Nursing History PATIENT¶S PROFILE
NAME: Rick Jordan AGE: 19 y/o GENDER: Male ADDRESS: San Juan S. Mayamot DATE OF BIRTH May 10, 1991: PLACE OF BIRTH: Antipolo City OCCUPAT OCCUPATION: ION: N/A (still a student) stude nt) NATIONALITY: Filipino CIVIL STATUS: Single RELIGION: Roman Catholic DATE ADMITTED: January 4, 2011 ADMITTING INSTITUTION: Antipolo City Mdeical Hospital CHIEF COMPLAINT: The patient complains of abdominal pain, headache, fever and
general flushing of skin with on and off vomiting FINAL DIAGNOSIS: Dengue Fever HISTORY OF PRESENT ILLNESS:
Three days prior to admission the patient pat ient has fever and loss his appetite. According to t he SO of the patient, they went to consult a physician during the first day of his fever. The physician prescribed. Paracetamol for the patient. On t he third day, the patient still had the said sympto ms. He went back for a check-up. He had CBC and was determined that he has dengue. Then the patient was immediately admitted to Antipolo City Medical Hospital
PAST HEALTH HISTORY: According
to the SO of the patient the patient did not yet experienced having serious
health problems other than fever, colds and cough. He had no previous hospitalization. FAMILY HISTORY: (-) Anemia (-) Diabetes (-) Asthma
(-) HPN (-) Kidney Disease GORDON¶S
11 FUNCTIONAL HEALTH PATTERN
A. HEALTH PERCEPTION-HEALTH MANA GEMENT PATTERN The patient perceived that he is not healthy because of his condition. NUTRITIONAL-METABOLIC PATTERN The patient has loss his appetite and hasn¶t eaten a lot. He is on a D AT (Diet as Tolerated) EDCF (Except Dark Colored Foods) ELIMINATION PATTERN The patient urinates 2-3 times a day. The color of her urine is yellow. The patient defecates once every two days.
ACTIVITY-EXERCISE PATTERN His activity was limited lying on bed but the patient is given his bathroom privileges
SLEEP-RESTPATTERN He doesn¶t have the adequate time of sleep since he is disturbed with the nurses that enter the room every now and then, and because of the environmental changes of his surroundings. He also has inadequate time to rest since he doesn¶t have enough time to sleep. COGNITIVE-PERCEPTUAL PATTERN He was normal as before in his cognitive and perceptual pattern. He responds clearly and well understood. He has no sensory deficit; He responds appropriately to verbal and physical stimuli and obeys simple commands. SELF-PERCEPTION ± SELF-CONCEPT PATTERN
He sees himself as a person with a good personality. He has been a good friend, brother and a son. He said he has to be a good person in order not to hurt others. He also describes himself as a typical type of student and person. ROLE-RELATIONSHIPPATTERN He said that it was a nice feeling to know that your family is so supportive to him. He learned to appreciate the beauty of having a family that gives you strength and support no matter what. SEXUALITY-REPRODUCTIVE PATTERN He is not yet married and not sexually active COPING-STRESS TOLERANCE PATTERN He shares his problems to his family. He verbalizes his feelings VALUE-BELIEF PATTERN He is a Roman Catholic devotee. He was taught by his family to believe and have fear to GOD.
Physical Assessment BP=110/70mmHg PR=118bpm Area Assessed
Method Used
Normal Findings
Actual Findings
Light to deep brown
General flushing
No lesions, scars or inflammation Smooth Moist
No lesions, but presence of scars Smooth Moist
The skin springs back to its previous state after being pinche
The skin springs back to its previous state after being pinched
Inspection
Pink
Pale
Inspection
Convex
Convex
Inspection
No inflammation of
No inflammation of
Palpation
the skin around the
the
Palpation
nail
skin around the nail
Firm
Firm
SKIN Color and
Inspection
pigmentation Lesions Texture Moisture Temperature Mobility and turgor
Inspection Palpation Palpation Palpation Palpation
N AILS Nail bed color Shape Lesions Thickness capillary refill
RR=25bpm Temp=38
Normal capillary refill HE AD Size
Symmetry
Inspection
Inspection
Proportion to the
Proportion to the
body
body
and the skull is
and the skull is
rounded and
rounded
smooth
and smooth
Symmetrical
Symmetrical No nits/lice present
SC ALP Distribution of hair Lesions Other findings
Inspection
Evenly distributed
No inflammation,
Inspection
No inflammation,
lumps
Inspection
lumps or masses
or masses
F ACE Skin color Texture Facial movement
Inspection
Light to deep brown
Pinkish
Inspection
Smooth
Symmetric facial
Inspection
Symmetric facial
Symmetric facial
movement
movement
EYES
Inspection
Evenly distributed
Pink conjunctiva
External structure
Inspection
Evenly distributed,
Evenly distributed
Eyebrows
Inspection
Evenly distributed,
Evenly distributed
Eyelashes
Inspection
curved outward
Inspection
Same as facial
Symmetric to head
Inspection
color
No discharges and
Inspection
Symmetrical at the
inflammation
level of the eyes
Normal
Eyelids E ARS Color Symmetry Shape and size
corner Symmetric to head No discharges and inflammation Same as facial colo NOSE Color Shape Discharges
MOUTH Lips Symmetry Moisture TONGUE
Inspection
Same with facial
Same with facial
Inspection
color
color
Inspection
Symmetric
Symmetric
No discharges
No discharges
Inspection
Symmetric
Symmetric
Inspection
Pink
Pink
Inspection
Moist
Dry
Position
Inspection
Positioned at the
Central position
Color
Inspection
center can move
Dull red
Texture
Inspection
freely
Smooth
Mobility
Inspection
Dull red
Can move freely
Lesion
Inspection
Smooth
No lesions or
Can move freely
inflammation
No lesions or inflammation NECK Position Symmetry Range of movements
Inspection
Head centered
Head centered
Inspection
Symmetrical
Symmetrical
Palpation
Smooth movements
Smooth
without discomfort
movements
Symmetric and at
without discomfort
midline position
Symmetric and at midline position
UPPER AND LOWER EXTREMITIES Size Symmetry Distribution of hair Skin color Lesions
Temperature
Inspection
Equal size
Equal size
Inspection
Symmetrical
Symmetrical
Inspection
Evenly distributed
Evenly distributed
Inspection
Light to deep brown
Light to deep brown
Inspection
No lesions,
No lesions,
deformities or
deformities or
inflammation
inflammation
Normal
Normal
Palpation
LABORATORYEXAMINATIONS January 6, 2011 P AR AMETER
NORM AL FINDINGS
ACTU AL
FINDINGS
White Blood Cells Hemoglobin
M: 140-160g/L
145
Hematocrit
M: 0.40-0.54
46
Nuetrophils
50-70%
70%
Lymphocytes
30%
25-40%
Platelet Count Urinalysis: Jan 4, 2011 Color: Yellow Transparency: Hazy Specific Gravity: 1.010 Chemical Examination: Albumin: Trace Sugar: Negative pH: 5.0
DRUG STUDY ISOPRINOSINE Dosage : 2 tsp TID 250 mg Classification: Antivirals Indication: Rhinovirus; herpes genitalis; measles; encephalitis; influenza; herpes zoster; herpes simplex; type A & B hepatitis; AIDS related complex; neoplastic diseases; anergy and hypoergy prior to major surgery Action: >Synthetic antiviral: it stimulates T-lymphocytes; used for HIV and Hepatitis >non-toxic immune system stimulant Adverse Reactions: >Transient increase in urine and serum uric acid level; very rarely skin rashes; pruritis; GI upset; nausea; fatigue; malaise Contraindications: >Hypersensitivity. Patients w/ adnormally low neutrophil counts (< 0.75 x 10x9/L), or abnormally low haemoglobin levels (< 7.5 g/dL or 4.65 mmol/L) Nx Considerations: >Monitor increase in serum uric acid level, gout, urolithiasis or renal dysfunction; pregnancy and lactation >Monitor hematological parameters Patient Teaching: >Inform patient that the drug must be taiken 1 hour apart on an empty Stomach >Instruct the patient to notify prescriber if unusual effects occurs AMOXICILLIN
Dosage : 375 mg TID Classification : Antibiotic Indication: Infections due to susceptible strains; helicobacter pylori infections in combination with other agents; post-exposure prophylaxis against bacillus anthracis;Chlamydia trachomatis in pregnancy Action:
Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death Adverse Reactions: >CNS ± lethargy, hallucinations, seizures
>GI ± glossitis, stomatitis, gastritis, sore mouth, furry tongue (black hairy), nausea, vomiting, diarrhea (bloody), enterocolitis,pseudomembranous colitis, nonspecific hepatitis >GU ± nephritis >Hematologic ± anemia, thrombocytopenia, leucopenia, neutropenia, prolonged bleeding time >Hypersensitivity ± rash, fever, wheezing, anaphylaxis >Others ± superinfections: oral and rectal moniliasis, vaginitis Contraindications: >Contraindicated with allergy to cephalosporins or penicillins, or other allergens >Use cautiously with renal disorders and lactation Nx Considerations: >Culture infected area prior to treatment; reculture area if response is not expected >Give in oral preparations only; amoxicillin is not affected by food >Continue therapy for at least 2 days after signs of infection have disappeared; continuation for 10 full days is recommended >Use corticosteroids or antihistamines for skin reactions Patient Teaching: >Take this drug around-the-clock >Take the full course of therapy; do not stop because you feel better >This antibioticis specific for this problem and should not be used to self-treat other infections >Eat frequent small meals to avoid GI effects; frequent mouth care may prevent sore mouth >Report unusual bleeding or bruising, sore throat, fever, rash, hives, severe diarrhea, difficulty of breathing P AR ACET AMOL Dosage: 250 mg/5ml q 4° RTC Classification: Nonopioid Analgesics & Antipyretics Indication: Mild pain or fever Action: Produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin inthe CNS or of other substances that sensitize pain receptors to stimulation. The drug mayrelieve fever through central action in the hypothalamic heatregulating center. Adverse Reactions: Hematologic: Hemolytic Anemia, Neutropenia, Leukopenia, Pancytopenia Hepatic: Jaundice Metabolic: Hypoglycemia Skin: Rash, Urticaria Contraindications:
Contraindicated in patients hypersensitive to drug.
Use cautiously in patients with long-term alcohol use because therapeutics doses
cause hepatotoxicity in these patients. Nx Considerations:
ALERT:
Many OTC and prescription products contain acetaminophen; be aware of
this when calculating total daily dose.
Use liquid form for children and patients who have difficulty in swallowing.
In children, don¶t exceed five doses in 24 hours.
Patient Teaching:
Tell parents to consult prescriber before giving drug to children younger than age 2.
Advise
patient or parents that drug is only for short-term use; urge them to consult
prescriber if giving to children for longer than 5 days or adults for longer than 10 days.
ALERT: Advise
patient or caregiver that many OTC products contain
acetaminophen, which should be counted when calculating total daily dose.
Tell patient not to use for marked fever (temperature higher than 103.1°F [39.5°C]),
fever persisting longer than 3 days, or recurrent fever unless directed by prescriber.
ALERT:
Warn patient that high doses or unsupervised long-term use can cause liver
damage. Excessive alcohol use may increase the risk of liver damage. Caution longterm alcoholics to limit acetaminophen intake to 2g/day or less.
Tell breast-feeding woman that acetaminophen appears in breast milk in low levels
(less than 1% of dose). Drug may be used safely if therapy is short-term and doesn¶t exceed recommended doses. Interactions o Drug-Drug -Barbiturates, Carbamazepine, Hydantoins, Rifampin, Sulfinpyrazone: high doses orlongterm use of these drugs may reduce therapeutic effects and enhance hepatotoxiceffects of acetaminophen. Avoid using together.
