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.