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c Personal and `ocial History A Healt Perce tion and Healt Management Pattern c
5c c$ cc7 Dc c c7 cc c c
c7 c$c c c cc c c c c$ cc cc7$ccc c c$ !cccc cc c.$c c c c c cc$c c cc c7 c$$c cc ccc $c cc7 Dc c ccc V Nutritional and Metabolic Pattern cc
ccc$c c c c7c c@c c cc
cc@c c !cc c c c c c c$c c $c$c c . !c !c $ c c cc 77cc ccc c c c
cc c c c c c c c cc cc cc
c c cc ccicc c c c c. ccc. c 7 !cc c. c$ c$cDc c c c c c c c c. c cccc c c c C Elimination attern c
5c c$ cc 7ccc c c$$ c cc !c
c7 c $ ccc c c.c .c$ c c5c$ $c cc cc$ !c c cc ccc. c 7 !cc cc$ cc 7c. cc c c cc cc. c c D Activity and Exercise Pattern c
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c7ccc c7c c$!c. c 7ccc c c7c
cc. cccc. c 7 !cc7c7 c$ cc 7c c c
c c cc. c c cc cBc c 7c c c ccccccccccccccccccccc c F Cognitive and Perce tual Pattern c
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c$ cc7 7c cc c7 c.ccc c cc c cc 7c c7 c.c $c c.cc. c cc$ c $ 7c c.c c7 c c H `exuality and Re roductive Pattern c
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c Co ing and `tress Tolerance c
cc$ 7c7c cc$ cc.ccc c c c
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c DATE &TME * c?!c'())c c 'c C+((c cc c c c 'c C+4(c c c c c 'c ))+((c c c c c c c c 'c )'+((c c
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c 'c 57+c4@= c +c)4=$7c +c4( 7c 'c % +c0 c c c)'(cc c. c 37+c?(cc:c)c 7c$ ;c
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c c c c c c c c c c c 'c 1c$ * c
c c c c c c c c 'c 57+c4@= c +c)4Ac$7c +c4(c 7c 'c % +c0 c c=(cc c. c 37+c?(cc:c)c 7c$ ;c c
Review of `ystemsc
=eneral ccccccccccccccccccccccccccccccccccccccccccccccccccccccc:H;c c7c7 c ntegumentary `ystem :H;c7c cc c c c c c =astrointestinal `ystem c c c c. c .cc$ !cIc c c7 $c$7c c c c c .$c c c Pysical Assessment (MAY 10, 2011) c =ENERA APPEARANCE
. !c $ $ !c $c c c c c c:)cc ;c c
c 'c ,3 #,c6%"5%3"c
Antro ometric measurement
nitial ital `igns
c c c
Findings ccc+c@?c$c cc+cC=c c c$c +c?Ec c$c +c J=Ec c c$$ $c+cA@c$c c$ $c+cAAc $c c$$ $c+cA=c $c c
c c+c)4(c 7c 7 c c+c4Ac$7c 57 c+c4@=cYc
c
Reference alue cccc+c>)c*C)c$c ccc+cC@*)'' c c7$c c+c=E* ?=Ec c7$c c+c=E* ?=Ec c c$ $c c Jc'c$c c c $$ $ccc c c$$ $c+c 7 c c c c c+c)'(*)@(c 7c 7 c c+c'(*A(c$7c 57 c+c4@=*4>=Yc
Organ/ system
Tecniques of ysical examination c:1 $ c %7$ c
c;c c c c c c c c c 7 c c c c c c c c c c %7$ c c c c c c c c c c c c %7$ c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c %7$ c c c c c c c c c c c c c c c c c c 7 c c c c c
Findings
Vc :*;c c Vc :*;c c c c Vc $c $ c
c c
Reference findings
Vc :*;c c Vc :*;c c c c Vc $c $ c
c c Vc :*;c7 7 c c c c Vc :H;c7 c7c
Vc :*;c7 7 c c c c Vc :H;c7 c7c c c c c Vc c c Vc c c $ c c $ c c Vc :*;c c Vc :*;c c Vc cc Vc cc c c Vc .c Vc .c $ c c $ c c Vc c< c Vc c< c c c Vc :H;c cc Vc :*;c cc Vc $$c$ c Vc $$c$ c Vc c$ c Vc c$ c Vc c B$ c Vc c B$ c Vc # c .cc Vc 0 $ cc Vc :H;c,c:'*4c Vc :H;c,c:'*4cc c c cc c c;c Vc :*;c$ c Vc :*;c$ c c c Vc $ c Vc $ c c c Vc % $c7 $c Vc % $c7 $c c c Vc :*;c cc Vc :*;c cc Vc :*;c$ c Vc :*;c$ c Vc :*;c c c Vc :*;c c c c Vc c c Vc c c $ c ccc c $ c ccc c c c Vc c c$ c Vc c c$ c Vc :*;c c c Vc :*;c c c c c
" c c c c c 5 c c c c c c c c c c c c c c c c c c c c c c c "$ cc
%7$ c c c %7$ c c c c c c c c c c c c c c c c c c c c c c c c %7$ c c c 7 c c
5 c c ,c
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Vc 5c:H;c$ c c c$ c c 77c c .c Vc /c c$ cccccccccc :*;cc.c :*;cc c :*;cc $ c :*;cc.c7 $c Vc /c c7 c Vc c c c 5 c1 cc Vc c c c c $ c Vc :*;c.c c c Vc :*;c7c c7 c c c Vc 5 cc7 !c c c cc 7 c c Vc :*;c c c c c c Vc 77c Vc :*;cc c c Vc +c *7 7 c 7c c :*;c7 $ c :*;c $$7 c :*;c7 $ c$$ c :*;c7 c$$ c :*;c c :*;c c$$ c :*;c7 $ $ c :*;c7 $ c :*;c c :*;c c Vc c:*;c c c c 7c Vc 7 c" $+c Vc :*;c7 c c Vc :H;c$ c 7 c.c
Vc 5c:H;c$ c c c$ c c77c c .c Vc /c c$ cccccccccccc :*;cc.c :*;cc c :*;cc $ c :*;cc.c7 $c Vc /c c7 c Vc c c c 5 c1 cc Vc c c c c $ c Vc :*;c.c c c Vc :H;c7c c7 c c c Vc 5 cc7 !c c c cc7 c Vc :*;c c
Vc 77c Vc :*;cc c c Vc +c *7 7 c 7c c :*;c7 $ c :*;c $$7 c :*;c7 $ c$$ c :*;c7 c$$ c :*;c c :*;c c$$ c :*;c7 $ $ c :*;c7 $ c :*;c c :*;c c Vc c:*;c c c c 7c Vc 7 c" $+c Vc :*;c7 c Vc c:H;c$ c 7 c.c
c c
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%7$ c c c 7 c c c c c c c c $ c
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7 c c Vc :H;c5 $c c c Vc :H;c c c c Vc c:H;c c$ c c c Vc :*;c c c c c Vc :H;c c c%cc c c Vc :H;c cc Vc $ +cc ccccccccccc:*;c7 ccccccccccc 7c ccccccccccc:*;cc Vc %*c7 7 cc=c ccccccccccccc%!c 7$ c c c Vc )*c c c c 7!c ccc Vc '*c c c c !c Vc c *c:H;c4!c Ac Vc :*;c Vc :H;c7 c Vc :*;c$ !c c Vc :H;c% c c c .cK c :H;c cc :H;c c :H;cc c c c c c c c Vc :H;c7c c : .c ;c=*)(c $c Vc :*;c c c Vc $c 1 $ ccI'$c
7 c c Vc :H;c5 $c c c Vc :H;c c c c Vc :H;c c$ c c c Vc :*;c c c c c Vc :H;c c c%cc c c Vc :H;c cc Vc $ +cc ccccccccccc:*;c7 ccccccccccccc 7c ccccccccccc:*;cc Vc %*c7 7 cc=c ccccccccccccc%!c 7$ c c c Vc )*c c c c 7!c ccc Vc '*c c c c !c Vc c *c:H;c4!c Ac Vc :*;cc Vc :H;c7 c Vc :*;c$ !c c Vc :*;c% $c cc .cK c Vc % c +c :H;c cc :H;c c :*;cc cc c c c Vc :H;c7c c=* )(c$c Vc :*;c c Vc
$c 1 $ ccI'$c
c
%7$ c c c c c c c c c 7 c c c c c c c c c c c c c c c c %7$ c c c c c c c c c c c 7 c
:*;c c Vc c :H;c7 7 c cc c . cc Vc
:*;c c Vc c :H;c7 7 c cc c . cc Vc c c:*;c7 c c:*;c7 c c:H;cc$ c c:*;c$ c c:*;c c c:*;c c c:H;c4c B c$ c c c:H;c4c B c$ c c ccccccc7 c cccccccc7 c c:H;c7 c c c:H;c7 c c c :*;c cc :H;c c c cc c c $ c c c c$ 7 c c c ccc c cccc :H;cc c c$ cc :*;cc c c c ccc c $ c :*;cc. c c $c :*;c. c c $c :*;ccc c :*;ccc c :H;c c7$c c $ ccccc :H;c c7$c c $ ccccccc 7c 7c c7c c c c7c c c $c $c :H;c$ 7 c c :H;c$ 7 c cc c c c c c Vc v c c ccccc:*;c7 c cccc:*;c7 c ccccc:*;c$ c cccc:*;c$ c ccccc:*;c c cccc:*;c c :*;c c :*;c c :H;c c c$ c cccc:H;c c c$ c :*;c c$ c c cccccccc:*;c c$ c c c $ c c ccccccc c# c7ccccc c c c# c7c c c c. c c c c. c c c$c c c$c ccccc:*;c7 7 c7 7 c :*;c7 7 c7 7 c cc c c:H;c$ 7 c c c:H;c$ 7 c c.c .c'c$c:*;c$ c 'c$c:*;c$ c c c$ c
/ c
%7$ c c c c c c c c c c c %7$ c c 7 7 cc
$ cc Vc i :H;c $$$c c cc c :*;c c c c c Vc :*;c$ c :H;cc c c $c c7c7cc c Vc ` :H;c cc cc c ccccc:H;c cc. ccccccccccccc c .c cc c Vc :*;c c :*;c7 7 c1 c ,7c c
Vc i :H;c $$$c :*;c c c c c c Vc :*;c$ c :H;cc c c $c c7c7c c Vc ` :H;c cc cc c :H;c cc. c c .c cc Vc :*;c c :*;c7 7 c1 c ,7c c c
c
c Diagnosis $c/ c.c cc c c c Differential Diagnosis Anatomy and Pysiology The Gastrointestinal System
c
ccc c c cc
c c cccc cccc cc c c cc c c c c cc c cc c ccc c !c cc cc c ccc c c"c cc c c c c c"cc c cc#c c c c c cc c c c c c c c ccccc " cc c" !c c c c c c c c c cc$ c c c%!c" ! c c c c!!%c cc &c ! c c!c c" c'ccccc cc c c c c!c cccc c"c c&cc& c c cc c cc c c"!(c c !c c c cc " "cccc" !c cccc c!cc c !cc cc c" c c c " "cc" cc"cc cc c c " "ccc"cc c cc c" c" c c!c ccc c " "cc c c c 'c Eso agus 5c7$c c ccc7 c c. .!c.$c<cc
c cc 7 c 5c 7 !c c $ c c c '=c $c :)(c ;c !c 7 c c c $ c c c c 7 c c 7 c :$ c . c .cc$c c ;c c $cc $c1 c $c c c c$ c c c c$c$c$ $ c:;c .c c 7 c 5c 7 $c c .c $$ c $c c c 7 c . c $ $c c c:.;c c cc !c<c c .. c . cc $c 1 c ccc cc 7 cc. c cc$ cc
c$$ c$c$ cc 7 c7$c7 cc 7 c c c $cc cc. .!cc $c !c c c 7c c .$c c c $ c 7 c c c $c 5c c $c $ $!c $ c c 7c c 7c c c c $ c c c 7 c 5c 7 c 7$ccc c c c$c$c cc c$ c5c$c $c c c c cc7 c c c c 7cc c c $ . cc 'c `tomac 5c $!c $ c c c 77c c Bc .c c 7 !c c c $ c$c.c !c$ c. c5c $c$ c7 c $ c c c c c c c c c c c $ $ c c $$ c 7 $c 5c $c$ $c ccc7c!c$cc c ccc.c $c B$c 5c !c $c c c c $c c c c c c c $!c $ c c . !c $ $c $!c c c $ c 77!c c $c :c c$ 7 c c$;c $ $c $c$ cc $$c c c 77c c c c c .c7 c%c c c $ c c c c cccc c$c$ cc $!c7 $cc cc
$c c c $c c 77c c c c c c c c !c c 7 $c c c $!c$ c$!c c7 c c c c cc cc7 $c7$c cc !cc c7 c cc ccc 'c `mall ntestine c !c c .c c 7 c c c !c $$c c c c c5c .!c.c !c c'=c$c:)c;cc !c c c cc .c !c c c @c c :'(c ;c c c 3c c 7 c c c c c
!c 7 c c $c c c c c c c 7 c c c c !c c BB!c c c c c !c c c $ c c c c c#cc!cc c$c c cc c c cc c $c 0c c c c c c c 7!c .$c c c c c c $ c $c 7 c $ $c B$!c $c c c 7 $ !c c c c c c c 7 $ $c $c $ $c B$c $ c c c c .c c c $c c7c !c c c c $c c$ !c c 7 c c c $c / c c c c . c $c c c c c .c $c c$ 7c c cc ccc c $c $ c 0Dc c $c $c c 7 $c c c . c cc $c
$c ccB$cc 5c c Dc $ 7 $c c 7 c c $ c c c c
c 7 B$ c $ c !c .$c c c c . c c c c c $c c c c (=c c )=c c :(('c c ((@c ;c c c $ c .c c c c c $c c c c 7 B$ c $ c $ c $ c c $c $c 5c $ c c c c $ c $ c c $c c c c c Dc c c c )=(c !c 7c c $ 7 $c c 7 c 0 ccDcc c c$c $ 7 c:c;c cc c cc 7 $cc5c$ 7 c .cc7 $c c c c c c c $c c c c 7c c c c $c 7 c c c $ 7 c c c c c 1 c $c c $ c 7 c c c c 7 $ccc 'c arge ntestine
c. cc c c c ccB$c c c 5cc cc c cc c c c c c7 c cc c!c.cc7c)'c c'Ac c5c cc c cc c cc$ c cc cc%c c cc .c* cc cc c cc cc .c * cc5c ccc)=c c)Ccc:=c c@c ;c c c c@c$c:'=c;cc cc 5c ccc c7 c $ c%c c. Lc c @c c :)@c ;c L c .c c c c c c c 7 c c c c cc%c !c $ ccc cc7 cc .c cc c c c c !c c c-!c.$cc c c c c$ c5c c c c c c$ c . cc $!c.$c c7cc c)=c c'(c$c:@c cCc;c cc c$ c5c $c c c $L. c c c $ c c c c !c cB$!c $ !c c$Lc c5!c$c$ $ cc c. c cc$c7cc $c . cc cc7$c .cc $c c c !cc $c7 c c cc c
FD` & EECTROYTE` $ c c cc c c c c c$$c$ c5c cc c !cc c c c ccc $c c$ c7c c Mc c $!c $c $ c c c 7 $c !c$ $!c
7 !c$ !c7 7 c c c c c$ c& ccc c c c c c cc c c c ,c c$ cc c c$ c $ c c .c c cc5 c$ c 77c .c c c c. cc c c $ c c $c c $!c !c !c . c c c 7 c c c c $$c.cc c !c7 c c$ $c Pato ysiology aboratory Result MAY 8, 2011 Hematology Com onent
Result
Normal alues
nter retation
Hgb
))4c
)A*)C8,c
ron Deficiency
Hct
(4=c
(A(*(=Ac
ron Deficiency
WVC Count
)C@c
A*)))(?8,c
RVC Count
A4c
=(*@Ac
(('c
(('*((Ac
`egmenters
(A?c
(=(*(>(c
ym ocytes
(ACc
('(*(A(c
nfection
Monocytes
(()c
(('*((=c
Release of toxins in
nfection ron Deficiency
Different Count Eosino ils
" c
Neutro il
te blood; infection Platelet Count
Remarks: Pricked
MAY 4, 2011
'CCc
)=(*A=(c
" c
Macrosco ic Examination Examination
Result
Color
# c& .
Consistency
nter retation " c ncreased eristaltic movement
Occult Vlood Examination
Result
nter retation
WVC
"
" c
RVC
"
" c
N" c c7 cc c MAY 4, 2011 Cemical Cemistry `ection
Test Name
`
nit
Range
Cony
nit
Result
Range
')'*
C(Ac
C=(*
cccccitamin D
'='c
8,c
)()(c
deficiency,
Result Total
'()c
8,c
Calcium
nter retation
over consum tion of os ates `odium
)4?c
8,c
)4@*)A=c
)4?((c
)4@*)A=c " c
<8,c Potassium
4@c
8,c
4=*=)c
4@(c
4=*=)c " c
<8,c Cloride
)(4c
8,c
?C*)(>c
)(4((c
?C*)(>c " cc
<8,c
APR 30, 2011 Com onent
Result
Normal alues
Hgb
)(Ac
)A*)C8,c
ron Deficiency
Hct
(4'c
(A(*(=Ac
ccccccccccccron Deficiency
?
nter retation
WVC Count
C4c
A*)))( 8,c
" c
RVC Count
4?c
=(*@Ac
(()c
(('*((Ac
`tab Cells
(()c
c
c
`egmenters
(A'c
(=(*(>(c
c
ym ocytes
(='c
('(*(A(c
ccccccccccc nfection
Monocytes
((Ac
(('*((=c
" c
Platelet Count
'@'c
)=(*A=(c
" cc
ccccccccccccron Deficiency
Different Count Eosino ils
" cccccccccc
Neutro il
APR 28, 2011 7$c0 ccc % c+c" c .c c'c c c$ c c APR 27, 2011 Macrosco ic Exam Examination
Results
Color
nter retation ack of bile, roblem in biliary tract or liver
Consistency
ncreased eristaltic movement
Occult Vlood Examination
Results
nter retation
WVC
(*)
" c
RVC
"
" c
Remarks N" c c7 cc Examination
Results
Yeast Cells
3$$ c
nter retation nfection
c
APR 27, 2011 Cemical Cemistry `ection
Test Name
`
nit
Range
Cony
nit
Result
Range
')'*
C(Ac
C=(*
'='c
8,c
)()(c
)4@*)A=c
)4?((c
)4@*)A=c
Result Total
'A(c
8,c
Calcium `odium
)44c
8,c
<8,c
nter retation
Normal
Prolonged sweating, vomiting and diarrea
Potassium
A'c
8,c
4=*=)c
4@(c
4=*=)c
Normal
?C*)(>c
oss of body
<8,c Cloride
?(c
8,c
?C*)(>c
)(4((c <8,c
fluid due to
rolonged vomiting and diarrea
Remarks: Pre- extracted; onized Calcium: Not available
APR 25, 2011 Macrosco ic Examination Examination
Results
nter retation
Color
,c& .
" cc
Trans arency
"
`ugar
:*;
" c
Protein
:*;
" c
H
@(
" c
)('(
" c
`=
Microsco ic Examination Examination
Result
nter retation
WVC
*)81c
c
RVC
(*)81c
c
E itelial Cells
3$$ c
" c
1.c
" c
1.c
nfection
Crystals Amor ous rates/Pos ates Oters Vacteria
APR 25, 2011 Com onent
Result
Normal alues
Hgb
))'c
)A*)C8,c
ron Deficiency
Hct
(4Ac
(A(*(=Ac
ron Deficiency
?
nter retation
WVC Count
)>@c
A*)))( 8,c
RVC Count
A'c
=(*@Ac
`egmenters
(=)c
(=(*(>(c
" c
ym ocytes
(A@c
('(*(A(c
ccc
Monocytes
((4c
(('*((=c
" c
Platelet Count
A'Cc
)=(*A=(c
" cc
nfection ron Deficiency
Different Count Neutro il
APR 25, 2011 Cemical Cemistry `ection
Test Name
` Result '4Ac
nit
Range
8,c
')'*'='c
Sodium
44c
)*c
Potassium
c
Chloride
,c
Total Calcium
Cony Result C(Ac 8,c
nit Range C=(* )()(c
4+4 c
4c )*c
4+4 c
)*c
+4c
+4c
)*c
-+4,c
c )*c 4c )*c
-+4,c
nter retation Normal Prolonged sweating, vomiting and diarrhea Vomiting Loss of body fluid due to prolonged vomiting and diarrhea
APRIL 24, 2011 Chemical Chemistry Section
Test Name
SI Result
Unit
Range
Total Calcium Sodium
c
)*c
4+c
4c
)*c
4+4 c
Potassium
c
)*c
+4c
Chloride
,c
)*c
-+4,c
Cony Result - c )*c 4c )*c
Unit Range -+ 44c 4+4 c
c )*c 4c )*c
+4c
c
GLUCOSE MONITORING SHEET APRIL 25, 2011 12pm 8pm APRIL 26, 2011 4am 12pm 8pm APRIL 27, 2011 4am 12pm 8pm APRIL 28, 2011 4am 12pm 8pm APRIL 29, 2011 4am 12pm APRIL 30, 2011
c )*c 4c )*c 4c )*c 44c )*c c )*c 44 )*c 4 )*c 44 )*c 44 )*c )*c )*c 4 )*c 4c )*c
-+4,c
Interpretation Normal cccccProlonged sweating, vomiting and diarrheac Vomiting Loss of body fluid due to prolonged vomiting and diarrhea
4am 12pm 8pm MAY 1, 2011 4am 12pm 8pm MAY 2, 2011 4am 12pm 8pm MAY 3, 2011 4am 12pm 8pm MAY 4, 2011 4am 12pm 8pm MAY 5, 2011 4am 12pm 8pm MAY 6, 2011 4am 12pm 8pm MAY 7, 2011 4am 12pm 8pm MAY 8, 2011 4am 12pm 8pm MAY 9, 2011 4am 12pm 8pm MAY 10, 2011 4pm
-c )*c ,c )*c - c )*c c )*c 4c )*c 4c )*c 4 c )*c 44,c )*c -c )*c 4c )*c 44c )*c 4c )*c -c )*c ,,c )*c 4c )*c c )*c 4c )*c c )*c --c )*c -4c )*c 4 c )*c c )*c -c )*c 4c )*c --c )*c ,c )*c 4c )*c 4c )*c 4c )*c -c )*c 4c )*c
Nursing Care Plan c c
c
Drug `tudy ð cc
c ð
c
cc cc cc c c c c c c c c cc cc
cc c
c c cccc c c cc c
c
c c c c c c c cc cc c c c
cc c c c c c c cc c c c c c
ð cc c
c
c ð
c c c c c c c c !c c " #c c$c cc
c c c c c c ccc %c%c %c c c c
c
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c c cc c c c
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ð c c c cc c c c c c c c c
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ð
c
c c
c
c c
cc c c c c
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c c
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c
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c c c c c c c cc
c cc cc c cc c c c
c c c c c c
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c
c c c c
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c c c '(c c
c
c c c c c c c cc c c c c cc
c c c - c c c c c c c c c #c cc c c c c * c c
ð cc c
c ð
c c c c c c3c c c c !c c " #c c8c c
c c c c c c c cc
c c c c c
c c
%c %c %c %c c9c c c c cc c c c c c c c cc %cc c c c*+,%c %c c c c c c cc c c c c c c cc &c c
c
c c c cc c ccc c ':*-;34%444%c cc %c cc
c c/ c c c c c c c c c &c # c cc c '<1c (cc cc c c &c c c c cc c c c / cc7c %ccc c c c c c c cc cc c c c
cc
c c c c c c
ð c c
c ð
c
c c cc c c c , 0cc =c c c c c c c c c c - c
> c c
c c c ccc
%c c c cc c %c / cc &c c c c
c
c c c ) c c c c c c c - c cc ccc cc c c c c c c
c c
ð cc c
c
c ð
c c c c c c3
c c c c ?c c c c c
c c c c c c c c c c
c c
c c c c c c cc cc c c 2 c %c c c c c c ?c c c & cc c c
c c c c / c cc cc c
ð c c c cc c "
c c c c c c c c
c
ð
c
c
c c c c c c
c c c 2 c c cc c c
c c c 2 c
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c
c 3<@%c
c c<4@c
c c c 14@c
ð cc c
c
c ð
c c c c c c3A c 345cc<c c c> c c " #c c c c
c c c c c c cc c c c c c c c %cB%c c c c c c c c c
c %c
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c c c cc c c c &cc c cc
ccB%c B c c
cc c / c
c c c c c c c c cc c c c cc c c c c c cc c c
cc c c c c c ccc c c c ccc c c c c c
Discarge Planning
M*c$ c 'c %$cc c c cc .c$ c cc$c c 7$ c cc7$ +c c mc mc mc mc c
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