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Review of Systems

SkinLast Feb. 2007, Mr. X has experienced boils on his left leg with a scar formation.

Head Mr. X was complaining of being light headed occurring after drinking alcohol.

EyesMr. X was not complaining of any visual changes and had never used eye glasses

until now.

EarsMr. X was not complaining of pain, hearing changes without any discharges.

Nose

Mr. X was not complaining of any nasal discharges or any obstruction in the nose.

ThroatThis august 2008, Mr. X had experienced difficulty of swallowing, sore throat, and

regurgitation.

RespiratoryThis August 2008, Mr. X complaints of difficulty of breathing.

CardioThe patient was not complaining of chest pain.

GastroThis august 2008, Mr. X experienced abdominal pain, loss of appetite, dysphagia of

solid foods, and regurgitation.

Genitourinary

The patients urine output decrease with a dark yellow in color, and had not

experienced UTI.

Musculo-skeleto

Mr. X experienced weakness and had limitations in performing his ADLs.

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Demographic Data

Mr. X is a 31 year old male, presently residing at Sta. Ignacia, Tarlac. Mr. X ismarried and lives with his family with two children and his wife. They are Roman

Catholic. He was admitted on August 22, 2008 with a chief complaint of abdominal pain

under the service of Dr. R.

Present Health History

Thirteen hours prior to consultation, Mr. X had an alcohol binge. Five hours prior

to consultation Mr. X started having vomiting, abdominal pain on epigastric area, and

diarrhea. Two hours prior to consultation Mr. X is sought to consult to a private hospital

seen and examined and diagnosed alcohol intoxication.

Past Medical History

Mr. X stated that he has been immunized with BCG, Tetanus Toxoid, Measles, andPolio Vaccines.

Family Health History

Mr. Xs mother is known of having hypertension and his father is known of having

a Pulmonary Tuberculosis.

Social History

Mr. X was a former carpenter and lives with his family. Their house is situated in a

slum-like neighborhood and is within close proximity with Barangays road network and

Local Health Unit. Their house is made up of sawali, has adequate space for the entirefamily members and has no problem with the house ventilation. They get their water from

the water pump which is going to be used for both drinking and washing purposes. Garbage

is thrown in a sack and is collected by a garbage truck weekly. They used pail-system fortheir toilet.

Mr. X is alcoholic, drinking for about an average of two to three times a week.

Based on Mr. X he is eating three meals per day and he is fond of eating fatty foods.

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Nursing Diagnosis Intervention Rationale

Alteration in

Comfort; Acute Pain

related toHyperperistalsis

1. Encouraged client to report

feeling of discomfort or pain

2. Assess or instruct to report of

abdominal cramping or pain, notinglocation, duration, intensity,investigate and report changes in

pain characteristics

3. Review factors that aggravate oralleviate pain

4. Observe and record abdominaldistention, increased temperature,

decreased BP

1. May try to tolerate pain

rather than request analgesics

2. Colicky intermittent pain

occurs with Crohnspredefecation pain frequentlyoccurs in with urgency, which

may be severe and continuous

3. May pinpoint precipitatingor aggravating factors or

identify developing

complications

Nursing Diagnosis Intervention Rationale

Fluid Volume Deficitrelated to Excess

Losses through

1. Encouraged client to reportfeeling of discomfort or pain

2. Assess or instruct to report ofabdominal cramping or pain, noting

location, duration, intensity,

investigate and report changes inpain characteristics

3. Review factors that aggravate oralleviate pain

4. Observe and record abdominaldistention, increased temperature,

decreased BP

1. May try to tolerate painrather than request analgesics

2. Colicky intermittent painoccurs with Crohns

predefecation pain frequently

occurs in with urgency, whichmay be severe and continuous

3. May pinpoint precipitatingor aggravating factors or

identify developingcomplications

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UES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

PLAN/GOAL NURSING

DIAGNOSIS

RATIONALE EXPECTED

OUTCOME wala

kong

anang

umain

serbalized

y the pt.

:

weight

sspoor skin

urgor

sunken

yes

imbalancednutrition less

than body

requirements

R/T loss ofappetite as

evidenced by

weight loss

>Due tomalabsorption of

nutrients in the

gastro intestinal

tracts predisposesthe pt. to

dehydration;

factors mayinclude are loss of

appetite, nausea

and vomiting thatleads the pt. to

loss an adequate

caloric and protein

requirements lossof fluid, nutrients

and minerals

>after seriesof proper

nursing

intervention

the pts bodyrequirements

will be able to

regain

windependent:w

>weight daily

h

>Encourage bed

rest and limitedactivity during

acute phase of

illness

>monitor intakeand output

collaborative

mngt..

>Provide morenutrients and

vitamins to the

client

>Ascertainunderstanding of

individual

nutritional needs>Instruct the

client about the

need for a wellbalanced diet

other

collaborative:

>Provides

information/

effectiveness oftherapy

>Decreasing

metabolic needsaids in

preventing

caloric depletion

and converseenergy

>for monitoringpurposes and to

detect the

possible

dehydration

>To meetincrease

metabolic

demands

>to determinewhat

information to

provide in theclient

>To prevent

furtherdehydration

>After seriproper nurs

intervention

thepts bod

requiremenwill regain

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>Keep patient

n NPO asindicated

>Intravenous

total parenteralnutrition

>

>Resting the

bowel decreasesperistalsis and

diarrhea limiting

malabsorption/

loss of nutrients>this regimen

rest the GI tractcompletely

while providing

essential

nutrients shortterm TPN is

indicated during

periods ofdisease

exacerbationwhen bowel restis needed