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OBJECTIVES
General
To render efficient and effective nursing care by the utilization of the nursing process
Specific
1. To establish rapport with the patient.
2. To acquire knowledge and fully understand the disease process.
3. To gather vital information or data about the patient
4. To asses the patient and indentify present and potential health problems
5. To make effective nursing care plan to help solve health problems
6. To render care and health teachings to the patient and relatives to promote recovery
and prevent complications using the knowledge acquired.
7. To establish camaraderie among the group.
PATIENT’S PROFILE
NAME: E. Lucila
ADDRESS: 15 Pikador St. Midtown Subdivision San Roque, Marikina City
AGE: 65 y/o
Date of Admission: 9/16/10
Birth date: 8/25/1945
Admitting impression: AGE with mild dehydration T/C Amoebiasis
Principal Diagnosis: Amoebiasis
PATIENT HISTORY
Past Health History:
Few hours PTA, patient had unrecalled episodes of watery stool due to
persistence of symptoms, hence admission.
Present complaint: watery stool
Past history: had gastritis 3 months ago
Occupation and environment:
Retired housewife
Alcohol (-) Drug allergies (-)
Tobacco (-) Other allergies (-)
Family History:
Father: heart disease
Course in the ward
Patient is a 65 year old, female from San Roque Marikina City admitted at Antipolo City
Medical Hospital last September 16, 2010.
At the day of admission, the patient arrived in the ER with severe abdominal pain. She
was then put to bed, assessed with Dr. Cornel and was suggested to be admitted due to
symptoms of Amoebiasis. At 9:05 am, she was hooked with IVF of PLRS, 1 liter to run for 8
hours. Then, 1 ampule of Buscopan was given TIV PRN every 8 hours for pain. The patient was
advised to have CBC, sodium, potassium, and fecalysis to determine if it is really amoebiasis
that caused her to have frequent watery stools. At 10:10 am, metronidazole 500 mg TIV every 8
hours was started. At 12 noon, she was then seen and examined by Dr. Cornel with orders and
carried out. The patient was advised to have a soft diet, but NPO temporarily until 12 noon. At
1:30 pm, the patient was sent to the holding area via wheelchair and was properly endorsed.
Physical Assessment
Height: 5 ft. 3 inches Vital signs: Initial 1pm
Weight: 55 kg Temperature: 36.20 C 38.1
Cardiac rate: 111 bpm 110
Respiratory rate: 24 cpm 34
BP: 110/70 mmhg 90/60 mmhg
Body parts Methods used Actual findings Interpretation
Head Inspection Rounded,
smooth skull
Normocephalic and
symmetrical with frontal,
parietal, and occipital
prominence
Face Inspection Symmetric facial
features
Symmetric of structures
Eyes Inspection Pupils constrict
and respond to
light
Normal
Ears Inspection symmetric, no Good hygiene
discharge
Nose Inspection Symmetric and
straight
No discharges
No lesions
Normal
Mouth Inspection 5 missing teeth
Presence of
cavity
Dry lips
Indicates poor dental
hygiene
Denotes poor nutritional
intake and fluid deficit
Neck Inspection and
palpation Head centered
lymph nodes
palpated
Weak muscle
movement with
coordination
With active infection
In a covalence period
Breast Inspection Asymmetric of
nipples
Normal
Upper extremities Inspection Open, fresh
wound on his
right hand
Dry wound on
his left hand
Implies high risk for
infection
Nails Inspection,
palpation
Slow capillary
refill
Prolong iron deficiency
Lower extremities Inspection Swollen left
knee
Both soles of
feet have dry
wound
Sign of the disease
process
Implies high risk for
infection
Genetalia Inspection With Foley
catheter
Indicates urinary
incontinence and need for
output monitoring
Skin Inspection,
palpation
Presence of Implies high risk for
scalding
Dry
infection
Indicates dehydration
Gordon’ 11 Functional Health Pattern
Functional
health problems
Before
hospitalization
During
hospitalization
Analysis
Health perception/
management
The patient
consults her doctor
annually to have a
general check up.
She consults her
doctor right away
whenever she feels
sick. She said she
does exercise by
walking in the mall
at least three times
a week. Taking of
vitamin C daily is
her routine for
prevention of
sickness.
The patient readily
complies to her
medication therapy.
She still takes her
vitamins but cannot
do exercises
because of being
hospitalized.
The patient gives
importance to her health.
It’s a good behavior
because she manages her
health very well and takes
immediate action, such as
consulting to a doctor right
away, to facilitate easy
recovery.
Nutritional-
Metabolic
The patient loves
to eat fish, chicken,
and vegetables. But
she is not fond of
drinking lots of
water.
The patient was
NPO temporarily,
but was shifted to
soft diet later the
day. She had
porrigde and
milkfish soup at
The patient was in NPO
temporarily so that her
physician will observe hier
well regarding her
condition. She had a soft
diet because of having lose
watery stools.
lunch.
Elimination The patient
bowels regularly
usually early in the
morning. Her stools
were normally
brown and
semisolid. She
voids frequently at
least every after
meals.
The patient
experiences
frequent lose
watery stools.
She had
unrecalled
episodes of
bowel movement
prior to
admission and
described it as
fishy-smelling
(malansa). Her
voiding
frequencies
remained
normal.
Frequent bowel
movement can indicate that
the patient had ingested a
contaminated food or water
prio to admission. This may
indicate that the patient
may have amebiasis.
Activity/ exercise Patient takes a 30
minute walk inside
the subdivision and
the mall, at least
three times a week.
She does the
simple household
chores like washing
She cannot do her
usual activities of
daily living. Her only
leisure and activity
was chit-chatting
with her husband.
It shows that
hospitalization hinders her
in doing her usual activities
at home. This might make
her bored during
hospitalization.
the dishes and
sweeping the floor.
She loves watching
the television and
sometimes go out
with her co-
teachers before in
Roosevelt College.
Cognitive/
perceptual
The patient uses
eye glasses when
reading. Her
hearing, taste,
smell, and touch
perceptions are
still normal. She
has low pain
threshold and is
afraid of
experiencing
physical pain.
The patient still
has good memory
and can
communicate
well. She can
understand
simple
instructions.
the patients still
has low pain
threshold and
seemed very
afraid of having
pricked with a
syringe.
The patient
sometimes was
restless and
irritable. She
cannot
communicate
well to others.
The patient seemed
irritated and restless
because of the pain she
was experiencing. As a
result, her communication
skills was impaired.
Sleep- rest The patient
usually goes to
sleep at 9pm and
N/A The patient is aware that
having an enough sleep is
wakes up at 5am.
She sometimes get
a snap in the
afternoon. She said
this makes her
energized the whole
day.
very important for her.
Self-perception/
Self-concept
The patient thinks
of herself as a
loving mother.
She feel much
comfort
whenever they
visit her here in
the Philippines or
when they visit
them in the
states.
The patient
thinks her
siblings may get
worried if they
knew she was
hospitalized.
The patient exudes love
of her family and it seems
that she really longs to be
with her siblings.
Role-relationship The patient
considers herself
as a good mother
of her three
siblings. She said
she was fulfilled
with her family
now that her
siblings already
have stable lives.
She thought her
hardwork paid
The patient said
that she may feel
more loved and
secured if all of
her siblings were
there in the
hospital caring
for her.
The patient is indeed a
responsible mother
because she was able to
supprot her children’s
education, up until they had
stable lives. This may be
the reason why she longs
for them especially in the
times when she needs
them most.
off.
Coping stress
tolerance
The patient
shares his
problems to his
husband and
friends and asks
for help. She
handles stress by
goind to the mall.
The patient
reduces anxiety
by asking the
nurses about her
condition.
The patient can cope with
her situation because she
understands her condition
and what caused her
condition.
Values- Belief The patient is
Roman Catholic.
She does not
believe in quack
doctors.
Her condition
encouraged her
to pray and ask
for God’s
healing.
Her condition increases
her faith in God. She
thought that God is the
Only healer that can help
her recover with her
condition.