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CASE ABSTRACT

this is a case study of S.R from dona rita diaz st. furtuna village sucat
paranaque city. 17 years old. he was admitted at olivarez general
hospital last sept. 05, 2016. with the cheif complaint of fever and
watery stool and vominting .attending physician was Dr. Orteza. his
mother is his companion when he was admitted, prior to admission his
Baseline data was taken. upon admission to the ward, vital sign was
taken. thus has the following report: BP-100/70 PR-72 RR-18 and
temp:38 'c. his physician also prescribed medication to reduce fever,
he given paracetamol 500 mg/tab. he also given cotrimoxazole 800
mg/tab, ercefuryl cap, 1 cap imodium 1 cap, ctoneprazole 40 mg via
(IV) and plasil.his final diagnosis is AGE with moderate Dehydration.

LEARNING OBJECTIVES:
1. to gather comprehensive data through interview and medical chart.
2. to perform physical assessment head to toe approach.
3. to have a review of anatomy ang physiology of the system effected.
4. to trace the pathophysiology of AGE.
5.To determine the different medical and nursing management
employed.
6. to interpret the results of the laboratory and diagnostic procedures.
7. to study the drugs prescribed to the patient and its effect to his
current condition
8.to furmulate and apply nursing care plan utilizing the nursing process

BIOGRAPHIC DATA

NAME: S.R
AGE: 17 Y/O
GENDER: male

STATUS: single
ADDRESS: dona rita diaz st. furtuna village sucat paranaque city
PLACE OF BIRTH: Sucat paranaque
RELIGION: roman catholic
EDUCATIONAL ATTAINMENT: college
OCCUPATION: student
LANGUAGE SPOKEN: filipino
ADMITTING DIAGNOSIS: AGE with moderate dehydration
SOURCE OF INFORMATION: From the patient, hospital record and lab
result

History of Present Illness


Two days prior to admission , the patient had vomiting for 3 times
associated with abdominal pain and passage of watery stool due to his
intake of ice-cold coke and water according to his mother. A day prior
to admission , the patient still attended his classes but still with
vomiting and passage of watery stool. And last September 5,2016, he
was rushed to olivarez general hospital due to fever and watery stool
and vomiting.

Past History
The client had fever, cough and colds. She had completed all
vaccinations including BCG, DPT, Oral Polio Vaccine, MMR and Hepatitis
B vaccine. The patient had never been any of the childhood disease
such as measles, mumps and chicken pox. The patient had no history
of accident or any injury. She does not have allergy in any food or drug.
She was not hospitalized before and she does not take any medication
or supplements to maintain her health.

Family History
According to the significant others of S.R they have a familial disease
of asthma, on his father side. And an incident of hypertension on his

mother side.

GORDON'S FUNCTIONAL HEALTH PATTERN

1.PATTERN OF HEALTH PERCEPTION AND HEALTH MANAGEMENT:


the patient feels so unhealthy because of his hospitalization. He
is obedient in taking his medications and is participative in all the
nurses interventions.
2. NUTRITIONAL AND METABOLIC PATTERN:
Before his hospitalization, the patient takes his meal three times
a day without any restrictions. he has food preferences on fatty
foods. Her mother even shared that when they eat adobo, he
prefers to eat the fat rather than the muscle because he gets
irritated with foods between his teeth. He has no difficulty in
swallowing and he usually eat junk foods when its snack time. He
drinks 4-5 glasses of water a day.
During his hospitalization, his appetite decreased. He was
restricted from eating dairy products. His fluid intake increased
for about 5-7 glasses of water a day.
3.Elimination Pattern:
Before his hospitalization, the patient used to eliminate once a
day everymorning before going to school .He usually urinates 2
times a day with the normal light yellow color. He also perspires
every time he plays.
During is hospitalization, the patients stool is watery with a brown
color.He urinates 2-3 times a day. Elimination Pattern
Before his hospitalization, the patient used to eliminate once a
day everymorning before going to school with a semi-solid
consistency and is brownishin color. He usually urinates 2 times a
day with the normal light yellow color and aromatic odor. He also
perspires every time he plays.
During is hospitalization, the patients stool is watery with a
brown color.He urinates 2-3 times a day.

4.Activity-Exercise Pattern:

Before his hospitalization, especially during the weekend, he


used to play outside with his cousins. They usually play
basketball and the usual mobile games.
During his hospitalization, sometime if he feel good he playing
mobile games. Most of his time was spent for resting and
sleeping.

5.Cognitive-Perception Pattern:
Before his hospitalization, the patient is normal in terms of his
cognitive abilities. He has no problems with his senses.
During his hospitalization, he is able to ask question and he also
cooperative.

6.Sleep-Rest Pattern:
Before his hospitalization, he usually sleeps 8-9 hours. he
wathing NBA and making some homework.
During his hospitalization, the patient sleeps early but has sleep
disturbances when the nurses take his vital signs, administer
medicines and also due to the environment.

7.Self-Perception/ Self-Concept Pattern:


According to the patients, hes a good son and he always listen
to there parents.

8.Role-Relationship Pattern:
The patient has a close relationship with his family, but he is
closer to his father. becouse his father and him is always playing
basketball every sunday.

9.Coping Stress- Tolerance Pattern;


According to his mother, when he has problems he always
approach his parents. She even added that when he gets
scolded, he just stays in his room.When he is bullied or when his

cousins get his toys, he does not quarrel withthem but instead he
reports it to his parents. During his hospitalization, hefeels
unsafe with people when his mother is not with him. He cries
without thesight of his mother.
10. Value-Belief Pattern:
He is a Roman Catholic. They attend mass regularly with there
family.

PHYSICAL EXAMINATION:

VITAL SIGN: 100/70


PR: 72 bpm
RR: 18 bpm
TEMP.:30 c
weight: 55 kg

GENERAL APPEARANCE:
The patient is awake, lying on bed, concious and coherent with an IVF
of D5NM 1L.

PHYSICAL ASSESSMENT
1. SKIN:
the patient skin color is light brown, dry skin, rough due to
deviated slight dehydration.
2. head:
hair color is black, no dandruff, no lission and masses palpeted.

3.eyes:

pupils are brown in color, equal pupil, eyelids symetrical in size.

4.ears:
client normaly hears word, ears are symmetrical external pinae.

5.nose:
nose are smooth symmetric with same color as the face. nasal
septum close to midline.

6. mouth
slightly pink, dry lips becouse of dehydration, no tooth decay
precent.

7.neck:
while inpection the trachea is in midline no difficulty of
swallowing.

8. chest and lungs:


clear sound breath

9. abdomen:
upon inpection skin same at the rest of the body, and when
auscultation there hyperactive sound diviated to diarrhea.

LABORATORY RESULTS
HEMATOLOGY RESULTS
Normal Value
Analysis
WBC
noramal

normal
5.5-10.0

Results
10.0

Lymphocyte
decrease

15-50

GRA
increase

10.5%

35-80%

mid
increase
Hgb
g/dl

81-9%

2-15%

increase

Hct
normal

7.6%

14-18
43.5-53-7

mch
increase

27-32

segmenters
normal

60%-70%

16.7
%

30.20

FECALYSIS

Method used: Direct Smear

analysis

Results

Physical properties:
Color
Normal

brown

Consistency
d/t profuse secretion

Watery

of water and electrolytes

URINALYSIS
Analysis

50.0%

Results

69%

Color:
Normal

Yellow

Transparency
d/t increased

Slightly turbid

urineconcentration
Reaction
Normal

acidic

Specific gravityDecreased:d/tdehydration

1.020

Sugar
Normal
albumin
few

Negative
negative

ANATOMY AND PHYSIOLOGY

THE DEGESTIVE SYSTEM: