VELEZ COLLEGE – COLLEGE OF NURSING

F. Ramos St., Cebu City

A Case Study on Patient T.J.E, 20 years old, Male, with Fever, Thrombocytopenia, and Abdominal Pain

Submitted by:
Cabatingan, Nicole Marie S.
Heruela, Elisha A.
Ortega, Maria Isabel R.
Postanes, Jerkin Razhed C.
Villacastin, Khizlyn C.

Submitted to:
TONI ANGELIE P. CAPRECHO, R.N., M.N.
KEESHIA ROSE A. GILLIANA, R.N.
KACHIRI S. MERCADAL, R.N., M.N
 INTRODUCTION
Fever

Definition

Fever is an elevation in body temperature or a high body temperature. Technically, any body temperature above the normal oral measurement of 98.6 degrees Fahrenheit (37
Celsius) or the normal rectal temperature of 99 F (37.2 C) is considered elevated. However, these are averages, and one's normal body temperature may be 1 F (0.6 C) or more
above or below the average of 98.6 F. Body temperature can also vary up to 1 F (0.6 C) throughout the day.
Fever is not considered medically significant until body temperature is above 100.4 F (38 C), which is the temperature considered to be a fever by medical professionals.
Anything above normal but below 100.4 F (38 C) is considered a low-grade fever. Fever serves as one of the body's natural infection-fighting defenses against bacteria and
viruses that cannot live at a higher temperatures. For that reason, low-grade fevers should normally go untreated, unless accompanied by troubling symptoms or signs. It is also
one of the ways our immune system attempts to combat an infection.
Cause

Fever or elevated body temperature might be caused by:

· A virus

· A bacterial infection

· Heat exhaustion

· Certain inflammatory conditions such as rheumatoid arthritis — inflammation of the lining of your joints (synovium)

· A malignant tumor

· Some medications, such as antibiotics and drugs used to treat high blood pressure or seizures

· Some immunizations, such as the diphtheria, tetanus and acellular pertussis (DTaP) or pneumococcal vaccine

Sometimes the cause of a fever can't be identified. If you have a fever for more than three weeks and your doctor can’t find the cause after extensive evaluation, the diagnosis
may be fever of unknown origin.
Types

Fevers can be classified according to how long they last, whether they come and go, and how high they are.

Severity

A fever can be:

· low grade, from 100.5–102.1°F or 38.1–39°C

· moderate, from 102.2–104.0°F or 39.1–40°C

· high, from 104.1–106.0°F to or 40.1-41.1°C

· hyperpyrexia, above 106.0°F or 41.1°C

The height of the temperature may help indicate what type of problem is causing it.

Length of time

A fever can be:

· acute if it lasts less than 7 days

· sub-acute, if it lasts up to 14 days

· chronic or persistent, if it persists for over 14 days

Fevers that exist for days or weeks with no explanation are called fevers of undetermined origin (FUO).

In children
Children with a high temperature may develop a febrile seizure, also known as a febrile fit or febrile convulsion; most of these are not serious and can be the result of an ear
infection, gastroenteritis, or a respiratory virus, or a cold. Less commonly, febrile seizures may be caused by something more serious, such meningitis, a kidney infection, or
pneumonia.

Febrile seizures most commonly occur in children aged 6 months to 6 years and affect boys more often than girls.

Seizures occur because the body temperature rises too fast, rather than because it has been sustained for a long time.

There are two types of febrile seizures:

1) Simple febrile seizure - the seizure lasts no longer than 15 minutes (in most cases less than 5 minutes) and does not occur again during a 24-hour period.

It typically involves the whole body — a generalized tonic-clonic seizure. Most febrile seizures are of this type. Symptoms — the body becomes stiff and the arms and legs start to
twitch, the patient loses consciousness (but the eyes stay open).

There may be irregular breathing, and the child might urinate, defecate, or both. There could also be vomiting.

2) Complex febrile seizure - the seizure lasts longer, comes back more often, and tends not to affect the whole body, but rather only part of the body.

This type of seizure is a cause for more concern than simple febrile seizures.

In most cases, a child with a seizure should be seen by a healthcare provider. Temperature may be controlled with acetaminophen (paracetamol) or sponging. If necessary, an
anticonvulsant, such as sodium valproate or clonazepam may be prescribed.
Risk Factors

· Infections are commonest cause of fever. Some of the risk factors for fever include:
· Age: Children are at greater risk of contracting any disease and developing fever. Children in preschool and elementary school can experience six to 12 colds per year
often associated with fever and adolescents and adults usually have two to four  colds per year which may or may not be associated with fever.
· Contact: Being in close contact with a person who is sick increases your risk of catching the infection and fever.
· Immunity: People with weak immune system (weakened by medications such as corticosteroids or diseases such as HIV/AIDS) are at increased risk of developing any
infection and fever.
· Food and water: Having contaminated food or water increases the risk of infection and fever.

Signs and Symptoms

A fever can cause a person to feel very uncomfortable. Signs and symptoms of a fever include the following:
· Temperature greater than 100.4 F (38 C) in adults and children
· Shivering, shaking, and chills
· Aching muscles and joints or other body aches
· Headache
· Intermittent sweats or excessive sweating
· Rapid heart rate and/or palpitations
· Skin flushing or hot skin
· Feeling faint, dizzy, or lightheaded
· Eye pain or sore eyes
· Weakness
· Loss of appetite
· Fussiness (in children and toddlers)
· Also, important to note in children are symptoms that can accompany an infection, including sore throat, cough, earache, vomiting, and diarrhea
 · With very high temperatures (>104 F/40 C), convulsions, hallucinations, or confusion is possible. Always seek medical attention for a high fever or if these symptoms
occur.
Diagnosis
To evaluate a fever, your doctor may:
· Ask questions about your symptoms and medical history

· Perform a physical exam

· Order tests, such as blood tests or a chest X-ray, as needed, based on your medical history and physical exam

Because a fever can indicate a serious illness in a young infant, especially one 28 days or younger, your baby might be admitted to the hospital for testing and treatment.

Treatment

For a low-grade fever, your doctor may not recommend treatment to lower your body temperature. These minor fevers may even be helpful in reducing the number of microbes
causing your illness.

Over-the-counter medications

In the case of a high fever, or a low fever that's causing discomfort, your doctor may recommend an over-the-counter medication, such as acetaminophen (Tylenol, others) or
ibuprofen (Advil, Motrin IB, others).

Use these medications according to the label instructions or as recommended by your doctor. Be careful to avoid taking too much. High doses or long-term use of acetaminophen
or ibuprofen may cause liver or kidney damage, and acute overdoses can be fatal. If your child's fever remains high after a dose, don't give more medication; call your doctor
instead.

Don't give aspirin to children, because it may trigger a rare, but potentially fatal, disorder known as Reye's syndrome.

Prescription medications
Depending on the cause of your fever, your doctor may prescribe an antibiotic, especially if he or she suspects a bacterial infection, such as pneumonia or strep throat.

Antibiotics don't treat viral infections, but there are a few antiviral drugs used to treat certain viral infections. However, the best treatment for most minor illnesses caused by
viruses is often rest and plenty of fluids.

Treatment of infants

For infants, especially those younger than 28 days, your baby might need to be admitted to the hospital for testing and treatment. In babies this young, a fever could indicate a
serious infection that requires intravenous (IV) medications and round-the-clock monitoring.

Lifestyle and home remedies

You can try several things to make yourself or your child more comfortable during a fever:

· Drink plenty of fluids. Fever can cause fluid loss and dehydration, so drink water, juices or broth. For a child under age 1, use an oral rehydration solution such as
Pedialyte. These solutions contain water and salts proportioned to replenish fluids and electrolytes. Pedialyte ice pops also are available.

· Rest. You need rest to recover, and activity can raise your body temperature.

· Stay cool. Dress in light clothing, keep the room temperature cool and sleep with only a sheet or light blanket.

THROMBOCYTOPENIA

Definition
Thrombocytopenia a lower than normal number of platelets (less than 150,000 platelets per microliter) in the blood. Normal platelet counts range from 150,000 to 400,000 per
microliter in the blood. Platelets (thrombocytes) are colorless blood cells that help blood clot. Platelets stop bleeding by clumping and forming plugs in blood vessel injuries.

Cause
Trapped Platelets - The spleen is a small organ about the size of your fist located just below your rib cage on the left side of your abdomen. Normally, your spleen works to fight
infection and filter unwanted material from your blood. An enlarged spleen — which can be caused by several disorders — may harbor too many platelets, causing a decrease in
the number of platelets in circulation.

Decreased production of platelets - Platelets are produced in your bone marrow. If production is low, you may develop thrombocytopenia. Factors that can decrease platelet
production include:

· Leukemia

· Some types of anemia

· Viral infections, such as hepatitis C or HIV

· Chemotherapy drugs

· Heavy alcohol consumption

Increased breakdown of platelets - Some conditions can cause your body to use up or destroy platelets more rapidly than they're produced. This leads to a shortage of
platelets in your bloodstream. Examples of such conditions include:

· Pregnancy - Thrombocytopenia caused by pregnancy is usually mild and improves soon after childbirth.

· Immune thrombocytopenia - This type is caused by autoimmune diseases, such as lupus and rheumatoid arthritis. The body's immune system mistakenly attacks and
destroys platelets. If the exact cause of this condition isn't known, it's called idiopathic thrombocytopenic purpura. This type more often affects children.

· Bacteria in the blood - Severe bacterial infections involving the blood (bacteremia) may lead to destruction of platelets.

· Thrombotic thrombocytopenic purpura - This is a rare condition that occurs when small blood clots suddenly form throughout your body, using up large numbers of
platelets.

· Hemolytic uremic syndrome - This rare disorder causes a sharp drop in platelets, destruction of red blood cells and impairment of kidney function. Sometimes it can occur
in association with a bacterial Escherichia coli (E. coli) infection, such as may be acquired from eating raw or undercooked meat.

· Medications - Certain medications can reduce the number of platelets in your blood. Sometimes a drug confuses the immune system and causes it to destroy platelets.
Examples include heparin, quinine, sulfa-containing antibiotics and anticonvulsants.
Risk Factors

· Having certain types of cancer, aplastic anemia, or autoimmune diseases

· Being exposed to certain toxic chemicals such as pesticides and arsenic

· Having a reaction to certain medicines such as penicillin, furosemide, quinine

· Having certain viruses such as  Epstein-Barr virus, cytomegalovirus

· Having certain genetic conditions such as inherited thrombocytopenia

· People at highest risk also include heavy alcohol drinkers and pregnant women.

Signs and Symptoms

Thrombocytopenia signs and symptoms may include:

· Easy or excessive bruising (purpura)

· Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs

· Prolonged bleeding from cuts

· Bleeding from your gums or nose

· Blood in urine or stools

· Unusually heavy menstrual flows

· Fatigue

· Enlarged spleen

· Jaundice
Diagnosis

The doctor will ask questions about your medical history and symptoms. You'll also get an exam to look for bruises, petechiae or spots of blood in your skin, and other signs of
low platelets. You'll be checked for signs of infection, like a fever or rash.

You might get a blood test that measures the number of platelets. A normal count is 150,000 to 450,000 platelets per microliter of blood. You can have bleeding problems if your
count drops below 50,000. 

The doctor will most likely consult with a blood specialist (hematologist). You might get other tests,  including:

· Blood smear to look at your platelets under a microscope and see how healthy they are
· Bone marrow test to see what cells are in the bone marrow, how full the bone marrow is with cells, and whether they are normal
· Your doctor might want you to take other tests that check if your blood clots normally.
Treatment

If your platelet count isn't too low, you might not need treatment. You won't bleed too much, even if you get cut.

Sometimes your platelet count will go up when you avoid the cause of the problem. For instance, if taking a certain medicine is behind your thrombocytopenia, your doctor will
have you stop that drug.

For severe thrombocytopenia, you might get:

· Steroid medicines to stop your body from destroying platelets if the cause is related to your immune system.
· Blood or platelets from a healthy person, called a transfusion
· Surgery to remove your spleen
If your condition is ongoing despite other treatments, your doctor may prescribe medicines such as romiplostim (Plate) and eltrombopag (Promacta, Revolade). A new medicine
called fostamatrinib (Tavalisse) may be another option.

To prevent bleeding when your platelets are low:

· Avoid medicines that can affect your platelet function, like aspirin and ibuprofen
· Limit how much alcohol you drink, because it can make bleeding worse.
· Don't play contact sports, like football or boxing, where you might get injured.
 · Use a soft toothbrush to prevent bleeding gums.
· Wear a seatbelt in the car and put on gloves and goggles when you work with power tools to prevent injury.

Abdominal Pain

Definition

Abdominal (belly) pain is pain or discomfort that is felt in the part of the trunk below the ribs and above the pelvis. It comes from organs within the abdomen or organs adjacent to
the belly. It is caused by inflammation, distention of an organ, or by loss of the blood supply to an organ. In irritable bowel syndrome (IBS) it may be caused by contraction of the
intestinal muscles or hyper-sensitivity to normal intestinal activities.

Cause
Abdominal pain is a common symptom, and most people have experienced some sort of abdominal pain (belly or stomach pain). Causes of more serious causes of abdominal
pain include:
· Bloody stools
· Black tarry stools
· Dehydration
· Painful urination
· Lack of urination
· Abrupt cessation of bowel movements
· Dehydration
Risk Factors
Abdominal Pain is caused by a variety of factors. Broadly speaking, these factors can be divided into two distinct groups:

· Problems within the digestive tract or “digestive tract diseases”

· Problems involving important organs in the body or “systemic diseases”
Signs and Symptoms
Signs and Symptoms associated with it may include:
· Bloating
· Belching
· Gas (flatus, farting)
· Indigestion
· Discomfort in the upper left or right; middle; or lower left or right abdomen
· Constipation
· Diarrhea
· GERD (gastro-esophageal reflux disease)
· Heartburn
· Chest discomfort
· Pelvic discomfort
Diagnosis
Doctors determine the cause of the pain by relying on:
1. Characteristics, physical signs, and other accompanying symptoms
2. Findings on physical examination
3. Laboratory, radiological, and endoscopic testing
4. Surgery
Treatment
· The pain of IBS and constipation often is relieved temporarily by bowel movements and may be associated with changes in bowel habit.
· Pain due to obstruction of the stomach or upper small intestine may be relieved temporarily by vomiting which reduces the distention that is caused by the obstruction.
 · Eating or taking antacids may temporarily relieve ulcer pain from the stomach or duodenum because both food and antacids neutralize the acid that is responsible for
irritating the ulcers and causing the pain.
· Pain that awakens a patient from sleep is more likely to be due to non-functional causes and is more significant.
· Other associated symptoms that accompany abdominal pain may suggest:
· Fever suggests inflammation or infection.
· Diarrhea or rectal bleeding suggests an intestinal cause.
· Fever and diarrhea suggest inflammation of the intestines that may be infectious or non-infectious.
· How is the cause of abdominal pain diagnosed?
· Doctors determine the cause of the pain by relying on:
· Its characteristics, physical signs, and other accompanying symptoms
· Findings on physical examination
· Medical laboratory, radiological, and endoscopic testing
· Surgery
Anatomy and Physiology

The Digestive System

The digestive system is made up of the gastrointestinal tract—also called the GI tract or digestive tract—and the liver, pancreas, and gallbladder. The GI tract is a series of hollow
organs joined in a long, twisting tube from the mouth to the anus. The hollow organs that make up the GI tract are the mouth, esophagus, stomach, small intestine, large
intestine, and anus. The liver, pancreas, and gallbladder are the solid organs of the digestive system.

The small intestine has three parts. The first part is called the duodenum. The jejunum is in the middle and the ileum is at the end. The large intestine includes the appendix,
cecum, colon, and rectum. The appendix is a finger-shaped pouch attached to the cecum. The cecum is the first part of the large intestine. The colon is next. The rectum is the
end of the large intestine.
Bacteria in your GI tract, also called gut flora or microbiome, help with digestion. Parts of your nervous and circulatory  systems also help. Working together, nerves, hormones,
bacteria, blood, and the organs of your digestive system digest the foods and liquids you eat or drink each day.

Main functions of the digestive system:

· Proteins break into amino acids

· Fats break into fatty acids and glycerol
· Carbohydrates break into simple sugars

Movement of food in the GI Tract

Food moves through your GI tract by a process called peristalsis. The large, hollow organs of your GI tract contain a layer of muscle that enables their walls to move. The
movement pushes food and liquid through your GI tract and mixes the contents within each organ. The muscle behind the food contracts and squeezes the food forward, while
the muscle in front of the food relaxes to allow the food to move.

Mouth. Food starts to move through your GI tract when you eat. When you swallow, your tongue pushes the food into your throat. A small flap of tissue, called the epiglottis, folds
over your windpipe to prevent choking and the food passes into your esophagus.

Esophagus. Once you begin swallowing, the process becomes automatic. Your brain signals the muscles of the esophagus and peristalsis begins.

Lower esophageal sphincter. When food reaches the end of your esophagus, a ring like muscle—called the lower esophageal sphincter —relaxes and lets food pass into your
stomach. This sphincter usually stays closed to keep what’s in your stomach from flowing back into your esophagus.

Stomach. After food enters your stomach, the stomach muscles mix the food and liquid with digestive juices. The stomach slowly empties its contents, called chyme, into your
small intestine.
Small intestine. The muscles of the small intestine mix food with digestive juices from the pancreas, liver, and intestine, and push the mixture forward for further digestion. The
walls of the small intestine absorb water and the digested nutrients into your bloodstream. As peristalsis continues, the waste products of the digestive process move into the
large intestine.

Large intestine. Waste products from the digestive process include undigested parts of food, fluid, and older cells from the lining of your GI tract. The large intestine absorbs
water and changes the waste from liquid into stool. Peristalsis helps move the stool into your rectum.

Rectum. The lower end of your large intestine, the rectum, stores stool until it pushes stool out of your anus during a bowel movement.

The small intestine absorbs most of the nutrients in your food, and your circulatory system passes them on to other parts of your body to store or use. Special cells help absorbed
nutrients cross the intestinal lining into your bloodstream. Your blood carries simple sugars, amino acids, glycerol, and some vitamins and salts to the liver. Your liver stores,
processes, and delivers nutrients to the rest of your body when needed.

The lymph system , a network of vessels that carry white blood cells and a fluid called lymph throughout your body to fight infection, absorbs fatty acids and vitamins.

Your body uses sugars, amino acids, fatty acids, and glycerol to build substances you need for energy, growth, and cell repair.

The Body’s Control of the Digestive Process

Your hormones and nerves work together to help control the digestive process. Signals flow within your GI tract and back and forth from your GI tract to your brain.

Hormones
Cells lining your stomach and small intestine make and release hormones that control how your digestive system works. These hormones tell your body when to make digestive
juices and send signals to your brain that you are hungry or full. Your pancreas also makes hormones that are important to digestion.

Nerves
You have nerves that connect your central nervous system—your brain and spinal cord—to your digestive system and control some digestive functions. For example, when you
see or smell food, your brain sends a signal that causes your salivary glands to "make your mouth water" to prepare you to eat.
You also have an enteric nervous system (ENS)—nerves within the walls of your GI tract. When food stretches the walls of your GI tract, the nerves of your ENS release many
different substances that speed up or delay the movement of food and the production of digestive juices. The nerves send signals to control the actions of your gut muscles to
contract and relax to push food through your intestines.
Hematology

Normally, blood makes up 7-8% of human body weight. Its main function is to transport oxygen and nutrients to the cells and tissues in our body, while getting rid of carbon
dioxide, ammonia and other waste products. It also plays a vital role in our immune system and maintaining a constant body temperature. There are 4 main components of blood,
red blood cells (RBC), white blood cells (WBC), platelets (PLT), and plasma. All of the cells in the blood, red blood cells, all types of white blood cells, and platelets are made in
the bone marrow. This happens primarily in the flat bones in your body such as the skull, the sternum, and the pelvis.

Functions of blood:
Blood has three main functions: transport, protection and regulation.

Transport
Blood transports the following substances:
-Gases, namely oxygen (O2) and carbon dioxide (CO2), between the lungs and rest of the body
-Nutrients from the digestive tract and storage sites to the rest of the body
-Waste products to be detoxified or removed by the liver and kidneys
-Hormones from the glands in which they are produced to their target cells
-Heat to the skin so as to help regulate body temperature

Protection
Blood has several roles in inflammation:
-Leukocytes, or white blood cells, destroy invading microorganisms and cancer cells

-Antibodies and other proteins destroy pathogenic substances

-Platelet factors initiate blood clotting and help minimize blood loss

Regulation
Blood helps regulate:
-pH by interacting with acids and bases
-Water balance by transferring water to and from tissue
Formed Elements:

Red Blood Cells (RBC)

Red blood cells or erythrocytes are large, anucleated cells. RBCs normally make up 40-50% of the total blood volume. There is gas transporting protein covering the RBC called
hemoglobin. Hemoglobin makes up 95% of the RBC; each RBC has about 270,000,000 iron-rich hemoglobin molecules. People who are anemic generally have a deficiency in
red blood cells, and subsequently feel fatigued due to a shortage of oxygen. The red color of blood is primarily due to oxygenated red cells. Red blood cells are produced in the
bone marrow from stem cells at a rate of 2-3 million cells per second.

Have two main functions:

1. To pick up oxygen from the lungs and deliver it to tissues elsewhere
2. To pick up carbon dioxide from other tissues and unload it in the lungs
An erythrocyte is a disc-shaped cell with a thick rim and a thin sunken centre. The plasma membrane of a mature RBC has glycoproteins and glycolipids that determine a
person's blood type. On its inner surface are two proteins called spectrin and actin that give the membrane resilience and durability. This allows the RBCs to stretch, bend and
fold as they squeeze through small blood vessels, and to spring back to their original shape as they pass through larger vessels.
White Blood Cells (WBC)
White blood cells or leukocytes make up a very small part of the blood’s volume, normally only about 1%. Leukocytes are not only located in the blood but also in the spleen,
liver, and lymph nodes. Lymphocytes, a type of WBC, are the first responders to our immune system. They seek out, identify, and bind to the alien protein on bacteria, viruses,
and fungi. Other types on WBC, granulocytes and macrophages then arrive to surround and destroy the alien cells. They also function to get rid of dead or dying blood cells.

Granulocytes:

1. Neutrophils: These contain very fine cytoplasmic granules that can be seen under a light microscope. Neutrophils are also called polymorphonuclear (PMN) because they have
a variety of nuclear shapes. They play roles in the destruction of bacteria and the release of chemicals that kill or inhibit the growth of bacteria.

2. Eosinophils: These have large granules and a prominent nucleus that is divided into two lobes. They function in the destruction of allergens and inflammatory chemicals, and
release enzymes that disable parasites.

3. Basophils: They have a pale nucleus that is usually hidden by granules. They secrete histamine which increases tissue blood flow via dilating the blood vessels, and also
secrete heparin which is an anticoagulant that promotes mobility of other WBCs by preventing clotting.

Agranulocytes:
1. Lymphocytes: These are usually classified as small, medium or large. Medium and large lymphocytes are generally seen mainly in fibrous connective tissue and only
occasionally in the circulation bloodstream. Lymphocytes function in destroying cancer cells, cells infected by viruses, and foreign invading cells. In addition, they present
antigens to activate other cells of the immune system. They also coordinate the actions of other immune cells, secrete antibodies and serve in immune memory.

2. Monocytes: They are the largest of the formed elements. Their cytoplasm tends to be abundant and relatively clear. They function in differentiating into macrophages, which
are large phagocytic cells, and digest pathogens, dead neutrophils, and the debris of dead cells. Like lymphocytes, they also present antigens to activate other immune cells.

Platelets (PLT)
Platelets or thrombocytes are anucleated cell fragments that work with blood clotting chemicals at the site of wounds. They do this by adhering to the walls of blood vessels,
thereby plugging the rupture in the vascular wall. They also can release coagulating chemicals which cause clots to form in the blood that can plug up narrowed blood vessels.
They are about 1/3 the size of RBCs, with a life span of 9-10 days.

Platelets have the following functions:

1. Secrete vasoconstrictors which constrict blood vessels, causing vascular spasms in broken blood vessels
2. Form temporary platelet plugs to stop bleeding
3. Secrete pro coagulants (clotting factors) to promote blood clotting
4. Dissolve blood clots when they are no longer needed
5. Digest and destroy bacteria
6. Secrete chemicals that attract neutrophils and monocytes to sites of inflammation
7. Secrete growth factors to maintain the linings of blood vessels
The first three functions listed above refer to important hemostatic mechanisms in which platelets play a role in during bleeding: vascular spasms, platelet plug formation and
blood clotting (coagulation).
 Present State

May 7, 2019
General Appearance
The Client was seen lying down in bed, awake, responsive, conscious and febrile with the
following vital signs
BP: 140/90mmhg
Temperature:37C/axilla
PR:72bpm
RR:21cpm

Skin
Inspection revealed smooth, evenly colored skin with good senile turgor ad warm to touch. Non
edematous and non-erythematous. No bruises at IV site at left hand.

Scalp & Hair

Hair was smooth, firm, black, had minimal presence of dandruff, evenly distributed with no lice
noted. Scalp was clean and w/o any lesions.

Nails
Transparent with pinkish white nailbed on both upper and lower extremities. Round nail with 160
degree nail base. Nails are hard and immobile smooth and firm. Nail palate was firmly attached to
nail bed in all extremities.
Capillary refill time
Upper extremities: R= <2 L=<2
Upper extremities: R= <2 L=<2
Lower extremities: R= <2 L=<2
Lower extremities: R= <2 L=<2

Head and face

Head was symmetric and round. Face is smooth with facial hairs. Lesions or redness were not
noted, no abnormal facial movement noted.
Eyes
Eyeballs are symmetric and non protuding. Eyebrows are evenly distributed. Eyelids are free of
lesions and no swelling. Bulbar conjunctivae is clear and sclerae is white. The upper and lower
Palpebral conjunctivae are free of swelling and lesions. Cornea is transparent with no opacities.
The iris is evenly colored, pupils are equal in size. There's ocular alignment in the patient while
doing the corneal light reflex. There's no difficulty in following the pencil and moving eyeballs
and eye movement is smooth. Patient was able to see in 20/20 vision

Ears
Ears are bilaterally symmetric and free of lesions. Auricle is non tender. External ear has small
amount of odorless yellowish cerumen.

Mouth
Lips are pale. Has yellowish teeth. Buccal mucosa is free of lesions. Tongue is bluish. Soft and
hard palate are intact. No foul breath odor noted. Uvula is intact and midline upon saying "ah".
Tonsils are normal at a grade of +1

Nose and Sinuses

External portion of the nose is free of lesions. There's no discoloration, smooth and symmetric.
The internal portion of the nose is moist and free of exudate. The nasal septum is intact and no
ulcers noted. Client was also able to sniff through each nostril while the other was occluded. The
frontal and maxillary sinuses are non-tender.
Neck
With head centered neck is symmetric and without mass noted. Full range of motion. No
palpable lymph nodes. Erect neck with no swelling noted. Trachea is located at midline

Chest and Lungs

Scapulae are symmetric and non-protruding. No retraction and bulging noted. No
tenderness, crepitus noted. Fremitus identified in the upper region and decrease on the
lower region Resonance all over lung field.
Heart and Peripheral Vasculature
Apical pulse noted at 5th intercostal space. No unusual pulsations noted. Distinct s1 and
s2 and no extra heart murmurs were noted. Jugular venous pressure is 1 cm above
sternal angle with head on bed elevated at 30 degree. No bruits or arm and leg edema
noted.

Rectum and Male genitalia were not assessed

Back and extremities

Clients stature and posture is slouching. Range of motions for upper eremites, Hand &
Fingers, Lower extremities are all limited.
Muscle strength are all +2 for all lower and upper extremities.
Neurologic Assessment

Mental Status
Patient shows proper facial expression toward emotion felt, speech is low due to
abdominal pain. Patient can say words with proper diction. Communicates properly. He
listens and can follow limited directions due to pain. Patient can also recall recent and
remote memory. GCS score of 13.

Motor /cerebellar functionWas able to perform the rapid alternating movement test, heel
to shin and finger-thumb-test. Patient cannot a perform Romberg’s test and Tandem
walk.

Sensory Function
The patient can discriminate between sharp and dull sensation, light touch sensation,
temp sensation, vibratory sensation, stereognosis, graphesthesia and kinesthesia well.
Cranial Nerve Testing:
I- The patient identifies different scents
II- Can see object or person approximately 2ft distance.
III, IV, VI- Equal eye movement, congruent eye movement based by observation.
V- Corneal reflex present, can feel touch sensation on face, able to clench teeth.
VII- Able to smile, frown, shows teeth, wrinkles forehead, closes and open eyes.
VIII- Turns his head when name is called.
IX, XII-Can swallow and cough without any difficulty. Gag reflex is intact. Uvula and
palate rise symmetrical when client says “AH”
XI- Able to shrug shoulders with weak resistanceXII- Able to move tongue to left and
right without difficulty.
NURSING CARE PLAN
 KEY ISSUES DESIRED OUTCOME INTERVENTION EVALUATION
1. Acute Pain related to abdominal For 3 days of 1-2 hours Independent Interventions Day 1 (May 7, 2019)
pain as evidenced by verbalization of of student nurse-patient After 1-2 hours of student nurse – patient
“sakit akong kuto-kuto” with a pain interaction, the patient 1. Assess pain reports, noting location, interaction, the patient was able to:
score of 4/10 aggravated by facial will be able to: intensity (0–10 scale), frequency, and · report his pain with a pain scale of 4/10
grimacing upon palpating the RUQ. · Report lessen of time of onset. Note nonverbal cues like with 1 as the lowest and 10 as the
pain score restlessness, tachycardia, grimacing. highest
R: To have a baseline data of the condition · show facial grimacing and guarding
SB: · Report pain 2. Encourage verbalization of feelings. behavior
The unpleasant feeling of pain is highly relieved/controlled R: Can reduce anxiety and fear and thereby · verbalize “sakit akong kuto-kuto”
subjective in nature that may be . reduce perception of intensity of pain.
experienced by the patient. Acute pain 3. Provided diversional activities: provide Day 2 (May 8, 2019)
serves a protective function to make · Demonstrate reading materials. After 1-2 hours of student nurse - patient
the patient informed and relaxed R: Refocuses attention; may enhance coping interaction, the patient was able to:
knowledgeable about the presence of posture/facial abilities. · report his pain with a pain scale of 3/10
an injury or illness. The unexpected expression. 4. Encouraged adequate periods of rest with 1 as the lowest and 10 as the
onset Acute Pain reminds the patient to and sleep highest
seek support, assistance, and relief. R: to prevent fatigue · show facial grimacing and guarding
The physiological signs that occur with behavior upon movement
acute pain emerge from the body’s
response to pain as stressor

Source:
https://nurseslabs.com/acute-pain/

Day 3 (May 9, 2019)

After 1-2 hours of student nurse - patient
interaction, the patient was able to:
· report his pain with a pain scale of 1/10
with 1 as the lowest and 10 as the
highest
2.Imbalanced Nutrition: Less than After 3 days of student Day 1 (May 7, 2019)
Body Requirements related to nurse-patient interaction, Independent Interventions:
decreased appetite secondary to the patient will be able 1. Discussed eating habits including food After 8 hours of student nurse-patient
unwillingness to eat as evidenced by to: preferences, intolerance and aversion interaction, the patient:
verbalization of “wa koy gana mokaon” •Retain current weight R: To gain baseline on his likes and dislikes · Reported weight loss during that day.
and no excessive loss of · Less energy levels
SB: weight noted. 2. Encouraged family members to bring the
patient's favourite food from home if not
The body is like a machine that needs •Regain his normal Day 2 (May 8, 2019)
contraindicated.
to be supplied with the right kind and appetite. After 8 hours of student nurse-patient
R: Patients feel comfortable with food brought
amount of fuel. This may refer to •Reported adequacy of from home and can improve the appetite of the interaction, the patient:
nutrition or the food requirements of a energy levels. patient. · Reported adequacy of energy levels.
person or patient. Adequate nutrition is •Tolerance to dietary
essential to meet the body’s demands. needs.
Several diseases can greatly affect the 3. Encouraged family members to offer large Day 3 (May 9, 2019)
nutritional status of an individual, this portions of food during the day when the After 8 hours of student nurse-patient
includes gastrointestinal malabsorption, appetite is high. interaction, the patient:
burns, cancer; physical factors (e.g., R: By administering a large portion can maintain
adequacy of nutrition intake.
· Reported adequacy of energy levels.
muscle weakness, poor dentition, · Did not report weight loss during that
activity intolerance, pain, substance day
4. Encourage as much physical activity as
abuse); social factors (e.g., economic possible.
status, financial constraint); R: May improve appetite and general feelings of
psychological factors (e.g., boredom, well-being.
dementia, depression). In certain
conditions such as trauma, sepsis, 5. Made sure the diet meets the needs of the
surgery, and burns, adequate nutrition body as indicated.
is vital to healing and recovery. Also, R: High carbohydrate, protein, and calories
religious and cultural factors greatly needed or required during treatment.
influence the food habits of patients.

Source:
https://nurseslabs.com/imbalanced-
nutrition-less-body-requirements/
3. Stress overload related to multiple within 3 days of patient – Independent interventions Day 1 (May 7, 2019)
co-existing stressors as evidenced by student nurse 1. Provide information about stress and After 8 hours of student nurse – patient
patients’ statement “Naa pakoy ipang interaction, the patient exhaustion phase, which occurs when interaction, the patient was able to:
pass nga mga projects ug will be able to: a person is experiencing chronic or · Report the stressors affecting them.
assignments” · Assess current unresolved stress.
situation Day 2 (May 8, 2019)
SB accurately. 2. Allow client to react in own way without After 8 hours of student nurse – patient
· Verbalize or interaction, the patient was able to:
judgement.
demonstrate · Report slight improvements in their
reduced stress 3. Incorporate strengths, assets, and past body.
reaction. coping strategies that were successful
· Avoid triggering Day 3 (May 9, 2019)
for client.
factors of stress · Report big improvements with the clients
psychological being
 4. Disturbed Sleep Pattern related Within 3 days of patient - Independent interventions Day 1 (May 7, 2019)
to abdominal pain in the RUQ as student nurse 1. Assessed and monitored patient’s After 8 hours of student nurse – patient
evidenced by verbalization interaction, the patient sleep interaction, the patient was able to:
“permi ko mag mata-mata kay will be able to manifest: R: To determine if there’s an improvement in · Report interruptions of sleep.
sakit jud kaayo” · 8 hours of sleep the patient’s sleep
2. Provided and environment conducive · Report unfamiliar sleep surroundings
· Uninterrupted to rest
Scientific Basis: sleep R: Environmental stimulation inhibits the
Adequate rest is extremely important patient’s to be relaxed
but may be difficult to obtain because if · Best physical 3. Assisted in positioning the client Day 2 (May 8, 2019)
distressing symptoms/ change in health comfort comfortably on bed After 8 hours of student nurse – patient
status interfere with the patient’s sleep- R: To facilitate good amount of sleep to the interaction, the patient was able to:
awake pattern. Any condition that may patient and to give comfort to the patient · Report less interruptions of sleep
result in discomfort, injury and
environmental factors has potential to · Report temperature, humidity, and
disrupt sleep. noxious odors inside the room
Source:
Lippincott Williams & Wilkins., 2002; Day 3 (May 9, 2019)
Gulanick, 2007; Kozier, et al, 2007; After 8 hours of student nurse - patient
Black, J & Hawks, J, 2005 interaction, the patient was able to:
· Report improved sleep pattern.
· Report increased sense of well-being
and feeling rested
 5. Readiness for enhanced hope After 3 days of student Independent interventions Day 1 (May 7, 2019)
nurse-patient interaction, 1. Demonstrate and encourage After 8 hours of student nurse – patient
the patient will be able use of relaxation techniques, interaction, the patient was able to:
to: guided imagery, and meditation · Plan of care, specific interventions.
· Identify and activities. · Cooperate in making a care plan.
SB verbalize feelings 2. Assist client to develop Day 2 (May 8, 2019)
related to manageable short-term goals. After 8 hours of student nurse – patient
expectations and 3. Determine level of commitment
desires.
interaction, the patient was able to:
and expectations for change · Attainment or progress towards desired
· Verbalize belief in and congruency of expectations
possibilities for the outcomes.
future. with desires. · Cooperate in doing the interventions.
· Discuss current Day 3 (May 9, 2019)
situation and desire After 8 hours of student nurse – patient
to enhance hope. interaction, the patient was able to:
· Perform all teachings, interventions, and
actions performed.
· Do all the teachings, interventions, and
actions performed smoothly.