Case Pres Mikko

7/30/2019 Case Pres Mikko

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Alarcon, Mikko Anthony P.

BSN 406/ Group 21A

I. Biographic Data

The client Mrs LR, was diagnosed of Hyponatremia, possible 2 dehydration, and.

She was admitted because of complaint of epigastric pain.She also stated naconfine

ako dito kase masakit yung tiyan ko pag umuubo. 2 days before she was admitted

she was having multiple episode of vomiting associated with epigastric pain and

diarrhea. Client also has type 2 Diabetes mellitus. She was born on April 23, 1951.

She is married to Mr MR. She is 62 years old and her husband Mr MR is 69 years

old. They are Iglesia ni Cristo. She has no work. They live in Blk 2 Lot 6 East view 2

Antipolo City. Her physician is Dr Soriano.

II. Nursing History

A. Past health history

When asked about her childhood sickness she stated Hindi kona maalala e siguro ubo

lang at algnat lagi kong sakit noon. She indicated Hindi ko na rin maalala kung

kumpleto yung bakuna ko hindi ko naman alam na itatanung dito yan. Client has no

known allergies. She also did not have any accidents before. She said that naoospital

lang ako pag nanganganak ako. She stop her maintenance on her type 2 Diabetes

Mellitus since December 2000. Client did not go to any foreign travel.

B. History of Present Illness

According to client, 2 days prior to admission, she always have this feeling of pain in her

stomach when she is coughing. Because of that pain she cannot do her daily living

activities. She also stated that she was vomiting. And she also stated that had diarrhea

during that time.

C. Family History


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The client stated that her father is deceased, she has seven siblings and they have a

family history of Hypertension. In her family she is the only one with Diabetes mellitus.

Her husbands and his parents have hypertension.

D. OB history

G6 P7 (8 0 0 8)

III. Physical Assessment

A. General Appearance

The clients skin is color brown. Her nails are clean and neat. Clients clothing is

appropriate. The client is very cooperative and response appropriately to the

given instruction.

Norms:

Color is even without obvious lesions: light to dark beige-pink in lighted skinned

client; light tan to dark brown or olive in dark-skinned clients. Dress is appropriate

for the occasion and weather. The client is clean and groomed appropriately for

occasion. Stains on hands and dirty nails may reflect certain occupations such as

mechanic or gardener. Client is cooperative and purposeful in his or her

interactions with other. Affect is appropriate for the clients situation.

Source: Health Assessment in Nursing. Weber and Kelley. Third Edition.

Interpretation:

The clients appearance and her attitude is suitable for her condition. There is no

deviation from normal.

B. HEENT

The head of the patient is rounded, and symmetric. The hair of the client is thick

and colorered brown with white. The color of the pupil is black, the eyelids are

intact, symmetric, and blinks bilaterally, and when eyes are closed there is no

sclera visible. The clients eyebrows are evenly distributed, the skin is intact, it is

symmetrically aligned, and has equal movements. The cliets eyelashes are

equally distributed and is curled slightly outward. Pink palpebral conjuctiva. The

patients ears has minimum amount of cerumen. The color is as same as the

face. The pinna recoils after it is folded. The nose of the patient is straight

symmetrical


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Mouth:

The clients lips are pale in color. The client wears dentures.

Norms:

The skull is rounded, normocephalic and symmetrical with frontal, parietal, and

occipital prominences. Smooth skull contour. Hair is evenly distributed, thick hair,

silky, resilient hair, no infection and no infestations. Eyebrows are evenly

distributed, skin intact, eyebrows symmetrically aligned, equal movements.

Eyelashes are equally distributed and curled slightly outward. Bulbar conjunctiva

is transparent, capillaries sometimes evident, sclera appears white.Ears is

mobile, Firm, and not tender, Pinna recoils after it is folded. Color same as facial

skin, symmetrical, auricle aligned with outer canthus of eye, about 10 degrees

from vertical. Nose is symmetric and straight, no discharge or flaring, uniform

color. Lips is uniform pink in color. 32 adult teeth, smooth shiny white teeth, pink

gums, moist, firm gum texture. Light pink, smooth palate.


Interpretation:

The patients head, eyes, ears, nose are normal. Mouth is deviated because of

her dentures

C. Extremities

Lower and upper extremities moves symmetrically. Joints move smoothly.

Smooth coordinated movements.

Norms:

Equal size on both sides. No fasciculations/tremors. Joint moves smoothly.

Normally firm

Smooth coordinated movement. Equal strenght on both sides. No swelling, no

tenderness, no nodules.



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Interpretation:

The patients movements are appropriate to her situation. There are no deviations

from normal.

IV. Patterns of functioning

A. Nutrition

Before she is hospitalized, she said that she eats pandesal and egg in the

morning with coffee. She eats adequate amount of rice with small amount of the

dish being served and drinks only water and sometimes she drinks softdrinks.

Client is not taking any muliti vitamins.

During hospitalization, the client more on fruits and drinks water but she also said

that she drinks juice.

Norms:

Various daily food guides have been developed to help healthy people meet the

daily requirements of essential nutrients and to facilitate meal planning. Food

group plans emphasize the general types or groups of foods rather than the

specific foods, because related foods are similar in composition and often have

similar nutrient values. For example, all grains, whether wheat or oats, are

significant source of carbohydrate, iron, and the B vitamin thiamine. Daily food

guides that are currently used includes Dietary Guidelines for Americans and the

Food Guide Pyramids.

Source: Fundamentals of Nursing. Kozier and Erb. 2008. Pp 1246.

Interpretation:

Patients food intake before hospitalization is not so good for health but she said

she is aware what are the foods she must eat and not to eat. But during

hospitalization she is always eating health fruits but still no multivitamins to help

her more in her current condition,

B. Rest and Sleep

Client is satisfied with her sleep during her stay in the hospital. But she

complained about her sleep during the afternoon because the nurses are always

taking her vital signs.


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Norms:

Most healthy adults need 7 to 9 hours of sleep a night. However, there is individual

variation as some adults may be able to function well with 6 hours of sleep and others

may need 10 hours to function optimally. (Fundamentals of Nursing 8 th edition by Kozier

and Erb pp. 1168)

Interpretation:

The patient sleeping hours are adequate and she is very satisfied with it. Because if she

has problems with her sleep her current condition might be affected.

C. Elimination

The patient stated that she has no problems with her elimination pattern. She said that

she is not anymore constipated since she got admitted to the hospital. The clients urine

color is yellow and a little foul. According to her the amount of urine she excrete when

she void is about 150 ml or more that half a cup.

Norms:

Voiding or urination all refer to the process of emptying the urinary bladder. This occurs

when the adult bladder contains between 250 and 450 mL of urine. Each person must

take 8-10 glasses of water every day. The frequency of defecation is highly individual,

varying from several times per day to two or three times per week. Many people believe

that regularity means a bowel movement every day.

(Fundamentals of Nursing 8th edition by Kozier and Erb pp. 1326 and 1325).

Interpretation:

The patients elimination patterns are good.

D. Health and Illness

Patients perception of health is a person who is fat, is not sick, and does not have

disabilities. She said that she is not healthy now because she is in the hospital. Her

perception of the cause of her being in the hospital is because of too much stress and


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fatigue. She also said its because of what she eats. If a member of a family is sick, she

immediately go to the nearest hospital but depending on the condition. If the sickness is

only mild she would just self prescribe.

Norms:

Health is a highly individual perception. Many people define and describe health as the

following:

Being free from symptoms of disease and pain as much as possible

Being able to be active and to do what they want or must

Being in good spirits most of the time

These characteristics indicate that health is not something that a person achieves

suddenly.

Source: Fundamentals of Nursing. Kozier and Erb. 2008. Pp 295.

Interpretation:

Clients perception of health is proper and very realistic.

E. Activity Exercise

Clients stated that her activities and exercise are the same for her. She wakes at 5 am in

them morning to cook for breakfast for her family at 8am she cleans the front of her

house. at about 2pm she relaxes and watch her noontime shows.

Norms:

Make an activity or exercise for at least 30 minutes. (Fundamentals of Nursing 8th

edition by Kozier and Erb pp. 1105)

Interpretation:

The patients activity exercise pattern is good. She relaxes so she doesnt get fatigue all

the time.


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V. Problem Prioritization

Nursing Diagnosis Cues Rationale

Hyperthermia related toillness

O Temperature 38.2 C- flushed skin

-Clients want to prioritize thisfirst because she does not

feel good about it.

Ineffective health

maintenance related to

insufficient resources:

finances

S- Hindi ko mamaintain

yung gamot ko sa diabetes

ko kase nauubos lang pera

namin dun.

-Diabetes if not controlled

may lead to more life

threatening conditions.

Risk for unstable blood

glucose related toinadequate blood glucose

monitoring; medication

management

-To prevent diabetes from

getting worse and leading tomore conditions.


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VI. Drug study

Name of drug Indication Mode of action Nursing resposibilies

Generic name:

Cefuroxime

Brand name:

Ceftin

It is effective for

the treatment of

penicillinase-

producing Neisseria

gonorrhoea(PPNG).

Effectively treats

bone and joint

infections,

bronchitis,

meningitis,

gonorrhea, otitis

media,

pharyngitis/tonsilliti

s, sinusitis, lower

respiratory tract

infections, skin and

soft tissue

infections, urinary

tract infections, and

is used for surgical

prophylaxis,

reducing or

eliminating

infection.

Bacteriacidal:

inhibits

synthesis of

cell wall of

sensitive

organisms,

causing cell

death.

-Determine history

of hypersensitivity

reactions to

cephalosphorins,penicillins

and history of allergies

particularly to drugs before

therapy is initiated.

-Report onselt of loose

stools

-Absorption of cefuroxime

isenhanced by food.

-Notify prescriberabout

rashes orsuperinfections

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Case Pres Mikko