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MANILA TYTANA COLLEGES President Diosdado Macapagal Blvd.

, Metropolitan Park, Pasay City

Nursing Process

Submitted by: De Leon, Maria Larisse S. Dela Cruz, RJ King C. BSNIII B-04 Area: Manila Doctors Hospital Shift: 5:30am 2pm Clinical Instructor: Mrs. Germono

MANILA TYTANA COLLEGES President Diosdado Macapagal Blvd., Metropolitan Park, Pasay City NURSING PROCESS I. ASSESSMENT A. General Data Patients Initial: D.H. Informant: Himself Address: Tanza, Cavite Date of Admission: 02/27/12 Age: 33yrs. Old Order of Admission: Ambulatory Sex: Male No. of Days in the Hospital: 3 days Date of Birth: 09-04-1978 Place of Birth: Manila Civil Status: Single Occupation: CPA Bangko Sentral ng Pilipinas B. Chief Complaints Patient complains of fever C. History of Present Illness Patient was apparently well until 4 days prior to admission, patient had a fever with associated with sore throat and body malaise. No cough and colds, LBM, abdominal pain and vomiting noted. No consult was done. Patient took paracetamol tablet which gave temporary relief of fever. 1 day prior to admission, persistence of fever and throat pain with colds and difficulty in swallowing. Patient consulted at their office clinic and was given azithromycin and allerta. Persistence of symptoms prompted consult. D. Past History 1. 2. 3. 4. 5. 6. 7. 8. Childhood Illness/es: Adult Illness/es: N/A Immunizations: Complete Previous Hospitalization: Operation/s: Injuries: None Medications taken prior to confinement: Erythromycin 1drop Allergies: None

E. Systems Reviews Health Perception/ Health Management Pattern Para sa akin 7/10 ang health scale ng anak ko,kasi nung hindi pa siya nagkakasakit e di naman siya matamlay at masigla naman siya sa arawaraw as verbalized by the patients mother. Mother stated also that she let her son drink multivitamins everyday and she let her eat nutritious food. During the hospitalization process of the patient mother states that naging matamlay at iritable anak ko nung time na ospital na siya. Di na kasi siya masyadong nakakapaglaro. Nutritional-Metabolic Pattern

Days Breakfast

June 28 cup of fried rice Egg 1 glass of water cup of rice Nilagang baka 2 glass of water

June 29 cup of fried rice Egg 1 glass of water 1 cup of rice Chicken 2 glass of water

June 30 1 Cup of fried rice 1 scrambled egg 1 glass of water 1 cup of rice Adobong baboy 2 glass of water

Lunch Dinner

Five days prior to confinement, these are the foods that were taken by the patient. Mostly carbohydrates and protein are the basic components of his diet. Elimination Pattern According to the patient, he only defecates once a day. The stool is brownish in color and he has no discomforts in defecating. He voids at least 12 times in a day it is yellowish in color, and he has no discomforts in urinating. He has no body odors or excessive sweating. But during the stay in the hospital the patient can defecate regularly. Activity-Exercise Pattern According to the patient, he plays badminton and goes to gym for his regular exercise at least 4 times a week. During the hospitalization process, patients usual activities were altered because of his condition wherein he couldnt go to gym to have some exercise. F. Family Assessment

Name Rodolfo Leanesa Anarica Mechel

Relation Father Mother Sister Sister

Age 51 26 7 6

Sex M F F F


Educational Attainment

Construction College Worker Housewife Student Student Graduate Elementary Undergraduate

G. Heredo *Family Illness Maternal: Tuberculosis Paternal: Asthma Both Paternal and Maternal:

H. Developmental History

Theories Erikson

Age 33 y/o

Intimacy vs. isolation This is the first stage of adult development. This development usually happens during young adulthood, which is between the ages of 20 to 24. Dating, marriage, family and friendships are important during the stage in their life. By successfully forming loving relationships with other people, individuals are able to experience love and intimacy. Those who fail to form lasting relationships, may feel isolated and alone.

Patients description the patient verbalized that he is experiencing love and intimacy toward his family, friends and special someone.


33 y/o

Genital StagePhysical sexual changes reawaken repressed needs. Direct sexual feelings towards others lead to sexual gratification.

the patient is


33 y/o


33 y/o

Pre-operational Learns to use language and to represent objects by image and words Thinking is still ego centric: has difficulty taking the viewpoint of others. Classifies objects by a single feature: e.g. groups together all the red blocks regardless of shape or all the square blocks regardless in colour. Pre-conventional Stage one: (obedience and punishment driven), individuals focus on the direct consequences of their actions on themselves. For example, an action is perceived as morally wrong because the perpetrator is punished. "The last time I did that I got spanked so I will not do it again." The worse the punishment for the act is, the more "bad" the act is perceived to be.[15] This can give rise to an inference that even innocent victims are guilty in proportion to their suffering. It is "egocentric", lacking recognition that others' points of view are different from one's own.

the patient is having difficulty in reasoning given by his mother like him not being hurt in a thermometer check using a thermometer as seen during assessment the patient at his age is not well-exposed in environment in his neighborhood since his parents are getting mad due to their reasoning that the patient is their only child as verbalized by the mother

There is "deference to superior power or prestige"

I. Physical Examination Height: 56 Weight: 65.5 kg BMI:

Vital Signs: Initial Vital Signs T: 39.6 PR: RR: Regional Examination A. Skin I: Upon inspection, the client has a fair complexion. There is uniformity in color. There were no edemas, bruises, abrasions or lesions. Heplock present on his right arm. P: Upon palpation, clients skin is smooth and warm to touch. There is uniformity in skin temperature. Client has positive skin turgor test, when pinched, skin springs back to previous state. B. Nails I: Upon inspection, the client has a slightly long convex curvature shaped nails. Client has light pink nail beds. Skin surrounding his finger and toenails are intact. No clubbing. P: Upon performing the capillary refill test, there is prompt return of nail beds usual color. C. Head and Face I: Upon inspection, clients head is round and normocephalic with smooth skull contour. Client has symmetric facial features and nasolabial folds. T: PR: RR: Latest Vital Signs

P: Upon palpation, there were no nodules or masses. No tenderness detected. D. Eyes I: Upon inspection, clients eyes are symmetrically aligned. His eyebrows and eyelashes are also symmetrically aligned and evenly distributed. His eyelashes are slightly curled outward. Clients eyelids are intact with no discharges or discolorations. There are symmetrical eye movements. Client blinks bilaterally. His conjunctivae are light pink and moist. Has transparent, shiny and smooth cornea. Clients pupils are black in color and equal in size and shape. No known visual problems. P: Upon palpation, there was no tenderness or edema over the lacrimal gland. E. Ears I: Upon inspection, the clients auricles have the same color as facial skin. They are symmetrically aligned with the outer canthus of his eyes. P: Upon palpation, clients auricles are mobile, firm and not tender. His pinna recoils immediately after it is folded. F. Nose I: Upon inspection, the clients nose is symmetric and straight. It is uniformed in color. Has no flaring or discharge. The air moves freely as he breathes through the nares. P: Upon palpation, there was no tenderness or lesions. G. Mouth and Pharynx I: Upon inspection client outer lips are reddish, moist and cracked. There is no presence of wound on his upper lip. Client has a total of 23 shiny and yellowish milk teeth with 3 missing lower incisors. Client has pink gums. Client has a reddish, inflamed protruding tongue with wounds and is slightly bleeding with no purulent discharges. Tongue has a thin whitish coating. Client is still able to move his tongue. H. Neck I: Upon inspection, clients head is centered. His neck has no swellings or masses. Has coordinated and smooth movements with no discomfort. P: There were no lymph nodes palpated. There was no tenderness. I. Thorax/ Lungs I: A: Upon inspection, the clients chest skin is intact. Upon auscultation, there was no wheezing or crackles.

J. Cardiovascular/ Heart I: Upon inspections, there were no visible pulsations. No lifts or heaves. P: Upon palpation, carotid has full and symmetric pulsation with a thrusting quality. A: Upon auscultation, negative murmurs.

K. Abdomen I: Upon inspection, clients abdomen is uniformed in color with unblemished skin. His abdomen is slightly distended with a measurement of 52 cm. There is symmetric movement caused by respiration. A: Upon auscultation, there were audible bowels sounds and absence of arterial bruits or friction rubs. P: Upon palpation, there was no tenderness. L. Extremities I: Upon inspection, client can move his joints freely. It is uniformed in color and has no deformities or swelling. P: Upon palpation, there was no tenderness. M. Genitals

Not assessed.
N. Rectum and Anus

Not assessed
O. Neurologic Exam

Not Assessed.


PERSONAL/ SOCIAL HISTORY Habits: play badminton Rank/Order in the family: Eldest Vices: None Travel (For the Last 6 Months Only): None Lifestyle: Healthy Lifestyle Educational Attainment: College Graduate Social Affiliation: Clients usual day like:




OB/GYNE HISTORY *FOR FEMALES ONLY* (Based from the client. N/A if Not Applicable) Menarche (Age): ______ ________________________ Duration: ___________________________________ Associated Symptoms: ____________________________ Deliveries: G: P: Operations: OB Score: T: P: A: L: When: __________________________ Amount and Characteristics:



Maternal and Birth History Birth Date: Birth Weight: Type of Delivery: Condition after Birth: Hospital: *Mother Complications of Delivery: Anesthesia Drug during Labor: Exposure to Teratogenic agents during Pregnancy: *Neonates ONLY Neonatal History: Feeding History: Type of Feeding:


PATHOPHYSIOLOGY A. Theoretical Based Endothelial Cell Proliferation

Rapid Proliferation Phase

Proliferation of Blood Vessels

Formation of small thin walled vessels within endothelial cells

Slow involution of cutaneous plump

Formation of reactive lesion that develops rapidly

Bleeding occurs associated with inflammation

Oral hemorrhagic hemangioma

B. Client Based Endothelial cell proliferation

Rapid Proliferation Phase

Red/ Purple Tongue

Proliferation of Blood vessels

Small thin walled vessels within endothelial cells


Formation of reactive lesion that develops rapidly

Injury to oral/ Tongue

Oral hemorrhagic hemangioma


Bleeding Swallowing

Chewing g Difficulty in Speaking



Result Hemoglobin 137

Reference Value 140-175 g/L




Interpretation/ Significance This is the component of RBC that carries and transports oxygen to the cells. The result was below the normal range. This test was ordered by the doctor to determine the health of the patient and to assess presence of underlying diseases. Hct is the percentage of RBC mass to original blood volume that is occupied by RBC. This depends of the number of RBC. The result was within the normal range. RBC is part of complete blood count. This test was done to differentiate between the components of RBC indices to determine a health problem. The client's RBC is within the normal range. WBC is part of the bodys defense system. They respond immediately to foreign invaders by going to the site of

Below normal


RBC Count


4.50-5.90 x 1012/L


WBC Count


4.0-10.50 x 109/L


involvement. The result of the test was within the normal range. This test was ordered to determine the presence of an infection or underlying health problems in the patient. Basinophil Eosinophil Stab Neutrophil Lymphocyte Monocyte Platelet Count RDW MCV MCH MCHC 0.00 0.00 0.00 0.77 0.11 0.12 212 12.8 93.1 30.4 32.6 0.00-0.01 0.00-0.04 0.00-0.05 0.36-0.66 0.24-0.44 0.02-0.12 150-450 x 109/L 12-17.00 % 80-96 fL 27.50-33.20 pg 33.40-35.50 g/dL Normal Normal Normal Above Normal Below Normal Normal Normal Normal Normal Normal Below Normal

VIII. DRUG STUDY Drugs Indication Action Side Effects/ Adverse Reaction Nursing Consideration/ Patient Teaching -assess patients infection before and regularly throughout therapy -be alert for adverse reactions and drug interactions -if adverse GI reactions occurs, monitor patients hydration. -teach patient how to store oral solution. -tell patient to take entire amount prescribed even after he feels better. -warn patient that I.M. injection may

Date Ordered: Feb. 27, 2012 Generic Name: Clindamycin Brand Name: Cleocin Classification: Lincosamide Antibiotic Dosage: 150 mg IV Q6

Treatment of respiratory tract, skin or soft tissue, chronic bone or joint infections; septicemia; intraabdominal, female genitourinal infections; bacterial vaginosis; endocarditis. Can be used for acne vulgaris. Clindamycin is used for treatment of malaria, otitis media, Pneumocystis carinii

Bacteriostatic. Clindamycin binds to bacterial ribosomal receptor sites. Topically, it decreases fatty acid concentration on skin. It inhibits protein synthesis of bacterial cell wall and prevents outbreak of acne vulgaris.

Abdominal pain Nausea and Vomiting Diarrhea Vaginitis and itching Dry scaly skin Phlebitis, thrombophlebitis with IV administration Pain, induration, at the IM injection site Allergic reaction, urticaria, pruritus Headache and dizziness

pneumonia, and toxoplasmosis.

Contact dermatitis Hypersensitivity reaction

be painful -instruct patient to report diarrhea and to avoid selfthreatening pseudom embranus colitis -tell patient receiving drug I.V. to report discomfort at infusion site.

Antibioticassociated colitis (Severe abdominal pain, tenderness, fever, watery and severe diarrhea) Blood dyscrasias (Leukopenia and thrombocytopenia ) Nephrotoxicity (Proteinuria, azotemia, oliguria)

IX. 1. 2. 3. X.



February 27, 2012 : admitted this 4 years old male to room under the service of Dr. Villafuerte awake conscious and coherent with spontaneous non-labored breathing. On general cold liquid diet. Chest x-ray done. On seizure precaution with oxygen support , diazepam , paddle tongue guard , suction machine at bedside. Positive swelling of tongue with blood clot. Initial vital signs taken and recorded. Febrile , 37.8 . IV inserted by Dr. Daquilanea D5 MB500 x 53-54 cc .intact and regulated for continuity of care. February 29, 2012: Received patient awake on bed with spontaneous non-labored breathing. On general cold liquid diet, with ongoing IVF intact and infusing well, swelling of tongue and lips noted. On seizure precaution with suction machine at bedside, with diazepam on bedside. Vital signs taken and recorded, Afebrile. Due meds given. Monitored accordingly kept comfortable at all times for continuity of care. March 1, 2012 : Received patient awake on bed with spontaneous non-labored breathing. On general cold liquid diet, with ongoing IVF intact and infusing well, possible discharge on Saturday. Vital signs taken and recorded. Monitored accordingly for continuity of care. March 2, 2012: Received patient awake on bed accompanied by relative conscious and coherent with spontaneous non-labored breathing, on general cold liquid diet, positive swelling

of tongue with ongoing IVF intact and infusing well, vital signs taken and recorded. Possible discharge on Saturday.


DISCHARGE PLAN M- Medication E- Exercise T- Treatment H- Health Education O- OPD Follow Up D- Diet S- Spiritual