CLINICAL SCENARIO: NURSING HEALTH HISTORY A. Patient’s ProfileName: Patient GRLBirthday: May 4, 1973Age: 48 years old Sex: MaleNationality: Filipino Religion: Born Again Christian Marital Status: MarriedAddress: Valenzuela City Chief Complaint: severe epigastric painAdmitting Diagnosis: Appendicitis History of Present IllnessPatient complained of abdominal pain @ 9pm after going home last night . Prior to admission due to persistent abdominal pain patient found it difficult to sleep so he took one buscopan tablet . However , pain is not relieved .The following morning, the pain worsened in intensity, became sharp, and localized to the right lower quadrant, patient was rushed to FUMC . He also experienced loss of appetite, nausea and vomiting. He vomitted once. He had undergone no previous abdominal or pelvic surgery.His physical examination revealed tenderness in the right iliac fossa, local guarding and rebound tenderness at the McBurney point, consistent with signs of complicated acute appendicitis. His body temperature was 38°C, his pulse rate was 97 beats/minute and his blood pressure was 140/100 mmHg, RR=25/min. The urine examination result was normal. Laboratory investigations, including serum electrolyte levels and complete blood count, were within normal limits, except for a moderately elevated white cell count (14,000/mm3). Plain chest and abdominal radiography showed no abnormal signs. He was admitted for further evaluation and management. Family History (+) Hypertension (father side)(-) DM, TB, Cancer Personal and Social History The patient is a non-smoker and occasionally drinks alcohol beverages. Physical Assessment General Survey- Received patient lying on bed conscious, alert and coherent, but irritable , with facial grimace and hands on his abdomen with pain scale of 9/10 Vital signs as of 9 am: BP: 140/100 T:38°C. PR:97 RR:28IntegumentaryWarm to touch with poor skin turgor Head- Round and smooth skull contour- Symmetrical facial features- Symmetrical facial movementsEyesInspection: – Anicteric sclera, pink palpebral conjunctivae, (-) cervical lymphadenopathyEarsInspection: – Auricles with same color as facial skin and symmetric (-) discharges Palpation: – Firm and soft to touchNose and SinusesInspection: – Nostrils are patent- Nose is symmetricPalpation: No tenderness upon palpationMouth and ThroatInspection: – Oral mucosa (moist)- (-) lesions and swelling Thorax and Lungs Inspection: – Equal chest expansion Auscultation:- clear breath soundsAbdomenPalpation: revealed tenderness in the right iliac fossa, local guarding and rebound tenderness at the McBurney point ExtremitiesNo edema GORDON’S FUNCTIONAL HEALTH PATTERNFunctional Health Pattern Before HospitalizationDuring hospitalizationHealth perception / Health managementHe seek professional careHe practiced self medication Complies with medications regimenNutritional -metabolicEats 3 times a day with snacksin between Drinks at 8-10 glass of waterFavorite foods are fish and vegetables No allergies to food Patients is on NPO, with NGTElimination Defecates once a adayUrinates 4-7 times a day With foley catheter , no bm when operatedActivity -exercise Playing basket ball only every Sunday He works 8 hours Mon.- Sat.Patient place on Flat on bed post op for 8hrs, gradually ambulate along the roomCognitive / perceptual pattern Makes decision for himself and familySensory percetion with normalSleep rest Sleeps 8 hours a day Patient is having intermittent sleeping pattern due to rounds of staff nurses and doctorsSelf perception /self-concept He is confident what he can do as a person , especially when he can fullfill his responsibilities as father The patient assist by his wife because of his post-op condition Role /Relationship Pattern He is a father of one child Has agood relationship with family Her wife always at his side during his confinementSexually / Reproductive Pattern The patient has no problem in sexual functioning The patient is no active because of post op conditionCoping / Stress tolerance Handle stress efficiently Often neglects signs of stressThe patient is worrying about his conditionValue – belief He is a Christian active church -goer with his family every Sunday The patient ‘s faith in God became stronger . Laboratory Tests Clinical Chemistry – Serum Electrolytes LAB TEST Sodium139.0 mmol/LPotassium4.07 mmol/LChloride99.4 mmol/L Hematology TEST WBC14Hemoglobin143Hematocrit0.46RBC5.5Blood type O+ Course in the Ward A 48year old male patient was admitted at exactly 7:15 am last August 9. 2020 accompanied by his wife with a chief complaint of severe severe epigastric pain under the service of Dr. B. G. R. with following doctors order. patient placed on NPO, with IVF of PNSS 1L x 8 hrs , with following diagnostic procedure as follows CBC , Na, K, CL, BT, CX-ray , ECG with medication ordered Tramadol 50mg TIV now but no relief and scheduled for OR @ 6pm For ” E” appendectomy and secure consent. Cefuroxime 1.5 g TIV ANST() and Metronidazole 500mg TIV now prior to OR.The surgeon noticed the appendix ruptures and developed peritonitis and done the perotineal lavage. @ 11 pm recieved patient from PACU with post-OP order, with IVF PNSS IL x 8hrs,with side drip of D5W 500ml + 300mg of Tramadol to run for 24hrs. With IFC monitor urine oputput Q1 hr. refer if < 300cc /hr. With jackson pratt maintained on negative pressure and measure the out q shift and record recorded , with NGTconnect to bedside bottle, maintain on NPO , Flat on bed for 8 hour due @ 8 am, medication ordered Unasyn (ampicillin and sulbactam)1.5 g TIV Q 8 hrs ANST( ), Gentamycin 80 mg TIV q 6 hrs. Metronidazole 500mg TIV every 6 hrs. Omeprazole 40mg IV OD, Ketorolac 30mg TIV every 6 hrs. Vital signs were taken BP 140/90 , RR 25, PR 97, Temp 37.8. Encouraged client to perform deep breathing exercise and relaxation technique ,with urine out put of 600cc, jackson pratt output of 250cc, NGT output 250 cc greenish in color , no bowel movement Day 2 and 3 Recieved patient on bed with IVF of PNSS 1L x 8 hrs , with side drip of D5W 500ml + 300mg of Tramadol to run for 24hrs. With IFC draining in moderate urine out put ,with NGTconnect to bedside bottle and maintained on NPO,continue present medication ,instructed to turn side to side , encourage deep breathing exercise , with flatus as claimed by the patient ,vital sign taken BP 130/90 , RR 22, PR 84, Temp 37.2. Encouraged client to perform deep breathing exercise and relaxation technique ,with urine out put of 1200cc, jackson pratt output of 150cc, NGT output 150 cc greenish in color ,still no bowel movement. Day 4 Recieved patient on bed with IVF of PNSS 1L x 8 hrs , with side drip of D5W 500ml + 300mg of Tramadol to run for 24hrs. With IFC draining in moderate urine out put ,with NGTconnect to bedside bottle and maintained on NPO,continue present medication ,instructed to turn side to side , encourage deep breathing exercise , vital sign taken BP 120/80 , RR 23, PR 83, Temp 36.9. Encouraged client to perform deep breathing exercise and relaxation technique ,with urine out put of 1600cc, jackson pratt output of 100cc, NGT output 100 cc greenish in color ,with bowel movement once. His physician made his rounds and with order made to continue antibiotics, remove NGT now, start progressive diet , clear liquid , to general liquid , soft diet then DAT, remove foley catheter ,applied abdominal binder , may start ambulate along the room with assistance , discontinue Ketorac IV shift to Arcoxia 120 mg OD per orem , shift Omeprazole to oral 1 capsule OD. For removal of jackson pratt tomorrow. Consumed Tramadol drip . After 6 days patient place on DAT with abdominal binder.IVF consumed and discontinued his physician change of dressing and ordered may go home and take home medication Cefuroxime 500 mg tab 3x a day for 7 days.Arcoxia 120 mg tablet OD and for follow up after one week. COURSE TASKS: 1. Conceptualize the pathophysiological alterations distinct to the case.Trace the pathophysiological changes and highlight problems that are experienced by the client.Connect the pertinent nursing care and medical – surgical management to the various signs and symptoms presented by the client.Interpret the laboratory results obtained from the patient.3. Make at least two nursing care plan based on your assessment that needs to prioritize. Reference:Hinkle, J. L., & Cheever, K. H. (2017). Brunner & Suddarth’s textbook of medical-surgical nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins Health Science Science NursingNUR MM21
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