I.INTRODUCTION
Pancreatitis is the inflammation of the pancreas. The pancreas is damaged when digestive enzymes are activated before they are secreted to the duodenum and began attacking the pancreas. There are two types of pancreatitis, acute, and chronic. Acute pancreatitis is a sudden inflammation by a short period of time. Most of the cases of acute pancreatitis are primarily caused by gallstones or h eavy alcohol use. Some of the causes are medications, infections, trauma, metabolic disorders, and surgery, but up to !" of people with this disease, the cause is unknown. #n very severe cases, acute pancreatitis can result in bleeding into the gland, serious tissue damage, infection, and cyst formation. #n some cases it can also affect vital organs such as the heart, lungs, and the liver. $hronic pancreatitis is commonly caused by an on%going pancreatitis. About &'" of the people, chronic pancreatitis is caused by prolonged alcohol use. (ther causes include gallstones, hereditary disorders of the pancreas, cystic fibrosis, high triglycerides, and certain medicines. )*cessive alcohol use may not cause symptoms for many years, but he+she then sudde nly develop severe pancreatic symptoms like severe pain, and loss of pancreatic function, that results digestion and blood sugar abnormalities. allstones are small particles that develop in the gall bladder when, bile, form hard, crystal%like particles. allstones are composed of -! " cholesterol and ! " pigment stones. $holesterol stones are usually white or yellow in colour and primarily made of cholesterol. Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. allstones vary in size that varies as small as a grain of sand or as large as a golf ball.
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#n the Philippines, there is !./ " of the total population who has pancreatitis as of year !!/. 0orldwide, 0orldwide, the incidence of pancreatitis ranges between ' and -! per 1!!,!!! populations. As of !!2, there are ',!3,!&! people reported that have gallstones in the population of -2,&1,2/3. 4According to http5++www.rightdiagnosis.com+g+gallstones+st http5++www.rightdiagnosis.com+g+gallstones+stats%country. ats%country.htm6 htm6 Pancreatitis can be treated through pharmacologic treatments or surgical management. #t depends upon the prognosis and type of disease occurring in a specific client. The group chose this case because it appears to be uni7ue and interesting among the cases available in the Surgery 0ard. 0ard.
II.OBJECTIVES:
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General Objective:
This study aims to ac7uire knowledge about abo ut gallstones, pancreatitis, the disease process, its prognosis, complications, and treatment and to apply the nursing interventions suitable for the client with effectiveness and efficiency. efficiency.
Specific Objectives:
Assess the client properly and gain baseline data by building rapport with the client and his+her significant others. 8ormulate the correct diagnosis based from the thorough assessment done to the client. Plan the nursing actions that are to be done through the problem which has been addressed and found through the assessment. Apply the appropriate nursing interventions with efficiency and with observance to the 11 core competencies. Achieve the e*pected outcomes and gain a positive response from the client with the interventions done.
III.NURSING ISTOR!
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BIOGR"#IC"$ D"T"
9ame Ag e ender Address $ivil Status 9ationality ;eligion
5 Patient : 5 1 5 Male 5 Sta. $ruz, Makati 5 Single 5 8ilipino 5 $atholic 5 8ebruary 1&, 1/- 5 (spital ng Makati, Surgery 0ard
>ate of Admission
5 ?une 12, !1
>ate of #nterview
5 ?une &, !1
#nformant
5 Patient : and significant other
;eliability
5 / !"
Sour Source ce of info inform rmat atio ion n $riteria for reliability
5 Pati Patien entt and and Signi Signifi fica cant nt othe other r 5
A. )*tent of data gathered demographics, history habits @ !"
<. evel of consciousness of interviewee condition, willingness to disclose info @ '"
$. $ompleteness of correlating facts 8luidity of transpiring events @ '"
CIE% CO&#$"INT:
Abdominal pain radiating to the back
4|Page
ISTOR! O% #RESENT I$$NESS:
Patient :, a 1 year old male was admitted to the hospital with a complaint of abdominal pain.
1 month prior to admission, client was e*periencing pa in in his left upper 7uadrant part of the abdomen but he Bust ignores it. Pain was intermittent and he doesnCt take in pain medication. =e also e*periences the same kind of pain when he is full or whenever he Bust finished his meal. $lient also feels fullness of the stomach and indigestion. $lient did not go to the hospital for check%up because he did not take it seriously. =e was fond of eating foods rich in fat and he is an occasional o ccasional alcohol drinker.
1 week prior to admission, pain e*perience became continuous even to the point that he is having a hard time to go to sleep making him feel restless. (ne event that he feels fullness he drank 1 bottle of coke and red horse to make himself burp. =owever, =o wever, there was no relief of symptoms upon burping.
1 day prior to admission, client e*perience e* treme pain and he is having hav ing difficulty of breathing that is why he sought for medical assistance.
$lient was admitted at the emergency room of (spital ng Makati ?une 12, !1 at around pm%pm, he e*perienced 1 episode of vomiting and no relief from abdominal pain now located in the epigastric area, crampy in character, radiating to the back. $lient was hooked to 1 P9SS * - hours. =e also stated that blood was e*tracted from him for laboratory purposes. $lient was moved to the Surgery 0ard 0ard ?une 13, !1.
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#"ST &EDIC"$ ISTOR!:
$lient doesnCt have hypertension or diabetes. =e has no known allergies. =is last hospital visit was !!2 in (spital ng Makati, Malugay due to tonsillitis.
#ERSON"$ "ND SOCI"$ ISTOR!
Patient : was a habitual smoker since he was 1' years old. =e consumes '%1! sticks of cigarette a day. =e is also a fre7uent alcohol drinker and he consumes bottles of '!!ml of red horse beer to make himself sleep.
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%"&I$! %"&I$! ISTOR! O% I$$NESS I$ $NESS
8a 8 ather
Mother
4D6 allstones
Sister
Sister
Patient :
Sister
Sister
4D6 allstones
4D6 =P9
egend5 8emale
Male
>eceased 7|Page
IV. GORDON'S %UNCTION"$ E"$T #"TTERN #"TTERN O% #RIOR TO DURING E"$T OS#IT"$I("TION OS#IT"$I("TION #. =ealth Perception According to the According to the and =ealth patient, he is not fond patient, he now sees Management of going to the hospital the importance of Pattern whenever he feels health as an integral something wrong with part of life. =e is now his body. =e often conscious about his ignores it and Bust goes health especially when to the hospital if he can the nurses or the no longer tolerate the student nurses are feeling of alteration. administering his $lient doesnCt take his drugs. health seriously
"N"$!SIS "ND INTER#RET"TION ;eadiness for enhanced self%=ealth Management
IV. GORDON'S %UNCTION"$ E"$T #"TTERN #"TTERN O% #RIOR TO DURING "N"$!SIS "ND E"$T OS#IT"$I("TION OS#IT"$I("TION INTER#RET"TION #. =ealth Perception According to the According to the ;eadiness for and =ealth patient, he is not fond patient, he now sees enhanced self%=ealth Management of going to the hospital the importance of Management Pattern whenever he feels health as an integral something wrong with part of life. =e is now his body. =e often conscious about his ignores it and Bust goes health especially when to the hospital if he can the nurses or the no longer tolerate the student nurses are feeling of alteration. administering his $lient doesnCt take his drugs. health seriously because he believes that he needs to enBoy life. $lient is a habitual smoker. =e started smoking when he was 1' years old and consumes '%1! sticks a day. =e said that he is an occasional alcohol drinker but then he stated that everyday is an occasion for him. 0hen he drinks with friends, he said ETulog na silang lahat ako umiinom paF. )very (Page 425 of Nurse’s night he takes in Pocket Guide 12th bottles of red horse Edition by Doenges which is '!! ml per et., a! bottle.
##. 9utritional and Metabolic Pattern
According to the According to the #mbalanced 9utrition5 patient, he likes eating patient, he is not able ess than body foods high in fat such to eat anything since he re7uirements as liempo, and lechong is in 9P( from the day
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###. )limination Pattern
#H. Sleep I ;est Pattern
kawali. =e drinks glasses of water a day. =e has a good appetite and he eats more than 1 cup of rice especially when his viand is high in fats. =e drinks alcoholic beverages especially beer. =e also loves drinking soft drinks. =e seldom eats vegetables and fruits. According to the patient he normally has his bowel movement once daily in the morning. Stool characteristics were usually formed, dark brown in color, hard and dry. =e doesnCt feel constipation. =e never used la*atives. 0hen he knew that he didnCt have his bowel movement he usually feels uncomfortable and he will do management such as drinking water to pass out stool. =e urinates regularly and more fre7uent when he takes in alcoholic beverages. Grine characteristics were usually amber% yellow in color and donCt have any foul odor. According to the patient he usually
of his admission. =e acknowledges that he gets nutrition from the intravenous lines connected to him.
According to the patient, he still has his bowel movement once a day but now stool characteristic is fluid since he is in 9P(. $lient also has an indwelling foley catheter.
According to the patient, he doesnCt
(Page 5"4 of Nurse’s Pocket Guide 12th Edition by Doenges et., a!
Altered defecation due to diet
(Page 122# of $unda%entas of Nursing & th Edition by 'oier et., a! >isturbed sleep pattern
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H. Activity and )*ercise Pattern
H#. $ognitive I Perceptual Pattern
sleeps - hours or more sleep - hours during during the night. =e his hospital stay. =e doesnCt sleeps nor only sleeps about & takes an afternoon nap. hours or less due to the After sleeping he feels hospital activities and rested and energized. because of the pain. =e sometimes feels unrested and whenever he gets awaken by a (Page &&5 of Nurse’s health care provider. Pocket Guide 12th =e is e*periencing Edition by Doenges difficulty going back to et., a! sleep again because he is in hourly monitoring. According to the client, According to the client, Activity #ntolerance he doesnCt do e*ercise he cannot perform the daily. =e seldom plays activities of daily basketball. =e can living by himself. =e perform activities of often needs assistance daily living without and he cannot move any assistance. freely because his pain increases especially when he is moving. (Page ") of Nurse’s Pocket Guide 12th Edition by Doenges et., a! According to the client, According to the client, ;eadiness for he has normal vision he still has normal enhanced $omfort and hearing. =e senses. =is perception doesnCt e*perience about his life is still the difficulty in terms of same. The client stated reading, that Egusto ko ng comprehending, and gumalingF. communicating with others. =e can speak both in 8ilipino and )nglish. =e can easily interact with others. =e said that he has a good tolerance in pain that
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H##. $oping I Stress Tolerance I Perception+ Self $oncept Pattern
H###. Se*uality and ;eproductive Pattern
he doesnCt want to take pain medications. =e is (Page 1## of Nurse’s a college undergrad. Pocket Guide 12th $lient perceives Edition by Doenges everything as part of et., a! life and everything happens for a reason. According to the client, According to the >efensive coping family and friends are patient, he accepts his very important for him. condition and he said =e likes the company that he cannot stop his of his friends and vices when he gets specially his special discharged from the someone. 0henever he hospital (Page 25* of Nurse’s is stressed, he often Pocket Guide 12th drinks alcohol with his Edition by Doenges friends. et., a! According to the client According to the client #neffective se*uality he had his first coitus his feeling of se*uality pattern when he was 1/ years is a little bit affected old. =e has been because he has foley se*ually active and he catheter. uses condom for his (Page &4# of Nurse’s protection. =e only has Pocket Guide 12th 1 se*ual partner. Edition by Doenges et., a!
#:. ;ole ;elationship Pattern
According to the client he is not yet married but he has a girlfriend and they are together for years already. alread y. =e is currently unemployed though he used to work as a staff in the $ity =all.
:. Halue I
$lient is catholic. =e believes that od is always there for him and =e hears his
According to the client, ;eadiness for whenever a family enhanced ;elationship member or his girlfriend is in the hospital to take care of him, he feels loved and enBoys how they treat (Page "") of Nurse’s him. Pocket Guide 12th Edition by Doenges et., a! =is belief in od ;eadiness of spiritual becomes stronger and well%being he believes that od will never leave him. (Page 4+2 of NND
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prayers.
-ook!
V. REVIE) O% S!STE& S!STE&S
S!&#TO&S
#ntegumentary
EMedyo masakit ang tinurukan sa aking brasoF
;espiratory
EMinsan nahihirapan akong humingaF
astrointestinal
EMasakit ang aking tyan, sa tagiliran hanggang likod lalo na kapag gumagalaw akoF P I provokes I mobilization, Palliates % immobilization J % cramping ; I epigastric to back S I 1!+1! T I during mobilization and ambulation.
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VI. #!SIC"$ "SSESS&ENT "SSESS&ENT Date: ?une &, !1 Ti*e: -5!2 am General s+rve,: $lient was lying on the bed on a moderate high back rest, conscious conscious and coherent. 8acial features of the client were symmetrical with movements. Skin color is even , intact e*cept from his right forearm which has his peripheral parenteral nutrition and noticeable bruise his left forearm due to #H insertion.
=eight5 0eight5
13!.2cm 'kg 1-.K Gnderweight 1!+-! mm=g 3 $ 33bpm 1-cpm
Techni7ue #nspection
9ormal 8indings $olor5 Pinkish
Actual 8indings $olor5 8air skin
#nterpretation 9ormal
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Palpation
depending upon the skin tone
tone, even
Moisture5 Moist
4D6 moist
9ormal
Te*ture5 Smooth
4D6 smooth
9ormal
Turgor5 skin 7uickly returns to its original shape.
Skin 7uickly returns to original shape
9ormal
9ormal
=air
#nspection
Temperature5 warm )ven distribution
Symmetrical facial features
4D6warm )venly 9ormal distributed $olor5
4%6 area of deformity
4%6 area of deformity
9ormal
4%6 lesions Symmetrical
9ormal 9ormal
)ye lids5 4%6 lesion 4%6redness
4%6 lesions Symmetrical eyes )ye lids5 4%6 lesion 4%6redness
4%6discharges
4%6discharges
9ormal
$onBunctiva5 Pinkish in color $lear and Shiny
$onBunctiva5 Pale in color $lear and Shiny
AbnormalK indication of low ;<$ or anemia 9ormal
Sclerae5 white or buffy
Sclerae5 white
$olor5
=ead
)yes
#nspection
#nspection
9ormal 9ormal
9ormal Pupil5 P);;A
Pupil5 P);;A &mm
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)yelids5 4%6 Masses Palpation )ars
9ose
Mouth
#nspection
#nspection
#nspection
9ormal )yelids5 4%6 Masses
Symmetrical
Symmetrical
9ormal
4%6 discharges
4%6 discharges
9ormal
4%6 lesions
4%6 lesions
9ormal
4%6 nodules
4%6 nodules
9ormal
4%6 redness
4%6 redness
9ormal
Symmetrically aligned
Symmetrically aligned
9ormal
4%6 discharge
4%6 discharge
9ormal
4%6 flaring of nares ips $olor5 Pinkish
4%6 flaring of nares ips $olor5 >ark % Pale
9ormal
4D6Moist
4D6 dryness
Abnormal, may indicate dehydration due to 9P( diet
4%6 lesions
4%6 lesions
9ormal
4%6 lumps
4%6 lumps
9ormal
4%6 mass
4%6 mass
9ormal
Tongue5 $olor5 Pink I red
Tongue5 $olor5 Pink but
9ormal
AbnormalK dark color of lips indicate the long term of smokingK paleness is an indication of anemia due to blood loss
Palpation
#nspection
15 | P a g e
with whitish film
9eck
#nspection
4%6 lesions
4%6 lesions
9ormal
4%6 thrush
4%6 thrush
9ormal
Teeth5 $olor5 white
Teeth5 $olor5 white
9ormal
ums5
ums5
$olor5 Pink I ;ed
$olor5 Pink I ;ed
(ral Mucosa5 $olor5 Pinkish
(ral Mucosa5 AbnormalK $olor5 Pale% pink indication of low ;<$ or anemia
4D6 Moisture
4D6 Moisture
9ormal
4%6 lesions
4%6 lesions
9ormal
4%6 odor
4%6 odor
9ormal
Symmetrically aligned
Symmetrically aligned
9ormal
4%6 scars
4%6 scars
9ormal
4%6 mass
4%6 mass
9ormal
4%6 swelling
4%6 swelling
9ormal
4D6 symmetrical e*pansion with respiration
4D6 symmetrical e*pansion with respiration
9ormal
4%6 use of accessory muscle
4D6 use of accessory muscle
AbnormalK may indicate difficulty of breathing
9ormal
Palpation
;espiratory System $hest +Thora*+ ungs
#nspection
16 | P a g e
Palpation
Auscultation
=eart
Gpper )*tremities
#nspection
Auscultation #nspection
Palpation
4%6 retraction
4%6 retraction
9ormal
4D6 smooth
4D6 smooth
9ormal
4D6 warm
4D6 warm
9ormal
4D6 dry
4D6 dry
9ormal
4D6 normal breath sounds
4D6 normal breath sounds
9ormal
4%6 adventitious sound
4%6 adventitious sound
4%6 visible PM#
4%6 visible PM#
9ormal
4D6 regular rhythm
4D6 regular rhythm
9ormal
4%6 thrills
4%6 thrills
9ormal
4%6 murmurs Gpper )*tremities 4%6 pallor
4%6murmurs Gpper )*tremities 4%6 pallor
9ormal
4%6 rashes
4%6 rashes
9ormal
4%6 bruise
4D6 bruise on the left forearm
AbnormalK bruise is due to the 1st insertion of the #H cannula
4%6 contraptions
4D6 peripheral parenteral nutrition insertion
9ormal
4D6 tattoo on left deltoid area
9ormal
4%6 swelling
4%6 swelling
9ormal
4%6 edema
4%6 edema
9ormal
17 | P a g e
9ails
Abdomen
4D6 ;adial and
4D6 ;adial and
9ormal
$olor5 Pinkish
$olor5 Pale $olor5 Pale
AbnormalK may indicate anemia
$ontour5 slightly curved or flat
9ormal
Symmetrical
$ontour5 flat ong and has stains Symmetrical
4D6 globular shape
4D6 globular shape
9ormal
4%6 masses
4%6 masses
9ormal
4%6 lesions
4%6 lesions
9ormal
Auscultation
4D6 bowel sounds
4D6bowel sounds 9ormal
Percussion
4D6 dull sounds when organs are percussed
4D6 dull sounds
Palpation
4%6 masses
4%6 masses
#nspection
#nspection
4D6 bulge in the GJ to J
enitalia
#nspection
9ormal
9ormal
4%6 tenderness
4D6 tenderness
4%6 rigidity
4D6 rigid
4%6 pallor
4%6 pallor
AbnormalK may indicate organ enlargement AbnormalK may indicate organ enlargement AbnormalK may indicate organ enlargement 9ormal
4%6 edema
4%6 edema
9ormal
4%6 redness
4%6 redness
9ormal
4%6 swelling
4%6 swelling
9ormal
18 | P a g e
ower )*tremities
#nspection
4%6 pallor
4D6 indwelling foley catheter 4%6 pallor
9ormal
4%6 rashes
4%6 rashes
9ormal
4%6 bruise
4%6 bruise
9ormal
4%6 swelling
4%6 swelling
9ormal
4%6 edema
4%6 edema
9ormal
4D6 popliteal, posterior tibial, and dorsalis pedis pulses
4D6 popliteal, posterior tibial, and dorsalis pedis pulses
9ormal
(naysis and nter/retation 0eference Essentias of nato%y and Physioogy, " th edition 3eath ssess%ent ade ncrediby ncrediby isua! isua!
VII. COURSE IN TE )"RD D"TE - SI%T
DOCTOR'S ORDER
NURSE'S RES#ONSIBI$ITIES
#T. RE"CTION EV"$U"TION
19 | P a g e
?une &, !1
%Maintain on 9P(
%$ontinue HS and #L( monitoring 71
?une ', !1
%)*plain to the client the importance of the order.
%Patient understand the importance of the order.
%Maintain oral hygiene and give sips of water to prevent dryness of the lips and relieve thirst.
%Patient feels comfortable and thirst has been relieved.
%Monitor Hital Signs hourly and document % $lient was monitored and checked thoroughly
%$ontinue giving meds
%Administer medication with the right dosage, route and fre7uencyK and without adding inBury to the patient.
%;efer accordingly
%;efer if there are alterations
%9P(
%)*plain to the client the importance of the order.
%Patient understood the importance of the order.
%Maintain oral hygiene and give sips of water to prevent dryness of the lips and relieve thirst.
%Patient feels comfortable and thirst has been relieved
%PP9 1&!! kcal * &hrs
%Make sure that client %Patient received the receives the right proper nutrition solution without adding needed. inBury and assuring aseptic techni7ue.
20 | P a g e
%#H8 P9SS 1 hrs * 1>ts+min
%Monitored and regulated the #H fluid to prevent fluid deficit or overload.
%$lient did not e*perience fluid deficit or overload.
%$heck the #H site for signs of phlebitis or infiltration
%$lient did not have any signs of phlebitis or infiltration.
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VIII. DI"GNOSTICS
?une 12, !1 =)MAT(( C/*p/nent
N/r*al Val+es
Res+lts
Prothrombin Time
1!.&%1&.! seconds
11.1 seconds
"nal,sis an0 Interpretati/n 9ormal
" Activity
3%13"
11-.1"
9ormal
#9;
!.--%1.1
!./
9ormal
Activited PTT
!.&%&1.seconds
3. seconds
9ormal
?une 13, !1 C/*p/nent
N/r*al Val+es
Res+lts
Prothrombin Time
1!.&%1&.! seconds
11.1 seconds
"nal,sis an0 Interpretati/n 9ormal
" Activity
3%13"
11-.1"
9ormal
#9;
!.--%1.1
!./
9ormal
Activited PTT
!.&%&1.seconds
3. seconds
9ormal
?une , !1 C/*p/nent
=emoglobin =ematocrit 0<$ $ount
;<$ $ount
N/r*al Val+es
1&%1-g+ !.&!%!.'& &.11*1!N/
'.!%2.&
Res+lts
1. ! . 3 1'.2
&.1
"nal,sis an0 Interpretati/n 9ormal 9ormal AbnormalK #ncreasedK #ndication for infection
(Essentias of nato%y and Physioogy, " th edition /g. 64! AbnormalK >ecreased K may
22 | P a g e
indicate anemia (Essentias of nato%y and Physioogy, " th edition /g. 64! >ifferential $ount )osinophils 9eutrophils Segmenters
ymphocytes Monocytes
!.!%!.!&
!.!1
AbnormalK decreased
!.'!%!.3!
!.-
AbnormalK #ncreasedK #ndication for infection
!.!%!.&! !.!%!.!'
Platelet $ount
(Essentias of nato%y and Physioogy, " th edition /g. 64! AbnormalK decreased AbnormalK increase may indicate chronic infection
!.1! !.!3
1'!%&'!*1!N/+
(Essentias of nato%y and Physioogy, " th edition /g. 64! 9ormal
/
?une 13, !1 A<
?une 12, !1 $=)M#ST; S)$T#(9
Test Na*e
S.I Res+lts N/r*al Val+es
Unit
C/nventi/nal Res+lt N/r*al Unit Val+es
Amylase
2'&
G+
2'&
-%1!!
-%1!!
G+
"nal,sis an0 Interpretati/n
AbnormalK increasedK indication for
23 | P a g e
pancreatitis (Essentias of nato%y and Physioogy, " th edition, /g62!
.! 3/
.1%3.1 &'.!% 1!&.!
mmol+ umol+
-.&!.-/
2.!%!.! !.'1%1.1-
mg+d mg+d
9ormal 9ormal
1&1 ./ 1!&
12%1&' .'%'.1 /-%1!3
mmol+ mmol+ mmol+
1&1 ./ 1!&
12%1&' .'%'.1 /-%1!3
m)7+ m)7+ m)7+
9ormal 9ormal 9ormal
PA9) Sodium 49a6 Potassium 4O6 $hloride 4$l6
Test Na*e
Serum lutamic Pyruvate Transami Transaminase+ nase+ Alanine Transaminas Transaminasee 4S(T+AST6
N/r*al Val+es
!%&!
Res+lt
3/
Unit
G+
"nal,sis an0 Interpretati/n AbnormalK increased may indicate liver dysfunction due to drug and alcohol intake also gallbladder disease
(-ioche%istry 4th edition! Serum lutamic !%&1 (*aloacetic Transaminase+Aspartate transaminase 4SPT+AT6
'/&
G+
AbnormalK increased may indicate liver dysfunction due to drug and alcohol intake also gallbladder disease (-ioche%istry
24 | P a g e
4th edition!
Albumin actate >ehydrogenase 4>=6
'%' 1'%'
' -&
g+ G+
9ormal AbnormalK increased may indicate tissue damage.
?une 13, !1
Test 9ame
S.I ;esults 9ormal Halues
Gnit
CONVENTION"$ ;esults 9ormal Gnit Halues
&.3 -3
mmol+ umol+
1. !./-
Analysis and #nterpretatio n
G;)+
.1%3.1 &'.!%1!&.!
2.!%!.! !.'1%1.1-
mg+d mg+d
9ormal 9ormal
?une 1-, !1
Test 9ame
;esults
S.I 9ormal Halues
$reatinin 3e ?une , !1
&'.!%1!&.!
S.I
Gnit
CONVENTION"$ ;esults 9ormal Gnit Halues
umol+
!. - -
!.'1%1.1-
mg+d
Analysis and #nterpretatio n 9ormal
CONVENTION"$
25 | P a g e
Test 9ame
;esults
9ormal Halues
Gnit
;esults
9ormal Halues
Gnit
Amylase
-2
-%1!!
G+
-2
-%1!!
G+
Analysis and #nterpretatio n 9ormal
$omputed Tomography with #H $ontrast ;esult5 >ate5 ?une !, !1 eneralized enlargement of pancreas with inhomogenous demity. Peripancreatic contour is unsharp with thickening of adBacent retroperitoneal tissues and resenting lateral thickening. Pancreatic duct not dilated. I1. DI%%ERENTI"$ DI"GNOSIS SIGNS "ND S!&#TO&S Abdominal pain 4epigastric area that radiates to the J6 8ever Tenderness
Gallst/nes2 #ancreatitis
C3/lec,stitis
#erit/nitis
26 | P a g e
1. "nat/*, - #3,si/l/4,
The pancreas is located retroperitoneal, posterior to the stomach in the inferior part of the left upper 7uadrant. Parts5 ea0 I located near the midline of the body Tail I e*tends to the left and touches the spleen
The pancreas acts both endocrine and e*ocrine. The endocrine part of the pancreas consists of pancreatic islets 4#slets of angerhans6. The isletsC cells cells produce the hormones ins+lin and 4l+ca4/n , which enter the blood. These hormones are very important in controlling blood levels o f nutrients such as glucose and amino acids.
27 | P a g e
The e*ocrine part of the pancreas is responsible for producing digestive enzymes. The acini produce digestive enzymes, clusters of it are connected by small ducts which Boin to form larger ducts and form the pancreatic duct. The panc reatic duct Boins the common bile duct du ct and empties into the duodenum.
%+ncti/ns /f t3e #ancreas
The e*ocrine secretions of the pancreas include =$(%, which neutralize the acidic chyme that enters the small intestine from the stomach. The increased p= resulting from the secretion of =$(5stops pepsin digestion but provides the proper environment for the function of pancreatic enzymes. Pancreatic enzymes are also present in the e*ocrine secretions and are important for the digestion of all maBor classes of food. 0ithout the enzymes produced by the pancreas, lipids, proteins, and carbohydrates are not ade7uately digested. The maBor proteolytic 4protein%digesting6 enzymes are trypsin, chymotrypsin, and carbo*ypeptidase. These enzymes continue the p rotein digestion that started in the stomach, and pancreatic amylase continues the polysaccharide digestion that began in the oral cavity. The pancreatic enzymes also include a group of lipid%digesting enzymes called pancreatic lipases. 9ucleases are pancreatic enzymes that reduce >9A and ribonucleic acid to their component nucleotides. The e*ocrine secretory activity of the pancreas is controlled by both hormonal and neural mechanisms. Secretin initiates the release of a watery pancreatic solution that contains large amount of =$( %. The primary stimulus for secretin release is the presence of acidic chime in the duodenum. $holecystokinin stimulates the pancreas to release an enzyme%rich solution. The primary stimulus for cholecystokinin release release is the presence of fatty acids and amino acids in the duodenum, and the enzymes secreted by the pancreas digest fatty acids and amino acids. Parasympathetic stimulation through the vagus nerves also stimulates the secretion of pancreatic Buices rich in pancreatic enzymes. Sympathetic action potential inhibits pancreatic secretions.
The gallbladder is a small sac found Bust under the liver. #t stores bile made by the liver.
28 | P a g e
0eference Essentias Essentias of nato%y and Physioogy by 7eeey, 7i8th Edition, /.4"&64"#
29 | P a g e
1I.#"TO#!SIO$OG!
Modifable:
Non-Modifable
'ig% #a& die& ($o)ing 'ig% al*o%ol in&a)e
Age: 31 years old !" #a$ily %is&ory o#
ier se*re&es bile &%a& is %ig% in *%oles&erol
./*essie bile sal&s and a&er are reabsorbed reabsorbed in &%e gall bladder dring bile *on*en&ra&ion *on*en&ra&ion May en&er &%e *o$$on bile d*&
,ile be*o$es less solble
elllar inry *ased by in&o/i*a&ion o# a*inar *ell #ro$
elllar &ra*)ing and in*rease an*rea&i* se*re&ions
sion o# lysoo$al and ynogens
30 | P a g e
alls&one or$a&ion
islodge in &%e a$lla o# a&er
=e</ o# bile #ro$ *o$$on bile d*& &o
.arly a*&ia&ion o# &rysinogen &o &rysin
Pre$a&re a*&ia&ion o# o&%er an*rea&i*
./&rsion o# se*re&ory esi*les #ro$ basola&eral $e$brane &o in&ers&i&i$
>bs&r*&ion
Abdo$inal &enderness
%e$oa&&ra*&ion &o in
? rigidi&y
eer
;n
es&r*&ion o# d*&al &isse and an*rea&i* an*rea&i* *ells
.arly a*&ia&ion o# &rysinogen &o &rysin
alls&one or$a&ion
islodge in &%e a$lla o# a&er
Pre$a&re a*&ia&ion o# o&%er an*rea&i*
./&rsion o# se*re&ory esi*les #ro$ basola&eral $e$brane &o in&ers&i&i$
=e</ o# bile #ro$ *o$$on bile d*& &o
>bs&r*&ion %e$oa&&ra*&ion &o in
Abdo$inal &enderness
es&r*&ion o# d*&al &isse and an*rea&i* an*rea&i* *ells
? rigidi&y
eer
;n
@o$i&ing
Dr+4 Na*e
Pain in &%e ? &%a& radia&es &o Classificati/n D/sa4e R/+te %re6+enc, Abdo$inal bloa&ing
Pan*rea&i&is "cti/n
N+rsin4 C/nsi0erati/ns
Eval+ati/n
31 | P a g e
Generic Na*e:
#3ar*ac/l/4ic:
Tramadol hydrochloride
(piod antagonist
Bran0 Na*e:
Glmam
'!mg+ T#H+ 7-
"cti/n:
Assess clientCs pain.
$heck if client is allergic to the drug.
T3erape+tic:
Analgesic
#nhibits reuptake of 9orepinephrin 9orepinephrin e and serotonin In0icati/n:
Pain
;eassess clientCs level of pain at least ! mins. After administration. administration. Assess #H site for signs of phlebitis and infiltration. Monitor heart rate and respiratory status withhold dose if clientCs respirations are slow or rate is below 1bpm. Monitor bowel and bladder function. function.
Pain e*perience of client is decreased and controlled.
There is no adverse reaction e*perienced.
$lient and family state understanding about the drug therapy.
Generic Na*e:
#3ar*ac/l/4ic:
Tramadol hydrochloride
(piod antagonist
Bran0 Na*e:
Glmam
'!mg+ T#H+ 7-
"cti/n:
Assess clientCs pain.
$heck if client is allergic to the drug.
T3erape+tic:
#nhibits reuptake of 9orepinephrin 9orepinephrin e and serotonin
Analgesic
In0icati/n:
Pain
;eassess clientCs level of pain at least ! mins. After administration. administration. Assess #H site for signs of phlebitis and infiltration. Monitor heart rate and respiratory status withhold dose if clientCs respirations are slow or rate is below 1bpm.
Pain e*perience of client is decreased and controlled.
There is no adverse reaction e*perienced.
$lient and family state understanding about the drug therapy.
Monitor bowel and bladder function. function.
Dr+4 Na*e
Classificati/n
D/sa4e R/+te %re6+enc,
"cti/n In0icati/n
N+rsin4 C/ C /nsi0erati/ns
Eval+ati/n
32 | P a g e
Generic Na*e:
#3ar*ac/l/4ic:
Pantoprazole sodium
Proton pump inhibitor
Bran0 Na*e:
Protoni*, protoni* #H
T3erape+tic:
astrointestinal astrointestinal agent, Antiulcer
&! mg+ T#H+ (>
"cti/n:
;n%ibi&s &%e %ydrogen o&assi$adenosine&r i%os%a&as e in &%e gas&ri* arie&al *ells
Assess clientCs condition before the drug therapy. Assess the site for infiltration ad phlebitis. 8lush #.H. line with > '0, normal saline solution, or lactated ;ingerCs inBection before and after giving drug. )*plain the drug therapy
;n%ibi&s fnal to the client and significant s&e in other gas&ri* a*id rod*&ion
Prevents = from entering the stomach
>rug was administered to the patient safely. $lient state understanding about the dug therapy.
Generic Na*e:
#3ar*ac/l/4ic:
Pantoprazole sodium
Proton pump inhibitor
Bran0 Na*e:
Protoni*, protoni* #H
&! mg+ T#H+ (>
"cti/n:
;n%ibi&s &%e %ydrogen o&assi$adenosine&r i%os%a&as e in &%e gas&ri* arie&al *ells
T3erape+tic:
astrointestinal astrointestinal agent, Antiulcer
Assess clientCs condition before the drug therapy. Assess the site for infiltration ad phlebitis.
>rug was administered to the patient safely. $lient state understanding about the dug therapy.
8lush #.H. line with > '0, normal saline solution, or lactated ;ingerCs inBection before and after giving drug. )*plain the drug therapy
;n%ibi&s fnal to the client and significant s&e in other gas&ri* a*id rod*&ion
Prevents = from entering the stomach and additional =$l from forming In0icati/n:
);> Dr+4 Na*e
Classificati/n
D/sa4e R/+te
"cti/n
N+rsin4 C/nsi0erati/ns
Eval+ati/n
33 | P a g e
%re6+enc, Generic Na*e:
#3ar*ac/l/4ic:
Piperacillin Tazobactam
Penicillin, beta% lactamase inhibitor
Bran0 Na*e:
Tazocin, Qosyn
T3erape+tic:
Anti%infective
&.'g+ #H+ 7- A9ST
"cti/n:
Piperacillin
Assess clientCs condition before the drug therapy.
#nhibits bacterial cell cell wall synthesis
Perform skin testing to check if client has hypersensitivity hypersensitivity with the drug.
$ell death
Assess #H site for signs of phlebitis and infiltration.
In0icati/n:
#nfection
Monitor for signs and symptoms of superinfection.
$lientCs infection is controlled. $lient did not e*perience any adverse effects of drug.
%re6+enc,
&.'g+ #H+ 7- A9ST
Generic Na*e:
#3ar*ac/l/4ic:
Piperacillin Tazobactam
Penicillin, beta% lactamase inhibitor
Piperacillin
Bran0 Na*e:
Tazocin, Qosyn
"cti/n:
T3erape+tic:
Anti%infective
Assess clientCs condition before the drug therapy.
#nhibits bacterial cell cell wall synthesis
Perform skin testing to check if client has hypersensitivity hypersensitivity with the drug.
$ell death
Assess #H site for signs of phlebitis and infiltration.
In0icati/n:
#nfection
$lientCs infection is controlled. $lient did not e*perience any adverse effects of drug.
Monitor for signs and symptoms of superinfection.
CUES
NURSING
IN%ERENCE
GO"$
NURSING
R"TION"$E
EV"$UT"TION
34 | P a g e
DI"GNOSIS
INTERVENTIONS
S+bjective 7 EMasakit ang tyan ko sa may tagiliran hanggang sa likod.F As verbalized by the patient. P I provokes I mobilization, Palliates % immobilization J % cramping ; I epigastric to back S I 1!+1! T I during mobilization and
Pain related to current disease condition
(rgan inflammation 4pancreatitis6
Abdominal rigidity and tenderness
S3/rt5ter* G/al:
In0epen0ent:
)ncourage the After ! mins of client to verbalize nursing about the pain. intervention, clientCs pain e*perience will be lessening lessening Promote comfort from the scale of measures and deep 1! to 2. breathing e*ercise. e*ercise. $/n4 ter* G/al:
Pain After days of nursing intervention, client will
)ncourage the client to do diversionary activities such as listening to music or
Promotes cooperation and it can help in the thorough assessment.
After ! mins of nursing intervention, clientCs pain was relieved from the pain scale of of 1! to 3.
These activities calm the patient and making him+her feel pain relief.
oal partially met.
To divert clientCs attention away from pain thus making him+her lessen the
After days of nursing intervention, client knows how to manage his
DI"GNOSIS
INTERVENTIONS
S+bjective 7 EMasakit ang tyan ko sa may tagiliran hanggang sa likod.F As verbalized by the patient. P I provokes I mobilization, Palliates % immobilization J % cramping ; I epigastric to back S I 1!+1! T I during mobilization and ambulation. Objective:
Pain related to current disease condition
(rgan inflammation 4pancreatitis6
Abdominal rigidity and tenderness
S3/rt5ter* G/al:
In0epen0ent:
)ncourage the After ! mins of client to verbalize nursing about the pain. intervention, clientCs pain e*perience will be lessening lessening Promote comfort from the scale of measures and deep 1! to 2. breathing e*ercise. e*ercise. $/n4 ter* G/al:
Pain After days of nursing intervention, client will eventually know how to manage his pain.
)ncourage the client to do diversionary activities such as listening to music or reading books or newspaper.
Promotes cooperation and it can help in the thorough assessment. These activities calm the patient and making him+her feel pain relief.
After ! mins of nursing intervention, clientCs pain was relieved from the pain scale of of 1! to 3. oal partially met.
To divert After days of clientCs attention nursing away from pain intervention, thus making client knows how him+her lessen the to manage his cognition about pain. pain.
Depen0ent:
4D6 facial grimace 4D6 guarding behavior
Administer pain medications such as tramadol as ordered 35 | P a g e
4D6 rigid GJ to J 4D6 abdominal tenderness 4GJ to J6
by the attending attending physician. physician.
4D6 rigid GJ to J 4D6 abdominal tenderness 4GJ to J6
by the attending attending physician. physician.
36 | P a g e
CUES
NURSING DI"GNOSIS
SubBective5 E9ahihirapan akong huminga lalo na kapag nagsasalitaF
#neffective breathing pattern related related to pain
(bBective5 4D6 use of accessory muscle when breathing
IN%ERENCE
>iaphragmatic breathing
Affects the site of pain
#ncreases pain specially when talking
;;@ cpm $lient breathes more fre7uent
GO"$
After ! minutes of nursing intervention, clientCs breathing will will be improved improved and ;; will be normalized
NURSING INTERVENTION
#ndependent5 %Maintain or put client on high back rest or in fowlerCs position.
R"T R"TION" ION"$E $E
% To promote lung e*pansion % To assist client in taking control of the situation.
%)ncourage client to take slower and deeper respirations. %Teach client to learn breathing e*ercise. e*ercise. %Assist client in the use of rela*ation techni7ues.
%To check if client is having respiratory acidosis or alkalosis.
EV" EV"$U" $U"TION ION
After ! mins of nursing interventions, client e*perienced e*perienced relief and ;; was normalized from to 1-.
CUES
NURSING DI"GNOSIS
SubBective5 E9ahihirapan akong huminga lalo na kapag nagsasalitaF
#neffective breathing pattern related related to pain
IN%ERENCE
>iaphragmatic breathing
Affects the site of pain
(bBective5 4D6 use of accessory muscle when breathing
GO"$
After ! minutes of nursing intervention, clientCs breathing will will be improved improved and ;; will be normalized
#ncreases pain specially when talking
NURSING INTERVENTION
#ndependent5 %Maintain or put client on high back rest or in fowlerCs position.
$lient breathes more fre7uent
% To promote lung e*pansion % To assist client in taking control of the situation.
%)ncourage client to take slower and deeper respirations. %Teach client to learn breathing e*ercise. e*ercise.
;;@ cpm
R"T R"TION" ION"$E $E
%Assist client in the use of rela*ation techni7ues.
EV" EV"$U" $U"TION ION
After ! mins of nursing interventions, client e*perienced e*perienced relief and ;; was normalized from to 1-.
%To check if client is having respiratory acidosis or alkalosis.
#ncreased ;; $ollaborative5 Monitor A< #neffective breathing pattern
37 | P a g e
CUES
NURSING DI"GNOSIS
IN%ERENCE
GO"$
NURSING INTERVENTION
R"TION ION"$E "$E
EV" EV"$U" $U"TION
CUES
NURSING DI"GNOSIS
IN%ERENCE
GO"$
NURSING INTERVENTION
R"TION ION"$E "$E
EV" EV"$U" $U"TION
38 | P a g e
SubBective5 EAng hirap gumalaw dahil sumasakit ang tagiliran ko F (bBective5 4D6 uarding behavior 4D6 8acial grimace imited range of motion >ifficulty turning 4D6 J cramping pain that radiates to
Activity intolerance r+t pain or discomfort
Pain >ifficulty in moving
>ecreased movement
Activity intolerance
After ! minutes #ndependent5 of therapeutic % #nstruct use of % To promote communication, side rails overhead safety to the the client will be trapeze roller pads client. able to verbalize for position understanding changes or transfer. % To prevent and gain % Support affected ulceration and or cooperation of body parts parts using bed sores. his situation. pillow+rollsK air mattress especially the bony prominences. prominences. % Provide for safety measure and as indicated by individual situation including, environmental management+ fall prevention. prevention.
The patient verbalized understanding of his situation or risk factors and individual treatment regimen and safety measures.
SubBective5 EAng hirap gumalaw dahil sumasakit ang tagiliran ko F (bBective5 4D6 uarding behavior 4D6 8acial grimace imited range of motion >ifficulty turning 4D6 J cramping pain that radiates to the back with a pain scale of 1! 1! during mobilization and ambulation.
Activity intolerance r+t pain or discomfort
Pain >ifficulty in moving
>ecreased movement
Activity intolerance
After ! minutes #ndependent5 of therapeutic % #nstruct use of % To promote communication, side rails overhead safety to the the client will be trapeze roller pads client. able to verbalize for position understanding changes or transfer. % To prevent and gain % Support affected ulceration and or cooperation of body parts parts using bed sores. his situation. pillow+rollsK air mattress especially the bony prominences. prominences. % Provide for safety measure and as indicated by individual situation including, environmental management+ fall prevention. prevention. %To enhance ability to %9ote clientCs in report of weakness, participate in activities. fatigue pain
The patient verbalized understanding of his situation or risk factors and individual treatment regimen and safety measures.
%Promote comfort measures and provide for for relief of pain 39 | P a g e
40 | P a g e
CUES
NURSING DI"GNOSIS
SubBective5 >isturbed E>i na ako sleeping makatulog ng pattern related related maayos dahil sa to pain sakit na nararamdaman koF (bBective5 4D6 periorbital puffiness 4D6 restlessness
IN%ERENCE
$urrent medical condition
Pain
>isturbance to sleep
;estlessness
GO"$
NURSING INTERVENTION
Short term5 #ndependent5 After 1' mins % Advice client to of therapeutic do his routine communication before sleeping sleeping client will % Advice client to verbalize of do rela*ation understanding techni7ues on how to %>etermine client improve and significant sleeping pattern otherCs e*pectations of ong term goal5 ade7uate sleep. After days of %Promote comfort nursing measures such as intervention, therapeutic touch, client will change of position report of in bed. enhanced >ependent5
R"TION"$E
%To promote better way of getting to sleep. %To help client fall asleep faster. %Provide opportunity to address misconceptions or unrealistic e*pectations.
%To provide nonpharmacologica
EV"$U"TION
After 1' mins of therapeutic communication client verbalized understanding on how to improve sleeping pattern.
CUES
NURSING DI"GNOSIS
SubBective5 >isturbed E>i na ako sleeping makatulog ng pattern related related maayos dahil sa to pain sakit na nararamdaman koF (bBective5 4D6 periorbital puffiness 4D6 restlessness
IN%ERENCE
$urrent medical condition
Pain
>isturbance to sleep
;estlessness
GO"$
NURSING INTERVENTION
Short term5 #ndependent5 After 1' mins % Advice client to of therapeutic do his routine communication before sleeping sleeping client will % Advice client to verbalize of do rela*ation understanding techni7ues on how to %>etermine client improve and significant sleeping pattern otherCs e*pectations of ong term goal5 ade7uate sleep. After days of %Promote comfort nursing measures such as intervention, therapeutic touch, client will change of position report of in bed. enhanced >ependent5 sleeping pattern %Administer pain medications as ordered.
R"TION"$E
%To promote better way of getting to sleep. %To help client fall asleep faster. %Provide opportunity to address misconceptions or unrealistic e*pectations.
%To provide nonpharmacologica l pain management and promote sleep.
EV"$U"TION
After 1' mins of therapeutic communication client verbalized understanding on how to improve sleeping pattern.
After days of nursing intervention, client stated of enhanced sleeping pattern
%To lessen or eliminate feeling of 41 | P a g e
pain and achieve achieve sedation effect.
pain and achieve achieve sedation effect.
CUES
NURSING DI"GNOSIS
IN%ERENCE
GO"$
NURSING INTERVENTIONS
R"T R"TION" ION"$E $E
EV" EV"$U" $U"TION ION
42 | P a g e
(bBective5 4D6 8oley $atheter 4D6 #H 8luid
;isk for infection r+t inade7uate primary defenses
>isease process
owered primary defences
4D6 Peripheral Parental 9utrition
After 1 hr of nursing interventions the client verbalize understanding of individual causative or risk factor.
% Monitor clientCs visitors for respiratory illnesses
% To limit e*posures, thus reducing cross contamination
% Administer medication regimen.
% To determine effectiveness of therapy or presence of side side effects
% ;ecommend routine or preoperative preoperative body shower or scrubs when indicated
%To reduce bacterial colonization
;isk for infection
After - hrs. of nursing intervention the client was able to verbalize understanding of individual causative or risk factor.
(bBective5 4D6 8oley $atheter 4D6 #H 8luid
;isk for infection r+t inade7uate primary defenses
>isease process
owered primary defences
4D6 Peripheral Parental 9utrition
After 1 hr of nursing interventions the client verbalize understanding of individual causative or risk factor.
% Monitor clientCs visitors for respiratory illnesses
% To limit e*posures, thus reducing cross contamination
% Administer medication regimen.
% To determine effectiveness of therapy or presence of side side effects
% ;ecommend routine or preoperative preoperative body shower or scrubs when indicated
%To reduce bacterial colonization
%Stress proper hand hygiene to health care provide and client.
%A first line defense against nosocomial infection.
%Provide regular perineal care care
%To reduce risk of ascending GT#
;isk for infection
After - hrs. of nursing intervention the client was able to verbalize understanding of individual causative or risk factor.
43 | P a g e
%Maintain aseptic techni7ue when giving #H meds and PP9
%To prevent contamination of the #H line.
%Maintain aseptic techni7ue when giving #H meds and PP9
%To prevent contamination of the #H line.
44 | P a g e
1IV.DISC"RGE #$"N:
&e0icines o
#nstructed the client and his significant others to co ntinue the medications as ordered by the physician.
o
Stress the importance of compliance to prescribed medication.
E8ercise: o
Advised the client to do light e*ercises. Stressed to the client the importance of rest.
1IV.DISC"RGE #$"N:
&e0icines o
#nstructed the client and his significant others to co ntinue the medications as ordered by the physician.
o
Stress the importance of compliance to prescribed medication.
E8ercise: o
Advised the client to do light e*ercises.
o
Stressed to the client the importance of rest.
o
)ncourage patient rest and deep breathing e*ercise
o
)ncourage patient to resume daily activities which aides in achieving and maintaining an optimum level of wellness and heath.
Treat*ent o
o
)ncourage the patient to seek nearest hospital as soon as possible if symptoms are observed and canCt be relieved by the medications. Advise the patient to comply prescribed medica tions
ealt3 Te Teac3in4 ac3in4 o
#nstructed the client on the time of the administration of the drug.
o
#nstructed the client about the drugCs side effects or adverse effects such as5 diarrhea, increased heart rate etc.
o
#nstructed the client to take the prescribed medicines.
45 | P a g e
o
Teach the client or significant to others on how to clean the operative site to prevent infection.
o
Teach Teach the patient or significant to others to wash hands before changing and after disposing of dressing.
o
Teach Teach the patient when to notify the physician of complications 4infection , an unhealed wound and an*iety and to report any sudden chest pain or difficulty of breathing 6
o
)*plore the patientCs drinking pattern.
O+t 9 #atient o
#nstructed the client to have follow%up check up to monitor her condition.
Diet o
)ncourage the client to eat foods less in fat and sodium
o
)ncourage the client to increase oral fluid intake and restrain from drinking alcoholic beverages.
=eight I 'C2 0eight I ' kg
Desire0 B/0, )ei43t DB);
><0 @ '*1 @ 2! D 2 @ 22 * .'& @ 123.2& I 1!! @ 23.2& I 2.32 @ 2!.-- @ 21 ><0 @ 2!.-- kg
T/tal Ener4, Re6+ire*ent TER < DB) =ei43t /f patient 8 activit, T); @ 2! * ' @ 1!! ?.@55555555 NOR&"$ $=(@ 1!! kcal * .2! @ 12! kcalR &
46 | P a g e
@ A?@4ra*s $=(9@ 1!!kcal * .1' @ 1' kcal R & @ .@ 4ra*s 8at @ 1!!kcal * .' @ ''kcal R / @ @.AA 4ra*s
SAMP) A$TGA M)A PA95 inner5 1 cup of rice 1 cup stir I fried vegetables 1 slice of apple
Spirit+al o
)ncourage the client to keep, praying and visiting their church.
47 | P a g e
1V. EV"$U"TION
#n this case study, we were able to assess the client properly and gain b aseline data by building rapport with the client and his significant others. 0e have formulated the correct diagnosis based from the thorough assessment done to the client. And based from it we were able plan the actions that are to be done through the problem which has been addressed and found through the assessment. 0e have been able to give the appropriate nursing interventions with efficiency and observance to the 11 core competencies and able to achieve the e*pected outcomes and gain a positive response from the client with the interventions done.
48 | P a g e
