Patients Demographic Profile: Name: A.B.

Age: 39 Gender: M Marital Status: Married Address: Tondo, Manila Educational Attainment: HS Graduate Occupation: Tricycle Driver Religion: Roman Catholic Date of Birth: January 20, 1972 Nationality: Filipino Date of Admission: Jan.21, 2011 Primary Language: Tagalog Name of Primary Information Source: A.B. Attending Physician: Roberto Ibanez Chief Complaint Pressing headache during sudden movements with no radiation to other sites with pain scale of 9/10. Associated symptoms are general body malaise and fever for 2 days. History of Present Illness: 7 Days prior to confinement there are undocumented fever, body malaise, vomiting of previous ingested food four times, pressing headache during sudden movements with no radiation to other sites which the cilent graded as 8/10, generalized abdominal pain graded 8/10. Self Medicated Alaxan 1 tab and Bio Flu 250mg twice a day during the onset of symptoms. 6 Days prior to confinement patient felt relieved by the medications taken and go back to his work. After a few hours he felt again the sign and symptoms with the same intensity of pain scale and took again the previous medication taken. 5,4,3 Days prior to confinement patient experience the above sign and symptoms and took the medications stated above. 2 Days prior to confinement patient maculopapular rash starting from trunk extending to extremities. Few hours prior to admission there is severe headache during sudden movements with no radiation to other sites with pain scale of 9/10, decrease food/oral intake, decrease urine output and tea colored urine.

History of Past Illness: The patient had measles and chicken pox during his childhood years. The patient doesnt recall if he had a complete immunization. He was admitted and confined to Jose Reyes Hospital last 1996 due to Hepatitis A and was treated but did not remember the medications prescribed to him. The patient has no allergies to food or medicine, and has no any local and foreign travel. Family History:

Psychosocial History: The client is a 39 years old,male born and raised in Masbate. When he moved to Tondo,Manila and he acquired some health beliefs. Nagtatrabaho ako bilang, tricycle driver sa may blumentritt, araw-araw ako pumapasada dun,umulan man o umaraw, Hindi kasi ako nakatapos ng pagaaral,pag uwi ako hindi ako agad naghuhugas ng paa dahil baka mapasma ako as verbalized by the patient. The client lives in a Squatters area where he rents a studio-type house. He lives with his wife and 8 children.The nearest health facility is two rides away from his house due to his work he doesnt have any difficulty with transportation but due to lack of income he cant afford to have clinical checkup nor to buy medications. Developmental History: Erik Ericksons Stages of Development Generativity vs. Self Absorption and Stagnation Now work is most crucial. Erikson observed that middle-age is when we tend to be occupied with creative and meaningful work and with issues surrounding our family. Also, middle adulthood is when we can expect to "be in charge," the role we've longer envied. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness.

Gordons Functional Health Patterns

HEALTH-PERCEPTION MAINTENANCE PATTERN S> Sa ngayon kasi, masama lang ang pakiramdam ko, parang nanghihina yung katawan ko, wala namang masakit. Sana dumating yung araw na gumaling ako. siyempre ngayon ayoko ng kalagyan ko, matagal na rin kasi nung huli akong na ospital at sana hindi na ulit ako ma ospital Oo umiinom ako ng alak, mga hard kasi iniinom namin e, gabi-gabi yun, depende pa sa kasama kung gaano karami ang iniinom ko, kung mga apat o lima kami, siguro nakakadalawang long neck kami. Pero kahit kailan hindi ako nahilig sa sigarilyo kasi hindi ko nagugustuhan, masakit sa dibdib. Nagtatrabaho ako bilang, tricycle driver sa may blumentritt, araw-araw ako pumapasada dun,umulan man o umaraw, Hindi kasi ako nakatapos ng pagaaral,pag uwi ako hindi ako agad naghuhugas ng paa dahil baka mapasma ako.Hindi ko na nga maalala ang bakuna ko dahil nung kapanahunan ko sa hindi naman uso iyan sa probinsya eh. Oo, na ospital na ako noon, pangalawang beses ko na ito, noon ay dahil sa hepatitis A ang dahilan, mga 1996 pa yun. Nanggagaling lang ang panggastos naming sa pagtatricycle doon kaya ngayong nasa ospital ako nangngutang na lang si misis sa tindahan malapit sa amin, Minsan hindi sapat ang kinikita ko sa panggastusin namin pero pinipilit nalang namin na makabili ng gamot pag may nagkakasakit o kaya mag pa tingin sa doctor , pag ang mga anak ko ang nagkakasakit pinipilit namin na mapatignan sila sa doctor noong una akong nakaramdam ng sintomas hindi ko ininda akala ko noon ay pagod lamang , ininuman ko na lang ng isang tableta ng Alaxan, kasi parang nanghihina ako. Tapos pakiramdam ko ayos na, kinabukasan ng umaga nakaramdam ulit ako ng panghihina ng katawan. Pinilit ko parin mag trabaho pero, nagkalagnat din ako at nanakit ang ulo. Pagkalipas ng ilang araw ay ganoon pa rin kaya nagpadala na ako sa ospital. Wala na akong oras mag ehersisyo dahil maaga akong namamasad. Simula nagkasakit ako, parang nawalan ako ng gana kumain, parang pakiramdam ko, mapapait mga kinakain ko ngayon. as verbalized by the client. O>The patient is oriented to time, place and person, alert and cooperative.. The patient has curly hair with hair flakes and the nails are not trimmed. Skin is warm to touch, break in the skin of the right foot and presence scaling on both soles of the feet due to his work as a tricycle driver. He is ambulatory and can perform ADLs without assistance. A> Ineffective health maintenance related to lack of knowledge as manifested by inapprorpiate health practices. NUTRITIONAL METABOLIC PATTERN S> Noong hindi pa ako nao-ospital, sa almusal kumakain ako ng 2 order ng kanin at 1 order ng gulay. Sa tanghalian naman, ganoon din. Sa hapunan, sa bahay na ako kumakain, kapag sobrang ginanahan akong kumain, nakaka tatlong tasa ako ng kanin at 1 piraso ng isda. Halos gulay at isda ang kinakain ko. Madalang lang ako kumain ng karne ng baboy at manok, halos gulay at isda. Iniiwasan ko din kumain ng matatabang pagkain. Ngayon na-ospital ako, halos wala akong gana sa pagkain. Kung susukatin, ng kinakain ko dati ang nabawas sa pagkain ko ngayon. Kaninang umaga kalahating

kanin at itlog ang kinain ko, nung tanghalian kalahating kanin din at ilang piraso ng manok, ngayon gabi hindi pa ako nakakakain dahil wala akong gana. Nasa oras naman ako kung kumain. Minsan kapag nagiging abala na sa pamamasada, nalilipasan ako ng gutom. Hindi ako umiinom ng mga vitamins o herbal na gamot . Noong di pa ako naospital nakaka 3- 4 Litro ako ng tubig, ganoon din ngayon. Nagkakape ako bawat umaga ng isang tasa. Halos gabi-gabi umiinom din ako ng alak, 4 -5 tao kami nauubos naming minsan yung dalawang long neck. Wala akong problema sa paglunok o pagnguya ng pagkain, wala lang talaga akong panlasa, mapait lang ang nalalasahan ko pag kumakain. Sa ngayon, di nako nagpupunta sa dentista, noon lang kapag nagpapabunot ng ngipin. Nakadama ako ng pagkahilo at pagsusuka noong bago pa lang ako maospital, hanggang 3 araw yun dito sa ospital. Hindi naman ako nakakaranas ng pananakit ng tiyan ngayon. Hindi rin ako gumagamit ng mga gamot sa paninikmura. Kung dati bago ako magkasakit, nasa 66kg. ang timbang ko ngayon 60 kg. nalang. Wala akong ganang kumain dahil wala akong panlasa hindi katulad dati magana. as verbalized by the patient. O> Vital signs are: T: 37.3 C P: 76 Respiratory rate: 30 Height: 55 Weight: 60 kg. BMI: 22. Equal distribution of fat over waist, thighs and triceps is observed. Posture is erect. Skin is smooth, soft, warm, pinched-up skin returns back immediately to original in less than 2 seconds. Capillary refill is less than 2 seconds. Nails are pale, concave and untrimmed. Hair is dry and presence of dandruff is observed. Oral mucosa is dry. Lips are dry, pale and cracked. Tongue is whitish in color. Teeth are malpositioned and some are missing. Gums are smooth, firm and pale. Icteric sclera is observed and increased vascularity of both eyes is observed. Waist circumference is 37 inch. Mid-arm circumference is 27.5 cm. Normoactive bowel sounds. A> Risk for imbalanced nutrition: less than body requirement related to refusal to ingest food. ELIMINATION PATTERN S> Bago ako ma-ospital, normal naman ang pagdumi ko, dalawang beses sa isang araw at kalimitan kulay brown o light brown. Hindi ako gumagamit ng mga gamot na pampadumi at hindi pa ako naooperahan sa kahit anong parte ng kataawan ko. Hindi rin ako madalas magkaroon ng diarrhea o constipation, last year pa ata ako huling nagLBM pero hindi ako umiinom ng gamot para sa sakit sa tiyan. Sa pag-ihi naman, wala rin akong problema noon, kung gaano kadami ang iniinom ko halos ganoon din ang iniihi ko. Kung gaano kadalas ang pag-ihi ko depende sa dami ng nainom kong tubig. Kadalasan, yellow o light yellow ang ihi ko. As verbalized by the patient. Ngayong na-ospital ako isang beses sa isang araw nalang ako nadudumi at naging matubig ang dumi ko. 200cc naman ang naiiihi ko sa isang araw na parang kulay kalawang . Hindi pa ako nagkaroon ng UTI sa tanan ng buhay ako kahit na madalas akong magpigil ng ihi ko dahil nga sa pagbi-biyahe ko ng ilang oras. Wala naman masakit na nararamdaman kapag umiihi ako. Naka-catheter ako ng ilang araw, tapos tinaggal din kaninang umaga. Nakaihi na ako kanina pero yun nga lang kakaunti pa lang. As verbalized by the patient. O> Skin color in the abdomen is paler than the extremities. No presence of rashes or lesions noted. Abdomen is round and symmetrical. Bowel sounds: 5 10 times/min equally in all four quadrants. No friction rubs heard upon auscultation. Tympany is heard

over the stomach, dull over organs, and flat over bones. Tenderness on the right upper quadrant is noted upon palpation. Kidneys are not palpable and non-tender. No genitourinary assessment done. A > Impaired urinary elimination pattern related to infection secondary to leptospirosis; leptospira interrogans blocking the renal tubules as manifested by decrease urine output ACTIVITY-EXERCISE PATTERN S> "Wala naman akong nararamdaman na masakit sa mga kasukasuhan at katawan ko. Madalas na gawain ko sa pang araw-araw, gigising ako ng alas sais ng umaga, tapos magaalmusal ako at saka iinom ng isang tasa ng kape tapos maliligo at mamamasada na ko ng tricycle maghapon. Ang ruta ko biyaheng blumentritt pa rizal avenue. Uuwi ako ng ng mga 9:00 ng gabi tapos kakain ng hapunan at maliligo. Manunuod muna ako ng TV hanggang sa antukin ako, mga 10:00 siguro ako makakatulog nun. Wala na rin akong panahon para makapagexercise dahil sa pamamasada ko. Minsan nakikipaginuman din ako sa mga kabarkada ko kapag gabi, madalas nakakaubos kami ng dalawang long neck" as verbalized by the patient. O> Patient is ambulatory and is not cyanotic, weight is evenly distributed and patient is able to stand erect both on his right and left toes. Extremites are warm to touch. Radial pulses are palpable. There are no noted deviations upon inspection of the spinal column. Client sits and stands erect. No masses, tenderness, and crepitus palpated. Full ROM of the upper extremities, muscle tone of extremities have a grade of 5/5. Shoulders, scapula and posterior hip are non tender upon palpation and is warm to touch, able to shrug shoulders against resistance: 5/5. Biceps and tricep reflexes have a grade of +2, V/S taken are as follows: BP=130/90, T=37.3C, PR=76bpm RR=30cpm. No adventitious breath sounds heard. Posterior and lateral chest are are pinkish, intercostal spaces are even and relaxed. Slope of ribs is less than 90 degress. Diaphragmatic excursion 3 cm bilaterally. Antero-posterior diameter ratio is 1:2. Vibration decreased over periphery of lungs and increased over major airways upon assesment of vocal fremitus. Resonance were percussed on all lung fields. Bronchial breath sounds heard over the trachea, bronchovesicular on the large stem bronchi, and vesicular sounds heard at the periphery of the lungs. Sounds are muffled upon assessment of bronchophony and whispered petroliquy. Muffled "ee" sounds are heard upon egophony. Skin is smooth, evenly colored and warm to touch. No massess, tenderness and swelling palpated. Lower extremities have full ROM , muscle tone of extremities are graded 5/5. Patellar reflexes are present with a grade of +2. Client was able to sense light, dull, and sharp sensations bilaterally, able to to identify correct direction of body part moved. Gait: Toes point out when client is walking, arms swing in opposite direction equally on both sides. A> Sedentary lifestyle r/t lack of time and nature of work

SLEEP AND REST PATTERN S> Hindi pare-parehas ang tulog ko. Pero madalas, mga alas 10 ng gabi, natutulog na ko. Minsan nanonood ng T.V. o kaya umiinom pag hindi ako gaanong pagod. Tapos mga alas 7 gising na ko tapos kaunting almusal at kape lang, papasada na ko. Gusto ko talaga gawan ng paraan para makatulog ako nang maayos at pare-pareho ng oras. Pagkagising ko naman, hindi naman bitin o kulang. Naka tihaya ako kapag natutulog, tapos 1 unan lang ang ginagamit ko. Walan din naman akong iniinom na gamot kapag matutulog at maayos naman ang gising ko." as verbalized by the patient. O> There are no presence of dark circles around the eyes of the patient. He is not easily distracted nor irritated and didn't yawn for the whole physical assessment. No medications needed to induce sleep. A> Readiness for enhanced sleep COGNITIVE-SENSORY PATTERN S> "Naiintindihan ko yung sakit ko. Pinapaliwanag naman ng mga naka-DUTY nurse yung kundisyon ko, na sa mga ihi ng mga hayop ko posible nakuha ito. Hindi ko naman nakakalimutan uminom ng gamot, yung Paracetamol at yung Doxycycline. Mahirap kasi magastos na din para sa aming pamilya. Sinasabi ko sa kanila na paghatihatiin na lang yung gastos, bukod pa yung mga gastos dito sa ospital. Wala naman akong problema pagdating sa pang amoy, paningin at pandinig ko. Pero pakiramdam ko lahat ng kinakain ko mapakla" as verbalized by the patient. O> Patient is responsive, answers the questions by the interviewer, patient has soft voice. He can recall events such as what he was wearing the day. Patient keeps asking questions about the nature of other infectious diseases. the headache starts, that it was raining. Cranial nerve 1 - ability to identify coffee, and calamansi Cranial nerve 2 - vision is 80/20 Cranial nerve 3, 4, 6 - pupils are equal and round reactive to light and accomodation; eyes move in a smooth, coordinated manner in all 6 gaze directions Cranial nerve 5 - identifies light and deep touch, dull and sharp sensations; masseter and temporal muscle bilaterally Cranial nerve 7 - identifies the taste of calamansi, sugar and salt but with delay of 4 seconds; intact facial muscles Cranial nerve 8 - able to hear whisper on both ears Cranial nerve 9 - Swallowing muscles felt when asked, identified correct taste Cranial nerve 10 - Positive gag reflex when assessed with tongue depressor Cranial nerve 11 - good contraction of sternocleidomastoid muscle on opposite side when the patient was asked turn his head Cranial nerve 12 - symmetrical tongue, moves in all directions and movement; bilateral strength A> Readiness for enhanced knowledge

SELF-CONCEPTUAL PATTERN S> Nitong magkasit ako syempre kasama dun ang panghihina ng aking katawan pero kinaya ko naman. Dati nung wala pa akong sakit ako yung nagtratrabaho pero ngayon si misis ang nag-aasikaso ng gawain sa bahay at iba pa pero malapit na din akong gumaling kaya babalik na din ako sa pasada at ngayon madalas na ako maghuhugas ng paa kapag naglakad ako sa putikan o sa basang lugar. as verbalized by the patient. O> Patient is conscious, awake, and responsive. He can verbalize his feelings thoroughly. He is happy and relaxed during the interview, no stuttering, talks in a well modulated voice, uses Filipino language. Good eye contact. Good posture and gait. A> Readiness for enhanced self-concept. SEXUALITY REPRODUCTIVE PATTERN S>Sa ngayon medyo may mga limitasyon na pag dating sa relasyon namin bilang mag asawa partikular na yung sa sex life namin dahil na nga rin dito sa pagkakaospital ko. 8 ang aming anak. Wala namang masakit kapag umiihi. as verbalized by the patient. O> Beard and moustache noted, the private organs were not assesed. A> Ineffective sexuality pattern r/t altered body function ROLE-RELATIONSHIP PATTERN S> Simula nang ma ospital ako, bigla kong naramdaman ang hiya. Alam mo yun, dapat ako ang nagtatrabaho, pero ang mga anak ko na ang gumagawa noon. Medyo nakaka ilang lang kapag ganoon. Tapos kung kani kanino pa humi hiram ng pera ang asawa ko para sa ospital. as verbalized by the patient O> During the course of the affiliation, only the daughter was around and a few visitors that stood there for about an hour. After a series of conversations, the visitors left and the daughter rested again. A> Ineffective Role Performance related to Hospitalization COPING SKILLS S> Magmula ng nagkasakit ako syempre di na ako pumapasada kaya wala na kaming income. Yung misis ko ang dumidiskarte at nangungutang siya sa mga kaibigan niya. Alam ko naman, ako dapat ang dumidiskarte ng pera kaso nga lang nahospital ako, pero napagusapan na namin ng misis ko na magtutulungan kami sa gastusin ngayon at paglabas ng hospital. Siya din ang kausap ko kapag may problema o iniisip ako. As verbalized by the patient. O> Patient is responsive, alert, and conscious. Maintain eye contact during the interview. Family members are there support him. A> Readiness for enhanced coping. VALUE- BELIEF S> Katoliko kami. Nagdadasal ako bago at pagkatapos kumain pati bago matulog. Nagsisimba kami tuwing linggo. Hindi na lang ako nagsisimba ngayong linggo dahil nga nakaconfine ako ngayon. As verbalized by the patient. O> Patient has a rosary and tells eagerly about his religion and beliefs in life. A> Readiness for Enhanced Religiosity.

Laboratory Diagnostic Tests

Complete Blood Count Result Result Unit Reference January 21, January 24, 2010 2011 WBC 10.57 7.42 10^g/L 4.8-10.8 RBC 5.24 4.66 10^12/L 4.7-6.1 HmG 15.27 13.98 g/L 13-17 HcT 46.02 40.7 % 40-52 MCU 87.88 87.34 Fl 82-98 MCH 29.16 30.01 Pg 28-33 MCHC 33.18 34.35 g/L 33-36 Platelet 118 152 10^g/L 150-400 RDW 15.05 14.6 % 11.4-14 Neutrophil 74.6 61.5 % 40-70 Lymphocyte 15.3 25.9 % 19-48 Eusinophil 1 1.7 % 2-8 Monocyte 6.6 7.7 % 3-9 Basophils 2.5 3.2 % 0-5 INTERPRETATION DECREASED PLATELET: -This occurs because the platelet that do circulate are consumed at an accelerated rate, a greater percentage of them than normal are used for routine maintenance of vascular integrity. Urinalysis Report Result Glucose Protein Bilirubin Urobilinogen Ph Blood Ketone Nitrite Leukocytes Clarity Specific Gravity Color Ascorbic Acid RBC WBC Squamous Epithelial Mucous Negative 100mg/dL ++ Negative 2.0mg/dL + 5.0 >=1.0 mg/dL +++ Negative Negative Negative Turbid 1.012 Dark Amber Negative >20/HPF 11-20/HPF Rare Rare Reference <50mg/dl trace <10mg/dl trace <0.5mg/dl + <2.0 mg/dl + <0.03 mg/dL <5mg/dL <0.1mg/dL + <WBCs/UL

Amorphous Crystal

Rare

January 22, 2011 Sodium 125.70mmol/L 135-145 Potassium 3.79mmol/L 3.5-4.5 INTERPRETATION - Leptospira colonizes and multiplies in proximal tubule epithelial cells causing defect in proximal tubules ans to its function which is Na reabsorption. January 24, 2011 (Done Twice) Creatinine Urea Result 281.50 umol/L 13.53 mmol/L Result 3.18 mg/dL 81.25mg/dL Reference 71-115 umol/L 2.50-7.20 Reference 0.79-1.29 15.01-43.24

Creatinine Urea INTERPRETATION - Creatinine is a substance created by the muscles whenever they are used. Both creatinine and urea are markers for harmful toxins that make the kidney not functionable. If the creatinine and urea value are high it only means that the kidney cannot function well.

Anatomy and Physiology

` Urinary System consists of two kdneys, two ureters, the urinary bladder, and the urethra. A large volume of blood flows through the kidneys, which removes substances from the blood to form urine. The urine contains excess water and ions, metabolic wastes such as urea, and toxic substances consumed with food. The urine produced by the kidneys flows through the ureters to the urinary bladder, where it is stored until it is eliminated thouh the urethra.

Drug Analysis
GENERIC NAME Doxycycline MODE OF ACTION INDICATION SIDE EFFECTS NURSING CONSIDERATIONS Take on an empty stomach with a full glass of water Antacids, milk products, and ironsupplements should not be taken until at least 2hrs. after dose was taken Tell patient that he can experience sensitivity to sunlight. Encouraged patient to wear sunscreen and protective clothing Report rash, itching, difficulty of breathing, dark urine or light colored stools.

Bacteriostatic: Inhibits protein synthesis of susceptible Drug Classes: bacteria, causing cell death Tetracycline antibiotic Dosage: 100mg/tab, 1 tab BID

To treat infections caused by uncommon gram-positive, gramnegative organisms, respiratory and skin infections or disorders

nausea and vomiting rash flatulence, abdominal discomfort head ache pruritus epigastric distress

CONTRAINDICATION Contraindicated with allergy to tetracyclines. Use cautiously with RENAL or hepatic impairment

ADVERSE EFFECTS Thrombocytopenia, neutropenia, eosinophilia, leukopenia, hemolytic anemia

GENERIC NAME Penicillin G sodium Drug Classes: Penicillin antibiotic Dosage: 2mill IV q6 After Negative Skin test

MODE OF ACTION

INDICATION

SIDE EFFECTS

NURSING CONSIDERATIONS instruct client to check label w/ regard to administering food monitor renal function to avoid toxic levels

Bactericidal: Inhibits synthesis of cell wall of sensitive organisms, causing cell death.

Treatment of severe infections caused by different organisms

Lethargic, pain, fever, superinfections.

CONTRAINDICATION ADVERSE EFFECTS Hypersensitivity to penicillin, Seizures, gastritis, cephalosporins. bloody diarrhea, nephritis, anemia, Use cautiously with thrombocytopenia, renal disease. wheezing

Monitor serum electrolytes and cardiac status if given by IV infusion. Can cause severe electrolyte imbalances. collect any laboratory culture specimens before initiating penicillin therapy. Report unusual bleeding, sore throat, rash, hives, diarrhea, difficulty of breathing.

Nursing Care Plan

Assessment Subjective: Hindi ako makaihi ng maayos, kaya naka-theter ako isang araw pagkatapos kong ma-admit. 200 cc ang nakukuhang ihi sa akin sa isang araw at kulay kalawang. Tinanggal na kaninang umaga yung catheter, nakaihi na ako pero kakaunti palang. As verbalized by the patient. Objective: -Received patient lying in bed, awake, coherent to person, time and place. Diagnosis Impaired urinary elimination pattern related to anatomical obstruction secondary to leptospirosis; leptospira interrogans blocking the renal tubules as manifested by decrease urine output Rationale Leptospirosis colonizes and multiplies in proximal tubules epithelial cells causing defect in proximal tubules and to its function which is Na reabsorption (Vaccines for bio-defenses and emerging and neglected disease) Planning Goal: After 12 hours of nursing intervention, the client will achieve normal elimination pattern and participate in any means to accomplish it Objectives: After 2 hours of nursing intervention, the client will: -identify factors that may contribute to his disease the condition -verbalize understanding of his disease. -demonstrate behaviors /techniques to prevent urinary infection Intervention 1.Assessed Elimination pattern 2.Assessed vital signs 3. Monitored intake and output closely Rationale To get baseline data for further comparison Evaluation Goal: After 12 hours of nursing intervention, For baseline the client is data able to achieve normal elimination This shows any pattern and discrepancy participate in between the any means to normal and accomplish it abnormal values Objectives: This After 2 hours of encourages the nursing patient for intervention, bladder training the client is able to: -identify factors that may To provide a contribute to more natural his disease the setting for condition voiding -verbalize understanding of his disease. To relax the -demonstrate sphincters behaviors /techniques to prevent

4.Encouraged normal voiding patterns including privacy, ensuring an environment and body position conducive to voiding

-Urine output of 200cc/day

5.Assisted the patient with the use of bathroom when voiding. 6. Instructed patient to apply warm compress to the perineum 7.Encouraged patient to perform simple trigger techniques Such as turning on the water faucet while the patient is trying to void 8. Instructed patient that he can perform other trigger techniques such as stroking the abdomen or inner thighs,

This trigger technique encourages voiding

urinary infection

These can also trigger the patient to void

To determine if the bladder has not emptied completely

tapping above the pubic area, and dipping the To reduce risk patients hands for infection in warm water. 9. Instructed the patient to be alert for any signs that indicate full bladder such as perspiration, cold hands or feet, or feeling of anxiety 10. Emphasize importance of keeping area clean and dry

Nursing Care Plan

Assessment Subjective: wala lang talaga akong panlasa, mapait lang ang nalalasahan ko pag kumakain. dahil wala akong panlasa hindi katulad dati magana. as verbalized by the patient. Kung dati bago ako magkasakit, nasa 66kg. ang timbang ko ngayon 60 kg. nalang. Wala akong ganang kumain Objective: Impaired oral mucous membrane related to poor oral hygiene and care as manifested by dry lips and mouth and diminished taste Disruption of the lips and / or soft tissue of the oral cavity Diagnosis Rationale Planning GOAL : AFTER 24 HOURS OF NURSING INTERVENTION THE PATIENT WILL BE ABLE TO DISPLAY INTACT MUCOUS MEMBRANES, WHICH ARE PINK, MOIST, AND FREE OF INFLAMMATION/ULCER ATIONS OBJECTIVE: AFTER 1 HOUR OF NURSING INTERVENTION THE PATIENT WILL BE ABLE TO DEMONSTTRATE TECHNIQUES TO RESTORE/MAINTAIN INTEGRITY OF ORAL MUCOSA. Intervention Independent 1.assess mucous membranes / docuyment all oral lesion. Note reports of pain, swelling, difficulty with swallowing or chewing. 2.provide oral care daily and after food intake, using soft toothbrush, nonabrasive toothpast, nonalcohol mouthwash, floss, and lip moisturizer EDEMA, OPEN LESIONS, AND CRUSTING ON ORAL MUCOUS MEMBRANES AND THROAT MAY CAUSE PAIN AND DIFFICULTY WITH CHEWING / SWALLOWING ALLEVIATES DISCOMFORT, PREVENTS ACID FORMATION ASSOCIATED WITH RETAINED FOOD PARTICLES, AND PROMOTES FEELING OF WELL-BEING Rationale Evaluation After 24 hours of nursing interventio n, the patient displayed intact mucous membrane s that are pink, moist, free of inflammati on and / or ulcerations

3.suggest use of sugarless gum/candy or

STIMULATES FLOW OF SALIVA TO NEUTRALIZE

Vital signs are: T: 37.3 C P: 76 Respiratory rate: 30 Height: 55 Weight: 60 kg. BMI: 22 Oral mucosa is dry. Lips are dry, pale and cracked. Tongue is whitish in color. Icteric sclera is observed and increased vascularity of both eyes is observed. Waist circumferenc e is 37 inch. Mid-arm circumferenc e is 27.5 cm.

comnmercial salivary substitute.

ACIDS AND PROTECT MUCOUS MEMBRANES

4.plan diet to avoid salty, spicy, abrasive, and acidic foods or beverages.Offer cold/smooth foods.

ABRASIVE FOODS MAY OPEN HEALING LESIONS. OPEN LESIONS ARE PAINFUL AND AGGRAVATED BY SALT, SPICE, ACIDIC FOOD/BEVERAG ES. EXTREME COLD OR HEAT CAN CAUSE PAIN TO SENSITIVE MUCOUS MEMBRANE MAINTAINS HYDRATION; PRWEVENTS DRYING OF ORAL CAVITY

5.encourage oral intake of atleast 2500ml/day

COLLABORATI VE 1.refer for dental

MAY REQUIRE ADDITIONAL THERAPY TO

consultation if appropriate

PREVENT DENTAL LOSSES.

Nursing Care Plan

Assessment Subjective: Oo umiinom ako ng alak, mga hard kasi iniinom namin e, gabi-gabi yun, depende pa sa kasama kung gaano karami ang iniinom ko, kung mga apat o lima kami, siguro nakakadalawan g long neck kami. Nagtatrabaho ako bilang, tricycle driver sa may blumentritt, araw-araw ako pumapasada dun,umulan man o umaraw, Inability to Ineffective identify, health manage,and/ maintenanc or seek out e related to help to social belief maintain as health. manifested by health practices Diagnosis Rationale Planning GOAL : AFTER 24 HOURS OF NURSING INTERVENTION THE PATIENT WILL BE ABLE TO ADAPT LIFESTYLE CHANGES SUPPORTING INDIVIDUAL HEALTHCARE GOALS. OBJECTIVE: AFTER 1 HOUR OF NURSING INTERVENTION THE PATIENT WILL BE ABLE TO VERBALIZE UNDERSTANDIN G OF FACTORS CONTRIBUTING TO CURRENT SITUATION. Intervention Independent 1. Note clients age and level of dependence/inde pendence. Rationale Evaluation

2. Determine level of adaptive behavior, knowledge, and skills about health maintenance, environment and safety. 3. Discuss with client/SO beliefs about health and reasons for not following prescribed plan of care. 4. Evaluate environment

- May range from complete dependence (dysfunctional) to partial or relative independence requiring support in a single area. - Determines beginning point for planning and interventions to assist client in addressing needs.

- Determines clients view about current situation and potential for change.

AFTER 24 HOURS OF NURSING INTERVEN TION THE PATIENT WAS ABLE TO ADAPT LIFESTYL E CHANGES SUPPORTI NG INDIVIDUA L HEALTHC ARE GOALS.

OBJECTIV E: AFTER 1 - To note individual HOUR OF adaptation needs. NURSING INTERVEN

Hindi kasi ako nakatapos ng pagaaral,pag uwi ako hindi ako agad naghuhugas ng paa dahil baka mapasma ako.

5. Develop plan with client for self care.

Objective: patient has curly hair with hair flakes and the nails are not trimmed.

6. Encourage socialization and personal involvement

7. Provide information about individual healthcare needs, using clients preferred learning style 8. Help client develop realistic healthcare goals. Provide a written copy to those involved in the planning process. Dependent 1. Evaluate for substance abuse/use.

- Allows for incorporating existing disabilities with clients desires and ability to adapt and organize care activities. - To enhance support system, provide pleasant stimuli, and prevent permanent regression. - To assist client in understanding own situation and enhance interest/involvment in meeting own health needs. - For future reference/revision as approrpiate.

TION THE PATIENT WAS ABLE TO VERBALIZ E UNDERST ANDING OF FACTORS CONTRIB UTING TO CURRENT SITUATIO N.

- Affects clientss desire/ability to help self.

2. Monitor adherance to prescribed medical regimen Collaborative 1. Provide for communication and coordination between the healthcare facility team and community healthcare providers. 2. Identify ways to adapt things in current circumstances.

- To problem solve difficulties in adherance and alter the plan of care as needed. - To provide continuation of care.

- To meet clients changing needs and abilities/ environmental concerns