case study
TRANSCRIPT
FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
A CASE STUDY
ON
ACUTE GASTROENTERITIS
(AGE)
SUBMITTED BY: Noriel i. fabros
Franchesca michaella s. llagas
FE MARIE LIANA GONZALES
I. INTRODUCTION
Gastroenteritis is the infection or irritation of the digestive tract, particularly thestomach and the intestines. It is also known as gastric flu/ stomach flu, although it is notrelated to influenza. It is usually consist of mild to severe diarrhea that may beaccompanied by loss of appetite, nausea, vomiting, cramps and discomfort in theabdomen. Although Gastroenteritis usually is not serious for healthy adults, it can causelife-threatening dehydration and electrolyte imbalance in very ill, the very young and thevery old.(Merck Manual)
Gastroenteritis is a very common disease; most people are at some risk toencounter the widespread causes (mainly viral and bacterial). This risk is due to poor hygiene of a few people with the disease that may be encountered frequently in dailyliving (for example, infants, children, or some food handlers). Some people have higher risk for infection; for example, individuals on cruise ships or those that live or work incrowded conditions like child care centers, dorms, or barracks, because of the higher chance that an infected person will come in contact with many other people, and rapidlyspread the causative agent.( www.medicinenet.com )
II. NURSING HISTORYA. BIOGRAPHIC DATA
NAME: Christian Paul Manic ADDRESS: 5C Santos Balong-Bato, San JuanAGE: 6 years oldGENDER: Male DATE OF BIRTH: April 14, 2005 PLACE OF BIRTH: San Juan Medical Center NATIONALITY: Filipino ETHNIC GROUP: none PRIMARY LANGUAGE: Tagalog, Ilokano MARITAL STATUS: n/aEDUCATIONAL: Grade 1OCCUPATION: Student RELIGIOUS ORIENTATION: Catholic HEALTH CARE FINANCING: From their monthly income INCOME: work- 9,000; no work- from grandmother (father side)
III. Nursing History
B. PAST HEALTH HISTORY
The child’s immunization is complete. Last year, he has been hospitalized once because of Asthma. He was prescribed to take Salbutamol for his medication. Mrs. Manic explains that whenever she gives Salbutamol to her child, his condition aggravates. She stops giving Salbutamol and decided to go to Health Center. She asked the Barangay Health worker to nebulize her child every time his Asthma aggravates. The child is allergic to chicken, egg, dust, pollens, molds, and latex. They always ask the doctor’s prescription for any other medications. No foreign travel.
C. HISTORY OF PRESENT ILLNESS
History revealed that two days before the interview, the child had acute gastroenteritis and experienced diarrhea. The child’s stool was soft and experienced abdominal cramps
D. FAMILY HISTORY OF ILLNESS
They have history of Asthma on the mother side.
IV. FUNCTIONAL HEALTH PATTERNS
E. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN
The mother considers the patient’s health so important. She assures that her child receives enough nutrition and is alert to any abnormal condition his son is experiencing. Whenever her son has cough, she gives him home remedies in which if does not alleviate makes her decide to bring him on health center. She ensures that she is focused on her child’s health.
Analysis:
Health is the general condition of a person in all aspects. It is also a level of functional and/or metabolic efficiency of an organism, often implicitly human. WHO (1986) Concepts of Health Behavior Research, Reg. Health Paper No.13, SEARO, New Delhi.
Interpretation: Since the client is in good condition, the client is within normal.
E. NUTRITIONAL AND METABOLIC PATTERN
The child used to eat foods with soup like sinigang na baboy, tinolang manok. He is not fund of eating vegetables and often eat junk foods and noodles like pancit canton and lucky me. He drinks bear brand Chocó, sometimes coffee; every morning. At home, he eats with his family and at school, with his classmates. The child don’t feel any discomforts when eating and lost weight because of AGE. In terms of dental condition, he has complete teeth and has eight dental carries. His mother that his child seldom brushes his teeth, usually once a day or sometimes he doesn’t brush at all.
Analysis: Nutrition describes the processes by which all of the food a person eats are taken in and the nutrients that the body needs are absorbed. Good nutrition can help prevent disease and promote health. Adults who are physically active and who strength train or pursue athletic activities will have different nutrition needs than typical adults of the same age. Dietary Guidelines for Americans 2005.Washington, D.C.: U.S. Department of Health and Human Services, U.S. Department of Agriculture, 2005.
Interpretation: the client food intake is not balance, which makes his nutrition not normal.
F. ELIMINATION PATTERN
The child eliminates normally, usually 2-3 times a day. The consistency is good and the color is brown. No feeling of discomforts and pain. The mother verbalized that her child had diarrhea last week, which causes changes on the bowel elimination pattern. The child eliminates very often, the stool is yellowish, soft, watery and bubbly. There is inconsistency upon defecation, very much discomfort and pain. In terms urination, he usually urinates four times a day, yellowish in color, aromatic, and no feeling of discomfort and pain. The child used to play basketball that causes excessive perspiration and odor problems.
Analysis:
Urinary elimination and elimination of the waste products of digestion from the body is essentials to health, voiding can be postponed for only so long before the urge normally becomes to great to control. The normal color of urine is straw, amber or transparent. The volume ranges from 250-450 ml. ( Fundamental of Nursing Vol. 2 by Kozier and Erb’s 2008, page 1285, 1293)
Defecation is the expulsion of feces from the anus and rectum. The frequency of defecation is highly individual, varying from several times per day 2 – 3times per week. The color of thestool in adult is brown, The consistency is either formed, soft, moist and semi-solid. It is cylindrical in shape. The amount varies in the client’s diet and aromatic in odor.( Fundamentals of Nursing Vol 2 by Kozier and erb’s 2008 page 1325)Interpretation: the clients elimination pattern is normal
G. ACTIVITY AND EXERCISE PATTERN
Every morning, usually when schooldays, they walk their way to school. He usually plays outside their house after classes, usually 4-5 hours. He plays basketball very often, usually after classes and weekends.
Analysis:Exercise is essential for maintaining mental and physical health( Fundamentals of
nursing by Kozier and Erb’s vol 2 page 1113)
Interpretation: The client has good activity and exercise pattern.
H. SLEEP AND REST PATTERN
The client usually sleeps from 8:00 pm to 7:00 am, when he doesn’t have classes, and he sleeps from 8:00 pm up to 5:30 am when he have classes. The client verbalized that he feels refreshed when he wake up and doesn’t have any problem with the environment. He seldom takes a nap and when he does, it’s usually in the afternoon.
ANALYSIS:The school age child (5 to 12 years) needs 10-11 hours of sleep, but most receive less
because of increasing demands( e.g. homework, sports, social activities). They may also spending more time at the computer and watching TV. Some may drinking caffeinated beverages. All of these activities can lead to difficulty of falling asleep and fewer hours of sleep. ( Fundamentals of Nursing Vol 2 Kozier and erb’s page 1167-68)
Interpretation: the client has normal sleeping pattern.
I. COGNITIVE-PERCEPTUAL PATTERN
The client can read and write, he doesn’t have difficulty in auditory and vision. The client is not wearing eyeglasses. For him, the easiest way to learn things is to read, write and listen. He doesn’t have any problems with speaking but he has difficulty in reading English words. There are no changes in olfactory and taste.
Analysis:The ages 7-11 mark the phase of concrete operations. During this stage the child
changes from egocentric operations to cooperative interactions to cooperative interactions. (Fundamentals Of Nursing 7th edition vol. 1 by Kozier page382)
Interpretation: the client is in normal condition.
J. ROLE AND RELATIONSHIP PATTERN
According to the mother, he is a very active child and does not cry easily. He recognizes the people around him and play with them. He has a younger brother and they kept on playing with each other when he was around. He can cope easily with other person.
Analysis:The effectiveness of family communication determines the family’sability to
function as a cooperative, growth-producing unit. The information transmitted influences how members work together, fulfil their assigned roles in the family, incorporate family values, and develop skills to function in society. (Kozier, B. Fundamentals of nursing. 8 th
edition, Vol.I, p.429,534)
Interpretation: The client has a good social interaction.
K. SEXUALITY AND REPRODUCTIVE PATTERN
Prior to his age, the patient is not yet oriented with any sexual matters. According to his mother, he has not yet circumcised.
L. COPING AND STRESS TOLERANCE PATTERN
The child is not easily irritated and he is a jolly kid. He is fond of playing with people around him. He said that one of the stressful events for him was to play outside the house. He reduces his stress by entertaining himself with the different things around him.
Analysis:Stress can have physical, emotional, intellectual, social, and spiritual consequences.
Physically, stress can threaten a person’s physiologic homeostasis. Emotionally, stress can produce negative or nonconstructive feelings about the self. Intellectually, stress can influence a person’s perceptual and problem-solving abilities. Socially, stress can alter a person’s relationship with others. Spiritually, stress can challenge one’s beliefs and values. When a person faces stressors, responses are referred to as coping strategies, responses or mechanisms. Coping is the cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as taxing or exceeding the resource of the person. (Kozier, B. Fundamentals of nursing. 8th edition, Vol.II, p.1061)
Interpretation: the client has normal coping pattern
M. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
According to the mother he’s a good son though sometimes he tends to disobey his parents. Her mother said this is normal for his age.
Analysis:Self-concept is one’s mental image of oneself. A positive self-concept is essential to a person’s mental and physical health. Individuals with a positive self-concept are better able to develop and maintain interpersonal relationships and resist psychologic and physical illness. An individual possessing a strong self-concept should be better able to accept or adapt to changes that may occur over the life-span (Kozier, B. Fundamentals of nursing. 8th edition, Vol.II, p.1003)
Interpretation: the client’s condition does not affect his self concept.
N. VALUE AND BELIEF PATTERN
He is a Roman Catholic. They attend mass regularly. He afraid to do something bad because he believes that God will punish him.
Analysis: According to Fowler, the school age child is at stage 2 in spiritual development, the mythical literal stage. Children learn to distinguish fantasy from fact. Spiritual facts are those beliefs that are accepted by a religious group, whereas fantasy is thoughts and images formed in child’s mind.
Interpretation: the child has good spiritual development, he thinks god as an old man who punishes when behavior does not meet his standards.
V. PHYSICAL ASSESSMENT
FINDINGS NORMS ANALYSIS AND INTERPRETATION
Height 112.5 cm
Weight 18 kg
BMI 14.32
Temperature 36.9 degrees C 37-37.6 degrees C Normal
Pulse rate 98bpm 75-120bpm Normal
Respiratory rate 21cpm 25-30cpm Normal
B. P. Not assessed
GENERAL SURVEY
Body Parts Assessed Norms & Standards Actual Finding Analysis
Body built height and weight in relation to
the client’s age, health and lifestyle.
Proportionate, varies with lifestyle
Proportionate
Normal
Client’s posture and gait, standing, sitting,
and walking
Spinal Curvature posture coordinated movement
Spinal Curvature posture coordinated
movement
Normal
Client’s overall hygiene and grooming
Clean, neat unclean, he’s wearing t shirt and short, hands
are visibly dirty.
Hygiene is a highly personal matter
determined by individual values and practices. It
involves care of the skin, hair, nails, ears, eyes, nose
and teeth.
Body breath and odor No body odor or minor body odor relative to work
No body odor relative to immobilization;
or exercise;
No breath odor
presence of breath odor.
Normal
Signs of distress, in posture of facial
expression
No distress noted No distress noted Normal
Signs of health or illness
Healthy appearance Healthy appearance Normal
Client’s attitude Cooperative He’s cooperative. Normal
Client’s affect mood;
Appropriateness of client’s response
Appropriate to situation His mood and responses is
appropriate to the situation.
Normal
Quantity and quality of speech
Understandable, moderate pace; exhibits thought
association
He has a moderate tone of voice.
Normal
Relevance and organization of
thought
Logical sequence; makes sense; has sense or reality
Organization of thought has sense.
Normal
HEADBody Parts Assessed Norms & Standards Actual Finding Analysis
SKULLSkull size, shape or
symmetryRounded (normocephalic
and symmetrical, with frontal, parietal, occipital
prominences; smooth skull contour
Rounded ( normocephalic and symmetrical, with
frontal, parietal, occipital prominences and has smooth skull contour
Normal
Nodules, masses and depressions
Smooth, uniform consistency;
Absence of nodules or masses
Uniform consistency, absence of nodule and
masses
Normal
SCALPColor and appearance Hair is evenly distributed;
lighter than the skin color; no dandruff.
Evenly distributed no dandruff.
Normal
Areas of tenderness No tenderness No tenderness NormalHAIR
Evenness of growth,thickness or thinness
Evenly distributed hair; black in color, thick hair no
lice and nits.
Evenly distributed hair; thick hair, black in color,
no lice and nits.
Normal
texture and oiliness over the scalp
silky, resilient hair Silky hair Normal
FACEFacial features,
symmetry of facial movements
Symmetrical or slightly asymmetrical facial features;
palpebral fissures equal in size; symmetric nasolabial
folds; symmetric facial
Symmetrical or slightly asymmetrical facial
features; palpebral fissures equal in size; symmetric
nasolabial folds;
Normal
movements symmetric facial movements
EYESBody Parts Assessed Norms & Standards Actual Finding Analysis
EYEBROWSHair distribution,
alignment, skin and quality movement
Hair evenly distributed; skin intact; symmetrically
aligned; equal movement
Hair evenly distributed, symmetrically aligned,
equal movementNormal
EYELASHESHair distribution and
direction of curlEqually distributed; curled
slightly outwardEqually distributed curled
slightly outwardNormal
EYELIDSSurface characteristics,
position in relation to the cornea, ability to blink
and frequency of blinking
Skin intact; no discharge; no discoloration; lids close
symmetrically; Approximately 15-20 blinks
per minute; bilateral blinking; when lids are open, no visible sclera
above corneas, and upper and lower borders of
corneas areas are slightly covered
Skin intact with no discharge , no
discoloration, lids close symmetrically;
18 blinks per minute; bilateral blinking; when lids are open, no visible
sclera above corneas, and upper and lower borders of corneas areas are slightly
covered
Normal
CONJUNCTIVAColor, texture, and
presence f lesions in bulbar conjunctiva
Transparent; capillaries sometimes evident, sclera
appears white (yellowish in dark skinned clients)
Transparent, sclera appears white
Normal
Color, texture, and presence of lesions in palpebral conjunctiva
Shiny, smooth, and pink or red
Shiny, smooth, and pink in color
Normal
SCLERAColor and clarity White Sclera appears white. Normal
CORNEAClarity and texture Transparent, shiny and
smooth; details of the iris are visible. In older people, a thin, grayish white ring around the margin, called
senilis, may be evident
Visible clear covering; details of the iris are
slightly visible.Normal
IRISShape and color Round and flat Round and flat, brown iris,
there is a clear coveringNormal
PUPILSColor, shape and symmetry of size
Black in color; equal in size; normally 3-7 mm in
diameter; round smooth border
Black in color, approximately 5mm in
diameter and equal in sizeNormal
Light reaction and accommodation
Illuminated pupil constricts (direct response); Non-
illuminated pupil constricts (consensual response) ; Pupil constricts when looking at near object;
pupils dilate when looking at far object; pupil is
Illuminated pupil constricts (direct response); Non-illuminated pupil constricts (consensual response) ; Pupil constricts when looking at near object; pupils dilate when looking
Normal
converge when near object is moved toward nose
at far object; pupil is converge when near object is moved toward nose
VISUAL ACUITYNear vision Able to read newsprint held
at distance of 36 cm (14 in)Able to read newsprint
held at distance of 36 cm. NormalDistance vision 20/20 vision on snellen chart Not assessed
-----LACRIMAL GLAND, LACRIMAL SAC and NASOLACRIMAL DUCT
Inspect and palpate No edema or tearing;No tenderness; no masses
No edema or tearing;No tenderness; no masses Normal
EXTRAOCULAR MUSCLESAlignment and
coordination of both eyes
Both eyes coordinated move in unison, with parallel
alignment
Both eyes coordinated move in unison, with
parallel alignmentNormal
VISUAL FILEDSPeripheral fields Client can see the object to
the peripheryClient can see the object to
the peripheryNormal
EARSBody Parts Assessed Norms & Standards Actual Finding Analysis
AURICLESColor, symmetry and
positionColor same as facial skin;
symmetrical; Auricle aligned other cantus of the
eye, about 10° from vertical
Color same as facial skin; symmetrical; Auricle
aligned other cantus of the eye
Normal
Texture, elasticity and areas for tenderness
Mobile, firm and not tender; pinna recoils after it is
folded
Mobile, firm and not tender; pinna recoils after
it is folded
Normal
EXTERNAL EAR CANALPresence of cerumen, skin lesions, pus and
blood
Distal third contains hair follicles and glands; dry cerumen, grayish-tan in
color, or sticky, wet cerumen on various shades
of brown
There is a presence of dry cerumen. Color yellow
Normal
HEARING ACUITY TESTResponse to normal
voice tonesAudible to normal voice
tonesAudible to normal voice
tonesNormal
Watch tick test Able to hear the ticking both ears
Able to hear the ticking both ears
Normal
Weber’s test Sound is heard in both ears or localized at the center of the head (Weber negative)
Sound is heard in both ears or localized at the center of the head (Weber negative)
Normal
Rinne Test Air conducted (AC) hearing is greater than bone-
conducted (BC) hearing, (Rinne Positive)
Air conducted (AC) hearing is greater than bone-conducted (BC)
hearing, (Rinne Positive)
Normal
NOSEBody Parts Assessed Norms & Standards Actual Finding Analysis
Deviations in shape, size, Symmetric and straight; no Symmetric in shape,
or color, and flaring or discharge from snares
discharge or flaring; uniform color
straight;has uniformity in color; any discharge has
not been assessed because of discomfort it may give
to the patient.
Normal
Presence of redness, swelling, growths and discharge in the nasal
cavities
Mucosa is pink;Clear watery discharge;
No lesion
There is clear watery discharge with no lesion
Normal
Nasal septum between nasal chambers
Nasal septum is intact and in midline
Nasal septum is intact and in midline
Normal
Patency of both nasal cavities
Air moves freely as the client breathes through the
nares
Air moves freely as the client breathes through
the nares
Normal
Tenderness, masses displacements of bone
and cartilage
No tenderness; No lesion There is no tenderness and lesion.
Normal
Locate/plapate/identify the sinuses and note for
tenderness
No tenderness in frontal and maxillary sinuses
There is no tenderness in the sinuses. Normal
MOUTHBody Parts Assessed Norms & Standards Actual Finding Analysis
LIPSSymmetry of contour,
color and textureUniform pink color; soft; moisturized; able to purse
lips
Uniform pink color; soft; moist.
Normal
MUCOSAColor, moisture, texture and presence of lesions
Uniform pink color ( freckled brown
pigmentation in dark-skinned clients); moist,
smooth, soft, glistening and elastic texture (drier buccal mucosa on elderly is due to
decreased salivation)
Uniform pink in color, moist, smooth, soft and
elastic texture.Normal
TEETH
Color, number and condition; presence of
dentures
24 teeth; smooth, white, shiny tooth enamel; smooth
and intact dentures
24 teeth ; brown discoloration of the
enamel; 8 dental carries.
The brownish discoloration in the teeth is due to lack of oral hygiene.
GUMSColor and condition Pink gums (bluish or dark
patches in dark skinned clients) ; No retraction of gums (pulling away from
the teeth)
Pink gums, no presence of retraction. Normal
FRENULUM and UVULAColor and texture of the Smooth tongue base with Smooth tongue base with
mouth floor and frenulum
prominent veins prominent veins Normal
Position, color, texture, movement and base of
the tongue
Central position; pink in color (some brown
pigmentation on tongue borders in dark skinned clients); moist; slightly
rough, thin whitish coating; smooth. lateral margins; no
lesions; raised papillae; moves freely; no tenderness
Central position; pink in color, thin whitish coating; smooth. lateral margins; no
lesions; raised papillae; moves freely; no
tenderness.
Normal
Nodules, lumps or any excoriated areas
Smooth with no palpable nodules
Not assessed -----
Color, shape, texture and the presence of bony
prominences
Light pink smooth soft palate; lighter pink hard
palate; more regular texture
Not assessed-----
Position of the uvula and mobility while
examining the palate
Positioned in the midline of the soft palate
Positioned in the midline of the soft palate Normal
TONSILColor and texture Pink in color and smooth
posterior wall Pink in color and smooth posterior wall
Normal
Size of the tonsil, color and discharge
Pink and smooth; No discharge; No deviation
from normal sizePink and smooth; No
discharge; No deviation from normal size
Normal
INTEGUMENTARY
Body Parts Assessed Norms & Standards Actual Finding Analysis
SKIN
Skin Color; uniformity of color
Varies to light to deep brown; from ruddy pink to light pink; from yellow over
tones to olive.
Generally uniform except in areas exposed to the sun;
areas of lighter pigmentations(palms, lips, nail beds) in dark skinned
people
Deep Brown skin color
Normal
Presence of edema No edema No edema Normal
Lesions according to location, distribution, color, configuration, size, shape, type or
structure
Freckles, some birthmarks, some flat and raised nevi;
no abrasions or other lesions
There is presence of nevi and lesions.
Skin lesions are due to trauma and infection
due to initial response to some changes in the
external and internal environment.
(Kozier and Erbs. Fundamentals of Nursing pg 566)
Skin moisture Moisture is skin folds and the axillae
Excessive dryness In AGE the hallmark symptoms are nausea, vomiting, and diarrhea
which leads to dehydration.
(www.WD.com)Skin temperature Uniform, within normal
rangeUniform, within normal
rangeNormal
Skin turgor When pinched, skin springs back to previous state
Skin moves back slowly
NAILS
Fingernail plate shape to determine its
curvature and angle
Convex curvature; angle of nail plate about 160°
Concave curvature and angle of nail plate is
about 160º.
Normal
Fingernail and toenail bed color
Highly vascular and pink in light skinned clients; dark skinned client may have
brown or black pigmentation in
longitudinal streaks
Jaundiced color of the fingernails
Normal
Fingernail and toenail texture
Smooth texture Smooth texture Normal
Tissues surrounding nails
Intact epidermis Intact epidermis Normal
Blanch test of capillary refill
Prompt return of pink or usual color (generally less
than 4 seconds)
Prompt return of pink or usual color (generally less than 4 seconds)
Normal
NECK and LYMPH NODESBody Parts Assessed Norms & Standards Actual Finding Analysis
LYMPH NODESLocate/palpate/identify lymph nodes and note for tenderness
Not palpable Not palpableNormal
TRACHEAPlacement Central placement in
midline of the neck; spaces are equal on both
spaces
Not assessed----
THYROID GLAND
Symmetry and visible masses Not visible on inspection; Thyroid ascends upon
swallowing
Not assessed----
Smoothness and areas of enlargement, masses or
nodules
Lobes may not be palpated; If palpated,
lobes are small, smooth, centrally located, painless
and rise freely with swallowing
Not assessed ----
THORAXBody Parts Assessed Norms & Standards Actual Finding Analysis
POSTERIOR THORAXSize, shape, symmetry, and compare the diameter of the
anteroposterior thorax to transverse diameter; skin
color
Anteroposterior to transverse diameter in
ratio of 1:2; Symmetric chest
Not assessed ----
Spinal alignment Spine vertically aligned Not assessed ----Temperature, tenderness and
massesUniform skin
temperature; skin intact; No tenderness; No
masses
Not assessed ----
Respiratory excursion full and symmetric chest expansion
full and symmetric chest expansion
Normal
Vocal fremitus Bilateral symmetry of vocal fremitus; Fremitus is heard most clearly in the apex of the lungs
Bilateral symmetry of vocal fremitus; Fremitus is heard most clearly in the apex of the lungs
----
Percuss the posterior thorax Percussion notes resonate except over the scapula; Lowest point of
resonance is at the diaphragm
Not assessed ----
Auscultate the posterior thorax
Vesicular and bronchovesicular breath
sounds
Presence of adventitious breath
sounds( wheezes).
Asthma involves a process that produce mucosal
edema, mucus secretion and airway inflammation, when people with asthma are exposed to extrinsic allergens and irritants, their airways become
inflamed which causes wheezing initial clinical
manifestation.( Medical Surgical
Nursing Vol. 2 8th EditionANTERIOR THORAX
Breathing Pattern quiet, rhythmic and effortless respirations
quiet, rhythmic and effortless respirations Normal
Temperature, tenderness, and masses
uniform skin temperature; skin intact
No tenderness; no masses
uniform skin temperature, skin intact
No tenderness and masses
Normal
Respiratory excursion full and symmetric chest expansion
full and symmetric chest expansion
Normal
Vocal fremitus Bilateral symmetry of Not assessed -----
vocal fremitus; Fremitus is heard most clearly in the apex of the lungs
Percuss the anterior thorax Percussion notes resonate down to the
sixth rib at the level of the diaphragm but are
flat over areas of heavy muscle and bone, dull on areas over heart and the liver, and tympanic over the underlying stomach
Not assessed -----
Auscultate the trachea Bronchial breath sounds Not assessed -----
Auscultate the anterior thorax Bronchovesicular and vesicular breath sounds
Presence of adventitious breath sounds ( wheezes).
Asthma involves a process that produce mucosal
edema, mucus secretion and airway inflammation, when people with asthma are exposed to extrinsic allergens and irritants, their airways become
inflamed which causes wheezing initial clinical
manifestation.( Medical Surgical Nursing Vol. 2, 8th
Edition)
CARDIOVASCULARBody Parts Assessed Norms & Standards Actual Finding AnalysisAortic and pulmonic
areasNo pulsations No pulsations Normal
Tricuspud area No pulsations No pulsations Normal
Apical area Pulsation visible to 50% of adults and palpable in most
PMI in 5th LICS at or medial to MCL
Diameter of 1-2 cm;No lift or heave
Not assessed-----
Auscultate the aortic, pulmonic, tricuspid and
apical valves
S1: usually heard at all sight, usually louder at the apical
areaS2: usually heard at all sites, usually louder at the base of
the heartSystole: silent interval;
slightly shorter duration than the diastole at no deviation from normal heart rate (60-
90 bpm)Diastole: silent interval;
slightly longer interval than systole at no deviation from
normal heart rateS3: in children and young
Not assessed
-----
adultsS4: in many other adults
CAROTID ARTERIESPalpate carotid artery with extreme caution
Symmetric pulse volumes;Full pulsations, thrusting quality; quality remains
same when client breathes, turns head, and changes from sitting to supine
position; elastic arterial wall
Not assessed
----
Auscultate the carotid arteries
no sound heard on auscultation
Not assessed -----
JUGULAR VEINSJugular veins Veins not visible (indicating
right side of the heart is functioning normally)
Veins not visible Normal
BREAST and AXILLAEBody Parts Assessed Norms & Standards Actual Finding Analysis
Size, symmetry, contour or shape
Females: rounded in shape; slightly unequal in size; generally symmetric
Males: breasts even in chest wall; if obese, maybe similar in shape to female
breasts
Breast even in chest wall
Normal
Skin of breast for localized discoloration or hyperpigmentation, retraction, dimpling,
localized hypervascular areas, swelling or edema
Uniform skin color (same appearance as skin of
abdomen and back); skin smooth, intact; diffuse
symmetric horizontal or vertical vascular pattern in light skinned people; striae (stretch marks); moles and
nevi
Uniform skin color ,skin is smooth, intact
Normal
Areola area for size, shape, symmetry, color, surface, characteristics and any mass or lesions
Round or oval and bilaterally the same; colors
varies widely from light pink to dark brown;
irregular placements of sebaceous glands on the
surface of the areola (Montgomery’s tubercles)
Round and bilaterally the same; color is light
brown irregular placements of sebaceous glands on the surface of
the areola (Montgomery’s
tubercles)
Normal
Nipples for size, shape, position, color,
discharge, and lesions
Round, everted, and equal in size; similar in color;
sof and smooth; both nipples point same
direction
Round, everted, and equal in size, similar in color soft and smooth,
both nipples point same direction
Normal
ABDOMENBody Parts Assessed Norms & Standards Actual Finding Analysis
Skin integrity Unblemished skin; uniform skin color; silver-white striae or surgical scars
Uniform skin color Normal
Abdominal contour Flat, rounded (convex), or Distended It is one of the
scaphoid symptoms in AGE.
(www. WD.com)Enlarge liver or spleen No evidence of
enlargement of liver and spleen
Not assessed Normal
Symmetry of contour Symmetric contour Symmetric contour NormalAuscultate abdomen
for bowel sounds, vascular sounds and
peritoneal friction rubs
Audible bowel sounds; absence of arterial bruits, absence of friction rubs
There is a borborygmy sound.
It is one of the clinical
manifestation in AGE, it may
occur from gas released from
undigested food, irritation of
bowel mucosa and distension of
the intestines( Medical and
Surgical Nursing,Black
pg810)Percuss several areas in each of four quadrants
Tympanic over the stomach and gas-filled
bowels; dullness, especially over the liver
and spleen or a full bladder
Not assessed-----
Light palpation followed by deep
palpation of all four quadrant
No tenderness; relaxed abdomen with smooth,
consistent tension; tenderness maybe present near xiphoid process; over cecum and other sigmoid
colon
There is epigastric tenderness. It is one of the
clinical manifestation in
AGE, it may occur from gas released from
undigested food, irritation of
bowel mucosa and distension of
the intestines( Medical and
Surgical Nursing,Black
pg810)
VI. Ecologic Model
Analysis
The agent-host-environment model is primarily use in predicting illness rather than promoting wellness, identification of risk factors that result from the interactions of agent, host, and environment are helpful in promoting and maintaining health because each of the agent-host-environment factors constantly interacts with others. Health is an ever changing state. Health is seen when all three elements are in balance while illness is seen when one, two, or all three elements are not in balance
Agent- a factor (biologic, chemical, physical, mechanical, psychosocial) that must be present or absent for an illness to occur. In our patient’s case his exposure to bacteria was considered as the agent of his disease.
Host - living beings (e.g., human or animal) capable of being infected or affected by the agent. Christian Manic 6 years old was the host because he was the one who was infected with the disease that was possibly caused by the agent.
Environment – everything external to the host that makes illness more or less likely. The patient was exposed to different bacteria when their community was being flooded. As been said by his mother all of the other children have been affected by AGE after the flood has subsided.
Man
Disease Agent (Bacteria)
Environment (water)
VII. ANATOMY AND PHYSIOLOGY
THE DIGESTIVE SYSTEM
Every morsel of food we eat has to be broken down into nutrients that can be absorbed by the body, which is why it takes hours to fully digest food. In humans, protein must be broken down into amino acids, starches into simple sugars, and fats into fatty acids and glycerol. The water in our food and drink is also absorbed into the bloodstream to provide the body with the fluid it needs.
The digestive system is made up of the alimentary canal and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal (also called the digestive tract) is the long tube of organs — including the esophagus, the stomach, and the intestines — that runs from the mouth to the anus. An adult's digestive tract is about 30 feet long.
Digestion begins in the mouth, well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty snack, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that's triggered when we sense food or even think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal.
As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase, which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth.
Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx (pronounced: fair-inks), a passageway for food and air, is about 5 inches long. A flexible flap of tissue called the epiglottis reflexively closes over the windpipe when we swallow to prevent choking.
From the throat, food travels down a muscular tube in the chest called the esophagus. Waves of muscle contractions called peristalsis force food down through the esophagus to the stomach. A person normally isn't aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract.
At the end of the esophagus, a muscular ring called a sphincter allows food to enter the stomach and then squeezes shut to keep food or fluid from flowing back up into the esophagus. The stomach muscles churn and mix the food with acids and enzymes, breaking it into much smaller, more digestible pieces. An acidic environment is needed for the digestion that takes place in the stomach. Glands in the stomach lining produce about 3 quarts of these digestive juices each day.
Most substances in the food we eat need further digestion and must travel into the intestine before being absorbed. When it's empty, an adult's stomach has a volume of one fifth of a cup, but it can expand to hold more than 8 cups of food after a large meal.
By the time food is ready to leave the stomach, it has been processed into a thick liquid called chyme. A walnut-sized muscular tube at the outlet of the stomach called the pylorus keeps chyme in the stomach until it reaches the right consistency to pass into the small intestine. Chyme is then squirted down into the small intestine, where digestion of food continues so the body can absorb the nutrients into the bloodstream.
The small intestine is made up of three parts:
1. the duodenum, the C-shaped first part 2. the jejunum, the coiled midsection 3. the ileum, the final section that leads into the large intestine
The inner wall of the small intestine is covered with millions of microscopic, finger-like projections called villi. The villi are the vehicles through which nutrients can be absorbed into the body.
The liver (located under the ribcage in the right upper part of the abdomen), the gallbladder (hidden just below the liver), and the pancreas (beneath the stomach) are not part of the alimentary canal, but these organs are still important for healthy digestion.
The pancreas produces enzymes that help digest proteins, fats, and carbohydrates. It also makes a substance that neutralizes stomach acid. The liver produces bile, which helps the body absorb fat. Bile is stored in the gallbladder until it is needed. These enzymes and bile travel through special channels (called ducts) directly into the small intestine, where they help to break down food.
The liver also plays a major role in the handling and processing of nutrients. These nutrients are carried to the liver in the blood from the small intestine.
From the small intestine, food that has not been digested (and some water) travels to the large intestine through a valve that prevents food from returning to the small intestine. By the time food reaches the large intestine, the work of absorbing nutrients is nearly finished. The large intestine's main function is to remove water from the undigested matter and form solid waste that can be excreted. The large intestine is made up of three parts:
1. The cecum is a pouch at the beginning of the large intestine that joins the small intestine to the large intestine. This transition area allows food to travel from the small intestine to the large intestine. The appendix, a small, hollow, finger-like pouch, hangs off the cecum. Doctors believe the appendix is left over from a previous time in human evolution. It no longer appears to be useful to the digestive process.
2. The colon extends from the cecum up the right side of the abdomen, across the upper abdomen, and then down the left side of the abdomen, finally connecting to the rectum. The colon has three parts: the ascending colon and transverse colon, which absorb water and salts, and the descending colon, which holds the resulting waste. Bacteria in the colon help to digest the remaining food products.
3. The rectum is where feces are stored until they leave the digestive system through the anus as a bowel movement.