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LICEODECAGAYANUNIVERSITYR.N.P. Blvd., Carmen, Cagayan de Oro City
C O L L E G E O F N U R S I N G
A Case StudyPFC Omel Penar
With
Acute Gastroenteritis
Submitted to:
LTC. Domingo, RN
Clinical Instructor
As Partial Requirement for NCM501202
Submitted by:
Ramyr R. Ociones
March 21, 2008
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I. Introduction
a. Overview of the Case
b. Objective of the Study
c. Scope and Limitation of the Study
II. Health History
a. Profile of Patient
b. History of Illnesses
c. Chief Complain
III. Developmental Data
IV. Medical Management
a. Medical Orders and Rationale
b. Drug Study
V. Pathophysiology with Anatomy & Physiology
VI. Nursing Assessment (System Review & Nursing. Assessment II)
VII. Nursing Management
a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)
VIII. Health teachings
IX. Prognosis
X. Evaluation
XI. References
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INTRODUCTION
Overview of the Case
Acute Gastroenteritis is an infection of the bowel (intestines) that causes
diarrhea and sometimes vomiting. Diarrhea and vomiting can cause the loss of
important fluids and minerals the body needs (dehydration).
Acute Gastroenteritis is more common in the winter and early spring. Most
gastroenteritis is caused by a virus or one of several kinds of bacteria that get
into the intestinal tract (bowels). Bacteria or viruses get to the intestinal tract by
putting dirty hands, toys or other objects near or into the mouth. The most
common symptoms are diarrhea (frequent loose, watery stools) lasting 2-3 days
but usually not more than a week, nausea and vomiting lasting 1-2 days,
abdominal/stomach pain and possibly, fever.
b. Objective of the Study
The objective of this study is to find a case relating to our concept fluid
and electrolyte balance. Rule-out LBM and vomiting and later on diagnosed as
positive for acute gastroenteritis was the condition of my patient PFC Omel
Penar. As a nursing student, I have to do interventions for my patient and to
provide care which is relevant to her condition. Considering that my patient
needs systematic care to restore her fluids and electrolyte that is lost from her
condition. And one goal is that to provide a good patient outcome and prevent
conflicts to restore my patients normal state.
In the case of my patient who is suffering from acute gastroenteritis (AGE)
the etiology is to determine, it is most often results from any non-inflammatory or
inflammatory infection of the colon or either in the upper part of the small bowel.
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It can range from mild dysfunction to severe complication, and the most common
is dehydration due to diarrheal reaction of the body.
As an NCM501202 students, this care study helps us not just to pass this
said requirement but also to evaluate our efficacy upon rendering our services in
the optimum capacity or the ability to care to a patient suffering this kind of
illness. These studies also provide information on actual handling, caring and an
overview of the patients nutritional status and dietary management with acute
gastroenteritis.
c. Scope and Limitation of the Study
Our concept is about Fluid and Electrolyte Balance. At Camp Evangelista
Station Hospital, Cagayan de Oro City, I have to find a case which is relevant to
the concept. At the Military Ward where I am assigned, there are cases of acute
gastroenteritis and one of them is my patient PFC Omel Penar. For two days,
from January 30-31, 2008, my duty time is limited from 7-3pm. On the first day I
have assessed my patient and up to the last day of confinement of my patient
and did some interventions like maintaining hydration of the patient and ways toreturn her normal bowel functioning. Questions were being answered by the
patient. The actual nursing interventions were all carried out with the supervision
of a clinical instructor and limited to those which were permitted or allowed by
agency protocol. This study was completed altogether by both research using
different references and actual hands-on exposure and interaction with the
patient.
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HEALTH HISTORY
a. Profile of Patient
Patients Name: PFC Omel Penar
Birth Date:
Birthplace:
Age:
Sex: Male
Height:
Weight:Status: Single
Religion: Roman Catholic
Nationality: Filipino
Address:
Allergy: None
Date of Admission:
Time of Admission:
Chief Complaints: LBM and Vomiting
Admitting Diagnosis: Acute Gastroenteritis
Vital Signs:
Temperature:
Pulse Rate:
Respiratory Rate:
BP:
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b. History of Illnesses
My patient was PFC Omel Penar, he was admitted last August 3,
2007 and his condition started a day prior to admission, patient had 6
episodes of LBM associated with nausea & vomiting, abdominal pain
with no medications taken.
c. Chief Complaints
A case of my patient, PFC Omel Penar, was due to LBM and vomiting.
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DEVELOPMENTAL TASK
Eriksons Psychosocial Development:
My patient is under middle adulthood stage according to Erik Eriksons
Psychosocial Development theory. According to his theory, Generativity is the
concern of establishing and guiding the next generation. Simply having or
wanting children doesn't achieve generativity.
My patient is experiencing psychosocial crisis between Generativity vs.Stagnation, but because of evidently that he dont have his own family and work
as a military to supply his financial needs, he was able to overcome this stage.
Nurturing significance other or nurture close relationships; Management of career
and own household; the patient does not meet the satisfaction within himself; he
was trying to look for partners in life.
Jean Piagets cognitive Development:
According to this theory my patient is under the Formal Operational
Stage (Adolescence and adulthood). In this stage, my patients intelligence is
demonstrated through the logical use of symbols related to abstract concepts.
Freud Psychosexual Development:
In the genital stage, the clients energy once again focuses on his genitals,
interest turns to heterosexual relationships. According to this theory our patient
was not able to overcome this stage because he doesnt have a wife he was not
fully complete the criterion in actualization of his needs. As he grows into a more
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mature individual new crisis he will be experiencing but the past stages of
development he was able to overcome them all and was not stagnated or fixated.
MEDICAL MANAGEMENT
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DOCTORS ORDER RATIONALEAugust 6, 2007
> Vital signs every 2 hours
> NPO
> Meds:
Paracetamol 80mg IVTT every6 hours PRN
Ranitidine Hydrochloride 8g
IVTT every 8 hours
Cefuroxime 50mg IVTT every 8
hours
Buscopan 6mcg IVTT PRN
> Intake and Output every shift
> IVF follow up D5 IM B 500 cc
@ 30 gtts/min and D5LR /
PNSS 1L @ 40 gtts/min
Au ust 7 2007
> To monitor patients condition if there is an
improvement or if there is a change to prevent
further complications.
> Still for urinalysis and fecalysis exam.
> Paracetamol is for fever reduction.
> Relieves GI discomfort.
> Hinders or kills susceptible bacteria.
> To prevent nausea and vomiting for motion
sickness.
> To know if the patient has a normal fluid
intake and output. To know for normal kidney
functioning and for laboratory purposes.
> Fluids are required to replace losses, to
prevent patient dehydration. It aids also for
mobilization of secretion.
Name of
drug
Date
Ordered
Classificatio
n
Dosage/
Frequency
Route
Mechanism of
Action
Specific
Indication
Contraindications
Side EffectsNursing
Implicatio
Paracetamol
(Biogesec)
August
6, 2007
Antipyretic,
analgesic
80mg
IVTT
every 6
hours
PRN
Chemical
Effect: May
produce
analgesic
effect by
blocking pain
impulses, by
inhibiting
prostaglandin.
Therapeutic
Effect:
Relieves painand reduces
fever.
Relieves
pain and
reduces
fever.
- Contraindicated
in patients
hypersensitive to
drug.
- Use cautiously
in patients with
long term alcohol
use because
therapeutic
doses cause
hepatotoxicity in
these patients.
Hematologic:
hemolytic
anemia,
neutropenia,
leucopenia,
pancytopenia;
Hepatic: liver
damage,
jaundice;
Metabolic:
hypoglycemia;
Skin: rash,
urticaria.
- Assess
patients
pain or
temperatu
before and
during
therapy.
- Assess
patients
drug histor
- Be alert f
adverse
reactions
and drug
interaction
Name of
drug
Date
Ordered
Classificatio
n
Dosage/
Frequency
Route
Mechanism
of Action
Specific
Indication
Contraindications Side Effects Nursing
Implication
Cefuroxime
(Zinacef)
August
6, 2007
Antibiotic 50mg
IVTT
every 8
hours
Chemical
effect: Inhibits
cell-wall
synthesis,
promoting
osmotic
instability.
Therapeutic
effect: Kills
susceptible
bacteria
Hinders
or kills
susceptible
bacteria.
- Contraindicated
in patients
hypersensitive to
drug or other
cephalosporins.
- Use cautiously
in patients with
history of
sensitivity to
penicillin
because of
possibility ofcross-sensitivity
with other beta-
lactam
antibiotics.
CNS:
headache,
malaise,
dizziness.
GI: nausea,
anorexia,
vomiting,
diarrhea,
glossitis,
abdominal
cramps.
Respiratory:
dyspnea
Skin: rashes,
urticaria.
- Assess
patients
infection
before
therapy.
- Ask patien
about
previous
reactions to
cephalospor
- Be alert for
adverse
reactions an
drug
interactions.
Name of drug DateOrdered
Classification
Dosage/Frequency
Route
Mechanism ofAction
SpecificIndication
Contraindications Side Effects NursingImplicatio
Ranitidine
Hydrochlorid
e
(Zantac)
August
6, 2007
Histamine H2
receptor
blocking
drug
8g IVTT
every 8
hours
Chemical
Effect: Inhibits
action of
histamine on
the H2 at
receptor sites
of parietalcells,
decreasing
gastric acid
secretion.
Therapeutic
Effect:
Relieves GI
discomfort.
Relieves
GI
discomfort
- Contraindicated
in patients
hypersensitive to
drug and those
with acute
porphyria.
- Use cautiously
in patients with
hepatic
dysfunction.
Adjust dosage in
patients with
impaired renal
function.
CNS: vertigo,
malaise,
headache;
EENT: blurred
vision;
Hepatic:
jaundice;
Other: burning
and itching at
injection site.
- Assess
patient for
abdomina
pain. Note
presence o
blood in
emesis,stool, or
gastric
aspirate.
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Laboratory Results
Hematology
Complete Blood Count
August 3, 2007
Result Expected Values
ame of
drug
Date
Ordere
d
Classificatio
n
Dosage/
Frequen
cy
Route
Mechanism
of Action
Specific
Indicatio
n
Contraindicati
onsSide Effects
Nu
Imp
opolami
ne
tylbromi
de
scopan
)
August
6,
2007
Anticholiner
gics
6mcg
IVTT
PRN
Chemical
Effect:
Inhibits
muscarinic
actions of
acetylcholin
e onautonomic
effectors
innervated
by
postganglio
nic
cholinergic
neurons.
Therapeuti
c Effect:
Prevent
nausea and
vomiting
To
prevent
nausea
and
vomiting
for
motionsicknes
s.
-
Contraindicat
ed in patients
with
angleclosure
glaucoma,
obstructiveuropathy,
obstructive
disease of the
GI tract,
asthma,
chronic
pulmonary
disease.
- Use
cautiously in
children
younger than
age 6.
CNS:
disorientatio
n,
restlessnes
s, irritability,
dizziness,
drowsiness,headache;
GI:
constipation
, dry mouth,
nausea,
vomiting,
epigastricdistress;
Skin: rash
and
dryness.
- As
patie
drug
histo
- Be
for
adve
reac
and
inte
ns.
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White Cell Count - 7,300 5,000 10,000
Red Cell Count - 4.20 5.40 million
Hemoglobin - 12.0 12.0 16.0 gm/dl
Hematocrit - 36.2 37.0 47.0 vol. %
Platelet Count - 236,000 150,000 400,000 mm
Differential Count
Granulocyte - 58 43.4 76.2 %
Lymphocytes - 37 17.4 48.2 %
Monocytes - 4 4.5 10.5 %
Eosonophil - 1 0 7.0 %
Blood Electrolytes
Na+ - 133.2 135.0 148.0 mmol/L
K+ - 4.10 3.5 5.3 mmol/L
PATHOPHYSIOLOGY WITH ANATOMY& PHYSIOLOGY
Anatomy & Physiology
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The human digestive system consists of a series of organs and structures that
help break down food and absorb nutrients for use throughout the body. Food
enters the digestive system through the mouth and passes through the
esophagus, stomach, small intestine, large intestine, and rectum. Other organs,
such as the liver, further aid in the breakdown of food, absorption of nutrients,
and elimination of indigestible materials from the body.
Anatomy of the Stomach
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Located on the left side of the body, under the diaphragm, the stomach is a
muscular, saclike organ that connects the esophagus and small intestine. Its
main function is to break down food. Cells in the stomach lining secrete
enzymes, hydrochloric acid, and other chemicals to continue the digestive
process begun in the mouth and produce mucus to keep these substances from
digesting the lining itself.
Pathophysiology of the Gastroenteritis
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Definition: Gastroenteritis is the irritation and inflammation of the digestive tract.
This condition may cause abdominal pain, vomiting and diarrhea. Severe cases
of gastroenteritis can result in dehydration. In such cases, fluid replacement is
the primary factor in treatment. All ages and both sexes may be affected yet the
most severe symptoms are experienced by infants and those individuals over
sixty years old. The use of certain drugs such as aspirin, antibiotics or cortisone
drugs may increase risk for this condition.
Food poisoning, stress, excessive alcohol or tobacco use, viral infections, food
allergies, improper diet, certain drugs, food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another. Care should always be taken to wash the hands often,
especially when preparing food and after bowel movements. Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract.
Predisposing factor:
Stress
Gastritis
Cigarettes smoking
Alcohol
Drugs
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Hydrochloride+
Pepsin
EmptyStomach
Increased secretion [gatric andmucus]
HyperacidityInflammation Loss
BowelMovement
Dehydration
Damage of themucousmembrane
decreasehematocrit count
GASTROENTERITIES
Collaborative Management
Medical Management:Antacids,hystamin blockersFluid electrolyte replacementBland or liquid diet
Nursing InterventionsHealth Teachings:Avoid alcoholAvoid smokingAvoid pass meal or overeating
Signs and Symptoms:AnorexiaNausea & vomitingAbdominal paincrampingDiarrheaGastric painFever
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NURSING SYSTEMS REVIEW CHART
Name: Edwin Quilab Fabro Sr. Date: 01-09-08
Vital Signs:
Pulse: 80 bpm Bp: 150/100 mmHg RR: 20 cpm Temp: 36.5 CHeight: 57 Weight: 150 lbs.
EENT[ ] impaired vision [ ] blind[ ] pain redden [x] drainage[ ] gums [ ] hard of hearing [ ] deaf NGT inserted[ ] burning [ ] edema [ ] lesion [ ] teeth[ ] assess eyes ears nose productive cough[ ] throat for abnormality [ ] no problem
RESP: rashes[ ] asymmetric [x] tachypnea [ ] barrel chest[ ] apnea [ ] rales [x] cough abdominal distention[ ] bradypnea [ ] shallow [ ] rhonchi[x] sputum [ ] diminished [ ] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanotic[ ] assess resp. rate, rhythm, pulse blood[ ] breath sounds, comfort [ ] no problemCARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [ ] fatigue[ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort[x] No problemGASTROINTESTINAL TRACT:[ ] obese [x] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] pain[ ] assess abdomen, bowel habits, swallowing[ ] bowel sounds, comfort [x] no problemGENITO URINARY AND GYNE[ ] pain [ ] urine [ ] color [ ] vaginal bleeding[ ] hematuria [x] discharge [ ] nucturia[ ] assess urine frequency, control, color, odor,[ ] gyne bleeding [ ] discharge [x] no problemNEURO: hard to discharge[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] grip[ ] assess motor, function, sensation, LOC,[ ] grip, gait, coordination, speech [x] no problemMUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechie[x] rashes [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] flushed[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoreticAssess mobility, motion gait, alignment, skin color,texture, turgor, integrity [ ] no problem
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NURSING MANAGEMENT
Ideal Nursing Management (NCP)
ACTIONS/INTERVENTIONS
Sleep Enhancement (NIC)
Independent
Provide comfortable bedding and
some of own possessions; e.g., pillow,
afghan.
Establish new sleep routine
incorporating old pattern and new
environment. Match with roommate
who has similar sleep patterns and
RATIONALE
Increases comfort for sleep and
physiologic/psychologic support.
When new routine contains as
many aspects of old habits as
possible, stress and related anxiety
may be reduced, enhancing sleep.
NURSING DIAGNOSIS: Sleep Pattern Disturbances
Risk factors may include
Internal factors: illness, psychologic stress, inactivity
External factors: environmental changes, facility routines
Changes in activity pattern
Possibly evidenced by
Reports of difficulty in falling asleep/not feeling well-rested
Interrupted sleep, awakening earlier than desired
Change in behavior/performance, increasing irritability
DESIRED OUTCOMES/EVALUATION CRITERIA CLIENT WILL:
Sleep (NOC)
Report improvement in sleep/rest pattern.
Verbalize increased sense of well-being and feeling rested.
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nocturnal needs.
Encourage some light physical
activity during the day. Make
sure client stops activity several
hours before bedtime as
individually appropriate.
Promote bedtime comfort regimens;
e.g., warm bath and massage, a glass
of warm milk, wine/brandy at bedtime.
Instruct in relaxation measures.
Reduce noise and light.
Encourage position of comfort, assist
in turning.
Lower bed and position one side
against wall when possible.
Collaborative
Administer sedatives, hypnotics
with caution as indicated.
Decreases likelihood that night owl
roommate may delay clients falling
asleep or create interruptions that
cause awakening.
Daytime activity can help client
expend energy and be ready for
nighttime sleep; however,
continuation of activity close to
bedtime may act as stimulant,
delaying sleep.
Promotes a relaxing, soothing
effect.
Helps induce sleep.
Provides atmosphere conductive tosleep.
Repositioning alters areas of
pressure and promotes rest.
May heave fear of falling because of
change in size and height of bed.
May be given to help client
sleep/rest during transition period
from home to new sitting.
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Actual Nursing Management (SOAPIE)
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S Kalit lang nigamay iyang timbang as verbalized by the patients mother.
O
frequent touching of the abdomen
rashes noted on his arm
abdominal distention noted
ARisk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement.
PLong term: At the end of an hour, the patient will be able to demonstrate
maintenance of weight.
Short term: At the end of 45 minutes, the patient will be able to verbalize a
normal pattern of bowel functioning.
I
Monitor bowel sounds.
Promot pleasant, relaxing environment.
Check stools.
Consult dietitian.
Monitor laboratory studies.
E After giving an intervention the patient verbalized a normal pattern of bowel
functioning and regains his weight.
S Unsahay ra jud nako cya gapa totoyon as verbalized by the patients
mother.
O
frequent touching of the abdomen
loose of bowel movement
abdominal distention noted
A Interrupted Breastfeeding related to physiologic response of the stomach due
to over stimulation of the gastric acid as evidence by infant illness.
PLong term: At the end of an hour, the patient will be able to promote
breastfeeding to his mother.
Short term: At the end of 30 minutes, the mother of the patient will be able to
verbalize that the interventions are effective and to know how important
breastfeeding to her child is.
I
Check nutritional status of the mother.
Provide breast pump to the mother.
Promote breastfeeding technique to the mother.
Consult health care provider.
Monitor fluid intake of the mother.
E After giving an intervention the patient verbalized a response to feeding and
method.
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HEALTH TEACHINGS
SNag kalibanga man gud cya mao na gipa admit na dayon nako sa hospital
as verbalized by the patients mother.
O
vomiting
loose of bowel movement
abdominal distention noted
NGT inserted
A Diarrhea related to hyperactive bowel movement.
P
Long term: At the end of the shift, the patient will be able to promote return to
normal bowel movement.
Short term: At the end of 1 hour, the patient will be able to reestablish and
maintain normal pattern of bowel functioning.
I
Monitor intake and output.
Assess for fecal impaction.
Check stools.
Monitor bowel sounds.
Monitor laboratory studies.
EAfter giving an intervention the patient would be able to reestablished and
maintained normal pattern of bowel functioning.
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MEDICATIONS > Advised and encouraged patient or family
to give the patient paracetamol when she
has fever.
> Do not give patient more than 5 doses in
24 hours unless prescribed by physician.
EXERCISE > Patient was instructed to ambulate, do
ROM and deep breathing exercise and do
ADLs as tolerated by patient. Tolerable
exercises will promote blood circulation and,
sense of well being, and promote fast
healing. Relaxation exercise may do.
TREATMENT > Patient instructed to increased fluid intake.
This is to promote regain of electrolytes and
fluid balance. Treatment regimen such as
some diet restriction, exercise, compliance
on medication and to submit self 1 week
after being discharge from the hospital.
OUT-PATIENT
(Check-up)
> Advised the parents to visit the nearest
hospital for further check-up for their child.
DIET > Patient was instructed to avoid eating of
salty foods. Encourage to eat foods with
high protein content such as the egg whites,
and lean meats and also vegetable and
increased fluid intake.
PROGNOSIS
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Patients with acute gastroenteritis usually progress especially when it is
not yet to its mere complication. The rate of progression depends on the
underlying diagnosis, on the successful implementation of secondary
preventative measures, and on the individual patient. If the patient is untreated
the prognosis becomes worst and poor.
In the case of my patient, as he undergone tough treatment at Camp
Evangelista Station Hospital, his prognosis is considered as good. As evidenced
by tolerating slowly the abdominal pain and maintaining bowel movement in the
whole duration of the treatment.
EVALUATION
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At the end of my hospital duty, we as a student nurse were able to render
care to my patient to help him resolve his problem regarding health. Through
observing the patients status, we were able to identify some problems during our
assessment. Because of a couple of interventions or health teachings applied
and imparted to the patient, we were able to render his needs on his problem;
alleviated pains felt by the patient due to the effects of the eye surgery and even
have improved his sleeping/resting pattern.
Patient was willing to pursue his medical therapy just to promote health
and wellness for the betterment of his condition. During the treatment, the patient
was able to developed or enhanced health awareness on his disease and with
this knowledge instilled to his mind, he was then aware on how the disease was
occur and what are the proper ways or interventions done just to minimize or
prevent this disease from getting worst.
We have also made the patient realized the importance of completing the
course of therapy by taking the medicines prescribed or ordered to him by hisphysician. In addition, eating healthy or nutritious foods that were prescribed to
him by the health providers was further been explained to him especially the
benefits he will gain in eating these nutritious foods.
In general, the patient was very cooperative to what health measures
administered to him by the health providers.
Moreover, these several interventions given to the patient made his body
functions different than as before.
Reference
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WEBSITE:
o
http://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edit
o http://www.patient.co.uk/showdoc/40000681
o http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_deve
lopment#Middle_Adulthood_.2835-60_Years.29
"http://en.wikipedia.org/wiki/Erikson
%27s_stages_of_psychosocial_development"
Category: Developmental psychology
BOOKS:
1. Erikson, Erik H. Childhood and Society. New York: Norton,
1950.
2. Erikson, Erik H. Identity and the Life Cycle. New York:
International Universities Press, 1959.
3. Medical Surgical Nursing by Smeltzer
4. Nursing Pocket Guide by Sheesy Gail
http://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://www.patient.co.uk/showdoc/40000681http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development#Middle_Adulthood_.2835-60_Years.29http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development#Middle_Adulthood_.2835-60_Years.29http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/w/index.php?title=Special:Categories&article=Erikson%27s_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Category:Developmental_psychologyhttp://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://www.patient.co.uk/showdoc/40000681http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development#Middle_Adulthood_.2835-60_Years.29http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development#Middle_Adulthood_.2835-60_Years.29http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/w/index.php?title=Special:Categories&article=Erikson%27s_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Category:Developmental_psychology