follow the given instructions exactly as they are told

To let the patient and significant others recognize the possible efffects if compliance to the Doctor’s order is not attained

Hygiene Instruct patient for proper body hygiene such as routine handwashing.

To deter the spread of microorganisms

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Where is your nursing theory??

PROGNOSIS

61

Our patient no longer has fever and LBN and could be discharged the next day;

we rated the duration of illness as good prognosis. He eats fruits and vegetables with

good appetite, drinks at least 8 glasses of water every day. The patient readily compiled

with the treatment regimen, so we therefore conclude that our patient has a good

prognosis.

References

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Deglin, J. H., PharmD. Davis’s DRUG GUIDEFOR NURSES. F. A. Davis Company.

2011, 12th edition.

Deglin, J.H. &m Vallerand, A.H. (2009). Davis’s Drug Guide for NURSES (Eleventh

Doenges, M. E., APRN, BC–retired Nurse’s Pocket Guide Diagnoses, Prioritized

Interventions, and Rationales.Saunders ©2011.10th edition.

Elsevier, M. (2007). Maternity & Women’s Health Care (9th Edition). Elsevier Inc. 11 830

Gulanick, M. et al.(2007). Nursing Care Plan. Elsevier Inc. Singapore

James,SRPhd, Ashwill, JW RN, MSN, Medical Disability Advisor, Mosby ©2010

Jonas MS: Mosby's Dictionary of Complementary and Alternative Medicine. Elsevier (c)

2009, 6th edition.

Klossner, N. J., MSN, RNC. Introductory Maternity &Pediatric Nursing.Williams &

Wilkins, Philadelphia.2010, 2nd edition.

Linton, A. D., Phd. Mayo Foundation for Medical Education and Research

(MFMER)W.B .

Newfield S. A., PhD, RN, APRN. BC.COX’S CLINICAL APPLICATIONS OF NURSING

DIAGNOSIS: Adult, Child, Women’s, Mental Health,Gerontic, and Home Health

Considerations F. A. Davis Company. 2009, 7th edition.

Smeltzer, S. C. EdD, RN, FAAN. Brunner &Suddarth’s Textbook of Medical – Surgical

Nursing.Williams & Wilkins, Philadelphia.2010, 12th edition.

Tortora, G. J., Derrickson, B. H. PRINCIPLES OF ANATOMY AND PHYSIOLOGY.

John Wiley & Sons, Inc, Hoboken. 2012, 12thedition.Westline Industrial Drive, St.

Louis, Missouri 63146Wilkins. 323 Norristown Road, Suite 200, Ambler, PA 19002-

2756.York: Lippincott, Williams, & Wilkins

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