MANILA DOCTORS COLLEGE

President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay City

HEALTH CARE: RELATED LEARNING EXPERIENCE

NURSING PROCESS
I. PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA
1. Patient’s Name: E.G.C
2. Address:
3. Age: 50 y/o
4. Sex: Male
5. Birth Date:
6. Rank in the Family: Eldest
7. Nationality: Filipino
8. Civil Status: Married
9. Date of Admission:
10. Order of Admission: ambulatory

B. CHIEF COMPLAINT

Patient had fever and complaint of epigastric pain prompting immediately his family members to consult. The client
was weak and pale in appearance and noted to have facial grimacing. Patient has been guarding the affected area, furthermore,
cold clammy sweat has been observed.

C. HISTORY OF PRESENT ILLNESS

Patient’s condition started 1 week prior to admission with epigastric pain with on and off fever. He went to France for
consult on September with a diagnosis of cholelithiasis. After medical interventions, patient was then discharged and
apparently sends to Philippines at Manila Doctors Hospital for continuity of care. Until few hours prior to admission, patient
had fever and complaint of right upper quadrant (RUQ) abdominal pain was admitted. He has been given medications such as
Dobutamine and has had his initial laboratory exams.

D. PAST HEALTH HISTORY/STATUS

Childhood Illness: None

Adult Illness: None
Immunization: N/A
Adult Immunization: yellow fever (2010)
Previous Hospitalization: None
Operations: None
Injuries: None

Medications taken prior

to going to the hospital: not recall
Allergies: No known allergies

E. FAMILY ASSESSMENT

Name Relation Age Sex Occupation Educational

Attainment
E.G.C Father 60 Male seaman College graduate

I.M.C Mother --- Female hosewife College graduate

S.M.C son 14 male student 2nd year High School

student
S.M.C son 12 Male 1st year high school
F. SYSTEMS REVIEW – GORDON’S 11 FUNCTIONAL HEALTH PATTERNS ASSESSMENT

1. Health Perception - Health Management Function

Patient had stated that being healthy is free from sickness and the absence,of disease. He refers to doctors
whenever he or one of his family members gets sick.,He managed his health by following medical treatment being given by his
health,care providers. In addition, he perceived that he is not totally healthy because working at cargo ship is always at risk.

2. Nutrition – Metabolic Pattern

Before hospitalization, the client eats thrice a day with adequate amount of food. He has good appetite specially at
lunch. His usual daily menu includes meat and vegetables, but he is fund of eating steaks. He drinks 8-10 glasses of water.
When he was diagnosed, his appetite decreased. He wasn’t able to eat much because he felt weak. He also experienced
a drastic decrease of weight; 72 kg to 60 kg (12 kg weight loss) for two months duration. He verbalizes: “Wala akong ganang
kumain, kaya nga nabawasan talaga timbang loob ng 2 buwan.”
According to the patient, there was an improvement in his appetite in comparison to the time when he is experiencing
pain, difficulty of breathing, chest pain, excessive sweating when sleeping, and fatigue. He now eats three times a day, which
includes rice (1 to 2 cups a meal) and viand usually fried fish (tuyo, galunggong), pork, chicken, and vegetables (e.g ginisang
kangkong).

3. Elimination Pattern

Before being diagnosed he didn’t have any problems regarding his elimination pattern and didn’t use any laxatives to
aid him in eliminating feces. He defecates once a day, usually early in the morning or before going to bed, his stool was
formed and can be easily eliminated. He would urinate three to six times a day depending on his fluid consumption. He
describes his urine as slightly yellowish and clear in color. He does not have odor problems.
 At present He urinates 3-4 times a day with amber-colored urine. He further stated that urinating is not a problem.
Defecation pattern has been reported to be seven times a week most occurring in the morning with a semi-solid consistency
and brownish in color. No difficulty of defecating has been stated and did not have to use laxatives and other stool softeners.

4. Activity – Exercise Pattern

Before he was diagnosed he then work at ship for 8 hours a day he then consider his pushups and stretching as an
exercise every morning before going to work.
At present he doesn’t get hard work but the doctor advise him to ambulate every day for 15-20 minutes. His main form
of exercise now is walking

5. Cognitive – Perceptual Pattern

Before the diagnosis of, he use to were reading glasses and he doesn’t have nearing diffiuclty. At first, he was not
aware of his condition and its complications that prompt him to seek medical attention.

At present, upon understanding the severity, the patient immediately adhered to the medications needed to cure his
condition. The patient can relate to ideas and topics. He grasps ideas and questions easily, and he does not have difficulties in
learning with regards to health teaching. He thinks futuristically as evidenced by setting a goal- to be healthy again. He still
does not need to use aids for vision and hearing.

6. Sleep – Rest Pattern

Before he was diagnosed, he sleeps at around 9 or 10 pm. And have to wake up at 5 am to have his Morning
exercise before going to work start to have his daily activities. He would sleep 12 hours every day because he also sleeps at the
afternoon. He feels well rested when he wakes up and doesn’t need any sleeping pills to get him to sleep.

When he was interviewed, he told us that at present he is was not able to sleep well. His having hard time to have good
sleep. He now wakes up at every now and then because whenever he turns right there is pain because of the t-tube.
 7. Self-Perception And Self-Concept Pattern

He does not consider himself as a burden to his Aunt’s family. He even said that he helps in their daily expenses
by giving some of his earnings to them. As a patient, he said it’s normal that family members take care of him especially he
doesn’t have a family of his own. He considers himself as simple and hardworking person. At work, he is the one who cooks
for the whole crew. He said he is good in cooking. He is also a good mechanic though he wasn’t able to learn how to drive. He
said, he is too afraid to drive.
8. Role – Relationship Pattern

Before the diagnosis, he acted as a father figure. He helps with their finances by working as a mechanical support at
cargo ship. He serves as a role model to his family as he tells them how to act in different situations of life. Whenever they
have problem they would just let it pass and talk about it as soon as they have relaxed. There are no problems in relationship
among family members for they have close ties. He has close friends that he can rely on. The patient knows his right as a
person and he follows rules and regulation desired for the group and the society he belongs to.

9. Sexuality – Reproductive Pattern

He said he is still sexually active, though he does not practice safe sex

10. Coping – Stress Tolerance Pattern

Before he had diagnosed, he goes out of their house and talks to neighbors to relieve his stress. At times he would sleep
or read bible to help him forget about his problem.

Upon diagnosis, he sleeps to help him relax and stays at the room to avoid other distraction. For him not being able to
do things he usually does, at present time he doesn’t feel any stress.
 11. Value – Belief Pattern

He is a Catholic. He would go to church if there is time together with his family . He still believes that God would help
him to solve his problems. He prays to ask for assistance and guidance especially when they are travelling.

G. Heredo-Familial Illness

Maternal: none
Paternal: hypertension

H. DEVELOPMENTAL HISTORY

I. PHYSICAL ASSESSMENT

A. General Survey

Day 1: January 17, 2011

Vital Signs:
Temp: 37.6 C
PR: 94 bpm
RR: 26 cpm
BP: 130/80 mmHg
Height: 5’9’’ or 175.4 cm
Weight: 60 Kgs (BMI: 19.5)
Ideal Body Weight: 72.72kg

Day 2: January 18, 2011

Vital Signs:
Temp: 37 C
PR: 79 bpm
RR: 24 cpm
BP: 110/70 mmHg
Height: 5’9’’ or 175.4 cm
Weight: 60 Kgs (BMI: 19.5)
Ideal Body Weight: 72.72kg

Day 3: January 19, 2011

Vital Signs:
Temp: 37.1 C
PR: 85 bpm
RR: 24 cpm
BP: 120/90
Height: 5’9’’ or 175.4 cm
Weight: 60 Kgs (BMI: 19.5)
Ideal Body Weight: 72.72kg

BMI: 19.5

 Underweight = <18.5
 Normal weight = 18.5-24.9
 Overweight = 25-29.9
 Obesity = BMI of 30 or greater

C. Regional Exams
 January 19, 2011

A. Skin
I:
 Is pale and white
 There are lesions on arms.
P:
 Is cold to touch
 Absence of tenderness and masses
 good skin turgor and muscle tone

B. Nails
I:
 Are convex.
 Have long and transparent nails.
 Nail bed is pinkish in color.
P:
 Nail has a smooth texture.
 Has good capillary refill of 2-3 sec.

C. Head & Face

I:
.
 Is aligned at the center of the body.
 Facial features are symmetrical
P:
 Absence of tenderness and masses.
 Hair is short, smooth and shiny.
 Facial movements are symmetrical.
D. Eyes
I:
 Eyebrows are symmetrically aligned and hair is evenly distributed.
 Pinkish conjunctiva
 The eyelids do not cover the sclera and blink reflex is present.
 Pupils are equal in size, rounded and reactive to light and accommodation

E. Ears
I:
 Has the same color with facial skin.
 Are symmetrical.
 Are aligned with the outer cantus of the eyes.
P:
 Absence of tenderness and masses

F. Nose
I:
 Nares are symmetrical
 Absence of discharge
P:
 Absence of tenderness, especially in the sinuses.
 Absence of masses or nodules

G. Mouth & Pharynx

I:
 Internal structures of his mouth are pinkish in color.
 Lips are pink in color, dry and it is symmetrical
 Tongue can move freely
P:
  Absence of tenderness.

H. Neck
I:
 Is at the center of the body
 Neck muscles can move if full ROM, with discomfort
 Absence of neck vein distension
P:
 Not tenderness noted

I. Thorax & Lungs

I:
 With spontaneous breathing pattern
 Not Depressed clavicular area
 Ribs slope across and down.
 Active movement occurs within the intercostals spaces.
A:
 no vesicular and vesicular breath sounds are present at the posterior thorax
 No Crackles heard at both posterior lungs

J. Cardiovascular/Heart
I:
 The apical area has visible pulsation apical area has no visible lifts or heaves.
 The epigastric area has visible pulsation.
 Carotid has symmetric pulse as the radial pulse and the apical pulse.
Pa:
 A heart rate of 60 beats per minute (based on 8/7/2010); beat is strong and slow, with regular rhythm
A:
 No extra heart sounds was heard.
 K. Breast and Axillae
I:
 No lesion was present.
 Presence of hair was noted on the axillae.
P:
 Axillary is dry.

L. Abdomen
I:
 Stomach is flat, no scars is noted.
 Umbilicus is at midline.
 With t-tube close at right upper quadrant

M. Extremities
I:
 There are no gross deformities that are found in the body.
 Hair evenly distributed
 Skin color is pale white.
P:
 Absence of tenderness

M. Genitals
 Client refused to perform
 Client does not perform self testicular examination

N. Rectum & Anus

 Client refused to perform
 Client verbalized the absence of palpable lesions or masses, tenderness, no pain in defecation.
 O. Neurologic Exam

A. Mental and Emotional Status

 Conscious, coherent and oriented to time, place and date
 Responds easily to the question asked
 Is able to understand spoken words very well.

B. Intellectual Function
 The client’s immediate recall, recent and remote memory is normal.
 The client is able to answer simple questions properly.
 He is able to explain phrases in a complete detail and associates related concepts normally.
 Able to weigh the importance of seeking help.

II. PERSONAL/ SOCIAL HISTORY

The patient drinks 2 cups of coffee every day. He could consume a pack of cigarette in one day. He started smoking
when he was 25 years old.
He spends more time travelling because of the nature of his work. His last travel was in France. There was limited time
for him to socialize or to attend family gatherings.

III. ENVIRONMENTAL HISTORY (LIVING/NEIGHBORHOOD/CIRCUMSTANCES)

He lives in Batangas where he has his own house near the church; he lives with his wife and two son. the house is well
ventilated and has a long stair for about 15 steps to 2nd floor. The water source for washing is coming from NAWASA and they
used to have mineral water to drink. They have good electricity and the 4 rooms are air-conditioned. The neighborhood is quiet
 and peaceful. The patient said there are no circumstances that could endanger their lives. There were no incidents of crime or
illegal activities in the vicinity. There were no piggeries or poultry that could be a health hazard for them.

VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS

Date: jan 12, 2011

Prothrombin Time (PT)

Patient’s Time Normal Values Significance

17.1 seconds (done twice) 10-14 seconds prolonged PT my suggest hepatic

disease, deficiencies in fibrinogen,
prothrombin, Vit K or factors V, VII,
or X

Activated Partial Thromboplastin Time (APTT)

Patient’s Time Normal Values Significance

52.1 seconds (done twice) 26 - 36 seconds prolonged APPT my suggest

deficiencies in coagulation factors
(Vit. K)

Date: jan 12, 2011

Blood Results Normal Values Significance

Chemistry
BUN 6.89 mmol/L 2.9 – 8.2 mmol/L within normal range

Creatinine 176.8 µmol/L 53 -106 µmol/L an increase may suggest

 renal disease

Hepatic Results Normal Values Significance

Enzymes
SGOT/AST 7.1 U/L 8 – 33 U/L low levels suggests lack of
Vitamin B6

Date: jan 12, 2011

Whole Abdominal Ultrasound

R Mid-hepatic Length = 17.9 cm

L Mid-hepatic Length = 12.4 cm
Common Bile Duct = 1.5 cm
Main Portal Vein = 1.3 cm
Spleen = 8.7 x 3.8 cm
R Kidney = 10.2 x 4.9 x 4.7 cm
L Kidney = 10.6 x 5.1 x 5.3 cm
Prostate Gland = 2.5 x 2.9 x 3.1 cm (11.6 gms)

 The liver is enlarged without focal lesion. Common bile duct and intrahepatic ducts are dilated. Extrahepatic portions
of the common bile duct are obscured by bowel gas.
 Markedly distended gallbladder is noted
 Gallbladder is adequately distended without intraluminal echoes or wall thickening
 Pancreas cannot be properly evaluated due to presence of bowel gas
 Spleen is unremarkable
  Both kidneys are within normal size configuration, parenchymal echopattern, and cortical thickness. No focal lesion,
ectasis, or lithiasis noted
 Prostate gland is normal in size without calcifications
 Urinary bladder is underfilled with note of foley catheter

Impression:
Hepatomegaly with biliary obstruction
Markedly distended gallbladder vs. bowel loop
Underfilled urinary bladder

Date: jan 12, 2011

Blood Chemistry Results Normal Values Significance

Total Bilirubin 47.5 2 - 21 mmol/L increased values may suggest
hepatitis, biliary stricture

increased values may suggest

Direct Bilirubin 17 <5 µmol/L biliary obstruction
(B1)
increased values may suggest
hepatic damage
Indirect Bilirubin 30.5 2 – 17 µmol/L

Electrolytes Results Normal Values Significance

Sodium 152.4 mmol/L 136 - 142 mmol/L increased values may suggest
impaired renal function

decreased values may suggest

Potassium 2.90 mmol/L 3.8 – 5.0 mmol/L gastrointestinal and renal
disorders
 increased values may suggest
Chloride 121.7 mg/L 95 – 103 mg/L severe dehydration or complete
renal shutdown

Hematology Results Normal Values Significance

Blood Type Type O+
WBC 17.6 G/L 4.1 – 10.9 G/L -increased values may suggest infection
-decreased values may suggest anemia
RBC 3.68 T/L 4.2 – 6.30 T/L -decreased values may suggest
anemia, recent hemorrhage or fluid
HGB 112 g/L 120 – 180 g/L retention
-decreased values may suggest anemia,
hemodilution
HCT 360 L/L 370 – 510 L/L
-decreased values may suggest
immune disorders, Vit B12 deficiencies
Platelet 66 g/L 140 – 440 G/L
XI. DRUG STUDY

Generic Name: Cefuroxime

Dosage: 750 mg IVP q 8°
Indication: it is used as an anti-infective agent for urinary tract infections and severe infections

Mechanism of Action Side Effects Contraindications Adverse Reactions Nursing

Considerations
Inhibits bacterial cell diarrhea, nausea and Hypersensitivity to Allergic reactions like  Determine history
wall synthesis, vomiting, gas or cephalosporins and skin rash, itching or of hypersensitivity
rendering cell wall heartburn related antibiotics; hives, swelling of the reactions to
osmotically unstable, pregnancy (category B), face, lips or tongue, dark cephalosporins,
leading to cell death lactation urine, difficulty of penicillins, and
breathing, irregular history of allergies,
heartbeat or chest pain, particularly to
seizures, unusual drugs,
bleeding or bruising,  Inspect IM and IV
white patches or sores injection sites
inside the mouth frequently for
signs of phlebitis.
 Monitor I&O rates
and pattern:
 Monitor for
bleeding
 Generic Name: Metronidazole
Dosage: 500 mg IV infusion q 8°
Indications: It is used for the treatment of serious infection caused by susceptible anaerobic bacteria in
intra-abdominal infections, skin infections, gynecologic infections, septicemia, and for
preoperative and postoperative prophylaxis

Mechanism of Side Effects Contraindications Adverse Reactions Nursing Considerations

Action
It binds to bacterial GI discomfort, Blood dyscrasias. Convulsive seizures;  Obtain baseline
and protozoal DNA anorexia, nausea, Active CNS diseases. peripheral information on
to cause loss of furred tongue, dry Hypersensitivity to neuropathy; rash, patient’s infection:
helical structure, mouth and unpleasant imidazole. pruritus. Burning
fever, wound
strand breakage, metallic taste, Tuberculosis to mucous and skin irritation
inhibition of nucleic headache, less membranes and certain characteristics, WBC
acid synthesis and frequently vomiting, viral conditions. 1st count (>100,000mm3)
cell death. diarrhea, weakness, trimester of pregnancy. and regularly assess
dizziness and Lactation. Children. during treatment.
darkening of the urine. Leukopenia. Peripheral  Assess for allergic
Watery (tearing) eyes if neuropathy (long term
reactions: rash ,
applied near to eye therapy). Psychiatric
area, transient redness disorders. urticaria, pruritus.
and mild dryness.  Monitor renal
function: urine output,
input-output ration,
polyuria,dysuria,
pyuria, BUN and
creatinine. Decreasing
output and increasing
 BUN, creatinine may
indicate
nephrotoxicity.
 Monitor bowel
pattern, discontinue
drug if severe diarrhea
occurs.
 Assess for over
growth of infection:
peripheral itching,
fever malaise,
redness, swelling,
drainage, rash and
change in
cough/sputum.
 Generic Name: Paracetamol
Dosage: 300mg IVP q 4° for temp ≥ 38.5 °C
Indication: To relieve mild to moderate pain due to things such as headache, muscle and joint pain,
backache and period pains. It is also used to bring down a high temperature.

Mechanism of Action Side Effects Contraindications Adverse Reactions Nursing Considerations

Decrease fever by Side effects are rare Hypersensitivity to Skin rashes, blood  Assess patients fever or
inhibiting the effect of with paracetamol acetaminophen or disorders and acute pain: type of pain,
pyrogens of the when it is taken at the phenacetin; use with inflammation of the location, intensity,
hypothalamic heat recommended doses. alcohol. pancreas have
duration, temperature,
regulating centers by a occasionally occurred
hypothalaminc action in people taking the diaphoresis
leading to sweating nd drug on a regular basis  Assess allergic
vasodilation for a long time. One reactions: rash,
relieves pain by advantage of urticaria; if this occur,
inhibiting paracetamol over drug may have to
prostagalandin aspirin and NSAIDs is
discontinued
synthesis in CNS does that it doesn't irritate
not have inflammatory the stomach or causing  Assess hepatotoxicity;
action because of its it to bleed, potential dark urine, clay-colored
minimal effect Side effects of aspirin stools, yellowing of
and NSAIDs. skin and sclera; itching,
abdominal pain, fever,
diarrhea if patient is on
long term therapy.

 Monitor liver and renal

function. AST, ALT
 bilirubin, pro-time,
BUN, CREA
 Check input and output
ratio; decreasing output
may indicate renal
failures (long-term
therapy)
 Assess for chronic
poisoning: rapid, weak
pulse; dyspnea: cold,
clammy extremities;
report immediately to
prescriber
 Generic Name: Pantoprazole
Dosage: 80 mg IV infusion
Indications: Gastric acid pump inhibitor

Mechanism of Side Effects Contraindications Adverse Reactions Nursing Considerations

Action
Inhibits both basal Headache, diarrhea, Hypersensitivity. Insomnia, flatulence,  Assess for underlying
and stimulated abdominal pain, Moderate to severe hyperglycemia condition before therapy
gastric secretions by rash hepatic or renal and regularly thereafter to
suppressing the dysfunction.
monitor drug
final step in acids
production, through effectiveness.
the inhibition of the  Assess GI symptoms:
proton pump by epigastric/abdominal pain,
binding to and bleeding and anorexia.
inhibiting  Monitor for possible drug-
hydrogen-potassium
induced adverse reactions
adenosine
triphosphatase, the  Monitor hepatic enzymes:
enzyme system AST, ALT, alkaline
located at the phosphatase during
secretory surface of treatment
the gastric parietal  Assess patient and
cell.
family’s knowledge on
drug therapy.
 Generic: Vitamin K/ Phytomenadione
Dosage: 1 amp IVP q 8°
Indication: Used in the treatment and prevention of hemorrhage associated with Vitamin K deficiency

Mechanism of Side Effects Contraindications Adverse Reactions Nursing Considerations

Action
Synthetic analog Hypotension, Pronounced allergic Urticaria.  Assess for patients condition
of Vit. K w/c is cyanosis, diathesis. Infants<1 yr. Hyperbilirubinemiainclu before therapy and regularly
essential to headache, ding kernicterus. In thereafter to monitor drug
hepatic synthesis dizziness, rash. newborns. death after IV
effectiveness.
of blood clotting Anaphylactoid injection. Pruritic
factors II, VII, reactions; pain, erythematous plaques at  Assess for bleeding: bruising,
IX, X. swelling IM injection site. hematouria, black- tarry stools
and hematemesis.
 Monitor for possible drug-
induced adverse reactions
 Assess patient and family’s
knowledge on drug therapy
X. Identified Problems According to Priority

1. Ineffective breathing pattern related to decreased lung expansion secondary to liver enlargement
2. Acute pain related to ductal spasm secondary to biliary duct obstruction
3. Hyperthermia related to presence of disease process

XI. NURSING CARE PLAN

Assessment Nursing Scientific Goals Interventions Rationale Evaluation

Diagnosis Background
S> Ineffective The liver is After 2-3 hours > assess and > serve as baseline Goal partially
“hinahabol ko breathing located of rendering monitor vital data met. After 3 hours
ang aking pattern related immediately proper signs of rendering
hininga” as to decreased below the nursing proper nursing
verbalized by lung expansion diaphragm intervention, > monitor > to note for intervention, the
the client secondary to which is the the client will respiratory status worsening of client
O> liver major muscle demonstrate tachypnea demonstrated
- rapid and enlargement of respiration. easier > place client in easier respiration
shallow Upon respiration and sitting/high > it allows good and respiratory
breathing enlargement of respiratory rate fowler’s position lung excursion and rate decreased
-nasal flaring the liver, it will decrease chest expansion from 32 bpm to
noted compresses the from 32 bpm > provide 25 bpm
-use of diaphragm to 22 bpm adequate
accessory upward thus ventilation > to facilitate
muscles decreasing effective breathing
lung expansion > ensure O2
Vital Signs: during delivery system is > so that appropriate
RR: 32 bpm inspiration applied to the amount of oxygen is
BP: resulting to patient continuously
110/80 mm Hg rapid and delivered
CR: 100 bpm shallow > refer to
T: 39.6°C breathing physician
pattern accordingly > to assess
during tachyneic respiratory status
episodes

> explain effects

of wearing
restrictive > use of tight or
clothing restrictive clothing
compromises
respiratory
> teach patient excursion
appropriate
breathing > appropriate
techniques by breathing techniques
demonstration are important in
emphasizing slow maintaining
inhalation, adequate gas
holding end exchange
inspiration for a
few seconds and
passive inhalation
Assessment Nursing Scientific Goals Interventions Rationale Evaluation
Diagnosis Background
S> Acute pain As the biliary After 4 hours > monitor vital > to monitor any Goal partially
“masakit ang related to duct becomes of rendering signs changes from the met. After 4 hours
tiyan ko” as ductal spasm obstructed, the proper previous to present of rendering
verbalized by the secondary to pressure within nursing data. Serve as proper nursing
client biliary duct the bile duct intervention, baseline data intervention, the
obstruction increases thus the patient’s patient’s level of
O> producing level of pain of > to assess etiology/ pain subsided
- facial grimace involuntary 7/10 will > perform a contributing factors from 7/10 to 4/10
- with guarding contraction subside to 3/10 comprehensive
behavior noted usually assessment of
- restlessness accompanied pain to include
- pale and weak by pain that location, onset/
in appearance may last from duration, quality,
- rated pain as seconds to severity and
6/10 in a pain minutes precipitating
scale of 1-10; 1 factors
as the lowest and
10 as the highest > determine > to assess
possible precipitating factors
pathophysiologica
Vital Signs: l causes of pain
BP:
110/80 mm Hg > perform pain > to rule out
RR: 32 bpm assessment each worsening of
CR: 100 bpm time pain occurs underlying condition
T: 39.6°C
> provide comfort > to provide non-
measures pharmacological
pain management

> provide calm > to prevent anxiety

and quiet
environment
> to maintain
> administer acceptable level of
analgesics as pain
indicated
> so that immediate
> instruct the relief measures may
patient to report be instituted
pain
> this will contribute
to patient’s
> explain cause of understanding to his
pain, if known condition

> it will determine if

measures used were
> instruct the not effective to
patient to evaluate facilitate better
and report interventions
effectiveness of
measures used
Assessment Nursing Scientific Goals Interventions Rationale Evaluation
Diagnosis Background
S> Hyperthermia During After 1-2 hours > monitor vital > to monitor any Goal met. After 1-
“sobrang init related to inflammation of rendering signs changes from the 2 hours of
ko” as disease process or infection, proper previous to present rendering proper
verbalized by the area of nursing data. Serve as nursing
the patient infection or intervention, baseline data intervention, the
infection the patient’s patient’s
O> phagocyte temperature > to promote heat temperature
- febrile (39.6 releases will subside > remove excess loss through subsided from
°C) endogenous from 39.6°C to clothes or blanket evaporation 39.6°C to 37.5°C.
- flushed skin pyrogens 37°C or
- warm to touch (fever-causing maintain body > TSB opens the
-diaphoretic substance). temperature > perform TSB skin pores therefore
> pale and weak These will act within normal facilitating
in appearance as receptors in range (36.5°C conduction and
the – 37.5°C) evaporation of heat
Vital Signs: hypothalamus from a warm surface
BP: to cause to a cool surface
110/80 mm Hg upward
RR: 32 bpm alteration of its > to reduce
CR: 100 bpm temperature set metabolic demands
T: 39.6°C point
> provide > to support
adequate rest circulating volume
 and tissue
perfusion
> administer fluid
an electrolyte
replacement > to treat underlying
cause

> administer
medications as > this will provide
indicated patients knowledge
how to assess their
temperature; this
> explain will provide
temperature information on how
measurements to prevent or control
and all treatments temperatures
> provide especially when they
information were already
regarding normal discharged
temperature and
control
> discuss
precipitating
factors and
preventive
measures
XII. ONGOING APPRAISAL

XIII. DISCHARGE PLAN

M – Medicine
- advise patient to continue his prescribed medicines

E – Environment and Exercise

- maintain a quiet environment to promote relaxation
- provide clean and comfortable environment
- encourage walking everyday

T – Treatment
- continue home medications
- advise patient to take multivitamins for increased immunity
- teach patient about wound care

H – Health Teachings
- provide oral and written instructions about wound care, activity, diet
recommendations, medications, and follow-ups

O – Out-Patient Follow-Up
- patient will be advised to go back to the hospital in a specific date to have a follow-up check-up after discharge

D – Diet and Danger Signs

- encourage patient to increase protein intake for tissue repair
 - advise patient and family members to immediately consult if the patient is experiencing any likely symptoms, or
changes that may occur when the patient is at home.