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Nursing History PATIENTS PROFILE NAME: Rick Jordan AGE: 19 y/o GENDER: Male ADDRESS: San Juan S.

Mayamot DATE OF BIRTH May 10, 1991: PLACE OF BIRTH: Antipolo City OCCUPATION: N/A (still a student) NATIONALITY: Filipino CIVIL STATUS: Single RELIGION: Roman Catholic DATE ADMITTED: January 4, 2011 ADMITTING INSTITUTION: Antipolo City Mdeical Hospital CHIEF COMPLAINT: The patient complains of abdominal pain, headache, fever and general flushing of skin with on and off vomiting FINAL DIAGNOSIS: Dengue Fever HISTORY OF PRESENT ILLNESS: Three days prior to admission the patient has fever and loss his appetite. According to the SO of the patient, they went to consult a physician during the first day of his fever. The physician prescribed. Paracetamol for the patient. On the third day, the patient still had the said symptoms. He went back for a check-up. He had CBC and was determined that he has dengue. Then the patient was immediately admitted to Antipolo City Medical Hospital PAST HEALTH HISTORY: According to the SO of the patient the patient did not yet experienced having serious health problems other than fever, colds and cough. He had no previous hospitalization. FAMILY HISTORY: (-) Anemia (-) Diabetes (-) Asthma

(-) HPN (-) Kidney Disease GORDONS 11 FUNCTIONAL HEALTH PATTERN A. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN The patient perceived that he is not healthy because of his condition. NUTRITIONAL-METABOLIC PATTERN The patient has loss his appetite and hasnt eaten a lot. He is on a DAT (Diet as Tolerated) EDCF (Except Dark Colored Foods) ELIMINATION PATTERN The patient urinates 2-3 times a day. The color of her urine is yellow. The patient defecates once every two days.

ACTIVITY-EXERCISE PATTERN His activity was limited lying on bed but the patient is given his bathroom privileges

SLEEP-REST PATTERN He doesnt have the adequate time of sleep since he is disturbed with the nurses that enter the room every now and then, and because of the environmental changes of his surroundings. He also has inadequate time to rest since he doesnt have enough time to sleep. COGNITIVE-PERCEPTUAL PATTERN He was normal as before in his cognitive and perceptual pattern. He responds clearly and well understood. He has no sensory deficit; He responds appropriately to verbal and physical stimuli and obeys simple commands. SELF-PERCEPTION SELF-CONCEPT PATTERN

He sees himself as a person with a good personality. He has been a good friend, brother and a son. He said he has to be a good person in order not to hurt others. He also describes himself as a typical type of student and person. ROLE-RELATIONSHIP PATTERN He said that it was a nice feeling to know that your family is so supportive to him. He learned to appreciate the beauty of having a family that gives you strength and support no matter what. SEXUALITY-REPRODUCTIVE PATTERN He is not yet married and not sexually active COPING-STRESS TOLERANCE PATTERN He shares his problems to his family. He verbalizes his feelings VALUE-BELIEFPATTERN He is a Roman Catholic devotee. He was taught by his family to believe and have fear to GOD.

Physical Assessment BP=110/70mmHg PR=118bpm Area Assessed SKIN Color and pigmentation Lesions Texture Moisture Temperature Mobility and turgor Method Used

RR=25bpm Temp=38 Normal Findings Light to deep brown Actual Findings General flushing No lesions, but presence of scars Smooth Moist The skin springs back to its previous state after being pinched

Inspection Inspection Palpation Palpation Palpation Palpation

No lesions, scars or inflammation Smooth Moist The skin springs back to its previous state after being pinche

NAILS Nail bed color Shape Lesions Thickness capillary refill

Inspection Inspection Inspection Palpation Palpation

Pink Convex No inflammation of the skin around the nail Firm

Pale Convex No inflammation of the skin around the nail Firm Normal capillary refill Proportion to the body and the skull is rounded and smooth Symmetrical No nits/lice present





Proportion to the body and the skull is rounded and smooth Symmetrical

SCALP Distribution of hair Lesions Other findings FACE Skin color Texture Facial movement EYES External structure Eyebrows Eyelashes Eyelids EARS Color Symmetry Shape and size

Inspection Inspection Inspection Inspection Inspection Inspection

Evenly distributed No inflammation, lumps or masses Light to deep brown Smooth Symmetric facial movement Evenly distributed Evenly distributed, Evenly distributed, curved outward

No inflammation, lumps or masses Pinkish Symmetric facial Symmetric facial movement Pink conjunctiva Evenly distributed Evenly distributed

Inspection Inspection Inspection Inspection

Inspection Inspection Inspection

Same as facial color Symmetrical at the level of the eyes corner Symmetric to head No discharges and inflammation Same as facial colo Same with facial color Symmetric No discharges Symmetric Pink Moist

Symmetric to head No discharges and inflammation Normal

NOSE Color Shape Discharges

Inspection Inspection Inspection

Same with facial color Symmetric No discharges Symmetric Pink Dry

MOUTH Lips Symmetry Moisture TONGUE

Inspection Inspection Inspection

Position Color Texture Mobility Lesion

Inspection Inspection Inspection Inspection Inspection

Positioned at the center can move freely Dull red Smooth Can move freely No lesions or inflammation Head centered Symmetrical Smooth movements without discomfort Symmetric and at midline position

Central position Dull red Smooth Can move freely No lesions or inflammation

NECK Position Symmetry Range of movements

Inspection Inspection Palpation

Head centered Symmetrical Smooth movements without discomfort Symmetric and at midline position

UPPER AND LOWER EXTREMITIES Size Symmetry Distribution of hair Skin color Lesions

Inspection Inspection Inspection Inspection Inspection

Equal size Symmetrical Evenly distributed Light to deep brown No lesions, deformities or inflammation Normal

Equal size Symmetrical Evenly distributed Light to deep brown No lesions, deformities or inflammation Normal




White Blood Cells Hemoglobin Hematocrit Nuetrophils Lymphocytes Platelet Count Urinalysis: Jan 4, 2011 Color: Yellow Transparency: Hazy Specific Gravity: 1.010 Chemical Examination: Albumin: Trace Sugar: Negative pH: 5.0 M: 140-160g/L M: 0.40-0.54 50-70% 30% 145 46 70% 25-40%

DRUG STUDY ISOPRINOSINE Dosage : 2 tsp TID 250 mg Classification: Antivirals Indication: Rhinovirus; herpes genitalis; measles; encephalitis; influenza; herpes zoster; herpes simplex; type A & B hepatitis; AIDS related complex; neoplastic diseases; anergy and hypoergy prior to major surgery Action: >Synthetic antiviral: it stimulates T-lymphocytes; used for HIV and Hepatitis >non-toxic immune system stimulant Adverse Reactions: >Transient increase in urine and serum uric acid level; very rarely skin rashes; pruritis; GI upset; nausea; fatigue; malaise Contraindications: >Hypersensitivity. Patients w/ adnormally low neutrophil counts (< 0.75 x 10x9/L), or abnormally low haemoglobin levels (< 7.5 g/dL or 4.65 mmol/L) Nx Considerations: >Monitor increase in serum uric acid level, gout, urolithiasis or renal dysfunction; pregnancy and lactation >Monitor hematological parameters Patient Teaching: >Inform patient that the drug must be taiken 1 hour apart on an empty Stomach >Instruct the patient to notify prescriber if unusual effects occurs AMOXICILLIN Dosage : 375 mg TID Classification : Antibiotic Indication: Infections due to susceptible strains; helicobacter pylori infections in combination with other agents; post-exposure prophylaxis against bacillus anthracis;Chlamydia trachomatis in pregnancy Action: Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death Adverse Reactions: >CNS lethargy, hallucinations, seizures

>GI glossitis, stomatitis, gastritis, sore mouth, furry tongue (black hairy), nausea, vomiting, diarrhea (bloody), enterocolitis,pseudomembranous colitis, nonspecific hepatitis >GU nephritis >Hematologic anemia, thrombocytopenia, leucopenia, neutropenia, prolonged bleeding time >Hypersensitivity rash, fever, wheezing, anaphylaxis >Others superinfections: oral and rectal moniliasis, vaginitis Contraindications: >Contraindicated with allergy to cephalosporins or penicillins, or other allergens >Use cautiously with renal disorders and lactation Nx Considerations: >Culture infected area prior to treatment; reculture area if response is not expected >Give in oral preparations only; amoxicillin is not affected by food >Continue therapy for at least 2 days after signs of infection have disappeared; continuation for 10 full days is recommended >Use corticosteroids or antihistamines for skin reactions Patient Teaching: >Take this drug around-the-clock >Take the full course of therapy; do not stop because you feel better >This antibioticis specific for this problem and should not be used to self-treat other infections >Eat frequent small meals to avoid GI effects; frequent mouth care may prevent sore mouth >Report unusual bleeding or bruising, sore throat, fever, rash, hives, severe diarrhea, difficulty of breathing PRCTM L A A EA O Dosage: 250 mg/5ml q 4 RTC Classification: Nonopioid Analgesics & Antipyretics Indication: Mild pain or fever Action: Produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin inthe CNS or of other substances that sensitize pain receptors to stimulation. The drug mayrelieve fever through central action in the hypothalamic heatregulating center. Adverse Reactions: Hematologic: Hemolytic Anemia, Neutropenia, Leukopenia, Pancytopenia Hepatic: Jaundice Metabolic: Hypoglycemia Skin: Rash, Urticaria Contraindications:

Contraindicated in patients hypersensitive to drug. Use cautiously in patients with long-term alcohol use because therapeutics doses cause hepatotoxicity in these patients. Nx Considerations: ALERT: Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose. Use liquid form for children and patients who have difficulty in swallowing. In children, dont exceed five doses in 24 hours. Patient Teaching: Tell parents to consult prescriber before giving drug to children younger than age 2. Advise patient or parents that drug is only for short-term use; urge them to consult prescriber if giving to children for longer than 5 days or adults for longer than 10 days. ALERT: Advise patient or caregiver that many OTC products contain acetaminophen, which should be counted when calculating total daily dose. Tell patient not to use for marked fever (temperature higher than 103.1F [39.5C]), fever persisting longer than 3 days, or recurrent fever unless directed by prescriber. ALERT: Warn patient that high doses or unsupervised long-term use can cause liver damage. Excessive alcohol use may increase the risk of liver damage. Caution longterm alcoholics to limit acetaminophen intake to 2g/day or less. Tell breast-feeding woman that acetaminophen appears in breast milk in low levels (less than 1% of dose). Drug may be used safely if therapy is short-term and doesnt exceed recommended doses. Interactions o Drug-Drug -Barbiturates, Carbamazepine, Hydantoins, Rifampin, Sulfinpyrazone: high doses orlongterm use of these drugs may reduce therapeutic effects and enhance hepatotoxiceffects of acetaminophen. Avoid using together.