I.

Biographic Data

Name: Client X

Address: East Tapinac, Olongapo City

Age: 46 years old Gender: Male ReligiousAffiliation: Jehova’s Witnesses

Marital Status: Single Occupation: tricycle driver

Room and Bed number: Room 205, bed 8

Chief complaint: decrease in sensorium

Provisional diagnosis: t/c sepsis secondary to surgical site infection with DM type II

Attending physician: Dr. Peralta, Dr. Cacawa

II. Nursing History

Client X, experienced mild illnesses like flu, fever and cough during his childhood, her
mother never consulted in the health center or even in the doctor, just like the old practice from
the past experienced she gave her paracetamol for his fever and they used herbal medicine
specifically oregano for his cough, and drink kalamansi juice. “meron syang bakuna, kasi during
that time na ipinanganak sya meron ng mga nurses na nagbabahay-bahay para bakunahan ang
mga bata” stated by the clients sister. Client X, don’t have any allergies.

He had an accident last May 2010 and got fractured in his right upper leg which cause him to
undergone surgery, ORIF at right femur last may 27,2010 then he was discharge and sent home
last june 7,2010. Prior to that he was hospitalized three years ago, 2007 when he suffered a mild
stroke and experienced seizure during his hospitalization he was also in comma and admitted to
medicine ward, afterwards he was transfer to isolation, as narrated by the clients sister, it was also
during his hospitalization that he was diagnose that he has a DM type II.” Tinaningan na sya ng
doctor kaya ng desisyon na kami na i uwi na lang sya sa bahay” as verbalized by the clients
sister.and which he was recovered after a year.

Last April 2010, he was hospitalized due to his left leg. “Bigla na lang namaga ang kaliwang paa
nya wala naming sugat; tinusok ng doctor ung kanyang paa, puro nana ang lumabas” as
verbalized by clients sister, then he was treated and sent him back home.

Client X, use paracetamol for his fever and sometimes drink Alaxan if he experienced muscle
pain due to his work, for his maintenancehe use insulin for his DM.

One day prior to admission, the patient (+) fever, (+) purulent discharge on his right leg,on the
surgery site, (+) pain.

Few hours to prior to admission consult done and was subsequently admitted.
Client X, belongs to a big family, they were 12 siblings and he was third from the youngest, both
his parents are dead, his father died from a long disease. He has a brother with DM and a sister
with hypertension. Client X, is a single man, he lived alone but nearby with his sister to look for
him. Client X, drink alcohol beverages and don’t have any healthy diet, which he believes that he
acquire his DM from his daily living.

III.PATTERN OF FUNCTIONING

III. Pattern of Function

A . Health-perception/health-management pattern

“Umiinom siya ng Red horse nang siya ay 25 taong gulang”

“Nagkaroon siya nang PTB,Ear infection,fracture at mild stroke” as verbalized by the

client relative

INTERPRETAT ION:

The patient drink alcohol beverages at early age

ANALYSIS:

Excessive alcohol use contribute to nutritional deficiencies in a number of ways.

Alcohol may replace food in a person’s diet and it depress the appetite. Excessive
alcohol can have a toxic effect on the intestine mucosa, thereby decreasing the
absorption of nutrients .alcohol intake also increase the risk for hypertension.
(Fundamental of Nursing by Kozier 7th edition unit X p.1178)

B. Nutritional –metabolic pattern

“Mahilig siyang kumain matataba at maaasim na pagkain”

“Mahilig siyang makipag-inuman sa kanyang mga kaibigan”

“5 baso ng tubig lamang ang kanyang iniinum’as verbalized by the client relative

INTERPRETAT ION:

The patient eat fatty and sour food. He usually drink more alcohol beverage than
water.

ANALYSIS:
 Alcohol can impair the storage of nutrient and increase nutrient catabolism and
excretion. (Fundamental of Nursing by Kozier 7th edition unit X p.1178)

High intake of fatty food can cause atherosclerosis it is caused by accumulation

of fatty material including a high portion as well as other substances. One of the most
susceptible to atherosclerosis and to heart diseases are diabetetics and persons
consuming a diet high in saturated fat.(Basic nutrition and diet therapy by Caudalp.295)

C. Elimination Pattern

“ Ang tae niya ay kulay brown na medyo malambot”

“3 hanggang 5 beses siya umiihi at ito ay kulay dilaw”as verbalized by client relative

INTERPRETAT ION:

The patient excrete a brown semisolid bowel and urinate 3-5 times a day.

ANALYSIS:

The normal bowel are brown, formed, soft, semisolid and moist. (Fundamental
of Nursing by Kozier 7th edition unit X p.1227)

Normal urination straw,amber,transparent and 1200-1500ml. (Fundamental of

Nursing by Kozier 7th edition unit X p.1227)

D. Activity-exercise

“Isa siyang tricycle driver sa umaga at nakikipag-inuman paguwi sa bahay” as verbalized

by the client relative

INTERPRETAT ION:

The client expend the whole day working and have no time for other things”

ANALYSIS:

People participate in exercise programs to decrease risk factors for

cardiovascular disease and increase their health and well being. Normal exercise is 3x
per week or 30mins daily . (Fundamental of Nursing by Kozier 7th edition unit X p.1065)

E. Sleep-rest pattern
“ Pagatapos niya mamasada ay nakikipag-inuman na siya sa kanyang mga kaibigan
hanggang gabi ” as verbalized by the client relative

INTERPRETAT ION:

The patient always want to bonding with his friends than to stay at home to relax

ANALYSIS:

Sleep in some way restores normal levels of activity and normal balance among
parts of the nervous system. Sleep is also necessary for protein synthesis. (Fundamental
of Nursing by Kozier 7th edition unit X p.1115)

F. Cognitive-perceptual pattern

“Gumagamit na siya nang salamin kapag nababasa”

“minsan mahina na ang kanyang pandinig”

“Sa ngayon dahil sa kalaayan niya kami na ang nagdedesisyon”as verbalized by the client

INTERPRETAT ION:

The patient have a poor vision and sometimes poor hearing. The relative decide
for the patient because of his condition.

ANALYSIS:

A sensory deficit is impaired reception, perception or both of one or more

senses. Blindness and deafness are sensory deficits. When only one senses is affected,
other senses may become more acute to compensate for the loss. sudden loss of
eyesight can result in disorientation. (Fundamental of Nursing by Kozier 7 th edition unit
X p.941)

G. Self-perception/self-concept pattern

“Naaawa siya sa kanyang sarili’

“Napapansin nya ang pagbabago sa kanyang katawa lalo na sa kanyang balat”as

verbalized by the client relative

INTERPRETAT ION:

The patient experience self pettiness because of his condition.

ANALYSIS:

A person is not born with self-concept rather than it develop as a result of social
interaction with other. The individual who has a body image disturbance may hide or
not look at or touch a body part that is significantly changed in structure by illness or
trauma. Some individual may also express feelings of helplessness, hopelessness,
powerlessness, and may exhibit self-destructive behavior or suicide attempts.
(Fundamental of Nursing by Kozier 7th edition unit IX p.960)

H. Role-Relationship pattern

“Mag-isa lang siya sa buhay dahil wala pa siyang asawa”

“Madalas siyang sumasama sa kanyang mga barkada”as verbalized by the client relative

INTERPRETAT ION:

The patient don’t have wife because of his past experience in his ex-girlfriend
and he consider his friend as family.

ANALYSIS:

Throughout life people undergoes numerous role changes. A role is a set of

expectation about the person occupying one position behave. Each person usually has
several roles such as husband, friend, church member. Some roles are assumed for only
limited periods. (Fundamental of Nursing by Kozier 7th edition unit IX p.960)

I. Sexuality-reproductive pattern

“Wala siyang asawa dahil iniwan siya nang dati niyang GF”as verbalized by the client
relative

INTERPRETAT ION:

The client is not concerned to have a marital relationship because of his past
experiences.

ANALYSIS:

A positive sexual self-concept enables people to form intimate relationships

throughout life. A negative sexual self-concept may impede the formation of
relationships. . (Fundamental of Nursing by Kozier 7th edition unit IX p.974)

J. Coping/Stress-tolerance pattern
“Umiinom siya kapag may problema at barkada ang madalas niyang sabihan nang
problema”as verbalized by the client relative.

INTERPRETAT ION:

The client spends his time drinking alcohol beverages in order to forget his
problem and also he always tell his friends about his problem”

ANALYSIS:

Stress can has physical, emotional, intellectual and social consequences.

emotionally stress can reduce negative on nonconstructive feeling about the self.
Intellectually stress can influences a person perceptual and problem solving abilities.
(Fundamental of Nursing by Kozier 7th edition unit IX p.1014)

K. Values-beliefs pattern

“Katoliko siya pero Jehovah ang aming mga magulang”as verbalized by the client
relative

INTERPRETAT ION:

The client has a Christian belief differ for his parents however he does not go to
church regularly

ANALYSIS:

Religion is an organized system of beliefs and practice. It offer a way of spiritual

expression that provides guidance of believers in responding to life’s questions and
challenges. religious development of an individual refers to the acceptance of specific
beliefs, values, rules of conduct and rituals. (Fundamental of Nursing by Kozier 7th
edition unit IX p.996)

IV.ACTIVITIES OF DAILY LIVING

V. PHYSICAL ASSESSMENT

BEFORE AFTER INTERPRETATION AND

HOSPITALIZATION HOSPITALIZATION ANALYSIS

NUTRITION June 9 2010 June 15 2010 INTERPRETATION

BREAKFAST BREAKFAST The client maintains a

-“gatas na glucerna -“ dalawang diabetic diet.
na nasa nestle cup” kutsarang gatas na
as verbalized by the may kasamang 2
client relative kutsarang tubig dahil ANALYSIS:
natatamisan siya
kaya nilagyan ko ng Diabetes Mellitus is a
tubig” as verbalized metabolic disease that
by the client patient affects the endocrine
system of the body and the
LUNCH use of carbohydrates and
- “gatas lang ng fats. Specifically , there’s
LUNCH glucerna , un lang not enough insulin
ang kinain niya dahil available for the body’s
-“ gulay na sayote na needs. In some patients,
hindi na siya
may dahong the Islet of Langerhans of
makakain.Sabi ng
malunggay the pancreas is unable to
nurse pa nga
halohalong produce enough insulin. In
lalagyan siya ng tube
malunggay at isang other patient, the pancreas
para makakain, pero
basong tubig na requires some stimulation
di na naming
nasa nestle cup “as to manufacture enough
pinalagay dahil
verbalized by the insulin while in some, the
tinatanggal
client relative insulin that is produced for
niya,kaya
pinagtiyatiyagaan ko some reason cannot be
siyang subuan , used by the tissues.
sumusubo din The diet is essentially
naman siya “ as normal one except that the
verbalized by the amounts of food and their
client relative distribution in meals are
controlled from day to day.
DINNER
Some diet control will be
- “ dalawang necessary for the rest of
kutsarang glucerna, the patient’s life.
kapag ginugutom Individuals by normal
naman siya gatas weight are given sufficient
DINNER
lang ang binibigay calories to maintain
-“tinapay na ko.”as verbalized by weight. Frozen or canned
gardenia ung the client relative fruits packed with sugar
pangdiabetic at must be avoided.
gatas na glucenera” Concentrated sweets and
as verbalized by the June 16 2010 desserts are avoided,
sugar, jelly, jam
client relative BREAKFAST marmalade, syrup, honey,
molasses, soft drinks, cake,
-“gatas ulit na cookies, pies et.( Basic
glucerna , mga Nutrition and Diet therapy
tatlong kutsara” as Textbook for Nursing
verbalized by the
Students p. 276- 278)
client relative
June 10 2010

BREAKFAST
LUNCH
- “tinapay na
gardenia at gatas ulit -“naka isang orange
na glucerna na nasa siya ung binili sa
nestle cup, ” as kanya ng kapatid ko,
verbalized by the banana saba na
client relative niblend at tomato
juice yung fresh na
LUNCH kamatis ginawang
kong juice” as
-“gulay na sayote at
verbalized by the
malunggay halong
client’s relative
along
gulay,diningding,
minsan nilalagyan ko
ng patis para may
lasa kasi un lang DINNER
naman ung kinakain
nia at kalahating -“ganun ulit banana
basong tubig na saba blend at
nasa nestle cup” as tomato juice.
verbalized by the Pinainom ko rin siya
client’s relative ng tubig dahil ayaw
niya yung lasa ng
DINNER tomato” as
-“tinapay lang at verbalized by the
kalahating gatas client relative
naglucerna nasa
nestle cup, minsan
umiinom din siya ng June 17 2010
kape pero walang
asukal”as verbalized BREAKFAST

- “gatas na glucena
by the client relative na nasa nestle cup
nakalahati niya” as
verbalized by the
June 11 2010 client relative

BREAKFAST LUNCH

- “ tinapay sa - “avocado na
goldilocks ung niblend dahil hinatid
pangdiabetic at ng kapatid ko,
gatas na glucerna banana saba blend
isang basong naubos at tomato juice ang
nia” kinain niya “ as
verbalized by the
As verbalized by the client relative
client relative

LUNCH

-“tinolang manok ,
pero ung manok nia
konti lang at ung
sabaw mga limang
kutsarang sabaw at
tatlong kutsarang
kanin.nakaisang DINNER
baso din siya ng - “banana saba
tubig” as verbalized blend at isang
by the client relative basong nestle cup
na tubig.” as
DINNER
verbalized by the
- “ tinapay na client relative
gardenia at giniling
na baboy at kanin.
Mga tatlong subo
lang siya ng kanin na
may giniling na
baboy dahil ung gabi
na un wala na siya
gana kumain ni hindi
nga siya uminom ng
gatas” as verbalized
by the client
 relatives

ELIMINATION - “dalawa or tatlong -“ dalawang beses INTERPRETATION:

beses lang siya na siyang The client has normal
nagbabawas sa isang nagbabawas , elimination pattern .
araw tuwing umaga kaninang umaga sabi
ANALYSIS:
at gabi. Normal ng kapatid ko at
Defecation patterns vary at
naman ung ngayong 6:30 pm
different stages of life.
pagbabawas niya nagbawas na naman
Circumstances of diet, fluid
kulay brown at siya, kulay light
intake and output, activity,
matigas naman. Sa brown, malambot at
psychologic factors,
pag ihi niya naman medyo mabaho
lifestyle, medications, and
limang beses siya dahil sa iniinom
medical procedures and
umihi at kulay niyang gamot.hindi
disease also affect
yellow.” As naman siya
defecation. Elder should be
verbalized by the nasasaktan kapag
advised that normal
client relative nagbabawas at
patterns may be every
uniihi siya. Sa pag ihi
other day, for others, twice
niya naman ,tatlong
a day. Voiding and
beses lang siyang
urination all refer to the
pinalitang pampers
process of emptying the
yung isa may dumi
urinary bladder. Urine
at ung dalawa
collects in the bladder until
naman palit ihi na
pressure stimulates special
ung ihi niya ay kulay
sensory nerve endings in
yellow” as
the bladder wall called
verbalized by the
stretch receptors; the
client relative
average daily urine output
for elderly is 1500 ml or
less. ( Fundamentals of
Nursing ,7th edition , Kozier
p. 1228)

EXERCISE -“dati ung exercise -“ hindi na siya INTERPRETATION The

niya ay yung masyadong client is not engaged with
pamamasada niya makagalaw ang any strenuous activities. He
ng tricycle halos 12 exercise niya nalang was able to move in the
hours siyang ay ung pag gagalaw bed with assistance.
namamasada” as niya ng mga daliri
verbalized by the niya at ng pag galaw
ng katawan nia sa
 client relative ibat ibang posisyon” ANALYSIS:
as verbalized by the
Exercise is a type of
client relative
physical activity defines as
a planned structural and
repetitive bodily
movement done to
improve or maintain one or
more components of
physical fitness. People
participate in exercise
programs to decrease risk
factors for cardiovascular
disease and to increase
their health and well being.
Exercise involves the active
contraction and relaxation
of muscles. Exercise can be
classified according to the
type of muscle contraction
( isotonic , isometric or
isokinetic) and according to
the source of energy
walking, biking and
swimming are
recommended for
beginners and olders.
Activities that are more
strenuous include jogging,
running, and jumping rope
. ( Fundamentals of Nursing
,7th edition , Kozier p. 1065)

HYGIENE - “ isang beses lang -“pinupunasan ko INTERPRETATION The

siyang naliligo bago siya ng tatlong beses client cannot perform his
siya namamasada at ,hindi ko siya ma own care hygiene.
2 beses lang siya nag toothbrushan dahil
totoohbrush hindi pa siya
pagkatapos niyang masyado makatayo ANALYSIS:
kumain at bago at nahihirapan
 matulog . Hindi siya akong mag Hygiene is the science of
mahilig magsuklay at toothbrush sa kanya. health and its
magpango .At palagi Hindi ko rin maintenance. Personal
yang nag gugupit ng maputulan ung mga hygiene is the self care by
mga kuko sa daliri kuko niya dahil which people attend to
dahil namamasada nandito kami sa such functions as bathing ,
siya”. as verbalized hospital. toileting , general body
by the client relative Sinusuklayan ko siya hygiene and grooming .
para maging Hygiene is a highly
comfortable siya personal matter
dahil hindi siya determined by individual
nakaliligo” as values and practices .It
verbalized by the involves care of the skin,
client relative hair, nails, teeth, oral and
nasal cavities , eyes , ears
and perineal , genitial
areas. Early morning care is
provided to client as they
awaken in the morning .
This are consists of
providing a bedpAn to the
client confined to bed,
washing the face and
hands and giving oral care .
( Fundamentals of Nursing
,7th edition , Kozier p. 698)

SUBSTANCE USE “Umiinom siya nang “Simula na hospital INTERPRETATION:

alak, pero minsan siya hindi na siya
lang ,kasi umiinom ng alak. The client receives insulin
pagkatapos niyang Insulin nalang ang as a maintenance
namamasada ayun gmot niya” as
ang kanyang verbalized by the
relaxation dahil client’s relative. ANALYSIS:
minsan pagod.
Alcohol produces changes
Siguro mga 2 bote
in mood and behavior.
tapos 2 beses sa
Most people drink is able
isang lingo. Hindi
to control their intake of
siya nagsisigarilyo at
alcohol and to avoid
hindi rin siya
 nakatikim ng droga. considered and often
Ang maintenance harmful effects. Heavy,
niya gamut ay ung regular use of alcohol can
insulin, lead to cirrhosis of the liver
meloxican,evered , a leading cause of death.
ferrous sulfate” as Today’s greater use of
verbalized by the drugs, both legal and illegal
client’s relative is one of our most serious
health risk. Even some
some drugs prescribed by
your doctor can be
dangerous it taken when
drinking alcohol or before
driving using or
experimenting with illicit
drugs such as marijuana,
heroin, cocaine and other
street drugs may lead to a
number of damaging
effects or even death.
Cigarette smoking is the
single most important
preventable cause of
illness and early death .
Persons who stop smoking
reduce their risk of getting
heart disease and cancer . (
Fundamentals of Nursing
,7th edition , Kozier p. 130)

SLEEP AND REST -“ palaging puyat -palagi na siyang INTERPRETATION The

siya, kasi uuwi yang natutulog , client has an adequate
galing pasada ng nagigising lang siya sleep and rest
mga 9 pm tapos kapag kakain na at
nanunuod pa ng tv kapag may masakit
kaya mga 11 pm na sa kanya” as ANALYSIS:
siya natutulog at verbalized by the
nagigising siya ng client relative Rest and sleep are
mga 8 am dahil essential for health people
namamasada siya ng who are ill frequently
 mga 10 am. Araw require more rest and
araw pa siyang sleep than usual. Often
namamasada” as debilitated people expend
verbalized by the excessive amount of
client relative energy to regain health or
perform the activities of
daily living. The meaning of
rest and the need for rest
vary among individuals,rest
implies,calmness,relaxation
without emotional stress
and freedom from anxiety
.Sleep is a basic human
need, it is a universal
biological process common
to all people. Historically,
sleep was considered an
altered state of
consciousness in which the
individual’s perception of
and reaction to the
environment are
decreased. The older adult
sleeps about 6 hours a
night. ( Fundamentals of
Nursing ,7th edition , Kozier
p. 1114,1116)

Physical assessment

General Appearance Actual Findings Norms Interpretation and

Analysis

General Appearance
The patient cannot
1. Posture/Gait Semi- fowler‟s Walks in a rhythmic,
Position straight, upright position w/
arms swinging @ each
side of the body.
Shoulders level straight.
Brown to dark brow Skin color is brown to dark
brown and uniformly equal
2. Skin Color Well- groomed Well- groomed
maintain proper
posture.
Gait is smooth,
coordinated, and
rhythmic, even
weight borne on each
foot; it produces
minimal body swing
from side to side and
directs movement
straight ahead; and it
starts and stops with
ease.(Fundamentals
od Nursing 7th Edition
by Kozier, Erb,
Berman and Snyder,
p. 1073)
Normal
Normal

3. Personal
Able to eat with Able to eat Normal
Hygiene/
assistance, no
Grooming
restriction
4. Nutritional Status
Actions are Actions are appropriate to Normal
appropriate to his age
age
5. Age Speaks softly Speaks audibly. The patient had
Appropriateness (inaudible) experienced mild
stroke. Thus, he
6. Verbal Behavior cannot speak
audibly.
Any defects in or loss
of the power to
express oneself by
speech, writing or
signs, or to
comprehend spoken
language due to
disease or injury.
(Fundamentals od
Nursing 7th Edition by
Kozier, Erb, Berman
and Snyder, p. 603)
Shakes his head No involuntary movements Normal
when he answers
“NO”
7. Non-verbal
Behavior
Measurements
4 pm 6pm
1. Temperature 36.6°C 36.6°C 36.5- 37.5 °C Normal
2. Pulse Rate 94 83 60-100 Normal
3. Respiratory 18 27 16-20 Tachypnea. Those
Rate that increase the rate
include exercise
(increased
metabolism), stress
(readies the body for
fight or flight),
increased
environmental
temperature, certain
medications (e.g.,
narcotics), and
increased intracranial
pressure.(Fundament
als od Nursing 7th
Edition by Kozier,
Erb, Berman and
Snyder, p. 506)
4. Blood 130/80 140/80 120/80 Hypertension.
Pressure Factors affecting
blood pressure,
disease process, any
condition affecting
the cardiac output,
blood volume, blood
viscosity, and/or
compliance of the
arteries has a direct
effect on the blood
pressure
(Fundamentals of
Nursing 7th Edition by
Kozier, Erb, Berman
and Snyder, p. 510)

5. Weight 45 Kg. Normal

6. Height 133 cm. Normal

BODY PARTS ACTUAL NORMAL INTERPRETATION and

ANALYSIS
FINDINGS FINDINGS
a. Hair  Black color  Varies Patient‟s hair is evenly
 Hair equally  Hair evenly distributed, thick,
distributed, thick distributed, thick, without any signs of
silky and resilient infestations
 Dull, dry texture  Fine to coarse,
pliant
 (-) infestations  No infections or
infestations
b. Nails  surrounding cuticle  surrounding cuticle Patient‟s capillary refill
is intact is intact is normal.
 nails capillary refill  nails capillary refill
is 2 seconds not more than 3
seconds

c. Head and Face  skull is round  round, smooth skull Patient‟s head and face
contour is normal.
 head is  head is proportional
proportional to the to the body
body  skin of face has the
same color as the
whole body
 skin of face has  no involuntary
the same color as movements
the whole body  no masses
 no involuntary  no tenderness
movements
 (-) masses
 (-) tenderness
d. Eye  icteric sclerae  anicteric sclerae Patient‟s conjunctiva is
 eyes are parallel to  eyes parallel to abnormal.
each other each other
 pale conjunctival  pinkish conjunctival
sac sac
 eyelids close  eyelids close Pallor is the result of
symmetrically symmetrically inadequate circulating
 eyelashes are  eyelashes are blood or hemoglobin
distributed evenly distributed evenly and subsequent
and directed and directed reduction in tissue
outward outward
oxygenation.
 eyebrows are  symmetrical
symmetrical eyebrows (Fundamentals od
 no discharges  no discharges Nursing 7th Edition by
 pupils constrict  pupils constrict Kozier, Erb, Berman
when light was when light was and Snyder, p. 535)
shined to it shined to it
 pupils dilate when  pupils dilate when
light was removed light was removed
 Pupils are black,  Pupils are black,
equally-round, equally-round,
 reactive to both reactive to both light
light and and
accommodation. accommodation.

e. Ears
 auricles are bean-  auricles color same Patient‟s ear are
shaped and with facial skin and symmetrical, no lesions
symmetrical, symmetric noted and is able to
above the lateral hear normal voice
canthus and they sounds
are level with
each other  no lesion,
 absence of deformities and
deformities drainage present

 auricles are
smooth and has
no lesions
f. Nose Patient‟s nose is
 medially  medially located symmetric and normal.
located and and proportional
proportional to to the face
the face  mucosa is pink
 mucosa is pink and moist
and moist  nasal structures
 nasal firm and stable
structures are  no swelling or
firm and stable inflammation
 no swelling or  absence
inflammation deformities
 absence  no lesions
deformities  nares patent
 (-) lesions  sinuses not
 nares are inflamed and
patent swollen
 sinuses are not
inflamed and
swollen
g. Neck  skin of the  skin of the neck Patient‟s neck is normal
neck has the has the same
same color as color as the
the whole body whole body
 poor ROM  full ROM
 (-) masses  no masses
 (-) tenderness  no tenderness
 lymph nodes  lymph nodes
cannot be cannot be
palpated palpated
 thyroid gland is  thyroid gland
not enlarged not enlarged
and non-tender and non-tender
 trachea can be  trachea directly
directly palpated and is
palpated and it located at the
is located at midline
the midline
h. Thorax and  symmetrical or  symmetry in chest Patient‟s thorax is
Lungs proportional in movement normal.
chest movement  Respiratory rate
 RR = 24 cpm within normal Tachypnea. Those that
 No shortness of change (16-20cpm) increase the rate
breath  No shortness of include exercise
 no deformities breath (increased metabolism),
 chest expands  no deformities stress (readies the body
symmetrically with  chest expands for fight or flight),
each inspiration symmetrically with increased
 (-) lumps, masses, each inspiration environmental
tenderness  no lumps, masses, temperature, certain
tenderness medications (e.g.,
narcotics), and
increased intracranial
pressure.(Fundamentals
od Nursing 7th Edition
by Kozier, Erb, Berman
and Snyder, p. 506)
i. Breast  smooth  smooth Patient‟s breast is
 round  round, oval or normal.
everted nipples
 no masses  no masses
 no tenderness  no tenderness
j. Abdomen Patient‟s abdomen is
 Umbilicus is  Sunken, centrally normal.
medially located located umbilicus
 Flat  Flat contour
 (-) Inflammation  No Inflammation
 (-) Tenderness  No Tenderness
 (-) Mass  No Mass
k. Upper Extremities Upper Extremities Patient‟s right leg has
Musculoskeletal  skin color same as  skin color same as undergone surgery.
the whole body the whole body
 symmetrical  symmetrical People who have
shoulders and shoulders and arms impaired mobility due to
arms  full ROM paralysis, muscle
 full ROM  no masses weakness and poor
 (-) masses  no deformities balance or coordination
 (-) deformities
are obviously prone to
Lower Extremities Lower Extremities injury. Clients with
 Skin color is same  skin color same as spinal cord injury and
as the whole body the whole body paralysis of both legs
 very poor ROM  Full ROM maybe unable to move
 (-) masses  no masses even when they
 (-) lesions  no lesions perceived discomfort.
 (-) deformities  no deformities (Fundamentals od
 (-) edema  no edema Nursing 7th Edition by
 (-) tenderness  no tenderness
Kozier, Erb, Berman
and Snyder, p. 670-
671)

l. Genitals  The patient

refused to
examined his
genital area
m. Nervous  (Glascow Coma  (Glascow Coma Patient is in optimal
system Scale) Scale) level of consciousness.
Eye response : 4 Eye opening – eyes
(eyes open open spontaneously The client who scores
spontaneously) (4) 10 points or lower
Motor response: 5 Motor – follows needs emergency
(obeys command) command (6)
attention. (Nurse‟s
Verbal: 2 Verbal – oriented
(incoherent) to place and date (5) handbook of health
Total Score: 11 Score: 15 (indicates assessment, Weber
optimal level of page 387)
consciousness

VI.LABORATORY AND DIAGNOSTIC EXAMINATION RESULT

Date Procedure Result Normal Values Interpretation/Analys
is

June 15, Medical Many pus cells No organism seen Pus indicates that the
2010 Microbiology patient has
Section(specimen: No organism seen No or few pus cells infection.(*1. )
wound abscess)

Clinical Chemistry

a. Sodium 149.3 mmol/L 135-145 mmol/L Normal

b. Potassium
3.83 mmol/L 3.5-5.5 mmol/L Normal

Culture sensitivity No growth in 5 - Normal

test days of incubation

June 13, Radiology Report Segemental - This indicates that the

2010 fracture w/ callus patient has
a. Right Femur APL undergone an ORIF
formation
due to fracture in the
Right femur w/ right femur.
ORIF. Alignment
and opposition
appear satisfactory

June 12, Culture sensitivity No growth in 3 - Normal

2010 test days of incubation

Medical Many pus cells No organism seen Pus and bacteria seen
Microbiology indicates that the
Section(specimen: Gram (+) cocci= No or few pus cells patient has bacterial
occasional infection(*1.)
wound)

Clinical Chemistry

a. BUN 6.86 mmol/L 1.7-8.3 mmol/L Normal

b. Creatinine 60 umol/L 35.4-123.8 mmol/L Normal

c. Sodium 114 mmol/L 135-145 mmol/L This indicates

hyponatremia
 because results are
lower than normal
values(*2.)

Normal

d. Potassium 3.89 mmol/L 3.5-5.5 mmol/L

Hematology a. This indicates

anemia as evidence
a. Hemoglobin 73 M:140-180 by lower hemoglobin
b. Hematocrit 0.21 M: 0.40-0.50 count from normal
values(*3.)
c. WBC Count 12.3x109/L 5-10 x109/L
b. This indicates
d. Neutrophils 0.91 0.30-0.70 anemia as evidence
by lower percentage
e. Lymphocytes 0.09 0.20-0.40
of RBC to normal
f. Platelets 390 x109/L 150-350 x109/L values(*4.)

g. RBS(random blood 237 mg/dL 100-160 mg/dL c. This indicates

sugar) leukopenia as
evidence by increase
no. of WBC count
from normal
values(*5.)

d. This indicates
bacterial infection
due to elevated no. of
neutrophils from
normal values(*6.)

e. This indicates that

the patient is
immunosuppress as
evidence by lower no.
of result from normal
values(*7.)
 f. This indicates
thrombocytosis due
to elevated no. of
platelets from normal
values.(*8.)

g. This indicates
hyperglycemia as
evidence by elevated
glucose serum in the
blood.(*9.)

Radiology Report -Reticulonodular -Normal lung fields IMPRESSION:

and fibrotic seen
a. Chest X-ray densities in both -Consider minimal
upper lobes -No densities, lungs PTB
are clear
-Alveolar densities - Pneumonia
in both lower lobes -Right apical pleural
-Increased thickening seen
transversed -Upper lobe volume
diameter of the loss
heart due to
position -reticulonodular
densities and apical
-Diaphram and pleural thickening
sinuses are intact could be described as
-Right apical a residual x-ray
pleural thickening change due to a prior
seen infection. It could be
from pneumonia, but
-Both hila are in this lung location it
attracted upwards is most likely a
reflection of a prior
tuberculosis or fungal
infection(*10.)
*REFRERENCES

1. http://www.wisegeek.com/what-is-pus.htm

2. http://www.webmd.com/a-to-z-guides/sodium-na-in-blood

3. http://www.medicinenet.com/hemoglobin/article.htm

4. http://www.nlm.nih.gov/medlineplus/ency/article/000589.htm

5. http://emedicine.medscape.com/article/956278-overview

6. http://www.wisegeek.com/what-are-neutrophils.htm

7. http://www.wisegeek.com/what-causes-lymphocytosis.htm

8. http://www.wisegeek.com/what-are-platelets.htm

9. http://www.carbonbased.com/Definitions.htm

http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm

10. http://www.ehow.com/facts_6146452_apical-pleural-thickening_.html

http://www.medhelp.org/posts/Chronic-Obstructive-Pulmonary-Disorder/reticulonodular-
densities-and-apical-pleural-thickening/show/946668

http://www.medicinenet.com/pneumonia/article.htm

VII.COURSE IN THE WARD

VII. COURSE IN THE WARD

Date/Time Findings Physician’s Order

6/12/2010 RBS= 237mg/dl Please admit to surgery
To= 38 ward
4pm PR=100 Diabetic Diet
RR=20 IVF PNSS 1L x 30gtts/min
BP=120/80 Dx:
- CBC
- wound gs/cs
- RBS
Tx:
- Oxacillin 1g IV q6o
- Ketorolac (Ketomed)
30mg IV q8o
Incorporate 2 amps
mountvion to present IVF
Refer to IM for co-
management re: DM and
Pulmo and infection
Paracetamol 300mg IV
q4o prn for fever
KVO 300cc of present IVF
CBC, wound gs done

4:30pm DMHx:
DM- x 3yr
Metformin 500mg
PTB- incomplete
antiKoch‟s test

RBS monitoring q6o (6-12-

6-12)
Give 5 „u‟ RI SQ now
For blood culture
Suggest to shift antibiotic
to Piperacillin- Tazobactam
(Tazocin) 2.25g IV q8o
Na, K, BUN, Crea

8pm RBS= 209mg/dl Give 5 „u‟ RI SQ now

6/13/2010 Hgb= 73 Transfuse 3 „u‟ PRBC
properly typed
2:45am

7:45am Brother of patient refused

blood transfusion

3:30pm For ® femur APL x-ray

now

6/14/2010 RBS= 315mg/dl Give RI 5 „u‟ SQ

1am

7am Give 5 „u‟ RI SQ now

8:45am Advised debridement

under SA. Patient refused
blood transfusion w/c is
needed for patient‟s Hgb at
73.
For I&D („E‟) at the OR

12pm RBS= 267mg/dl Give 7 „u‟ RI SQ now

10:40pm BP= 120/80 I&D under LA

Give Nubain 10mg/IV now

6/15/2010 IVF regulated to

40gtts/min
7am For repeat Na, K
ff-up CS done (6/12/2010)
Novomix 30 „u‟ 30mins
pre- breakfast
20 „u‟ 20mins
pre-dinner

8:20pm Na= 114 (135-146) Na, K done

K= 3.89 (3.5-5.1)
6/16/2010 BP= 160/100 Captopril 25mg/tab now

12:08pm
 12:30am RBS= 277mg/dl Give 5‟u‟ RI SQ

7:10am (+) pain on ® thigh ff-up wound CS

Infected surgical site, For head CT Scan
DM, PTB

4:30pm Has episode of HPN Erythropoietin 5000 „u‟

today subcutaneous 2x a week
BP range 110-130/70-80 Novomix to 35 „u‟ 30mins
pre-breakfast
25 ‟u‟ 30mins
Latest VS
pre-dinner
BP= 130/70
PR= 88 Continue RBS monitoring
I&O q4o cc x cc accurately
RR= 20
and record
To = 36.7
6/17/2010 Refused CT Scan (Head)

7am

11:30am Continue
Piperacillin+Tazobactam
Start Metronidazole
500mg/IV q8o
Facilitate Erythropoietin
For Blood CS

IX PRIORITIZED LIST OF NURSING PROBLEM

IX: PRIORITIZED LIST OF NURSING PROBLEMS

Date Nursing Problems Cues Justification

Identified

June 18 HYPERTHEMIA Subjective : Hyperthermia is the top priority.

2010 Hyperthermia is an elevated body
“Pabugso bugso ang temperature due to failed
 lagnat niya ” as thermoregulation. Hyperthermia
verbalized by the occurs when the body produces or
client’s sister absorbs more heat than it can
dissipate. When the elevated body
temperatures are sufficiently high,
Objective: hyperthermia is a medical
emergency and requires immediate
 WBC count treatment to prevent for the
12.3x109/L complication such as disability and
 Temperature death.
38.6˚ C
Warm to touch

http://en.wikipedia.org/wiki/Hypert
hermia

June 18 ACUTE PAIN SUBJECTIVE: Pain affects the entire body. It can
2010 increase heart rate and blood
“Hindi ko magalaw pressure, alter mood and cause
yung kanang hita ko, stress and anxiety. Until the pain is
medyo masakit.”, as managed, it will be difficult to
verbalized by the
proceed with other lower priority
client. nursing interventions. Everything
else comes to a halt until that pain
reaches a manageable level. In the
P – Right Leg case of the client, the pain scale is 6
out of 10; therefore, it is still
Q – Sharp
tolerable. This is the reason why it is
R – Radiating not the top priority.

S – Pain scale 6 out of

10

T- Intermittent

OBJECTIVE:

- Pain Discomfort

T – 38.6°C
(Priority Nursing Diagnosis |
 PR – 105 bpm eHow.com
http://www.ehow.com/about_5409
RR – 27 cpm 228_priority-nursing-
BP – 130/120 mmHg diagnosis.html#ixzz0rAOz7O00).

WBC count: 12.3X109

June 18 DELAYED SURGICAL Subjective : Reports of an increased incidence of

2010 RECOVERY wound complications in surgical
“ Isang linggo na ang patients with diabetes mellitus may
tahi ng kapatid ko pero actually reflect the increased
sariwa pa rin” as incidence of general surgical risks or
verbalized by the metabolic abnormalities associated
client’s sister with diabetes mellitus may
contribute to wound infection and
delayed wound healing especially in
Objective: the type II diabetic patient.

 WBC count
12.3x109/L
 RBS
237mg/dL
 Difficulty in
moving about;
requires help
to complete http://www.ncbi.nlm.nih.gov/pubm
self-care ed/2179891

June 18 IMPAIRED SKIN Sbjective: Intact skin is the body’s first line of
2010 INTEGRITY defense against infection. Any break
“ malaki ang tahi niya in the integrity of the skin is a
sa hita” as verbalized potential route of entry for
by the client’s sister infection.

Objective:

 Disruption of
skin surface (http://www.medtrng.com/blackboa
 Destruction of
 skin layers rd/infection_asepsis.htm)
 Invasion of
body structure

June 18 IMPAIRED Subjective: Physical mobility, the capability of

2010 PHYSICAL movement, is necessary for the
MOBILITY “ hindi siya makaupo health and well-being of all persons,
dahil masakit ang tahi but is especially important in older
niya: as verbalized by adults because a variety of factors
the client’s sister impinge upon mobility with aging.
Hogue (1984) identified mobility as
the most important functional ability
Objective: that determines the degree of
independence and health care needs
among older persons population.
 Limited range Katz and colleagues (1983, 1985)
of motion ; limited have advocated the use of life table
ability to perform techniques to describe the health of
gross’ motor skills people in terms of function, or
 Slowed activities of daily living (ADL).
movement , decreased Impaired mobility in older person’s
reaction time
population, predispositions to and
 Engages in
substations for causes of impaired mobility,
movement ( e.g , consequences of impaired mobility,
increased attention to and interventions that have been
others activity , effective in enhancing mobility.
controlling behavior)

http://www.ninr.nih.gov/NR/rdonlyr
es/87C83B44-6FC6-4183-96FE-
67E00623ACE0/4767/Chap3.pdf

XI. DISCHARGE PLAN

Discharge Plan
Medications to take at home

 The client should maintain to receive insulin subcutaneously. The dosage of the
insulin will always depend on the sugar level of the client. The patient should
receive insulin twice a day in the abdomen subcutaneously before breakfast and
before dinner.

Exercise

 The client’s relatives are advised to move the patient in the bed as much as
possible. Moving the client in the bed is necessary to promote circulation and
prevent bed sores.

Health Teaching

 Since more of the health concerns of the patient is primarily to be considered by

the relatives, they should be advised with the following health teachings like the
regulation of the diabetic diet of the client, moving the client in the bed and the
maintenance of the insulin.

Diet

 The patient should maintain a diabetic diet.