Name of Student: Trixie Mei Ubaldo Date: March 05, 2021

Clinical Area: Pedia Ward

CLINICAL ANALYSIS

I. Patient’s Profile

Name: Dwight Tuazon

Age: 19 years old
Gender: Male
Civil Status: Single
Address: Gapan City, Nueva Ecija
Chief complaint: Having Shortness of breath and chest congestion or tightness
Admission Date: March 05, 2021
Admitting Diagnosis: Acute Bronchitis
Physician: Dr. Gatchalian
II. Medical History

A. Present
A 1onyear old patient with Acute Bronchitis was admitted to Immaculate Conception Medical center on December 25, 2021
with chief complaint of shortness of breath and chest congestion or tightness. In his Diagnosis revealed that he has a
presence of Acute Bronchitis.

B. Past
No chronic illness but the patient has been diagnosed with or inflammation of breathing tubes . It was first detected on the
patient’s physical exam that confirms he has a high body mass index (BMI).
No past surgical or hospitalization.

C. Socio-economic
Upon interviewing the patient, it was stated by his mother who had multiple pregnancies that the patient is the youngest of
four siblings. His father is a vendor at a market which they own and her mother is a housewife. They were staying at a
concrete house with 2 rooms at their grandparents' house at Cabanatuan since they were in the province.
III. Anatomy and Physiology
An umbilical hernia is a protrusion caused when a portion of the intestine pushes through a weak spot in the muscle wall of
the abdomen at or near the belly button.
Hernia Anatomy – The layers of the Abdominal Wall
 These layers are a bit different between the umbilical region and the groin, but overall the basic layers are the same. From
the outside to the inside is the skin, then a layer of fat. Underneath the fat is the layer of muscles which provide the strength to the
abdominal wall. Under the muscles is a thin layer called peritoneum which serves as a barrier between the muscles and the
internal organs which live underneath the peritoneum.

a. Skin- The skin is the largest organ of the body, with a total area of about 20 square feet. The skin protects us from microbes
and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold.
b. Fat- The body uses fat as a fuel source, and fat is the major storage form of energy in the body. Fat also has many other
important functions in the body, and a moderate amount is needed in the diet for good health.
c. Abdominal Wall- The abdominal wall surrounds the abdominal cavity, providing it with flexible coverage and protecting the
internal organs from damage.
d. The peritoneum- is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some
invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of
mesothelium supported by a thin layer of connective tissue.
IV. Pathophysiology ( in flow chart form)

Predisposing Factor:
Mother with multiple pregnancy Precipitating Factors:
and obesity has a higher risk of Heredity, Obese, Weakness of
having umbilical hernia. muscle wall around abdomen

During development of fetus

A small opening is present in the abdominal muscles,

so that the umbilical cord will pass through, connecting
mother to baby.
`
Part of your intestine bulges through
the opening in your abdominal
Signs and Symptoms: muscles near your belly button
(navel).
A bulge or swelling in or near
your belly button.

A bulge that gets bigger when

you cough, strain to have a Umbilical Hernia
bowel movement, or sit up.

Nausea or vomiting.

Constipation.
V. Diagnostic Test
a. Laboratory
b. Radiologic Test

Laboratory Test Result Clinical Significance

Ultrasound Presence of hernia Ultrasound is used to create images of soft
tissue structures, such as the gallbladder, liver,
kidneys, pancreas, bladder, and other organs
and parts of the body.
Chest X-Ray Normal Chest X-ray A chest X-ray is an imaging test that uses X-rays
to look at the structures and organs in your
chest. It can help your healthcare provider see
how well your lungs and heart are working.
CBC with APC Normal Limits Normal range value:
● Hemoglobin 12.5 12-16.0 g/dl
Hemoglobin is a protein in your red blood cells
that carries oxygen to your body's organs and
tissues. If a hemoglobin test reveals that your
hemoglobin level is lower than normal, it means
you have a low red blood cell count (anemia).
● Hematocrit 42.4 42-52%
A hematocrit test measures how much of your
blood is made up of red blood cells.
Hematocrit levels that are too high or too low can
indicate a blood disorder, dehydration, or other
medical conditions.
● RBC 4.5 4.0-6.0 10^6/ul
The test is important because RBCs contain
hemoglobin, which carries oxygen to your body's
tissues.
 ● WBC 6.0 5-11.0 10^3/ul
WBCs, also called leukocytes, are an important
part of the immune system.
● Platelets 164 150-400 10^3/ul
Platelets, also called thrombocytes, are tiny
fragments of cells that are essential for normal
blood clotting.
● PT and PTT Normal Limits Prothrombin Time (PT) which measures the
integrity of the extrinsic system as well as factors
common to both systems and Partial
Thromboplastin Time (PTT), which measures the
integrity of the intrinsic system and the common
components.
Blood Typing O positive Blood typing is a test that determines a person’s
blood type. The test is essential if you need a
blood transfusion or are planning to donate
blood. Not all blood types are compatible, so it’s
important to know your blood group. Receiving
blood that’s incompatible with your blood type
could trigger a dangerous immune response.
 VI. Medical Management
Drug Study
Name of Drug Dosage/ Route Action Adverse/ Side Effects Nursing Consideration
Generic Name: Dosage: 250mg Mefenamic acid has After
Mefenamic Acid analgesic, anti- - The promotion of comfort
Route: Oral inflammatory, and CNS: Drowsiness using techniques such as
Brand Name: antipyretic properties. The white noise, dim lighting, pain
Ponsten mechanism of action of management, stress reduction
mefenamic acid, like that of techniques, massage and the
other NSAIDs, is not elimination of environmental
completely understood but noise.
involves inhibition of - Discontinue drug promptly if
cyclooxygenase (COX-1 GI: Severe diarrhea, diarrhea, dark stools,
Pharmacological and COX-2). Mefenamic bleeding; nausea and hematemesis, ecchymoses,
class: Non steroidal acid is a potent inhibitor of vomiting epistaxis, or rash occur and
anti-inflammatory drug prostaglandin synthesis in do not use again. Contact
vitro physician.

Generic Name: Dosage: 250mg Cloxacillin is for use against - upset stomach/ - Allow the patient to use non
Cloxacillin staphylococci that produce nausea & vomiting pharmacological nausea control
Route: IV beta-lactamase. By binding techniques such as relaxation,
Brand Name: to specific penicillin-binding guided imagery, music therapy,
distraction, or deep breathing
Cloxapen, Cloxacap, proteins (PBPs) located
exercises
Tegopen and Orbenin. inside the bacterial cell - diarrhea - Discuss the importance of fluid
wall, cloxacillin inhibits the replacement during diarrheal
third and last stage of - and mouth sores episodes.
bacterial cell wall synthesis. - Maintain inside of the mouth
Pharmacologic moist with frequent sips of water
class: and salt water rinses.
semisynthetic - Provide scrupulous oral care to
antibiotic critically ill patients.
Generic Name: Dosage:250mg Ceftriaxone selectively and - loss of appetite - Eat small frequent meals and
Ceftriaxone irreversibly inhibits bacterial healthy snacks that are high in
Route: IV cell wall synthesis by protein and calories.
Brand Name: binding to transpeptidases, - headache - Hot or cold compresses to
Rocephin also called transaminases, your head or neck.
which are penicillin-binding - Maintain good posture, and
proteins (PBPs) that move around during the day.
catalyze the cross-linking of - lying down and closing the
Pharmacologic the peptidoglycan polymers - dizziness eyes.
Class: Cephalosporin forming the bacterial cell - acupuncture.
antibiotics wall. - drinking plenty of water and
keeping hydrated.
- reducing stress plus alcohol
and tobacco intake.
- getting plenty of sleep.

VII. Surgical Management

Name/ Type of Surgical Procedure Description
Herniorrhaphy It involves returning the displaced tissues to their proper position.
Hernia repair surgery is one of the most common surgeries to be performed.
INDICATION: COMPLICATION:
The indications for umbilical hernia repair
include: ● recurrence or return of the hernia.
● long-term hernia pain or discomfort. ● seroma or a fluid-filled sac under the surface of the skin.
● pain or discomfort that interferes with ● nerve damage and neuralgia or nerve pain that causes tingling or numbness.
everyday activities. pain or discomfort ● constipation or slow bowel movements.
intensifying or worsening over time.
● large hernias.

Preoperative Nursing Intervention

1. Assess the patient's understanding about the procedure. The patient who understands about the procedure to be
performed and what to expect after surgery will be less anxious.
2. Manage any symptoms that the patient might experience such as pain, vomiting and constipation. In such cases, the
symptoms might be discussed to the patient with the doctor to formulate a plan of medications that can ease the
symptoms.
3. Preparation of the day/ time of surgery. With preoperative assessment:
4. Check the chart to ensure that the consent form has been signed. Consent form should be signed by the patient/ guardian.
5. Physical examination and history should be complete to determine the site of hernia.
6. Request for imaging ready for Ultrasound and Chest X ray
7. Changed into a hospital gown and removed her underwear.
8. If ordered, administer a small cleansing enema and ask the patient to empty her bladder. This precaution helps prevent
contamination from the bowel or bladder during surgery
9. The patient should be on NPO diet for at least 6 hours temporarily before the surgery, make sure that he is kept hydrated
through adequate IV infusions.
10. OR Nurse notified.
 Postoperative Nursing Intervention
1. Assess the neurovital sign of the patient.
2. Vital signs taken in accordance follows
3. Flat on bed on the time induction of anesthesia with anesthesiology report.
4. Manage the location of the site including the size, general appearance and odor of site.
5. Assess for the pain, may use 1-10 as a rating scale. also assess for the characteristic of pain: dull or sharp.
6. Note for any presence of suture or dressing.
7. Discuss resumption of activities, avoid lifting heavy objects and strenuous activities.
8. Notify patients/ guardians about the signs/ symptoms that require medical attention like fever.
9. Assess the vital sign of the patient for every 4 hours.

VIII. Nursing Management

Nursing Care Plan/ NCP
Assessment Background Nursing Planning Nursing Intervention Rationale Evaluation
Knowledge Diagnosis
Subjective: An umbilical hernia Acute pain in After 4 hours of 1. Evaluate pain 1. Provide After 4 hours of
“Nurse masakit at occurs when part of the umbilical/ nursing regularly noting information rendering the nursing
namamaga ang the intestine or fatty belly area. intervention the characteristic about the need care, the goal were
bandang puson ko tissue bulges through patient will be location intensity. for or the met partially as
lalo na pag the muscle near the able to decrease (0-10) effectiveness evidenced by
nabibigla.” belly button (navel, the pain scale of 2. Administer of the decreased pain scale
As verbalized by umbilicus). Most (9 of 6 to 2 as analgesic intervention to the level of 3 to 2
the patient 10) umbilical hernias evidenced by appropriate for 2. Facilitates
in adults are acquired. stable vital signs. the severity of comfort and
Objective: This means that pain and age. decreases pain
● Pain scale increased pressure 3. Monitor vital 3. Changes in
of 6/10 near the umbilicus signs vital sign may
● Irritability causes the umbilical 4. Monitor for signs be used for
● Restlessne hernia to bulge out. of infection; such rough estimate
ss as fever, pain
excessive pain 4. Avoid possible
Vital signs taken and inflammation. complications if
as follow: the situation of
BP: 110/80 the patient is
PR:97 bpm not attended
RR: 19 bpm properly.
T: 36.5C
O2 Sat: 98%

Assessment Background Nursing Planning Nursing Intervention Rationale Evaluation

Knowledge Diagnosis
Subjective: A surgical site Acute pain After 24 hours of 1. Monitor patients' 1. This serves as a After 24 hours of
“Nurse namamaga infection (SSI) is related to nursing vital signs. base line. rendering nursing
ang tahi ko.” as an infection that surgical intervention, relief 2. Aseptic care, the goals were
verbalized by the occurs after procedure as pain of the patient 2. Maintain strict technique met partially as
patient. surgery in the part manifested by will be able to asepsis for decreases the evidenced by
of the body where patient decrease the pain dressing chances of decreased pain to the
Patient’s mother the surgery took verbalization. scale of 4 to 0 as changes, wound transmitting or level of 1 or 0.
mentioned that his place. Surgical site evidenced by care and spreading
son cannot move infections can stable vital signs. intravenous pathogens to or ● The patient
freely without pain sometimes be therapy between identifies and
and needs superficial patients. demonstrates
assistance to get infections involving 3. Encourage 3. Proper nutrition the intervention
down from the bed. the skin only. intake of protein- places a part in on how to
rich and calorie- supporting the prevent
Objective: rich foods. immune infections.
● Abdominal systems’
pain level is 4. Encourage responsiveness
a 4 on 0-10 patients to do 4. This helps to
rating scale. hand hygiene. prevent
● Presence of infections due to
wound patients
V/s taken as follow: frequently
BP: 110/80 touching their
PR: 87 eyes, nose, and
RR:18 mouth without
T: 37.7 even realizing it.

Comments and suggestions_____________________________________

Clinical Instructor: Ma’am Jhea Pauline Montes