Age Case Study

PATIENT’S PROFILE NAME

:

Mon Lexter Gacutan Fernandez

AGE

:

6 months

GENDER

:

Male

ADDRESS

:

Claveria, Cagayan

PLACE OF BIRTH

:

Enrile, Cagayan

OCCUPATION

:

N/A

NATIONALITY

:

Filipino

CIVIL STATUS

:

Single

RELIGION

:

Protestant

CHIEF COMPLAINT

:

LBM Vomiting

FINAL DIAGNOSIS

:

Acute Gastroenteritis

ATTENDING PHYSICIAN : DATE ADMITTED

:

TIME ADMITTED

:

ADMITTING INSTITUTION

:

Dra. Magdalena Velarde

Saint Paul Hospital

NURSING HISTORY Present Health History: 3 days prior to admission, the patient was experiencing loose bowel movement, fever, and vomiting. He was rushed to a hospital in Claveria, Cagayan for possible medications. He was given Hydrasec to prevent his watery stools. Past Health History: He has been experiencing diarrhea, colds, and cough before. Family Health History: According to the SO, hypertension is the detected disease on the both sides of the family.

GORDON'S 11 FUNCTIONAL NEEDS HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN Before hospitalization: According to the SO, the patient was so active at home. He plays frequently with his cousins. Whenver they would talk or tickle him, he would smile and laugh. He rarely cries at home. During hospitalization: The patient oftenly cries. He feels uneasy because the room was hot. He does not laugh or smile. When he does, this would just take a short period of time. NUTRITIONAL-METABOLIC PATTERN Before hospitalization: The patient eats soft food. He loves eating lugaws, cereals, and mashed squash. He even takes his meal almost 4 – 5 times a day. He loves to drink fruit juices. During hospitalization: He was advised to just take ISOMIL, a brand of milk, since he is suffering from diarrhea. They have stopped giving him soft diet. ELIMINATION PATTERN Before hospitalization: The patient does not have any problem on her elimination pattern. They usually change his diapers 3 to 4 times a day. He defacates twice a day, that is upon waking up in the morning and before sleeping at night. During hospitalization: His SO's change his diapers almost 12 – 15 times a day. They also said that they have almost consumed 1 and ½ packs of baby diapers because he defacates more than usual. His stool was watery and soft. ACTIVITY-EXERCISE PATTERN Before hospitalization: He loves playing baby rattles with his cousins. He actively listens to stories. He smiles and laughs whenever people play with him. He loves to turn around the bed because according to his mother, this is his way to stretch his arms and feet. He does not like to be carried. During hospitalization: He has been rarely smiling and laughing. Whenver the nurses touch or talk to him, he just cries and hide his head beneath his mother's arm. He just wants to be cuddled.

SLEEP-REST PATTERN Before hospitalization: He sleeps almost 12 – 14 hours a day. When people do not come and visit their house, he just sleeps. He loves sleeping almost every hour. During hospitalization: He has difficulty in getting his sleep. He could not get enough sleep because the room was so hot and the nurses kept on going in and out of the room, giving medications. COGNITIVE-PERCEPTUAL PATTERN SELF-PERCEPTION-SELF-CONCEPT PATTERN ROLE-RELATIONSHIP PATTERN SEXUALITY-REPRODUCTIVE COPING-STRESS TOLERANCE PATTERN Before hospitalization: They just give him milk or maybe cuddle him whenever he starts to cry. Sometimes, people play with him with baby rattles to deviate his focus. During hospitalization: They have to cuddle him until he stops crying. Whenver they try to give him milk or anything that he could play with, he refuses to hold it. He just hides on his mother's arm. VALUE-BELIEF PATTERN

LABORATORY EXAMINATIONS

URINALYSIS REPORT Date: August 4, 2009 PARAMETER Color Transparency Reaction Specific Gravity Sugar Protein Squamous Epithelial Cells Red Blood Cells Pus Cells Amorp. Urates/Phosphates

NORMAL FINDINGS Yellow Amber Clear to slightly turbid 4.5-8 1.005-1.030 Negative Negative Few

ACTUAL FINDINGS

ANALYSIS

Yellow Slightly Turbid

normal normal

5 1.03 Negative Positive 1 Occasional

normal normal normal

Few Few Few

0-2 01/02/09 Occasional

normal normal normal

normal

FECALYSIS REPORT Date: August 3, 2009 PARAMETER

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Physical Properties Color

Yellow

Yellow Light

Consistency

Semi-formed

Watery

Due to the presence of bacteria Due to presence of bacteria

Bacteria: Few Occult Blood: Negative REMARKS: NO OVA/INTESTINAL PARASITE SEEN

HEMATOLOGY REPORT Date: August 3, 2009 PARAMETER

ACTUAL FINDINGS

ANALYSIS

White Blood Cells Hemoglobin Hematocrit Segmenters Lymphocytes

NORMAL FINDINGS 5-10 x 10^g/L M: 13.0-18.0 g/dL 39-54 % 0.60-0.70 0.20-0.30

9.1 x 10^g/L 12.5 g/dL 38.00% 0.33 0.62

Monocytes Platelet Count

0.02 – 0.06 150-450 x 10^g/L

0.05

Normal Normal Normal Normal Increased due to the body’s increased immune system Normal Normal

442 x 10^g/dL

REVIEW OF ANATOMY AND PHYSIOLOGY If a human adult’s digestive tract were stretched out, it would be 6 to 9 m (20 to 30 ft) long. In humans, digestion begins in the mouth, where both mechanical and chemical digestion occur. The mouth quickly converts food into a soft, moist mass. The muscular tongue pushes the food against the teeth, which cut, chop, and grind the food. Glands in the cheek linings secrete mucus, which lubricates the food, making it easier to chew and swallow. Three pairs of glands empty saliva into the mouth through ducts to moisten the food. Saliva contains the enzyme ptyalin, which begins to hydrolyze (break down) starch—a carbohydrate manufactured by green plants.Once food has been reduced to a soft mass, it is ready to be swallowed. The tongue pushes this mass—called a bolus—to the back of the mouth and into the pharynx. This cavity between the mouth and windpipe serves as a passageway both for food on its way down the alimentary canal and for air passing into the windpipe. The epiglottis, a flap of cartilage, covers the trachea (windpipe) when a person swallows. This action of the epiglottis prevents choking by directing food from the windpipe and toward the stomach. Mouth The mouth plays a role in digestion, speech, and breathing. Digestion begins when food enters the mouth. Teeth break down food and the muscular tongue pushes food back toward the pharynx, or throat. Three salivary glands—the sublingual gland, the submandibular gland, and the parotid gland— secrete enzymes that partially digest food into a soft, moist, round lump. Muscles in the pharynx swallow the food, pushing it into the esophagus, a muscular tube that passes food into the stomach. The epiglottis prevents food from entering the trachea, or windpipe, during swallowing. Esophagus The presence of food in the pharynx stimulates swallowing, which squeezes the food into the esophagus. The esophagus, a muscular tube about 25 cm (10 in) long, passes behind the trachea and heart and penetrates the diaphragm (muscular wall between the chest and abdomen) before reaching the stomach. Food advances through the alimentary canal by means of rhythmic muscle contractions (tightenings) known as peristalsis. The process begins when circular muscles in the esophagus wall contract and relax (widen) one after the other, squeezing food downward toward the stomach. Food travels the length of the esophagus in two to three seconds.A circular muscle called the esophageal sphincter separates the esophagus and the stomach. As food is swallowed, this muscle relaxes, forming an opening through which the food can pass into the stomach. Then the muscle contracts, closing the opening to prevent food from moving back into the esophagus. The esophageal sphincter is the first of several such muscles along the alimentary canal. These muscles act as valves to regulate the passage of food and keep it from moving backward. Stomach The stomach, located in the upper abdomen just below the diaphragm, is a saclike structure with strong, muscular walls. The stomach can expand significantly to store all the food from a meal for both mechanical and chemical processing. The stomach contracts about three times per minute, churning the food and mixing it with gastric juice. This fluid, secreted by thousands of gastric glands in the lining of the stomach, consists of water, hydrochloric acid, an enzyme called pepsin, and mucin (the main component of mucus). Hydrochloric acid creates the acidic environment that pepsin needs to begin breaking down proteins. It also kills microorganisms that may have been ingested in the food. Mucin coats the stomach, protecting it from the effects of the acid and pepsin. About four hours or less after a

meal, food processed by the stomach, called chyme, begins passing a little at a time through the pyloric sphincter into the duodenum, the first portion of the small intestine. Liver The liver is the largest internal organ in the human body, located at the top of the abdomen on the right side of the body. A dark red organ with a spongy texture, the liver is divided into right and left lobes by the falciform ligament. The liver performs more than 500 functions, including the production of a digestive liquid called bile that plays a role in the breakdown of fats in food. Bile from the liver passes through the hepatic duct into the gallbladder, where it is stored. During digestion bile passes from the gallbladder through bile ducts to the small intestine, where it breaks down fatty food so that it can be absorbed into the body. Nutrient-rich blood passes from the small intestine to the liver, where nutrients are further processed and stored. Deoxygenated blood leaves the liver via the hepatic vein to return to the heart. Small Intestine Most digestion, as well as absorption of digested food, occurs in the small intestine. This narrow, twisting tube, about 2.5 cm (1 in) in diameter, fills most of the lower abdomen, extending about 6 m (20 ft) in length. Over a period of three to six hours, peristalsis moves chyme through the duodenum into the next portion of the small intestine, the jejunum, and finally into the ileum, the last section of the small intestine. During this time, the liver secretes bile into the small intestine through the bile duct. Bile breaks large fat globules into small droplets, which enzymes in the small intestine can act upon. Pancreatic juice, secreted by the pancreas, enters the small intestine through the pancreatic duct. Pancreatic juice contains enzymes that break down sugars and starches into simple sugars, fats into fatty acids and glycerol, and proteins into amino acids. Glands in the intestinal walls secrete additional enzymes that break down starches and complex sugars into nutrients that the intestine absorbs. Structures called Brunner’s glands secrete mucus to protect the intestinal walls from the acid effects of digestive juices The small intestine’s capacity for absorption is increased by millions of fingerlike projections called villi, which line the inner walls of the small intestine. Each villus is about 0.5 to 1.5 mm (0.02 to 0.06 in) long and covered with a single layer of cells. Even tinier fingerlike projections called microvilli cover the cell surfaces. This combination of villi and microvilli increases the surface area of the small intestine’s lining by about 150 times, multiplying its capacity for absorption. Beneath the villi’s single layer of cells are capillaries (tiny vessels) of the bloodstream and the lymphatic system. These capillaries allow nutrients produced by digestion to travel to the cells of the body. Simple sugars and amino acids pass through the capillaries to enter the bloodstream. Fatty acids and glycerol pass through to the lymphatic system.Most digestion, as well as absorption of digested food, occurs in the small intestine. This narrow, twisting tube, about 2.5 cm (1 in) in diameter, fills most of the lower abdomen, extending about 6 m (20 ft) in length. Over a period of three to six hours, peristalsis moves chyme through the duodenum into the next portion of the small intestine, the jejunum, and finally into the ileum, the last section of the small intestine. During this time, the liver secretes bile into the small intestine through the bile duct. Bile breaks large fat globules into small droplets, which enzymes in the small intestine can act upon. Pancreatic juice, secreted by the pancreas, enters the small intestine through the pancreatic duct. Pancreatic juice contains enzymes that break down sugars and starches into simple sugars, fats into fatty acids and glycerol, and proteins into amino acids. Glands in the intestinal walls secrete additional enzymes that break down starches and complex sugars into nutrients that the intestine absorbs.

Structures called Brunner’s glands secrete mucus to protect the intestinal walls from the acid effects of digestive juices The small intestine’s capacity for absorption is increased by millions of fingerlike projections called villi, which line the inner walls of the small intestine. Each villus is about 0.5 to 1.5 mm (0.02 to 0.06 in) long and covered with a single layer of cells. Even tinier fingerlike projections called microvilli cover the cell surfaces. This combination of villi and microvilli increases the surface area of the small intestine’s lining by about 150 times, multiplying its capacity for absorption. Beneath the villi’s single layer of cells are capillaries (tiny vessels) of the bloodstream and the lymphatic system. These capillaries allow nutrients produced by digestion to travel to the cells of the body. Simple sugars and amino acids pass through the capillaries to enter the bloodstream. Fatty acids and glycerol pass through to the lymphatic system. Large Intestine A watery residue of indigestible food and digestive juices remains unabsorbed. This residue leaves the ileum of the small intestine and moves by peristalsis into the large intestine, where it spends 12 to 24 hours. The large intestine forms an inverted U over the coils of the small intestine. It starts on the lower right-hand side of the body and ends on the lower left-hand side. The large intestine is 1.5 to 1.8 m (5 to 6 ft) long and about 6 cm (2.5 in) in diameter.The large intestine serves several important functions. It absorbs water—about 6 liters (1.6 gallons) daily—as well as dissolved salts from the residue passed on by the small intestine. In addition, bacteria in the large intestine promote the breakdown of undigested materials and make several vitamins, notably vitamin K, which the body needs for blood clotting. The large intestine moves its remaining contents toward the rectum, which makes up the final 15 to 20 cm (6 to 8 in) of the alimentary canal. The rectum stores the feces—waste material that consists largely of undigested food, digestive juices, bacteria, and mucus—until elimination. Then, muscle contractions in the walls of the rectum push the feces toward the anus. When sphincters between the rectum and anus relax, the feces pass out of the bod.

PHYSICAL ASSESSMENT Area Assessed Skin Color Soles and palms Moisture

Technique Inspection Inspection

Temperature Texture Turgor

Inspection/ Palpation Palpation Palpation Palpation

Skin appendages a. Nails

Inspection

Nail beds

Inspection

Nail base

Inspection

Normal Findings

Actual Findings

Evaluation

Light brown, tanned skin (vary according to race) Lighter colored palms, soles Skin normally dry

Light brown skin

Normal

Lighter colored palms, soles Skin normally dry

Normal

Normally warm Smooth and soft Skin snaps back immediately

Normally warm Smooth and soft Skin does not snap back immediately

Normal Normal Dehydrated

Transparent, smooth and convex Pinkish

Transparent, smooth and convex Pale

Normal

Firm White color of nail bed under pressure

Firm Returns within 2-3 seconds

Normal

Due to decreased blood flow Normal Normal

Capillary refill b. Hair Distribution Color Texture Eyes Eyes

Inspection/ Palpation

should return to pink within 2-3 seconds

Inspection Inspection Inspection/ Palpation

Evenly distributed Black Smooth

Evenly distributed Black Smooth

Normal Normal Normal

Inspection

Parallel to each other PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward Same color as the skin

Parallel to each other PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward Same color as the skin

Normal

Blinks involuntarily and bilaterally up to 20 times per minute

Blinks involuntarily and bilaterally up to 18 times per minute

Visual Acuity

Inspection (penlight)

Eyebrows

Inspection

Eyelashes

Inspection

Eyelids

Inspection

Conjunctiva

Inspection

Sclera Cornea Pupils

Inspection Inspection Inspection

Iris Ears Ear canal opening

Inspection

Hearing

Inspection

Inspection

Do not cover the pupil and the sclera, lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible

Normal

Normal

Normal Normal

Normal

Do not cover the pupil and the sclera, Normal lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible

Normal

Free of lesions, discharge of inflammation

Free of lesions, discharge of inflammation

Normal

Canal walls pink Client normally

Canal walls pink Client normally

Normal

Normal Normal Normal Normal

Acuity Nose Shape, size and skin color Nares

Mouth and Pharynx Lips Buccal mucosa Gums Tongue

Inspection

Inspection

Inspection Inspection Inspection Inspection

Teeth

Inspection

Hard and soft palate

Inspection

Neck Symmetry of neck muscles, Inspection alignment of trachea Neck ROM Inspection

hears words when whispered

hears words when whispered

Normal

Smooth, symmetric with same color as the face

Smooth, symmetric with same color as the face

Normal

Oval, symmetric and without discharge

Oval, symmetric and without discharge

Normal

Pink, moist symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny Hard palate- domeshaped Soft Palate- light pink

Light pink, dry, symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny With tooth decay Hard palate- domeshaped Soft Palate- light pink

Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Rises freely with swallowing Clear breath sounds

Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Rises freely with swallowing Clear breath sounds

Lack of fluid intake Normal Normal Normal Normal Normal

Normal Normal

Thyroid gland Thorax and Lungs Abdomen

Palpation

Inspection

Skin same color with the rest of the body

Skin same color with the rest of the body

Normal

Bowel sounds

Auscultation

Clicks or gurling sounds occur

Clicks or gurling sounds occur

Normal

Auscultation

Normal Normal

irregularly and range from 5-35 per minute

irregularly and range from 20 per minute

Extremities Symmetry

Inspection

Symmetrical

Symmetrical

Normal

Skin color

Inspection

Same with the color of other parts of the body

Same with the color of other parts of the body

Normal

Hair distribution

Inspection

Evenly distributed

Evenly distributed

Normal

Skin Temperature

Palpation

Warm to touch

Warm to touch

Normal

Presence of lesion

Inspection

No lesions

No lesions

Normal

ROM

Inspection

Moves freely without discomfort

Able to move but with assistance

Due to body weakness

Level of consciousness

Inspection

Fully conscious, respond to questions quickly, perceptive of events

Fully conscious, respond to Normal questions quickly perceptive of events

Behavior and appearance

Inspection

Makes eye contact with examiner, hyperactive expresses feelings with response to the situation

Makes eye contact with examiner, hyperactive expresses feelings with response to the situation

Neurology system

Normal