FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING
AY 2010-2011

In partial fulfilment
Of the requirements in
Nursing Care Management 103

Submitted to
Irene Latosa

Submitted by

Santos, Arizza Jane L.

Sison, Joanna Christie C.
Tan, Alyssa Joanna M.
Tizon, John Bernard
Tuazon, Raymund
Ubay, Justin
Ujano, Cristine Joy T.
Urban, Xavier Norbert C.
Valdecantos, Alejandro King
Valdenor, April Joy F.
Verdillo, Rachel Anne F.
Zapata, Molly Mae O.

9 August 2010
I. Biographic Data
Name: H.L.C.
Address: Taguig City
Age: 50 years old Gender: Male
Marital Status: Married Occupation: Fish Ball Vendor
Religious Affiliation: Roman Catholic
Chief Complaint: Carbuncle back at the right shoulder
Provisional Diagnosis: Carbuncle back at the right shoulder

II. Nursing History

A. Past Health History
The client had his hypertension at age of 42 and was confined for a week;
he has also myocardial infarction, and stroke. No medications were administered
after the diagnosis. It was his 2nd time to be hospitalized this year. He is a
smoker for almost 6 years and an alcoholic drinker every after work. He has no
known allergy and completely immunized.
B. History of Present Illness
1 week prior to confinement: started to a single small pimple and became
enlarged, (-) fever, (+) chills, (+) pain and no self medicated for his hypertension.

C. Family History
The mother side of the client has a history of hypertension.

III. Patterns of Functioning

A. Psychological Health
1. Coping Patterns
The client was asked to describe stressors around him, he said that “Dati
trabaho sa pabrika. Dami kasi ginagawa doon dati. Ngayon, Sa Bicutan Subd. ako. 2pm
ako napunta lagi doon para magtinda.” When asked about his coping mechanisms, he
said that, “Naninigarilyo ako. 1 kaha nauubos ko araw-araw. Katabi ko din ang sigarilyo
hanggang sa pagtulog.” He also added that “Pagkatapos ko magtinda ay umiinom ako
mag-isa o kaya minsan kasama ko panganay ko. Nakakalimutan ko din maghapunan
dahil sa gin.” He also verbalized, “Mahilig kasi talaga ako sa matatamis, tapos
mahilig din ako sa softdrinks, yun yung madalas kong kainin sa bahay.” The
client stated, “Pag ako ang may problema, minsan sinasarili ko, kasi nga
masikreto talaga akong tao pero kung pag problemang pampamilya naman
pinaguusapan namin.” When asked what he feels for being confined in the
hospital, he verbalized, “Siyempre hindi maganda, sa totoo lang gusting gusto
kong umuwi. Ayoko talaga ditto hindi ako komportable. Nag-aadjust na langako
kaya iniisip ko na lang para to sa ikabubuti ko at ng pamilya ko kaya pumayag
na lang akong magpahospital.”

INTERPRETATION: Mature persons are open to new experiences and

continued growth; they can tolerate ambiguity, are flexible, and can adapt to
change. ( Kozier and Erb’s. Fundamentals of Nursing 8th edition.Volume 1. P. 398)

ANALYSIS: Lifestyle patterns in combination with aging, family history and

developmental stressor sare often related to health problems to arise, For
example smoking and excessive alcohol consumption place an individual at
greater risk of developing chronic respiratory problems,lung cancer,diabetes
mellitus and liver disease (Kozier and Erb’s. Fundamentals of Nursing 8 th
edition.Volume 1. P.400)

2. Interaction Pattern
The client stated that sometimes he has a hard time dealing with other
people. He verbalized, “Hirap akong makisama sa ibang tao, pag umiinom nga
ako mag-isako lang at sa bahay lang ako. Minsan nakakainum man ko rin yung
anak ko, sila at sila din lang.” Interaction in their family is good as they usually
spend time with each other. He verbalized, “Minsan kasi nagbobonding din
naman kami nagkakantahan kasi may player sa bahay.” His wife also stated,
“Saka kung may hindi kami pagkakaintindihan pinaguusapan namin ng maayos
kaso minsan yung asawa ko medyo masikreto o malihim kumbaga.”

INTERPRETATION: Middle-aged person should interact effectively and share

companionable activities with life partner. ( Kozier and Erb’s. Fundamentals of
Nursing 8th edition.Volume 1. P. 401)

ANALYSIS: Family members support one another and have the ability to listen,
empathize and reach out to one another in times of crisis. When the needs of
family members are met, they are more able to reach out to meet the needs of
others in society. (FUNDAMENTALS OF NURSING BY BARBARA KOZIER, et al
pp.193,SEVENTH EDITION)

3. Cognitive Pattern
The client as well as his family knows how to read and write as he
verbally said, “Marunung naman akong magbasa pati mga anak ko at yung
asawa ko.” The client stated, “Ako kasi hanggang high school lang yung natapos
ko, salat na kasi kami sa pampaaral kaya di na ako nakapagpatuloy sa kolehiyo
kaya mas pinili kong magtrabaho na lang.” When it comes to his visuals, he said,
“Medyo malabo na yung mata ko, minsan di ko na makita yung binabasa ko lalo
na pagpagkaliit-liit.” When asked about his hearing capabilities, the stated that
he can still hear sounds the way he used to hear them. He stated, “Nakakarinig
pa rin naman ako gaya ng dati, malakas pa naman yung pandinig ko, hindi
naman ako yung tipo ng kailangan mung sigawan para lang marinig yung
sasabihin mo.”

INTERPRETATION: Cognitive processes include reaction time, memory,

perception, learning, problem-solving, and creativity. Reaction time during the
middle years stays much the same or diminishes during the later part of the
middle years. Memory and problem solving are maintained through middle
adulthood. Learning continues and can be enhanced by increased motivation at
this time in life. ( Kozier and Erb’s. Fundamentals of Nursing 8 th edition.Volume 1.
P. 400)

ANALYSIS: The diminishing of sensory perception that may come with chronic
disease or aging is generally gradual. For example, hearing loss is the third most
common condition reported by the elderly (Kozier and Erb’s. Fundamentals of
Nursing 8th edition.Volume 2. P. 983)

4. Self-Concept
The client stated, “Wala pa naman nagbago sa pagtingin ko sa sarili ko,
kaso nga lang kinakabahan ako baka pag umuwi ko may ilang bagay na akong
hindi puwedeng gawin yung mga ipagbabawal ng doctor.” The client also feels
that he is no longer young. He stated, “Tumatanda naman na ako kaya may mga
pagbabago din tulad ng paningin ko nang hihinana, pero ganun naman talaga,
tanggap ko naman.”

INTERPRETATION: The middle-aged person does not make comparisons with

others, often no longer fears aging or death, relaxes the sense of
competitiveness, and enjoys the independence and freedom of middle age.
( Kozier and Erb’s. Fundamentals of Nursing 8th edition.Volume 1. P. 399)

ANALYSIS: Midlifers begin to recognize that time is at a premium and that time is
at a premium and that life is finite. Youthfulness and physical strength can no
longer be taken for granted( Kozier and Erb’s. Fundamentals of Nursing 8 th
edition.Volume 1. P. 399)

5. Emotional Patterns
The patient stated, “Kung anu yung nararamdaman ko, siyempre gustong
gusto kong umuwi, matagal na ako dito sa hospital at hindi ko yun gusto.” The
client feels sad for being confined in the hospital for quite a long time. He stated,
“Gaya nga ng sabi ko kanina, hindi talaga ako komportable dito kaya medyo
nakakalungkot na matagal na ako dito at saka ayoko na problemahin
masiyadong pamilya ko yung gastusin kasi nga malaki ang mga bayarin sa
hospital.” The client also thinks that staying in the hospital too long is a burden
to his family. He also said that it is saddening for him to have such kind of illness.
The client said that it is really painful. When asked how painful through the use
of pain scale, the client verbalized, “Kung lalagyan ko ng score mga 7 siguro,
medyo makirot lalo na kapag nahihigan ko yung sugat ko.”

INTERPRETATION: The prevalence of pain in older people is generally higher due

to both acute and chronic disease conditions. (Kozier and Erb’s. Fundamentals of
Nursing 8th edition.Volume 2. P. 1194)

ANALYSIS: Pain tolerance does vary considerably from person to person even
within the same person at different times and in different circumstances (Kozier
and Erb’s. Fundamentals of Nursing 8th edition.Volume 2. P. 1189)

6. Sexuality
The client verbalized, “Gumagamit kami ng family planning, pero yung
asawa ko ha. Gumagamit siya ng pills, pero tinigil na niya ata.” When his wife
was asked why she stopped using pills, she answered, “Tumigil na ako sa
paggamit ng pills kasi pakiramdam ko naninikip yung dibdib ko.” The wife also
said that when she was still using pills, the pills were effective and she never
missed taking it. The patient had no doubts in his sexual preference and also
said, “Lalaking-lalaki ata ‘to, may pamilya nga ako di ba. Hindi ko naman
pinagdudahan yung pagkalalaki ko.”

INTERPRETATION: The middle-aged adult should exhibit appropriate knowledge

and attitudes about sexuality (e.g., about andropause). ( Kozier and Erb’s.
Fundamentals of Nursing 8th edition.Volume 1. P. 401)
 ANALYSIS: Gender identity is the result of a long series of developmental events
that may or may not conform to one’s apparent biologic sex. Once gender
identity is established, it cannot be easily changed(Kozier and Erb’s.
Fundamentals of Nursing 8th edition.Volume 2. P. 1023)

7. Family Coping Patterns

The client stated, “pag may problema, gaya nga ng sinabi ng asawa ko
kanina, pinaguusapan talaga namin, tuladngayon na nandito ako sa hospital.
Salitan silang pagbabantay sa akin, yung asawa ko at yung anak kong lalake,
yung panganay.” Sometimes most of their problems were due to financial
constraints. “Uutang sa 5/6 tapos utang ulit o kaya hulug-hulugan para makabayad.
The client was also asked about their family income and said that “Sa benta namin na
fish ball kami kumukuha ng pera. 250 lang kita tapos pinagkakasya na lang namin. 2
beses lang din kami nakakakain.Almusal at hapunan lang. When asked if there are still
other problems, the client said that “Minsan nag-aaway kami dahil nga sa pera.” The
client also added that “Hindi na nga-aaral yung 4 namin na anak.” He stated, “minsan
nag-away kami ng anak kong lalake, kasi ayaw sumunud sa akin.” When asked
what was done to fix the problem between him and his son, he stated, “ako
pinalipas ko muna yung init ng ulo ko, saka ko siya kinausap ulit at
nagpaliwanag. Medyo ang hirap kasi halos lalake lahat ng anak ko, iisa lang
yung babae yung bunso.” Their youngest which is their only daughter is their
problem right now, for she is already a mother at the age of 16. “Medyo masakit
sa loob kasi nag-iisang babae siya tapos may anak na siya sa edad niya, ang
hirap pa man din bumuhay ng pamilya ngayon, pero tanggap na naming,
pinagtutulungan na lang naming yung gastusin sa bata.”

INTERPRETATION: Mature persons are open to new experiences and

continued growth; they can tolerate ambiguity, are flexible, and can adapt to
change. ( Kozier and Erb’s. Fundamentals of Nursing 8th edition.Volume 1. P. 398)

ANALYSIS: Family members support one another and have the ability to listen,
empathize and reach out to one another in times of crisis. When the needs of
family members are met, they are more able to reach out to meet the needs of
others in society. (FUNDAMENTALS OF NURSING BY BARBARA KOZIER, et al
pp.193,SEVENTH EDITION)

B. Socio-Cultural Patterns
1. Cultural Patterns
The client came from Misamis Oriental. He stated, “hindi kasi talaga
magandang maggupit ng kuko sa gabi yun naman ang pinaniniwalaan ko.”
The client verbalized, “hindi naman ako masiyadong mapamahiin, may mga
pinaniniwalaan ako pero hindi naman lahat.”

INTERPRETATION: Nursing involves the identification of cultural traits and the

integration of such cultural elements in the delivery of care. . ( Kozier and
Erb’s. Fundamentals of Nursing 8th edition.Volume 1. P. 315)

ANALYSIS: Identify measures that will assist the client to develop or maintain
healthy nail practices. Kozier and Erb’s. Fundamentals of Nursing 8 th
edition.Volume 1. P. 763)

2. Significant Relationships
The client said that his family is really important to him. He stated, “yung
pamilya ko talaga ang importante sa akin, kaya nga ako nagtratrabaho
ng maiigi.” The client verbalized that his parents are important and as
well as his siblings. “Importante talaga yung parents ko sa akin, pati yung
mga kapatid ko, kasi kung nangangailangan man minsan,sila at sila yung
una kong malalapitan.” For the client, it is important to value those
people for they are necessary for you to survive and face the problems.

INTERPRETATION: In middle age, the individual is “linked to the

welfare of others” (Lachman, 2004, p. 306). Reference: ( Kozier and Erb’s.
Fundamentals of Nursing 8th edition.Volume 1. P. 399)

ANALYSIS: Family members support one another and have the ability to
listen, empathize and reach out to one another in times of crisis. When
the needs of family members are met, they are more able to reach out to
meet the needs of others in society. (FUNDAMENTALS OF NURSING BY
BARBARA KOZIER, et al pp.193,SEVENTH EDITION)

3. Recreation Patterns
The client stated, “every morning naman nag-eexercise naman ako kaso
mabilis ako mapagod, may dumbbells kasi sa bahay, mga at least 15
minutes araw-araw.” The client with his family sometimes spends time
 together through having sound trip or listening to music. One of their
recreational activities is that they watch television all together. He stated,
“eto talaga yung madalas naming gawin na kumpleto kami yung manood
ng T.V.”

INTERPRETATION: The middle-aged adult should be developing adult

leisure time activities. Marriage partners have more time for
companionship and recreation, thus marriage may be more satisfying in
the middle years of life. Generative middle-aged persons are able to feel
a sense of comfort in their lifestyle and receive gratification from
charitable endeavors. ( Kozier and Erb’s. Fundamentals of Nursing 8 th
edition.Volume 1. P. 399)

ANALYSIS: In elders, health promotion and illness prevention are

important, but often the focus is on learning to adapt and live with
increasing changes and limitations( Kozier and Erb’s. Fundamentals of
Nursing 8th edition.Volume 1. P. 285)

4. Environment
The client was asked to describe their home and community
environment. When the client was asked to describe the materials used
for their house he said “Sa semento gawa yung bahay namin.” The client
also said that “May electric fan yung bahay namin. Isa sa baba para sa
aming mag-asawa at yung isa ay para sa mga anak namin.” The client
described if there is an electrical supply to their house and he said
“Meron kaming supply ng kuryente.” When asked to describe their
garbage disposal, the client said “Isa lang ang basurahan namin, plastic
siya. Nasa labas ng bahay yung basurahan namin. May kumukuha din ng
basura namin araw-araw.” When asked about their water source, the
client said that “NAWASA yun supplyer ng tubig sa lugar namin.” The
client also described their source of drinking water as “Pinapakuluan
nmain yung tubig bago namin inumin tapos nilalagay namin sa pitchel o
garapon na may takip. Kada 2 araw din nmain nililinis yung mga lalagyan
na yun.” When asked to describe about their food storage, the client said
that “Nilalagay namin sa Tupperware na may takip tapos nasa ibabaw ng
lamesa. Wala kasi kaming ref kaya mahirap din. Pag panis na, tinatapon
na namin agad. Pag hindi pa panis, iniinit na lang namin sa kaldero.”
When the client was asked to describe their sleeping environment, the
 client said “Semento na may sapin at karton tapos tag-isang unan lang
kaming mag-asawa. Yung mga anak nmain ay natutlog sa taas. May
katol din kami gabi-gabi.” When asked about their community
communication system, the client described that “Nakakarating naman
sa amin pag may gagawin sa barangay tsaka yung health center lalo na
pag may bagyo o kaya minsan nalalaman na lang din namin sa mga
kapitbahay.Binabaha din yung lugar namin kaya minsan namimigay din
ng de lata yung barangay pag may bagyo.

INTERPRETATION: The environment of the client is vital to the health of

middle-aged adults as they are more prone to health problems.

ANALYSIS: Because each if the agent-host environment factors constantly

interacts with others, health is an ever-changing state. When the
variables are in balance, health is maintained; when variables are not in
balance, disease occurs (Kozier and Erb’s. Fundamentals of Nursing 8 th
edition.Volume 1. P. 298)

5. Economic
The client stated, “kasi hindi talaga sapat yung kinikita naming mag-
asawa kahit pa dalawa kami nagtratrabaho.” His wife gains 100 pesos
from her everyday work and the client gains 150 pesos per day. He
verbalized, “yang 250 na yan pinagkakasya talaga namin, pag kinulang
gaya ng pagkakaroon ng emergency talagang nang-uutang na lang kami
sa 5-6 saka naming babayaran araw-araw.” They also said that
sometimes they just eat 2 times a day. The client stated, “ang hirap kasi
talaga ng buhay ditto sa pilipinas, hirap kami ng asawa ko maghanap ng
trabaho may sapat na kita kasi nga hindi rin naman kami nakapagtapos
ng kolehiyo.” His wife stated, “minsan dagdag pa sa gastusin niyang
magyosi, nakakaisang kaha kasi siya kada araw.”

INTERPRETATION: The middle-aged adult should be establishing and

maintaining an economic standard of living. ( Kozier and Erb’s.
Fundamentals of Nursing 8th edition.Volume 1. P. 399)

C. Spiritual Patterns
1. Religious Beliefs and Practices
 The client stated, “ako kasi hindi madalas magsimba kasi nga trabaho talaga
inaaatupag ko, misis ko ang nagsisimba kasama yung iba kong anak.” The
client believes in God though he doesn’t visit the church frequently. The
client prefers to pray at home before sleeping. He verbalized, “mas maganda
pa nga magdasal minsan sa bahay lang kasi mag-isa mo lang, mas payapa.
Minsan pinagdadasal ko na lang talaga yung kalagayan ko,
pinagpapasadiyos ko na lang,” stated by the client.

INTERPRETATION: In middle age, people tend to be less dogmatic about

religious belief, and religion often offers more comfort to the middle-aged
person than it did previously. People in this age group often rely on spiritual
beliefs to help them deal with illness, death, and tradegy.. ( Kozier and Erb’s.
Fundamentals of Nursing 8th edition.Volume 1. P. 400)

ANALYSIS: Spirituality refers to that part of being human that seeks

meaningfulness through intra-, inter-, and transpersonal connection (Reed,
1992). Spirituality generally involves a belief in a relationship with some
higher power, creative force, divine being, or infinite source of energy. For
example, a person may believe in “God”, “Allah”, the “Great Spirit” or a
“Higher Power”. (Kozier and Erb’s Fundamental’s of Nursing p. 1042)

2. Values and Valuing

The client stated, “kasi ayaw talaga ng misis ko yung pagiging malihim ko
minsan, kasi nga mas gusto ko talagang sarilinin kung ako lang naman may
problema. Ayoko kasi idamay sila baka lalo lang maging pabigat sa kanila.” As
stated by the client earlier it is important for him to value other people for they
are important in facing problems.

INTERPRETATION: The person establishes ethical and moral standards that are
independent of the standards of others. The focus shifts from inner self and
being to others and doing. Religious and philosophical concerns become
important. ( Kozier and Erb’s. Fundamentals of Nursing 8 th edition.Volume 1. P.
399)

ANALYSIS: Emotional health depends on a social environment that is free of

excessive tension and does not isolate the persons from others. A climate of
open communication, sharing, and love fosters the fulfillment of the person’s
optimum potential
 IV. Activities of Daily Living:

ADL BEFORE DURING INTERPRETATION

HOSPITALIZATION HOSPITALIZATION AND ANALYSIS

Nutrition Before his hospitalization, During Mr. HLC‘s Mr. HLC’s food intake
Mr. HLC had eaten one hospitalization, he was decreased and
cup of rice and his viand, said that his food controlled during his
chicken adobo. He ate intake is controlled. hospitalization. Food
one match box sized intakes during
chicken and three hospitalization are
potatoes. He drank a closely monitored.
glass of water. During There are different
lunch, since he was busy kinds of diet that is
selling fish balls, he was ordered by the
only able to eat a pack of physician and it must
sky flakes and drank a be strictly
glass of water. During implemented.
dinner, he ate one pack
of lucky me noodles and
two slices of bread. He
also drank a glass of
water.

Elimination Before his hospitalization, Since he got to the Mr. HLC’s elimination
Mr. HLC usually has hospital, Mr. HLC still pattern has been
bowel movement every hasn’t defecated yet. changed since he
day. He said that he only He also urinates less. went to hospital.
defecates once a day. His Since his food and
stool varies light to dark liquid intake is
brown, formed, soft, decreased, Mr. HC
semisolid, moist, and was not able defecate
aromatic. There is no yet and his urine
signs of bleeding or output is decreased.
change in color. He
doesn’t feel any pain or
discomfort during
defecation. He urinates
about ten times a day.
He doesn’t feel any pain
or discomforts when
urinating.
Exercise Before, Mr. HLC usually
wakes up early in the
morning to prepare for
his work, which is selling
fish balls. After that he
performs dumbbell
exercises for about 15
minutes. In the
afternoon, Mr. HLC walks
a lot to sell his fish balls.
Hygiene Prior to hospitalization,
Mr. HLC takes care of his
hygiene by taking a bath
and brushing his teeth
once a day. He said that
he rarely wash his hands
because he is usually
busy working.
Substance Use Prior to hospitalization,
Mr. HLC is a smoker and
a drinker. He said that he
smokes one pack of
cigarette a day and he
drinks gin when he
arrives from work.
Sleep and Rest The patient sleeps late at
night when at home. He
drinks gin to be able to
fall asleep. He usually
sleeps for almost 6-8
hours.
Sexual Activity Mr. HLC said that
because both of them are
busy working, they rarely
perform sexual activities.
But since he got to Mr. HLC’s activity
the hospital, Mr. HLC level has decreased
wasn’t able to since he is at bed
perform any exercise most of the time.
at all. Patients on the
hospital are kept
rested for timely
healing.
During his Mr. HLC wasn’t able
hospitalization, Mr. to take a bath or
HLC wasn’t able to brush his teeth during
take a shower or his hospitalization
brush his teeth. because most of the
time he’s in his bed in
the ward.
During his Mr. HLC is not able to
hospitalization, of smoke and drink in
course, the patient the hospital. These
wasn’t able to smoke things are not
and drink. allowed in the
hospital premises and
it can aggravate his
condition.
His sleep during his His sleep and rest
hospitalization was during hospitalization
intermittent. He were intermittent
sleeps for 30 minutes because of frequent
or for an hour and he vital signs taking and
will wake up to take administering of
his medications and medications.
other stuffs.
Since he got to the Mr. HLC’s sexual
hospital, Mr. HLC and activity was absent
his wife can’t have when he went to the
sexual activities. hospital.
V. Physical Assessment:

A. GENERAL NORMS ACTUAL INTERPRETATION

APPEARANCE FINDINGS AND ANALYSIS

1. POSTURE AND Relaxed, erect Leans forward Normal

GAIT posture; due to
coordinated carbuncle back.
movements.
Needs
assistance
when walking

2. SKIN COLOR Healthy Brown skin Deviation from

appearance color with normal
carbuncle on
the back

3. PERSONAL Clean, neat Dirty in Deviation from

HYGIENE/ appearance normal
No body odor
GROOMING
or minor body With body odor
odor relative to or minor body
work or odor related to
exercise; no poor hygiene;
breath odor. no breath odor.

4. AGE Acts according Acts according Normal

APPROPRIATENES to age. to age.
S

5. VERBAL Understandable Understandable Normal

BEHAVIOR moderate moderate
phase; clear phase; clear
tone and tone and
inflection; inflection;
exhibits exhibits
thought thought
organization. organization.

Logical Logical
sequence; sequence;
makes sense; makes sense;
has sense of has sense of
 reality. reality.

6. NON VERBAL Cooperative, Elicits Deviation from

BEHAVIOR able to follow protective normal
instructions, behavior in IV
appropriate to infusion site.
situation.
Irritable
No distress
Follows
noted.
instructions.

B.
MEASUREMENTS

1. TEMPERATURE (Axillary) 35.9- 36.2°C Normal

36.9°C

2. PULSE RATE 60-100 bpm 92 bpm Normal

3. RESPIRATORY 12-20bpm 15 bpm Normal

RATE

4. BLOOD (systole) 90-140 100/70 mmHg Normal

PRESSURE mmHg

(diastole) 60-
100 mmHg

VI. Laboratory and Examinations Results:

Result Normal Range Analysis

Hemoglobin (Hgb) 101 130-170 Low hemoglobin means
having an anemia
Hematocrit (Hct) 0.295 0.40-0.54 Low hematocrit may be due
to:

•AnemiaAnemia
•Bleeding
•Destruction of red blood cells
•Leukemia
 •MalnutritionMalnutrition
•Nutritional deficiencies of
iron, folate, vitamin B12, and
vitamin B6
•Overhydration
HBA1C 12% 3.90-6.20 This means that the patient is
in greater risk of the different
complications of having
diabetes.
Glucose 19.86 3.88-6.38 An indication of risk in heart
diseases.
Cholesterol 3.91 <=5.20 Normal
HDL direct 0.58 0.91-1.29 A low HDL cholesterol level is
thought to accelerate the
development of
atherosclerosis.
Triglycerides 2.29 0.45-1.81 High triglyceride levels are
associated with an increased
risk of developing heart
disease.
LDL Cholesterol 2.29 3.20-4.10 LDL less than 100 mg/dL (2.59
mmol/L) if you have heart
disease or diabetes
VLDL 1.04 0.20-0.90 High levels may be associated
with a higher risk for heart
disease and stroke.
LDL/HDL Rate 1.54 1.60-6.60 Lower than the normal range.
Chole/HDL Rate 6.74 2.70-8.90 Within normal range.
 DRUG STUDY

DRUG CLASSIFICATION INDICATION ACTION AND CONTRAINDICATION ADVERSE EFFECT

PHARMACOKINETICS

Drug name: Anti-infective Treatment of Action: Hypersensitivity to Body as a whole:

infections due to penicillins;
Ampicillin Sulbactam Antibiotic susceptible organism Antibiotic agent with mononucleosis Hypersensitivity (rash,
in skin and skin broad spectrum of itching, anaphylactoid
Aminopenicillin activity resulting from reaction), fatigue,
structure (e.g.,
klebsiella pneumonia, beta-lactamase malaise, chills,
Dose:
staphylococcus inhibition. Sulbactam headache, edema.
750mg TIV q8 aureus) and inhibits beta-
lactamases most GI:
intraabdominal
infections (e.g., frequently
Diarrhea, nausea ,
Escherichia coli) and responsible for
vomitting, abdominal
for gynaecologic transferred drug
distention,
infections (e.g., resistance. Because
candidiasis.
Bacteroides sp. of this action, a wide
Including B. fragilis). range of Hematologic:
Also used for betalactamases found
infections caused by in organisms resistant Neutropenia,
ampicillin-susceptible to penicillins and thrombocytopenia.
organism. cephalosporins are
inhibited. Urogenital:

Dysuria

Pharmakonectics: CNS:

Peak: Seizure

Immediate after the Other:

IV.
Local pain at injection
Duration: site;
thrombophlebitis.
 6-8hours

Distribution:

Most body tissues;

high CNS
concentrations only
with inflamed
meninges;

Metabolic:

Minimal hepatic
metabolism

Elimination:

Excreted in urine

Half life:

1hour

DRUG CLASSIFICATION INDICATION ACTION AND CONTRAINDICATION ADVERSE EFFECT

PHARMACOKINETICS

Drug name: Central Nervous Effective agent for Action: Hypersensitivity to Body as a whole:
System agent; control of moderate tramadol or other
Tramadol to moderately severe Centrally acting opioid analgesics; Sweating,
Hydrochloride Opiate Agonist; pain. opiate receptore patients on MAO anaphylactic reaction
agonist that inhibits inhibitors; patients
Dose: Narcotic Analgesic the uptake of GI:
acutely intoxicated
norepinephrine and with alcohol, Nausea, constipation,
100mg TIV q8 x 3 serotonin, suggesting hypnotics centrally vomiting, xerostomia,
doses both opioid and acting analgesics, dyspepsia, diarrhea,
nonopioid opioids, or abdominal
mechanisms of pain psychotrophic drugs distetntion,anorexia,
relief. May produce flatulence
opoid like effects, but
causes less Urogenital:
respiratory
Urinary retention/
depression than
frequency
morphine
CNS:

Drowsiness, dizziness,
Pharmakonectics:
vertigo, fatigue,
Absorption: headache,
somnomlence,
Rapidly absorbed restlessness,
from GI tract, 75% euphoria, confusion,
reaches systemic anxiety, coordination
circulation disturbance, sleep
disturbance, seizures
Onset:
Special Senses:
30-60 minutes
Visual Disturbances
Peak:

2 hours

Distribution:

Approximately 20%
bound to plasma
proteins, probably
crosses blood-brain
 barrier

Metabolic:

Metabolized
extensively inliver by
cytochrome

Elimination:

Excreted primarily in
urine

Half life:

6-7 hours

DRUG CLASSIFICATION INDICATION ACTION AND CONTRAINDICATION ADVERSE EFFECT

PHARMACOKINETICS

Drug name: Central nervous Short term Action: Hypersensitivity to GI:

system agent; management of pain ketorolac; individuals
Keterolac It inhibits synthesis of with complete or Nausea, dyspepsia, GI
Tromethamine NSAID analgesics; prostaglandins and is partial syndrome of pain, hemorrhage
peripherally acting nasal polyps,
Dose: Antipyretic analgesics. Ketorolac CNS:
angioedema, and
does not have any bronchospastic
30mg TIV q6 x 4doses Drowsiness, dizziness,
known effects on reaction to aspirin or headache
opiate receptors other NSAIDS;
patients with severe Other:
Pharmakonectics:
renal impairments or
at risk for renal Edema, sweating,
Peak:
failure due to volume pain at the injection
 45-60 minutes depletion; patients site.
with risk of bleeding;
Metabolic: active peptic ulcer
disease; pre- or intra-
Metabolized in the
operatively;
liver
intrathecal or
Elimination: epidural
administration; in
Excreted in urine combination with
other NSAIDS.
Half life:

4-6hour

DRUG CLASSIFICATION INDICATION ACTION AND CONTRAINDICATION ADVERSE EFFECT

PHARMACOKINETICS

Drug name: Gastrointestinal Blocks daytime and Action: Safe use during Body as a whole:
agent nocturnal basal pregnancy or
Ranitidine HCL gastric acid secretion Potent anti-ulcer drug lactation is Hypersensitivity
Antisecretory stimulated by that competitively established. reaction, anaphylaxis
Dose: and reversibly inhibits
histamine and
histamine action at GI:
50mg q8 reduces gastric acid
release in response to H2-receptor sites on
Constipation, nausea,
food, pentagastrin parietal cells, thus
abdominal pain,
and insulin. Shown to blocking gastric acid
diarrhea
inhibit 50% of the secretion. Indirectly
stimulated gastric reduces pepsin Hematologic:
acid secretion. secretion but appears
to have minimal Reversible decrease
effect on fasting and in WBC count,
postprandial serum
gastrin thrombocytopenia
concentrations or
secretions of gastric CNS:
intrinsic factors or
Headache, malaise,
mucus.
dizziness,
Pharmakonectics: somnolence,
insomnia, vertigo,
Peak: mental confusion,
agitation, depression,
2-3 hours hallucinations in
older adult
Duration:
CV:
8-12 hours
Bradycardia
Distribution:
Skin:
Distributed into
breastmilk Rash
Metabolic:

Metabolized in the
liver

Elimination:

Excreted in urine with

some excreted in
feces

Half life:

2-3hours
Paracetamol Adult: 200mg q4 Analgesics (Non- Mild to Not recommended in severe renal impairment (CrCl
Opioid) & moderate pain <10 ml/min), severe respiratory insufficiency, liver
Antipyretics and fever disease or opioid dependent patients. Increased
intracranial pressure or head injury, patients at risk
of seizures or on drugs that may lower the seizure
threshold (e.g. SSRI, TCA, antipsychotics, centrally
acting analgesics or local anaesthesia), biliary tract
disorders, in a state of shock or unconsciousness.
May impair ability to drive or operate machinery.
Avoid abrupt withdrawal. May cause withdrawal
symptoms, dependence and abuse. Elderly.
Pregnancy, lactation.
VIII. Prioritized List of Nursing Problems

Diagnosis Rank Justification

Acute pain r/t debridement of 1 According to Maslow’s

upper Right back as evidence Hierarchy of needs, a person
by verbal Report of pain cannot do certain task when
pain is present. Pain is a factor
in which it may cause
disturbances to a client. Nurse
has resources such as
teaching the client on how to
decrease pain level. This is
also done by reinforcing client
to take pain medications as
needed.

Risk for infection r/t delayed 2 According to Maslow’s

healing of wounds Hierarchy of Needs, since it is
only a risk it is secondary to
the pain that is feeling by the
client , but must be
entertained to prevent further
complication.

Deficient knowledge r/t 3 Since knowledge is important,

unfamiliarity of information the patient should involve in
his treatment process that
may lead to other disease.
Also, if the client is involved
he/she will be less anxious
there for he will be more
cooperative.
IX. Nursing Care Plan

Nursing Diagnosis Goal and Objectives Nursing Intervention Rationale Evaluation

Acute pain related to Goal:

debridement of right After 8 hours of nursing The client verbalized a
upper back as evidenced intervention, client will decrease level of pain.
by verbal report of pain. demonstrate decreased From the pain scale of 7
level of pain. it becomes 5. The goal
Subjective: was achieved.
Objectives:
 Client rated his
pain as 7 out of 1. After the
10 using the pain discussion, client INDEPENDENT:
scale (1 is the will be able to:
lowest and 10 is
the highest) a.Describe the Provide an ample time Providing an enough The client verbalized the
 “ Medyo makirot characteristics of for the client to time for the client to characteristic of pain
lalo na kapag pain she feels in verbalize her feelings. verbalize her feelings and his other
nahihigaan ko 3 mins. promotes individualized complaints.
yung sugat ko.” plan of care.

Objective:
 Appears weak.
 Grimace was b. Return Discuss the proper Discussing proper The client was able to
noted. demonstrate breathing (deep breathing exercise gives demonstrate the proper
 Positioning to proper breathing breathing) exercise. information for the breathing exercise in 2
avoid pain. exercise (deep client. mins.
 Stain of blood on breathing) in 2
his clothes on mins Discuss the advantages Discussing the
the site of the of deep breathing advantages of deep
 wounds. exercise. breathing exercise
 Redness and enhances participation
swelling was of the client.
noted on the
affected site. Demonstrate the proper Demonstrating the deep
technique of deep breathing exercise
breathing exercise. promotes proper
exhibition of the
technique.

c. Perform and Discuss what is all about Discussion provides The client was able to
participate with guided imagery. information for the participate in the
the nurse in client regarding Guided discussion and
guided imagery Imagery. demonstration of guided
as a form of imagery.
relaxation for 2
mins. Discuss the importance Discussion of the The client was able
and benefits of Guided importance of Guided return demonstrate it in
Imagery. Imagery promotes 2 mins.
participation of the
client.

Return demonstrate Demonstration

how to perform proper promotes proper
Guided Imagery as a technique of guided
form of relaxation. imagery as one form of
relaxation.
Encourage client to Reduces muscle fatigue
change position and maximizes
frequently. circulation to tissues.

Monitor vital signs Monitoring is done to

know whether nursing
interventions were
effective.

For baseline data

COLLABORATIVE:

Reinforce the use of To relieve pain.

pain medication
(Tramadol). Reinforcing the use of
pain medications
promotes compliance to
take the medicines.
X. Discharge Plan

Medications:
a. Paracetamol
b. Ranitidine
c. Tramadol

Exercise:

Avoid strenuous exercise until wound at the back has been fully healed.

Treatments:

Wound debridement was done in the hospital to remove pus and abscess from the
carbuncle back.
Continuous blood glucose monitoring is done for the patient with suspected Diabetes
Mellitus.

Health Teachings:
a. Reduce carbohydrate consumption.
b. Avoid sweets
c. Blood glucose monitoring
d. Clean wound site regularly

Out-patient follow-up:

Check-up every 3 months

Diet:
Diabetic Diet
- Avoid sweets and carbohydrates.