PANPACIFIC UNIVERSITY NORTH PH

PANPACIFIC UNIVERSITY NORTH PHILIPPINES
Urdaneta City, Pangasinan

CASE STUDY

In Partial Fulfillment of the Requirements on
Related Learning Experience

Submitted By:
Submitted To:
Ms. Joan Guzman

Clinical Instructor
July 2010
I. PATIENT ASSESSMENT DATA BASE

A. GENEARAL DATA
1. Patient’s Name:
2. Address:
3. Age:
4. Sex:
5. Birth Date:
6. Nationality:
7. Civil Status:
8. Date of Admission:
9. Order of Admission:
10. Attending Physician:

B. CHIEF COMPLAINT:

C. HISTORY OF PRESENT ILLNESS:
Patient’s condition started 7 months prior to admission, patient complained of epigastric pain including to the back with no other sign and symptoms. No consultation done and no medications were taken. There are also no interventions done at home. One day prior to admission, the client had manifested the same signs and symptoms. Upon admission, Mrs. EBDC had manifested progressive epigastric pain and he was weak and pale in appearance and nurses started an Intravenous Line.
D. PAST HEALTH HISTORY/STATUS
Patient had chicken pox and mumps when she was still young. She had no major illness. The patient could no longer remember any immunization given during his childhood days.

E. FAMILY ASSESSMENT

NAME RELATION AGE SEX OCCUPATION EDU’L ATTAINMENT

F. SYSTEM REVIEW
1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
Mrs. EBDC perceived health as a very important aspect of human existence. For her, being healthy does not only depend on being physically capable but also emotional and mentally sound. Illness for him is inability to do activities of daily living. She complied with any prescribed medication and treatment given to her. In health maintenance and habit, she doesn’t consult the health center in maintaining her health rather she do what she wants.
2. NUTRITIONAL-METABOLIC PATTERN

* Usual Daily Menu
* Food –
* Water –
* Beverages –

3. ELIMINATION PATTERN
* Bowel habits:
* Color –
* Odor –
* Consistency
* Laxative use if any
* Bladder:
* Color –
* Odor –
* Alterations if any
4. ACTIVITY-EXERCISE PATTERN
* Self-care ability
___Feeding ___Dressing ___Grooming
___Bathing ___Toileting ___Cooking
___Bed mobility ___Home maintenance ___Others
LEGEND:
0 – full care
I – requires use of equipment
II – requires assistance or supervision from others
III – requires assistance or supervision from another, and equipment and devise
IV – dependent; doesn’t participate

5. COGNITIVE-PERCEPTUAL PATTERN
* Subjective:
* Hearing- client doesn’t have any hearing problem and doesn’t need any hearing aids.
* Vision- client didn’t complaint of having blurred vision. She doesn’t use any visual aid such as eyeglass or contact lenses.
* Sensory perception- client is responsive and is able to perceive stimuli. There is no problem with sense of taste and smell.
* Learning styles- client learns by experience and is involved in familial decision makings. She can easily understand simple things.
6. SLEEP-REST PATTERN
Client sleeps for at least 8 hours with some interrupting wakefulness related to abdominal pain. She doesn’t use any sleeping aid in order to sleep.

7. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
The life events that the client is experiencing at this time served to decrease his self control, and threaten his self esteem. She views self as a dependent person because of his state. According to her as this time of her confinement she is a burden. She can do household chores.

8. ROLE RELATIONSHIP PATTERN
Being the light of the family, the client knows well about her responsibilities. She said that, she is supposed to be working in order to earn a living for his family but no matter how she wants to she really can’t because of his condition and she knows also that her husband is also working for them.

9. SEXUALITY-REPRODUCTIVE PATTERN
People are actually sexual beings throughout their lives, though some think that sex is lessen as someone gets old.

10. COPING-STRESS TOLERANCE PATTERN
Such situations normally produce anxiety and stress, as stated by the client. She copes by praying with the presence of his ever supportive family. Stress is one that affects health of an individual. Same with stress, problem can also have effect the health.

11. VALUE BELIEF PATTERN
The client strongly believes and fears God. She has good values and right conduct.

G. HEREDO-FAMILIAR ILLNESS
MATERNAL
PATERNAL
H.DEVELOPMENTAL HISTORY
Erikson’s Theory (psychosocial development) Generativity vs. Stagnation
Work and Parenthood Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world.

James Fowler’s (faith development theory) Conjunctive Faith
Typically found at midlife and beyond; begin to distinguish between what is true and what one believes; realizes the stories, symbols, and teachings of one’s tradition are inherently partial and incomplete; seeks truth/wisdom from a multitude of sources (i.e., other traditions) in order to complement and/or correct one’s own; characterized by a “radical openness” to other viewpoints, acceptance of pluralistic views, and use of paradox for understanding; deepening of post-conventional morality.

I.PHYSICAL ASSESSMENT

A. General Survey
Client is conscious and coherent. Weak and pale in appearance, with cold and clammy skin. Client is well dressed.

B.Vital Signs
BP:
CR:
RR:
TEMP:

C.Regional Exam

AREA ASSESSED Techniques Used Findings
1. Hair, head and face
>color inspection Black
>distribution inspection evenly distributed
>moisture inspection oily
>texture inspection fine

2. Eyes
>eyebrows inspection symmetrically aligned, equal movement
>eyelashes inspection slightly straight
>ability to blink inspection blinks voluntarily and bilaterally
>size inspection round reactive to light
3. Nose
>symmetry, shape inspection symmetrical, smooth brownish
>size and color inspection normal and pinkish
>mucosa color inspection elongated and symmetrical
>nasal sputum inspection
>sinuses palpation non-tender during palpation
4. Ears
5. Mouth and Throat
>lips inspection red, symmetrical, dry
>sublingual area inspection pinkish, moist
>tongue inspection no swelling noted
>teeth inspection 30 teeth
>throat palpation no pain when palpated
6. Neck and Lymph nodes
7. Skin
>color inspection brown
>texture palpation
>temperature palpation
>moisture palpation
8. Nails
>color of nail bed inspection pinkish
>texture palpation smooth
>shape inspection convex curvature
>nail base inspection firm

9. Thorax and Lungs
>symmetry inspection symmetry
>respiratory rate inspection
>breathing pattern auscultation clear, no abnormal breath sound
10. Cardiovascular
>heart rate auscultation
>heart sounds auscultation no extra sounds noted
11. Breast and Axilla
12. Abdomen
>contour inspection flat
>texture palpation
>frequency and character auscultation burborygmus

12. Extremities
Upper Extremities
>skin color inspection brown in color
>size inspection equal and appropriate
>symmetry inspection symmetrical

Lower Extremities
>skin color inspection brown in color
>size inspection equal and appropriate
>Symmetry inspection symmetrical
13. Genitals N/A
14. Rectum and Anus N/A
15. Neurological/Cranial nerves
>level of consciousness interview,inspection respond quickly
>behavior and appearance interview good eye contact
>mood and affect inspection,interview not irritable
>thought process interview question are all answer
II. PERSONAL/SOCIAL HISTORY

a. Habits/Vices
The client had no bad vices.
a. Caffeine – none
b. Smoking- none
c. Alcohol- none
d. Tea- none
e. Drugs- none

b. Lifestyle
c. Social affiliation- none
d. Rank in the family- She is the light of the family.
e. Travel-
f. Educational attainment- She is college graduate
III. ENVIRONMENTAL HISTORY (LIVING/NEIGHBORHOOD/CIRCUMSTANCES)

IV. PEDIATRIC HISTORY(for neonates/infants and mothers)

a. Maternal and Birth History
* Date of Birth
* Birth Weight
* Type of Delivery
* Condition after birth
* Hospital

b. Mother
* Complications of delivery
* Anesthesia
* Exposure to teratogens
c. Neonates
* Neonatal history
* Enwind history
* Type of feeding
V. INTRODUCTION (RELATED TO THE DISEASE/CASE OF THE PATIENT

VI. ANATOMY AND PHYSIOLOGY
The gallbladder (or cholecyst) is a pear-shaped organ that stores bile (or “gall”) until the body needs it for digestion. It is connected to the liver and the duodenum by the biliary tract.

VII. PATHOPHYSIOLOGY

Gallstones

Pressure Obstruction

Bile Stasis

?Fat emulsification
Fat intolerance
Anorexia
Flatulence

Inflammation
Pain (RUQ)
Fever
Leukocytosis

?Bile flow in the colon
Alcoholic stool
?Vit K absorption

? s. bilirubin
Jaundice
Pruritus
Tea-colored urine

Infection
Cholecystitis

VIII. LABORATORY AND DIAGNOSTIC EXAMINATION
DATE:
TYPE OF EXAMINATION:
RESULTS NORMAL VALUES SIGNIFICANCE
Drug Name: Ketorolac Brand Name: Toradol
Dosage: 30 mg every 6 hours
Indication: short term management of pain
Mechanism of Action Classification Contraindication Adverse Reaction Nursing Consideration Possesses anti inflammatory, analgesic, and anti fyretic effect. Analgesic, anti-inflammatory Contraindicated in patient hypersensitive to drug in those with a history of nasal polyps, angioedema, bronchospatic reactivity or allergic reaction to aspirin or other NSAIDS,in those with advance renal impairment. * CNS:Drowsiness insomnia dizzinesss headache
* GI: nausea, dyspepsia, GI pain, diarrhea
* CV: edema hypertension,palpitation: >Assess pt before starting therapy
>Be alert for adverse reaction and drug interaction
> assess patient and family knowledge of drug therapy
Drug Name: Celecoxib Brand Name: ceebrex
Dosage: 400mg one a day
Indication: relief of S/Sx of osteo-arthritis and to reduce the number of edenomatous colorectal poplyps
Mechanism of Action Classification Contraindication Adverse Reaction Nursing Consideration Decreasing prostaglandin synthesis relieves pain and inflammation in joints and smooth muscle tissue Anti-inflammatory Contraindicated to patient hypersensitive to drug sulphonamides or aspirin or other NSAIDS and in patients with severe hepatic or renal impairment * CNS: dizziness, headache, insomnia
* GI: abdominal pain diarrhea, dyspepsia, nausea
* EENT pharyngitis,rhinitis sinusitis: >Assess pt before starting therapy
>Be alert for adverse reaction and drug interaction
> assess patient and family knowledge of drug therapy
Drug Name: Dexamethasone Brand Name: Dexasine
Dosage: 4mg every 6 hours
Indication: treatment and management of inflammatory condition, allergic reaction
Mechanism of Action Classification Contraindication Adverse Reaction Nursing Consideration Relieves cerebral edema reduces inflammation and immune response and reverse shock Anti-inflammatory Contraindicated with patients hypersensitive to drug and in those with systemic fungal infection * CNS: insomnia seizures
* GI: GI irritation, increased appetite, peptic ulceration
* CV: hypertension edema thromboembolism >obtain history of patient’s underlying condition before therapy
>Monitor patients bp glucose level and electrolyte levels
>Look for adverse reaction and drug interaction
>assess patient and family knowledge about the drug therapy

I. NURSING CARE PLAN
Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation CUES
S>
O>
> Vital sign taken and recorded
BP:
RR:
PR:
Temp: •Assess the vital sign.