ROOSEVELT COLLEGE SYSTEM

Institute of Nursing
SY 2009-2010
Nursing Care Proess!
TONSILLITIS
In "artia# fu#fi##$ent of t%e re&uire$ents in
Nursing Care Manage$ent 101
Re#ate' Learning E("eriene
Submitted by:
M)GLENTE* )##an
M)RI)NO* Marie )urora Gie#+ert ),
OM-GTONG* Marianne
ORCEN)* .oan-/ran0 P,
P).)NEL* Est%er Marie
S-MIL1IG* Maureen Moni&ue
TOT))N* Cat%erine
VEN-S* .o2e##
Submitted to:
Mrs, Grae G, Magno
Affiliating Hospital!
)nti"o#o Me'ia# 1os"ita#
3!00 ),M 4 2!00 P,M
2009* .u#2 1-15
I. INTRODUCTION
It is "resente' in t%is o$"re%ensi6e nursing "roess t%e ase of Ms,
7,),T* a 2-2ear o#' fe$a#e* 8%o %as %a' %ig% fe6er +eause of %er tonsi##itis, S%e
is un'er t%e are of nurses at )nti"o#o Me'ia# 1os"ita# sine .u#2 9* 2009, S%e
8as a'$itte' an' %as +een un'er t%e are of %er atten'ing "%2siian :ra,
/errer,
Tonsi##itis is an inf#a$$ation of t%e tonsi#s* t%e f#es%2 #usters of tissue on
+ot% si'es of t%e +a; of t%e t%roat t%at fig%t off ger$s t%at enter t%e +o'2
t%roug% t%e $out%, T%e tonsi#s +eo$e en#arge' an' re'* an' an +e oate'
8it% a 2e##o8* gra2* or 8%ite su+stane,
Most t2"es of tonsi##itis are ontagious, It usua##2 s"rea's fro$ "erson to
"erson +2 ontat 8it% t%e t%roat or nasa# f#ui's of so$eone 8%o is infete', )
"erson 8it% tonsi##itis $a2 %a6e a sore t%roat* fe6er* s8o##en g#an's in t%e ne;*
an' trou+#e s8a##o8ing,
Man2 ases of tonsi##itis ne6er rea% t%e 'otor<s offie* so t%ere are no
nationa# figures on t%e "re6a#ene of t%ese infetions, 1o8e6er* if t%e resu#ts of a
reent stu'2 fro$ Manito+a of tonsi##eto$2 rates %o#' aross t%e ountr2* it
a""ears t%at 50*000 "eo"#e %a6e t%eir tonsi#s re$o6e' ea% 2ear, Tonsillectomy
=tonsi# re$o6a#> %as a#8a2s +een t%e $ost o$$on %i#'%oo' o"eration* t%oug%
it re"resents a tin2 an' s%rin;ing fration of t%e tota# nu$+er of ases of
tonsi##itis* an' is onsi'ere' a #ast resort t%ese 'a2s,
T%is ase 8as %osen +eause of t%e "re6a#ent ases of Tonsi##itis $ost
es"eia##2 a$ongst %i#'ren age' t%ree to se6en* 8%o %a6e #arger tonsi#s t%an
a'u#ts an' o#'er %i#'ren, T%e stu'ents +e#ie6e in atten'ing to su% ases an'
a''ress t%e nee's of t%e #ient for e("eriene an' i$"ro6e$ent of s;i##s as t%e2
go on 8it% ot%er e("osures,
II. OB!CTI"!S
)fter i$"#e$entation t%is ase stu'2 t%e stu'ent nurse s%ou#' +e a+#e to!
1, Reogni0e an' +e a""ro"riate t%e $ain#2 suita+#e Nursing T%eor2 to "atient* in
assort$ent to "ro6i'e re#e6ane for t%e "atient %ea#t% status,
2, E#ui'ate an' +ui#' u" t%e $ost a""ro"riate nursing $anage$ent for t%e
e("ansion of nursing are "#an or NCP,
?, Intriate an' 'e6e#o" assess$ent s;i##s an' i'entifiation of "re'ita+#e
on#usion,
9, :isuss t%e )nato$2 an' P%2sio#og2 of 1u$an Res"irator2 S2ste$@s Tonsi#s,
5, Esta+#is% 'ifferent %ea#t% tea%ings t%at 8ou#' +e a'6antageous for t%e
"atient@s reent %ea#t% "ro6ision,
III. TH!OR!TICA# $RA%!&OR'
T%e ACore* Care* CureB T%eor2 8as 'e6e#o"e' in t%e #ate 1930@s, S%e
"ostu#ate' t%at in'i6i'ua#s ou#' +e one"tua#i0e' in t%ree se"arate 'o$ains!
t%e +o'2 are* t%e i##ness* ure* an' t%e "erson ore,
1a## t%oug%t "atients s%ou#' reei6e are $ere#2 fro$ "rofessiona# nurses,
Nursing in6o#6es interating 8it% a "atient in a o$"#e( "roess of tea%ing an'
#earning, 1a## 8as not "#ease' 8it% t%e one"t of tea$ nursing s%e sai' t%at
Can2 areer t%at is
'efine' aroun' t%e 8or; t%at %as to +e 'one* an' %o8 it is 'i6i'e' to get it 'one*
is a Ctra'eC rat%er t%an a "rofession,
Nursing funtions in a## t%ree of t%e +o(es =ore* are* an' ure> +ut
s%ares t%e$ to 'ifferent 'egrees 8it% ot%er 'isi"#ines, /or e(a$"#e* t%e nurse<s
funtion in t%e ure +o(es is #i$ite' to %e#"ing "atientsDfa$i#ies 'ea# 8it% t%e
$easures institute' +2 t%e "%2siian, S%e fe#t t%at t%e are +o( 8as e(#usi6e to
nursing, T%e ore +o( 8as s%are' 8it% soia# 8or;ers* "s2%o#ogists* #erg2* et,
T(e )atient
Soia# sienes
T%era"euti use of se#f4
as"et of nursing,
*T(e Co+e,
T(e Body
Natura# an' Eio#ogia#
Sienes
Inti$ate +o'i#2 are
)s"ets of nursing
*T(e Ca+e,
T(e Disease
Pat%o#ogia# an'
t%era"euti sienes
Seeing t%e "atient an'
t%e fa$i#2
T%roug% t%e $e'ia# are
E2 t%e P%2siian an'
Nurses
*T(e Cu+e
T%e t%eorist* L2'ia E, 1a## 8it% %er t%eor2 8%i% is Core* Care* an' Cure 8as
"referre' for t%is "artiu#ar ase +eause t%e stu'ent nurse@s "atient 8%o is
suffering %2"ertension 8as a ou#' 'o 8it% a great assess$ent an' t%e t%eor2 of
L2'ia E, 1a## 8as nee'e' to e("an' t%e "atient@s s;i## in "ro6i'ing a are for %er,
)s a stu'ent nurse* s%ou#' first reogni0e' a onnetion* a re#ations%i" 8it%
"atient so as to assess t%e "atient for t%e "resent "ro+#e$s or 'isease t%at t%e
"atient %as a#so t%is "ossi+#e 'isease or ris; t%at t%e "atient $ig%t enounter an'
"#an t%e suita+#e t%ings to +e 'one to t%e "atient, T%is is t%e en#ig%ten$ent for
t%e ore of %e stu'ent nurse@s "atient,
T%e re#e6ane of t%e nursing inter6ention or N)N:) 8i## %a6e a $assi6e ro#e
an' gi6e su""ort to "ro6i'e a "ro"er Care to t%e "atient to %e#" t%e "atient@s
'e6e#o"$ent fro$ a o$"#aint,
Cure is "ro6i'e' 8%en t%e stu'ent nurse a""#2 t%e ;no8#e'ge for t%e
treat$ent of t%e "atient, )s it s%ou#' +e "ro6i'e' a'$inistering $e'iation as
"resri+e' +2 t%e 'otor or "%2siian* 8%i% is a#so a "art of t%e reo6er2 of t%e
"atient,
Nu+sing Ca+e )+o-ess
I. BIO.RA)HIC DATA
Name: Ms, 7,),T,
Add+ess: E5 L1F CRC St,* Stee# 1o$es* )nti"o#o Cit2
Date of Bi+t(: No6e$+er 2?* 2003
Age: 2 2ears an' F $ont%s o#'
Se/: /e$a#e
Ci0il Status: Sing#e
)la-e of Bi+t(: Eaguio Cit2
!du-ational Attainment: ND)
O--upation: ND)
Religion: Ro$an Cat%o#i
!t(ni- .+oup ! None
)a+ents:
%ot(e+: M,T Age: 22 2,o
O--upation: %ouse8ife
$at(e+: M,T, Age: 29 2,o
O--upation: Sea$an
Healt( Ca+e $inan-ing: Me'ia# Insurane at -S)
Annual In-ome: P500* 000-PG00* 000
Room and Bed Numbe+: Roo$ 909E
C(ief Complaint: /e6er an' Tonsi##itis for ? 'a2s
)+o0isional Diagnosis: )ute Pain rDt Tonsi##itis
Attending )(ysi-ian: :ra, /errer
Admitting Date: .u#2 9* 2009 =9!95 ),M>
Admitting Do-to+: :ra, /errer
II. NURSIN. HISTOR1
), )ast Healt( Histo+y
T%e $ot%er of Ms, 7,),T, state' t%at s%e %as +een fu##2 i$$uni0e' sine
t%en, 1ere@s t%e ta+#e of %er i$$uni0ations in#u'ing t%e 'osage an' age s%e got
it,
I$$uni0ation :osage
TICE ECG 0,2 $L, "erutaneous#2
C%o#era Vaine
=Generi>
0,2 $L IM
)t1IE* Co$6a(* %i+TITER* #i&ui'
Pe'6a(1IV
=1ae$o"%i#us E onHugate' 6aine
an' %e"atitis E surfae antigen>
T%ree 0,5 $L, IM inHetions at 2 2ears
o#' 8it% 0,5 $L +ooster at 1 2ear an' ?
$ont%s o#'
Meningooa# Po#2sa%ari'e Vaine 0,5 $L SC
Pre6nar T%ree 0, $L, IM 'osesI G-11 $ont%s
o#'
T8o 0,5 $g, IM 'osesI 1 2ear o#' 4 1
2ear an' 11 $ont%s o#'
:TaP
='i"%t%eria an' tetanus an' ae##u#ar
"ertussis 6aine>
0,5 $L IMI 1 2ear an' 3 $ont%s o#'
T8inri(
=%e"atitis ) 6aine 8it% %e"atitis E
reo$+inant 6aine>
1 $L IMI 1 2ear o#'
/o##o8e' +2 +ooster 'oses at 2 2ears
an' 3 $ont%s o#'
Eia6a( II
=ru+e##a an' $u$"s 6aine>
0,5 $L0 SC
M-R-Va( II
=$eas#es an' ru+e##a 6irus 6aine>
0,5 $L SC
Ori$une
="o##o6irus 6aineI tri6a#ent>
1
st
'ose! 0,5 $L PO at 2 $ont%s o#'* 9
$ont%s o#' an' 1 2ear an' 3 $ont%s
o#'
2
n'
'ose! t8o 'osesI 2 2ears o#' an' 2
2ears an' 2 $ont%s o#'
Vari6a(
=against %i;en"o(>
0,5 $L SCI 1 2ear o#'
0,5 $L SCI 1 2ear an' 2 $ont%s o#'
1er $ot%er #ai$s t%at s%e %as e("eriene' a %i#'%oo' i##ness 8%i% is
-rinar2 Trat Infetion, S%e %a' no $aHor o"erations to 'ate nor serious inHuries
or ai'ents, S%e %as +een %os"ita#i0e' for four ti$es* in#u'ing "resent
onfine$ent* for so$e 'ifferent reasons, S%e %as +een onfine' 'ue to fe6er
re#ate' to %er Tonsi##itis,
S%e 8as 'iagnose' of %a6ing -rinar2 Trat Infetion an' s%e %as it
for 2 2ears, S%e %as no $aintaining $e'iation "resri+e' +2 %er "%2siian +ut
s%e ta;es u" $e'iine 8%ene6er s%e is onfine' in t%e %os"ita#,
S%e 'oesn@t e("eriene 2et an2 foreign tra6e#* on#2 out-of-to8n
ati6ities,
:ate P#ae Jit% 8%o$ :uration Pur"ose
23
t%
Mar%*
200G-2
n'
)"ri#*
200G
Eaguio Jit% fa$i#2 One 8ee; Vaation
22
n'
:ee$+er*
200G-12
t%
.anuar2* 200F
Eio# Jit% fa$i#2 T%ree 8ee;s Visite'
gran'$ot%er
29
t%
Ma2* 200F-
25
t%
of .une*
200F
I#oos Norte Jit% fa$i#2 One $ont% Visite'
gran'fat%er
20
t%
Mar%*
200F 4 23
st
Mar%* 200F
Eaguio Jit% fa$i#2 3 'a2s Vaation
E, Histo+y of )+esent Illness
T%e sai' #ient %as a %ief o$"#aint of inter$ittent %ig%-gra'e
fe6er aroun' ?F,5C an' it is "re'o$inant "rior to %er a'$ission, 1er fe6er 8as
ao$"anie' 8it% te$"ora# %ea'a%e* 8%i% resu#te' to %er 'erease' a""etite
8it% 8%i% %e re"orte' to %a6e not eating an2t%ing, S%e 'i' not %a6e an2 ot%er
"ain or re#ate' s2$"to$s #i;e oug%s an' o#'s 8it% %er fe6er, S%e 8as not se#f-
$e'iate' +2 %er $o$,
Jit% %is on'ition an' t%e signs an' s2$"to$s s%e is $anifesting*
%er $ot%er +roug%t %er to t%e %os"ita# to onsu#t a 'otor an' a#so to onfine %er
for se6era# 'a2s,
C, $amily Histo+y
T%e #ient is 7,),T 8%o is urrent#2 2 2ears an' F $ont%s o#', 1er
"arents are M,T an' M,T* age' 22 an' 29 2ears o#'* res"eti6e#2, S%e 'oesn@t
%a6e an2 si+#ings, 1er fa$i#2 'oesn@t %a6e a fa$i#2 %istor2 of an2 'iseases on
+ot% $atriar%a# an' "atriar%a# si'e,
DRU. STUD1
.ene+i-
Name
Spe-ifi-
Name
Dosage Uses A-tions
)$"ii##in )$"iin IV 500 $g - &F% Infetions of G-*
res"irator2* an'
GI trats an' s;in
an' soft tissuesI
a#so gonooa#
infetions*
+ateria#
$eningitis* otitis
$e'ia* sinusitis*
an' se"tie$ia
an' for
"ro"%2#a(is of
+ateria#
en'oar'itis,
-se' "arentera##2
on#2 for
$o'erate#2
se6ere to se6ere
infetions,
) +roa'-
s"etru$ se$i-
s2nt%eti
a$ino"enii##in*
is %ig%#2
+aterii'a# e6en
at #o8
onentrations*
+ut is inati6ate'
+2 "enii##inase
)#+utero# Vento#in PO 5$# - &3% To re#ie6e
+ron%os"as$
assoiate' 8it%
aute or %roni
ast%$a*
+ron%itis* or
ot%er re6ersi+#e
o+struti6e air8a2
'iseases, )#so
use' to "re6ent
e(erise- in'ue'
+ron%os"as$,
S2nt%eti
s2$"at%o$i$eti
a$ine an'
$o'erate#2
se#eti6e +eta2-
a'renergi
agonist 8it%
o$"arati6e#2
#ong ation, )ts
$ore "ro$inent#2
on +eta2
ree"tors
="artiu#ar#2
s$oot% $us#es
of +ron%i*
uterus* an'
6asu#ar su""#2
to s;e#eta#
$us#es > t%an
on +eta1 =%eart>
ree"tors,
Mini$a# or no
effet on a#"%a-
a'renergi
ree"tors,
In%i+its %ista$ine
re#ease +2 $ast
e##s,
Paraeta
$o#
Te$"ra PO 130 $g -
&9% RTC
/e6er re'ution,
Te$"orar2 re#ief
of $i#' to
$o'erate "ain,
Genera##2 as
su+stitute for
as"irin 8%en t%e
#atter is not
to#erate' or is
ontrain'iate',
Pro'ues
ana#gesia +2
un;no8n
$e%anis$*
"er%a"s +2
ation on
"eri"%era#
ner6ous s2ste$,
Re'ues fe6er +2
'iret ation on
%2"ot%a#a$us
%eat-regu#ating
enter 8it%
onse&uent
"eri"%era#
6aso'i#atation*
s8eating* an'
'issi"ation of
%eat, -n#i;e
as"irin*
aeta$ino"%en
%as #itt#e effet on
"#ate#et
aggregation*
'oes not affet
+#ee'ing ti$e*
an' genera##2
"ro'ues no
gastri +#ee'ing,
Healt( )e+-eption and Healt( %anagement )atte+n
:uring t%e inter6ie8* t%e #ient a#rea'2 is in %er fourt% 'a2 of onfine$ent at
)nti"o#o Me'ia# Center for %a6ing a "ro6isiona# 'iagnosis of inter$ittent %ig%-fe6er
re#ate' to %er Tonsi##itis, T%e #ient a'$itte' t%at for t%e "resent 2ear* t%is a#rea'2 8as %is
seon' ti$e to +e +roug%t to a %os"ita# for t%e sa$e 'iagnosis, /or t%e "ast %istor2 of
t%e #ient* s%e reei6e' a## t%e %i#'%oo' 6aines, S%e sti## "resent#2 %as -rinar2 Trat
Infetion, No8* s%e is not ta;ing an2 $e'iations +ut 'uring %er sta2 in t%e %os"ita# s%e
too; u" )$"iin=)$"ii##in>* Paraeta$o#=Te$"ra> an' )#+utero#=Vento#in>, 1ea#t%
aor'ing to %er $o$* para sa akin, para maconsider na healthy ang isang tao,
siya dapat ay walang sakit at physically healthy para walang problema.
)#so* %er $o$ rates %er o6era## %ea#t% as F out of 10 8it% 10 +eing t%e %ig%est,
Jit% %is tra'itiona# one"ts regar'ing %ea#t%* t%e #ient 'oes not +e#ie6e t%at %er+a#
$e'iines $ig%t +e goo' to i$"ro6e or "ro$ote 8e##ness, Ot%er t%an t%is* t%e #ient %as
no ot%er "artiu#ar +e#iefs an' "raties as %er $o$ 6er+a#i0e',
)s an a6erage "erson* t%e #ient@s $o$ regu#ar#2 "raties "ersona# %2gieni
$easures to $aintain %er #ean* "resenta+#e an' ger$-free, )n' for %er $o$* t%e $ost
i$"ortant t%ing to $aintain %ea#t% 8as t%ru "ro6i'ing a goo' #ifest2#e an' goo'
"ere"tion regar'ing t%eir %ea#t% for to'a2 an' for t%e o$ing 2ears of t%eir #ife, Last#2*
t%e #ient@s $o$ 'esri+es t%eir %o$e en6iron$ent +2 sa2ing AMa#inis sa #oo+ at #a+as*
aessi+#e na$an ang %ea#t% fai#ities an' a'e&uate ang s"ae "ara sa ;an2ang
"agta;+o at "ag#a#aro,B T%e #ient@s $o$ a#so state' t%at t%e2 %a6e a'e&uate su""#2 of
$inera# "urifie' 'rin;ing 8ater an' t%e2 %a6e a %a0ar' an' 6etor free o$$unit2
+eause of "ro"er 8aster $anage$ent o##etion of a+out t8ie a 8ee;, S%e a#so state'
t%at as $u% as "ossi+#e* t%e2 $aintain t%eir %o$e en6iron$ent #ean an' saniti0e
+eause t%is is as 8e## for t%eir o8n goo',
Interpretation: The clients mom exhibits a normal pattern with regards to maintaining
their health.
Analysis:
Each person defines health in terms of his or her own vales and beliefs. The
family, commnity, and society in which one lives also inflence ones personal
perception of health. !ealth, as defined by each person, integrates all the hman
dimensions"the physical, emotional, socio"cltral, spirital, and environmental aspects
as a whole person. #$ndamentals of %rsing: &oncepts, 'rocess, and 'ractice, (
th
Edition by )o*ier, p.+,-
.ehavior"specific knowledge, beiefs, and relationships are considered to be
ma/or motivators for engaging in health"promoting behaviors. #$ndamentals of %rsing:
&oncepts, 'rocess, and 'ractice, (
th
Edition by )o*ier, p.+0-
Nut+itional2%etaboli- )atte+n
T%e #ient@s usua# $ea# onsists of 1 u" of rie an' an2 6ian' 8%i% is "re"are'
+2 %er $o$, S%e ? to 5 g#asses of 8ater a 'a2 an' so$eti$es 'rin;s C2 in t%e $orning,
S%e 'oesn@t %a6e an2 foo' "referenes, S%e eats 8%ate6er s%e #i;es, 1er $o$ a#so
#ai$e' s%e %a' a %uge a""etite unti# %e e("eriene' signs an' s2$"to$s of %ea'a%e
an' fe6er +eause of %er tonsi##itis* sine t%en* %er a""etite 'erease' an' %asn@t eaten
nor$a##2 as +efore, S%e t%en annot onsu$e rie for t%e $ean ti$e, T%e #ient a#so %as
no 'iet restritions, S%e a#so ta;es Poten-Cee for %er 6ita$ins, T%e #ient %as no
'iffiu#t2 regar'ing s8a##o8ing or %e8ing of foo', 1er $o$ is t%e one 8%o "re"are
$ea#s for t%e$, T%e #ient %as no s"iritua# or u#tura# +e#ief regar'ing foo', 1er $o$ is
t%e one 8%o $anages t%e +u2ing an' "re"aring of foo',
Time of t(e
Day
Time of
!ating
Type of
food
3uantity %et(od of Coo4ing
Mon'a2
= .u#2 3* 2009>
Erea;
fast
F!15 ),M-
F!?0 ),M
-Erea'
-$i#;
-? "s, Regu#ar
si0e
-1 g#ass-250 $#
-Ea;e'
-Co#' $i#;
Lun%
12!00-
12!?0 "$
-.o##i+ee
+urger
-C2
-2 "s of +rea'
1 s#ie of to$ato
2 teas"oon of
$a2o 8it%
s%re''e' $eat
an' onion,
-1 +ott#e-250 $#

-+urger "att2 is frie'
-Ot%er ingre'ients
8ere not oo;e'
-Co#' 'rin;s
Sna;
9!?0 "$
8ater 1 g#ass-250 $# Co#' 'rin;s
:inner
= 9!?0-
9!95 "$>
-C%o"sue2
-Rie
-Jater
-+anana
-1 s$a## sauer
as +ig as a u"
- 1 g#ass-250 $#
-1 +anana
-Stir fr2
-stea$e rie
-o#' 'rin;s
-ri"e +anana
$NRI $ood )y+amid fo+ t(e $ilipinos
/irst #e6e# 4 8ater an' ot%er +e6erages
Seon' #e6e# 4 Car+o%2'rate-ri% foo's =root ro"s* rie>
T%ir' #e6e# - o$+ination of 6egeta+#es an' fruits
/ourt% #e6e# -Protein ri% foo's* ani$a# $eat #i;e "ou#tr2* "or;* fis%*
seafoo'* 'air2 "ro'uts an' as 8e## as 'rie' +eans
/ift% #e6e# - /ats an' oi#s

T(e daily needed se+0ings fo+ e0e+y food in t(e $ood )y+amid

Ee6erages - 3-F g#asses
Car+o%2'rate-ri% foo'- 3-F ser6ings
Vegeta+#es- ? ser6ings
/ruits - ? ser6ings
Mi#; - 1 g#ass
Egg -1 ",
/is%* $eat* "ou#tr2 -2 ser6ings
Sugars an' s8eets 4 5-3 ts"s,
/ats an' oi#s- 3-F ts"s,

S%e eats $ore "rotein ri% foo's =eggs>,
1er f#ui' inta;e is ?-5 g#asses of 8ater a 'a2 +ut $ost of t%e ti$e s%e
'rin;s C2 as for %er refres%$ent +e6erage,
S%e a#8a2s eats a #ot an2ti$e of t%e 'a2,
Interpretation:
The alteration in ntrient re1irements that reslts from illness and trama varies
with the intensity and dration of the stress. $or instance, fever increases the need for
calories and water. 2nlike fevers related to septicemia, however, fever cased by a mild
case of fl re1ires few dietary ad/stments.
#3orce: $ndamental of %rsing, Taylor, page 4504-
Analysis:
'ain, illness, anxiety and medications can contribte to anorexia and poor intake
when in healthcare facility or home. To the hospitali*ed patient, food and eating may
take on mch greater meaning. 6oss of control over food choice, the way food is
prepared, when and how food is served and eating alone may do little to encorage
normal eating.
#3orce: $ndamentals of %rsing, Taylor, page 45+,-
!limination )atte+n
T%e #ient urinates 3 ti$es a 'a2 or 8%ene6er nee'e', It is a$+er in
2e##o8 in o#or* aro$ati in o'or, S%e 'oesn@t fee# an2 'iso$fort* +urning
sensation or an2t%ing 8%i#e urinating, S%e an ontro# %er urine, 1e e#i$inates 1-
2 ti$es a 'a2, Nor$a##2 %is e(reta are +ro8n in o#or, 1e 'oesn@t fee# an2
'iso$fort 8%i#e e#i$inating, T%e #ient@s usua# +o8e# "attern is e6er2 ot%er 'a2*
or so$eti$es 8%en s%e Hust fee#s t%e urge to e#i$inate %er +o8e#, It is +ro8n in
o#or* soft for$e'* se$i-so#i'* 2#in'ria# an' $oist, S%e 'oesn@t e("eriene 2et
to %a6e 'iarr%ea or %istor2 of +#ee'ing,
S%e 'oesn@t %a6e e(essi6e "ers"iration, It 8as a#so $entione' t%at %er
"ratie to a%ie6e nor$a# e#i$ination is to 'rin; a #ot of 8ater,
Interpretation:
The client seems no difficlty in rinating, and rinates in normal amont. 3he
also defecates normal amont per day.
Analysis:
The fre1ency of mictration depends on the amont of rine being prodced.
The more rine prodced, the more often voiding is necessary, except when flid intake
is very large. 7ost people have individal patterns of bowel elimination involving
fre1ency, timing considerations, position and place. $or example many people defecate
after breakfast, when the gastrocolic and doodenocolic reflexes case mass proplsive
movements in the large intestine. #8eference: $ndamentals of %rsing 0
th
edition by
Taylor pg. 4595 and 4:;4-
A-ti0ity2!/e+-ise )atte+n
T%e "atient "rior to %os"ita#i0ation s"en's "rett2 $u% of %is ti$e at %o$e
"#a2ing an' 8at%ing te#e6ision a## t%e ti$e, S%e se#'o$ 8a#;s an' usua##2 foun' at %er
roo$, )#so as "art of %is ati6it2 an' e(erise* %er $o$ an' t%e #ient is stro##ing to
so$e "#aes 8%ene6er t%ere is free ti$e, S%e #i6es 8it% %er $o$ an' un#eI s%e 'oesn@t
%e#" in %ouse%o#' %ores sine s%e@s too 2oung to 'o so, )si'e fro$ t%e $entione'
routine of ati6it2 an' e(erise* %er $o$ 'i' not $ention an2 ot%er for$ of e(erising,
/ro$ t%e ti$e t%at %e 8as onfine' to t%e %os"ita# +eause of %a6ing fe6er for ? 'a2s*
s%e 8as ;e"t #2ing in +e',
ACTI"ITI!S O$ DAI#1 #I"IN.
A-ti0ities of Daily
#i0ing
Befo+e
Hospitali5ation
Du+ing
Hospitali5ation
Inte+p+etation and
Analysis
1, Nut+ition S%e usua##2 %as a
+ig a""etite, S%e
eats rie an' 6ian'
for +rea;fast* 8it% a
u" of $i#;, S%e
eats %ea62 #un%
an' %ea62 su""er,
1e usua##2 'rin;s ?-
5 g#asses of 8ater a
'a2,
)s s%e got si;* t%e
#ient@s $o$
re"orte' a 'erease
in a""etite, s%e a#so
8ent for 1'a2
8it%out eating 'ue
to t%is a""etite
'erease, s%e
'rin;s a+out ?-5
g#asses of 8ater a
'a2 an' 5 +ott#es of
Gatora'e,
Peo"#e of %er age
usua##2 ten' to eat a
%ea#t%2 'iet*
fo##o8ing t%e
reo$$en'e'
"ortions of inta;e of
foo' grou"s, 2-?L of
#i&ui' is usua##2
in#u'e' in t%e 'iet,
Nutritiona# inta;e*
%o8e6er* an +e
great#2 affete' +2 a
fee#ing of i##ness or
'isease,
=/un'a$enta#s of
Nursing +2 7o0ier*
",11F0>
2, !limination S%e urinates a+out
9 ti$es a 'a2
8it%out an2 "ain*
'iffiu#t2* or
'iso$fort, 1er
$ot%er state' t%at it
ou#' 6ar2
'e"en'ing on %o8
$u% %er 'aug%ter
%as eaten or 'ran;
or 8it% t%e
te$"erature of %er
s%e urinates a+out
10 ti$es a 'a2
8it%out "ain*
'iffiu#t2* or
'iso$fort, 1er
+o8e# $o6e$ent
%as 'erease' to
one e6er2 t8o or
t%ree 'a2s, T%oug%
t%is is t%e ase* s%e
'oes not fee# t%at
s%e is un'er
T%e inrease in t%e
fre&uen2 of 6oi'ing
is re#ate' to t%e
inrease in f#ui'
inta;e, T%e
'erease in +o8e#
$o6e$ent is re#ate'
to t%e 'erease in
a""etite 8%i%
'erease' %er
nutritiona# inta;e,
J%en it o$es to
en6iron$ent,
S%e e#i$inates
stoo# e6er2 ot%er
'a2* a#so 8it%out
an2 "ain* 'iffiu#t2*
or 'iso$fort,
onsti"ation, +o8e# $o6e$ent*
t%ere is no Anor$a#B
fre&uen2* an' if t%e
at of 'efeation is
"ain#ess ou"#e'
8it% regu#ar
inter6a#s an' soft*
for$e' stoo#* t%en
funtiona# "ro+#e$s
regar'ing
e#i$ination 8i##
se#'o$* if not*
our, =",1?90*
Ta2#or* 5
t%
e',> T%e
fre&uen2 of
urination 'e"en's
on t%e a$ount of
urine +eing
"ro'ues* 8%i%
'e"en's on t%e foo'
an' f#ui' inta;e, )s
t%e inta;e of foo'
an' f#ui's 'erease*
t%e fre&uen2 of
urination 8i## a#so
'erease, =", 1292*
Ta2#or* 5
t%
e',>
?, !/e+-ise S%e 'oesn@t %a6e
an2 regu#ar e(rise
ati6it2
T%e #ient %as not
%a' an2 %ane to
'o an2 ot%er for$s
of e(erise e(e"t
for 8a#;ing,
T%e #ient@s ati6it2
"attern %as %ange'
fro$ ati6e an'
regu#ar e(erise to
s%ort 8a#;s, T%is is
%in'ere' +2 %is
nutritiona# 'i#e$$as
an' IV t%era"2,
=",11G5* Ta2#or* 5
t%

e'>
9, Hygiene 1e #i;es to ;ee"
%i$se#f #ean, 1e
+at%es for 2-? ti$es
a 'a2 an' +rus%es
%is teet% for 2-?
ti$es a 'a2, 1e
1e an on#2 +at%e
for one a 'a2* +ut
sti## is a+#e to +rus%
%is teet% for 2-?
ti$es a 'a2, 1e is
sti## a+#e to atten' to
T%e #ient is
%2gieni, 1e sti##
8ants to ;ee" %is
%2giene e6en if %e
%as +een
%os"ita#i0e', )
tri$s %is nai#s an'
8ears #ean #ot%ing
an' foot8ear,
%is %2gieni nee's, 'isease or inHur2
$a2 re'ue a
"erson@s a+i#it2 to
"erfor$ %2gieni
$easures, In t%e
#ient@s ase* t%e
intra6enous fusion
re'ues t%e a+i#it2
to "erfor$ usua#
%2giene "raties,
=",1009* Ta2#or* 5
t%

e'>
5, Substan-e Use 1e is an ati6e
s$o;er for a#rea'2
10 2ears an'
onsu$es a+out a
"a; of igarettes in
a 'a2, 1e 'rin;s ?-9
+ott#es of +eer 1-2
ti$es a 8ee;,
1e %as not engage'
in an2 igarette
s$o;ing or a#o%o#
'rin;ing,
Su+stane a+use is
signifiant#2 re#ate'
to ris;-ta;ing
+e%a6ior, T%e
a+sene of su%
+e%a6ior $a2
in'iate t%at t%ere is
no a+use of
a#o%o#i +e6erages,
=",910-911* Ta2#or*
5
t%
e'>,
3, Sleep and Rest 1e usua##2 s#ee"s
for G-F %ours a 'a2,
1e 'esri+es t%e
s#ee" as ontinuous
an' satisf2ing
enoug% to "ro$ote
re#a(ation,
1e on#2 s#ee"s for ?-
9 %ours in t%e
nig%tti$e an'
anot%er ?-9 %ours in
t%e 'a2ti$e, 1e
re"orts %is s#ee" to
+e A"a"uto#-"uto#B*
an' so$e%o8 %e is
satisfies a#t%oug%
t%ere are ti$es %e
'oes not fee# too
re#a(e',
Mi''#e-age' a'u#ts
genera##2 $aintain
t%e s#ee"ing "attern
t%e2 %a6e
esta+#is%e' at a
2ounger age, T%e2
usua##2 s#ee" 3-F
%ours "er nig%t* 8it%
t%e nu$+er of
arousa#s "er s#ee"
inreasing, )n2
'isease or
'iso$fort an
affet t%e &uantit2
an' &ua#it2 of s#ee",
=/un'a$enta#s of
7o0ier* ",1113>
G, Se/ual A-ti0ity 1e usua##2 engages
in se(ua# interourse
for a+out one or
1e %as no se(ua#
ati6it2 or
interourse,
Se(ua# ati6it2 is
o$$on as one
esta+#is%es #ifest2#e
t8ie a 8ee;, 1e
re"orts not using
an2 ontrae"ti6e
'e6ies,
an' 6a#ues,
)#t%oug% t%e2 often
re&uire infor$ation
a+out $easures to
"re6ent "regnan2
=i,e,* a+stinene*
ontrae"ti6e
'e6ies>, Regu#ar
o$$uniation is
re&uire' to
un'erstan'
"artner@s se(ua#
nee's an' to 8or;
t%roug% "ro+#e$s
an' stresses,
=/un'a$enta#s of
Nursing +2 7o0ier>
Interpretation:
The patient does not exhibit a healthy form of activity and exercise since she
doesnt exert any effort to do so. 3he /st plays arond and watches television all the
time.
Analysis:
A nmber of changes take place dring the middle ages. At ;,, most adlts can
fnction as effectively as they did in their 5,s. 7any middle" aged adlts remain healthy
however< the risk of developing health problems is greater than that of the yong adlt.
Exercise involves the active contraction and relaxation of mscles. Exercises can be
classified according to the type of mscle contraction whether isotonic, isometric or
isokinetic and according to the sorce of energy sch as aerobic or anaerobic. =alking
and playing golf is inclded in the isotonic exercises in which the mscle shortens to
prodce mscle contraction and active movement. Isotonic exercises increase mscle
tone, mass and strength and maintain /oint flexibility and circlation. >ring isotonic
exercises, both heart rate and cardiac otpt 1icken to increase blood flow to all parts
of the body. 6ittle or no change in blood pressre occrs. Aerobic exercise is the activity
dring which the amont of oxygen taken in the body is greater than that sed to
perform the activity. This ses large mscle grops, is performed continosly and is
rhythmic in natre and an example of this is walking. #8eference: $ndamentals of
%rsing by )o*ier pg.4,+0-
T%e Ti$+re0a-Tu+a'e0a /a$i#2
J.T.
48 y/o
A and W
Legend:
- Female -male

-Client A and W- alive and well
M.T.
44 y/o
A and W
J.T.
20 y/o
A and W
J.T.
24 y/o
A and W
J.T.
1 y/o
A and W
M.T
22 y/o
A and W
F.T.
!1 y/o
A and W
".T.
!0 y/o
A and W
#.A.T
$ y.o
A and W
M.T
1% y/o
A and W
M.T
$0 y/o
A and W
M.T
1& y/o
A and W
M.T.
20 y/o
A and W
M.T.
24 y/o
A and W