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ACUTE
PANCREATITIS
NURSING
HEALTH
HISTORY
DEMOGRAPHIC DATA
We have a case 18 years old,
female, Filipino, Roman Catholic,
currently living in Caloocan City.
She was born on February 04,
1993 at Samar. She was admitted
in Tondo Medical Center last July
05, 2011. We gather information
from our patient with her mother
and we interviewed her lasts July
07, 2011 and conducted in Tondo
Medical Center.
CHIEF COMPLAINTS
• Abdominal Pain
PATIENT RELIABILITY
• The patient reliability is 90-95%.
HISTORY OF PRESENT
ILLNES
• One week prior to admission after
eating, the patient had
experienced abdominal pain at
epigastric area accompanied by
difficulty in breathing, and body
malaise/weakness. Last wednesday
morning she suddenly experienced
pain in abdominal pain in
epigastric area accompanied with
difficulty in breathing,
and body malaise/weakness that
lasts up to 5 minutes. She takes
mefenamic acid 500 mg/tab to
relieve pain but the pain does not
relieve. That’s why the mother
prompted to sent her to hospital
when the severe abdominal pain
occurs and she was diagnosed that
she has Acute Pancreatitis. She is
given to take Omeprazole 20 mg
TIV OD. Tramadol 500 mg/tab ½
amp TIV q8..Her attending
physician Dr. Santos.
PAST HISTORY
ALLERGIES
• The client denies for any
allergies on food, medication
and environment.
CURRENT MEDICATION
HABITS
• She drinks alcoholic beverages
occasionally, once a week and
she smoke and consume 1 stick
per week.
PERSONAL AND SOCIAL
HISTORY
• Height: 5’2
• Weight: 50 kg
• BMI (Normal -> 18.5-22.9):
20.01 NORMAL
• Desirble Body Weight: 51.82
• TOTAL ENERGY ALLOWANCE:
1560 1550 kcal
Food Fluid Energy
intake intake (kcal)
Breakfast - 200 kcal
200
Lunch 400+41 - 441 kcal
Dinner 400+86+ - 502 kcal
16
TOTAL:
1143
kcal
• Ideally patient should consume
1550 kcal per day but according
to her 24 Hour dietary recall,
patient was able to take 1143
kcal only, if not intervene, it
could lead to malnourishment
and decrease energy source
due to inadequate
carbohydratess, protein and
fats intake.
PHYSICAL
ASSESSMENT
• General Appearance
She has stooped posture.
Vital Sign:
RR: 31 cpm
Pain scale: 8/10
• Mental Status
She is conscious and coherent.
She is oriented to time, place
and persons. She is shy during
our interview.
• Skin
Skin is of the pallor. Warm to
touch. Oily and smooth in
texture.
• Nails
Nail bed color is pale.
• Head & Face
Facial grimace
• Eyes
None
• Ears
None
• Nose
None
• Mouth
Lips are pale & have cracks
• Chest & Lungs
Upon auscultation, crackles was
heard. The patient denies for
difficulty of breathing
Chest pain
• Breast
None
• Abdomen
Muscle guarding. Abdominal pain
• Lower & Upper Extremities
None
• Genetalia
None
DIAGNOSTIC
PROCEDURE
COMPLETE BLOOD
COUNT
Exam Name Result Unit Normal Value
COMPLETE
Hemoglobin 105 BLOOD
low COUNT
g/L 110 - 150
Hematocrit 0.323 low 0.37 - 0.45
WBC Count 18.7 high 10^g/L 4.6 - 10
Differential
Count
Segmenters 0.857 high 0.50 - 0.70
Lymphocytes 0.122 low 0.20 - 0.40
Monocytes 0.005 0 - 0.07
Eosinophils 0.013 0 - 0.05
Basophils 0.003
MCV 81.9 fL 80.9 - 99.9
MCH 26.6 low pg 27 – 31
MCHC 32.5 low % 33.0 - 37.0
Platelet Count 237 10^g/L 150 - 400
Blood Type A+
AMYLASE TEST
Blood
Chemistry
July 6, 2011 Electrolytes NPO Complete Bed Omeprazole IV fluid
rest
Blood Tramadol
chemistry