Chapter IV NURSING HISTORY

In this chapter the past and current condition of the patient is presented. This includes the patients lifestyles, beliefs and practices, behavior regarding health that may aggravate the condition of the patient. This will help us formulate diagnosis for the patients care plan and implement nursing interventions that will promote optimum health and wellness.

A. Reasons for Seeking Health Care Goals of Care His goal for seeking health care is for the treatment of diarrhea and excessive vomiting. Expectations of the services and care delivered He expects that the hospital will render him the best possible care. Expectations of the health system He believes that Mindanao Medical Center has competent physicians and nurses that will accommodate him and provide him care.

B. History of Present Illness Mr. C had experienced diarrhea on the night of January 11, 2011 after eating kinilaw from a fellow farmers house together with the other workers in the area. After experiencing abdominal pain, he decided to go home. And from there, he started to experience diarrhea. He frequently goes to the comfort room to loose his bowel more or less every 30 minutes. As verbalized by him, sa sige nako kabalik-balik ug banyo, tubig nalang mugawas. He thought by then that the cause of what he is experiencing is due to ingestion of the raw fish. He wasnt able to sleep well because of what had happened. He could go to sleep; nevertheless, it is being interrupted by his condition of loose watery stool. The next morning, he managed to have breakfast. While eating rice and bitter gourd, he suddenly felt nauseous and started to vomit the foods, water and other substances he had taken and experienced diarrhea again. They anticipated that it would be relieved after taking a medicine particularly diatabs. It was then effective after 1 hour. It stopped the diarrhea. The whole day returned to its usual day, but because he feels very weak, he decided not to work at the farm and have a rest instead.

The next two days are still the same. He becomes even weaker and his appetite was lessened. His mouth is also becoming dry. According to him, his skin including in upper and lower extremities became pale and cool. Since there is no chance for them to go the hospital because people are busy farming, and his wife is also busy in work at farm to manage, the only persons left at home were his 2 daughters to take care of him. He was only brought and dashed to the nearest hospital from their place which is Mindanao Medical Center by his fellow farmers after 4 days of experiencing all those signs and symptoms. It was January 15 when he finally sought for medical assistance and be seen by a physician, he was then advised to be admitted on that same day. After series of assessment, laboratory and diagnostic tests, he was diagnosed with acute renal failure secondary to severe and prolonged hypotension secondary to hypovolemic shock secondary to acute gastroenteritis secondary to amoebiasis and other protozoan secondary to septic shock secondary to GIT infection with metabolic acidsosis, hyponatremia, hypocalcemia and hypokalemia and minimal pulmonary tuberculosis. According to the physician, he must have been placed in an intensive care unit but because of financial status, they just chose to be admitted in a private room.
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When vital signs were taken, his temperature and blood pressure were both low and that rapid heartbeats and rapid deep breathing were noted. Deviations on his vital signs were caused by the rapid fluid loss and inadequate circulating volume. Aside from alterations in vital signs, it is accompanied with weakness, dizziness and polydipsia.

C. Past Medical History Immunization and Childhood Illness Mr. C could not recall what kind of immunizations he had received. He experienced chicken pox when he was still 6 years old and mumps on the same age. The common illnesses and conditions he is experiencing are cough and colds, sinusitis, fever, diarrhea, constipation, sore throat, rashes, and nausea and vomiting. Compliance to Health Management He rarely visits a doctor to have a check-up. Instead, he is following the tradition his family used to practice by going to manghihilot whenever he does not feel good. He also makes use
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of the herbal plants present on their backyard. These are guavas, bitter gourd, and pansit-pansitan. He also takes over the counter drugs and what he mentioned were Solmux, Neozep, Biogesic, Dolfenal, Alaxan, and Diatabs which depend on his condition. He does not have any multivitamins or food supplements. This is his first admission in a hospital. However, he already experienced undergoing a minor surgery last 1970 during work hours. His 3 fingers at the left hand were accidentally cut off because of the running sharp present in the machine at Dole Philippines.

D. Family History
Grandmother: died of Diabetes Mellitus Grandfather: died of hypertension

Grandmother: died of old age Grandfather: died of hypertension

Mother: died of Diabetes Mellitus

Father: died of hypertension

Older Sister: diagnosed with Diabetes Mellitus Mr. C: diagnosed with Acute Renal Failure

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Younger Sister: no known disease

Mr. C was diagnosed with acute renal failure. In tracing his family, it turned out that on his mothers side, his grandmother and grandfather died of diabetes mellitus and hypertension respectively. On his fathers side, his grandmother died of old age and his grandfather died of hypertension. His mother acquired diabetes mellitus from his grandmother and died because of it. On the other half, his father inherited hypertension from his grandfather. It also caused his fathers death. Between his sisters, it is his older sister who acquired diabetes mellitus from their mother.

E. Activities of Daily Living

Personal Hygiene Mr. C always takes a bath before leaving home and he is

using tawas. Since their source of living is farming, his work causes his body to be unclean every afternoon. Whenever he arrives at home, sometimes he tends not to wash his hands even before eating meals because of the perception of washing hands
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after heavy work will cause pasmo and is bad. But then, when he had the chance to take a rest, it is the only time he will be able to wash hands with water and soap. It is also occasionally when he will wash his feet with water and soap before sleeping. He brushes his teeth every after breakfast and dinner. During his admission, his wife takes care of him and assists him during bathing and brushing, and sometimes they just use face towel to give him a sponge bath.

Nutrition Since Mr. C owns a farm and a backyard planted with

various kinds of plants specifically crops and vegetables, their meals are usually composed of rice, vegetables, and accompany it sometimes with fish. They rarely serve meat and dried fish. He can sometimes consume 3 cups of rice with vegetables or fish. Mr. C loves to eat banana and papaya which are most of the times part of the meals. He also eats other available fruits. They eat their meals three times a day with or without snacks in between. Usually, when resting after work, Mr. C and fellow farmers sip a cup of coffee and eats bread.

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Mr. C and his family are drawing and using water from the river nearby their house without boiling it. He can drink 6-8 glasses of water a day which approximately is equal to 2L. He has no food and drug allergies with no vices such as smoking cigarette and drinking alcohol at all. His weight upon admission is 55kg and stands in a height of 67 in. BMI is 19.12 kg/m2 which belong to a normal range. He is on soft and fat-free diet which is composed mainly by either soup or porridge, or sometimes rice. He is also served with soft banana and mashed potato. He is also given ground fish for lunch and ripe papaya fruit. His eating pattern depends largely on the food prepared to him. He eats the prescribed amount of food served to him. He eats meal three times with fruits as part of it. He drinks warm water from the dispenser. He can still consume 6-8 glasses of water a day. His appetite was also stimulated and increased. He had experienced no food and drug allergies during hospital stay. He was not allowed to drink alcoholic beverages nor smoke a cigarette.

Elimination
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He is easily losing fluids by diaphoresis, emesis, and loose bowel movement. His usual voiding makes up of 5-6 times a day. His urine color is mostly dark yellow. He is experiencing no burning sensation or pain felt during urination. He typically defecates once in a day usually by morning with dark brown with normal consistency stools. During his first days in the hospital, vomiting and loose bowel movement with loose watery stools is still evident. However, as he experienced further stay and management in the hospital, vomiting and loose bowel movement disappeared. During hospitalization, he voids 2-3 times a day with decreased urine output which amounted to 400 cc a day or even zero urine output. He has dark colored urine. And, he has burning sensation during urination. He is already able to defecate with brown formed stools usually once in a day.

Rest and Sleep Mr. C can sleep up to 8 hours usually from 9:30 PM up to

5:30 AM. He needs to wake up early for him to prepare things to be used at work.
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Whenever he gets a chance to rest at noon, he will take a sleep for about 1 hour. Recently, due to condition, he cannot sleep well and is always distracted by the frequent urgency to void or defecate. On his hospital stay, he can usually sleep at 8:00 PM and wakes up at 6:00 AM. Thus, he can consume 10 hours of sleep. He is also provided with rest intervals and he usually sleeps for 4 hours in the middle of the day.

Exercise The patient ambulates within the house and towards their

farm. He can also perform simple exercises on the upper and lower extremities by means of shaking and stretching. He is still independent on doing his usual activities like eating, taking a bath, brushing teeth, toileting, and others. During hospital stay, he is resting to regain energy. He is being assisted during ambulation. He has limited range of motion. Decreased strength, motor movement, and generalized weakness are also noted. He feels dizzy whenever he rises up from bed and also during ambulation. Low blood pressure is very evident on him
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during the first days stay in the hospital. It is for the reason why his wife is the one who is assisting him in taking a bath, brushing teeth, toileting, and others even if he can do it by himself

Religion He is a Roman Catholic who has a strong faith in God. He

goes to the church to attend the mass every Sunday with his wife and three daughters. During hospital stay, his faith in God increases. Though he cannot attend the mass, he is being visited by a ministry pastor to be prayed over.

Sexuality The patient is married and has 3 children, all are females.

He has no history of Sexually Transmitted Disease or any disease affecting his sexual organ. He is supported and loved by his family until the course of treatment has been ended. They are there to help him especially in complying medications needed by the patient and assisting his needs for faster recovery. No diseases aroused in relation to the reproductive system.
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F. Hospitalization This is his first hospitalization. However, he already had experienced undergoing a minor surgery last 1970 during work hours. His 3 fingers at the left hand were accidentally cut off because of the running sharp present in the machine at Dole Philippines where he works as a machine operator. During hospitalization, he had met his expectations since the physicians and nurses present in Mindanao Medical Center for his proper management offered and gave him the best care.

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G. Developmental Task Mr. C has already surpassed the stage of generativity vs. stagnation with a positive outcome. He now belongs to the last stage of Erik Eriksons developmental theory of Ego Integrity vs. Despair. He, being a 67 year-old man, was able to manage in looking back into his life and evaluated his life whether he had lived a life full of fulfillment and acceptance or life full of depression and regrets.

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Erik Eriksons Developmental Theory Conflict: Ego Integrity vs. Despair Virtue: Wisdom Event: Reflection and acceptance of ones life Question: Have I lived a full life?
The most

Indicators

Patients Case

Age: 65 years old and above Task: Retrospection

67 years old Mr. C had reflected by viewing himself as a good husband and father since the time of their marriage and had a family of his own. He provided his family their daily needs with the help of their resources. Thus, he knew that he was productive, useful, and was able to contribute for the society. He believed that he had led a contented and fulfilled life together with his family. However, he still wanted to go work for their future as he mentioned, he wanted to be discharged already so that he can go back to his usual activities. They dont blame one another of their status in life. Instead, they help each other by not aspiring for more material things. Mr. C is grateful to have his familys love, care, and support. Mr. C does not fear death because he believes that this could happen to anyone, anytime, 21 and anywhere. Nevertheless, he still wanted to live and recover from his

important event at this stage is coming to accept one's whole life and reflecting on that life in a positive manner. According to Erikson, achieving a sense of integrity means fully accepting ones self and coming to terms with the death. Accepting responsibility for your life and being able to undo the past and achieve satisfaction with self is essential. The inability to do this results in a feeling of despair. Elements for a positive outcome: The adult feels a sense of fulfillment about life and accepts death as an unavoidable

Sense of Contentment

Own Perception about Death

H. Nursing Physical Assessment Date Conducted: January 24, 2011 a. General Appearance Conscious and coherent Calm and relaxed Generalized Weakness noted Clean and well groomed Oriented to people, time, and place Responsive to conversation Vital Signs January 24, 2011 8 AM T PR RR BP 36.40C 54 bpm 30 cpm 120/70mmHg 36.80C 54 bpm 26 cpm 120/80mmHg 12PM 36.5-37.50C 60-100 bpm 12-20 cpm 90/60-120/90 mmHg
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Normal

b. Skin, Hair, Nails Light brown in color same all throughout the body Senile skin turgor Wrinkles present on the face and neck Dry and flaky prominent over the extremities Brown-colored macules on the face and upper extremities
2+ edema present on both feet

No masses noted No lesions found Warm to touch

Evenly distributed short, thin, combination of black and white

hair Alopecia is evident Short and thick fingernails and toenails

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c. Head Normocephalic
Rounded-shaped

Smooth skull contour Symmetric facial features Symmetric facial movements Without lesions, lumps, or masses noted

d. Eyes Eyebrows are unevenly distributed and aligned Eyelashes are short and curl outwards White sclera Pale conjunctiva
Pupils appear smaller in 2mm size and both react to light

and accommodation Bilateral blinking

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e. Ears Color is same as facial skin Symmetrical Mobile and firm pinna that recoils after it is fold Pinna aligned with the outer canthus of the eye Cerumen present
Can hear sounds in both ears; no use of hearing aids

f. Nose Color is same as facial skin Symmetric No deformities noted No unnecessary discharges present No lesions

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g. Mouth Symmetric Dark colored dry lips Able to purse lips No lesions noted Dark colored gums
No swelling and bleeding

Uses dentures
Teeth yellowish in color

With dental caries Molars are lost

Tongue is moist and pink in color which is centrally

positioned

h. Neck Color is same with the head

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 Wrinkles present Not enlarged Carotid pulse is easily palpable Head centered Coordinated movement No enlargement of lymph nodes

i. Spine and Back

Slight spinal curvature is accentuated

Spine is centrally positioned Able to support the body

j. Thorax and Lungs Vibrations present and can be felt on the chest No chest pain Productive cough With Crackles upon auscultaton
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 Rapid shallow breaths Use of accessory muscles during respiration Respiration rate is 30 cpm

k. Breast Color is same all throughout the abdomen Generally symmetric

No nodules, masses and lesions found

Areola and nipples are darker in pigmentation No discharges noted

l. Heart
Present and audible apical pulse

Beats with regular rhythm

Cardiac rate at the point of maximal impulse is 60 bpm

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m. Abdomen Uniform light brown color Unblemished skin

Flat with symmetric contour Rises with inspiration and falls with expirations

Umbilicus centrally positioned

Normal bowel sounds auscultated No tenderness, masses, rashes noted

n. Upper Extremities Both arms are in the same size and length Muscles symmetric in position Weakness noted though movement is coordinated With scars 3 fingers at the left hand is not present No lesions noted
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 No masses noted No rashes found Dry and flaky skin

Brown-colored macules noted

Senile skin turgor

o. Lower Extremities Both legs are in the same size and length
No lesions and masses noted Dry and flaky skin; fissures noted

2+ edema present on both feet

With lesser hair distributed in the legs

p. Musculoskeletal
No tremors found and no presence of tenderness or swelling Limited range of motion Decreased strength 30

 Becomes weak in prolonged activities

q. Neurologic Feels dizzy when rising up from bed and during ambulation Reaction to stimuli is good Motor weakness noted
Has reduced speed of movement

Conscious and aware Neuro vital signs score of 14

r. Genitourinary
No history of disease affecting reproductive organ

Urinary functioning is good Dark yellow urine

No pain or burning sensation during urination

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