I.

INTRODUCTION
Scleroderma is a connective tissue disease that involves changes in the skin, blood vessels, muscles,
and internal organ.It is a chronic, progressive autoimmune disorder where inflammation and the
overproduction of collagen accumulate in the body. It can cause swelling or pain in muscles and
joints.There are two main types of Scleroderma- Systemic and Localized. Systemic Scleroderma may
affect multiple systems such as the integumentary, cardiopulmonary, vascular, gastrointestinal,
genitourinary, or musculoskeletal. There are three forms of Systemic Scleroderma. With Diffuse
Scleroderma skin thickening occurs more rapidly and involves more skin areas than in limited. In
addition, people with diffuse scleroderma have a higher risk of developing sclerosis or fibrous
hardening of the internal organs.Sine Scleroderma involves organ fibrosis with no skin involvement.
With Limited Scleroderma (CREST syndrome) skin thickening is less widespread, typically confined to
the fingers, hands and face, and develops slowly over years. Internal problems occur, but they are less
frequent and tend to be less severe than in diffuse scleroderma. The limited symptoms of
Schleroderma are referred to as CREST, Calcinosis(calcium deposits in the skin), Raynauds
Phenomenon (spasm of blood vessels in response to clod or stress in the hands or feet), Esophageal
Dysfunction (acid reflux and decrease in motility of esophagus),Schlerodactyly (Thickening &
tightening on the fingers and hands) and Telangiectasias (dilation of capillaries causing redmarks on
surface of the skin or depigmentation). Nearly everyone who has scleroderma experiences a
hardening and tightening of patches of skin. These patches may be shaped like ovals or straight lines.
The number, location and size of the patches vary by type of scleroderma. Skin can appear shiny
because it's so tight, and movement of the affected area may be restricted. One of the earliest signs of
scleroderma is an exaggerated response to cold temperatures or emotional distress, which can cause
numbness, pain or color changes in the fingers or toes. Called Raynaud's phenomenon, this condition
also occurs in people who don't have scleroderma. In addition to acid reflux, which can damage the
section of esophagus nearest the stomach, some people with scleroderma may also have problems
absorbing nutrients if their intestinal muscles aren't moving food properly through the intestines.
Rarely, scleroderma can affect the function of the heart, lungs or kidneys. These problems can become
life-threatening.
Based on the said symptoms the current disease that patient H.A. have is most likely as Systemic Limited
Scleroderma in which fatigue or excessive weight loss, digestive difficulties and nutrient deficiencies are
common and the symptoms of CREST are present.Her skin is shiny and tightened with visible straight
line white patches in some areas, fingertips distorted. She is suffering from epigastric and joint pain,
accompanied with heartburn and vomiting. The attending physician explained that symptoms of
heartburn will not disappear because ofswelling of the esophagus, the tube between the throat and
stomach and esophageal injury from acid exposure. It will only manage by reducing the symptom by
taking proton pump inhibitors.There is no cure, but various treatments can control symptoms and
complications.The current best evidence that can be beneficial is Physical Therapy Management.
Physical therapists can design a program of regular stretching and gentle exercise to help manage pain,
improve strength, improve or maintain mobility, minimize joint contracture improve circulation,enhance
or maintain performance of activities of daily living in order to encourage independence. In addition, an
appropriate level of exercise can promote relaxation and a sense of well-being. And yet, Patient H.A. is
currently undergoing Physical therapy

II. DEMOGRAPHIC

II.A PATIENT PROFILE
Name: H.A.
Current Address: #3855 R. De Santos, Sta. Mesa, Manila
Previous address: Aparri, Cagayan Valley
Gender: Female
Age: 40 years old
Birthdate: October 23, 1973
Status: Married
Educational Attainment: 2
nd
year College, undergraduate
Occupation: Businesswoman
Nationality: Filipino
Ethnicity: Ilocano
Religion: Roman Catholic
Source of income: Owned Business with husband
Living environment: Bungalow, owned, 4 occupants, Barangay

II. B. Chief Complaint: Abdominal epigastric pain and joint pain for 1 month,
Admitting Diagnosis: Steroid Induced Gastritis
Admitting Physician: Dr. R. Ramos
Date of admission: July 23, 2014 @ 2:36 p.m.

III. B. PRESENT ILLNESS
One month prior to admission, patient noted sudden onset of epigastric pain (Pain scale 8/10)
and generalized body pain, and sought consult to physician and was prescribed Decilon 500mg.
Pain was not relieved by medications after taking it three times a day. Pain was slightly relieved
by vomiting.
Two weeks prior to admission, epigastric pain was still noted, since onset of symptoms was
noted after intake of Decilon, Patient opted to discontinue medication. However despite this
change pain still persisted.
On the day of admission, patient was still noted to have epigastric pain and being referred due
to multiplepigmented macules some scattered into patches with areas of normal skin all over
the body, positive tapering of digits and taut and hardened skin thus also prompting consult
followed by admission.






II. C. PAST MEDICAL HISTORY
Patient had hypothyroidism and undergone operation in thyroidectomy last 2012. On May 2014
she was diagnosed case of Scleroderma that initially presented as thickening of the skin.
II. D. FAMILY HISTORY
The mother of the patient had breast cancer and her father had laryngeal cancer. Her sister
had goiter.
II. E. SOCIAL HISTORY
Patient H.E. is a neither non-smoker nor alcoholic drinker. Has casual relationship with her
neighbors.
II. F. DEVELOPMENTAL TASK
Patient H.A. is 40 years old, married and has 2 children, her developmental task is to establish a
sense of generativity versus stagnation. People under this task extend their concern from just
themselves and their families to the community and the world. They are self- confident and
better able to juggle their various lives (mother,church member, gourmet cook). But people
without this sense become stagnated or self-absorbed. Due to her condition she cannot
perform most of the functions of being motherhood.

II. G. PREVIOUS MEDICATIONS: Levothyroxine 50 m once daily for Hypothyroidism(2013) ,
Penicillamine 250mg once daily and Prednisone 10mg/mg 1 tab Once daily for
Scleroderma(2014)and Decilon 500 mg TID (.03/kg/day)

III. GENOGRAM























(Laryngeal
Cancer ) 57
y
( BreastCancer ) 55 y
A/W
57

A/W
54
A/W
51
A/W
47
A/W
45
goiter
Client
40
A/W
45

A/W
17

A/W
14

= Client
=Deceased
=Deceased
= Female
= Male
A/W = Alive & Well
( ) =Cause of death
GENOGRAM KEY
PHYSICAL ASSESSMENT:

Assessment Findings Normal findings
1. General Survey
Height: 55
Weight: 51 kg.
RR: 30 cpm
PR: 124 bpm
Temp: 36.7 C
BP: 110/70

2. Mental status and Level of
consciousness
Clients level of
consciousness

Posture and body
movement

Behaviour and affect



Dress and grooming



Facial expressions


Speech


Client is alert and oriented
to time and date. Client
responds appropriately.

Slumped posture


Client follows through
instructions. Mild anxiety is
present

Dress is neat and clean,
appropriately dressed
according to weather

Facial expression symmetric
& correlate with mood(
smiles and frowns
appropriately)
Speech is clear &
appropriate

Alert & oriented to what happening
at the time of interview & physical
assessment

Appears to be relaxed and back
erect when standing or sitting
Cooperative
Mild to moderate anxiety may be
normal in a client who is having
physical assessment

Dress is appropriate for occasion &
weather


Maintains eye contact, smiles and
frowns appropriately
Speech is in moderate tone, clear,
with moderate pace, and culturally
appropriate
3. Skin, Hair, Nails














Skin:Dark brown, warm to
touch, excessively dry,
waxy, thickened and
tightened with straight line
white patches, diffuse DE
pigmented macules.
Scalp & hair: Black in color,
straight, thin & dry in
texture evenly distributed,
No scalp or
Flaking.
Nails:Pale in color ,
thickened, 180 angle, and
greater than 2 seconds
capillary nail bed refill
Reveals evenly colored skin tones
without unusual or prominent
discolorations, smooth without
lesions, normally thin, Skin pinches
easily and immediately return to its
original position.
Natural hair color varies in race.
Color is determined by the amount
of melanin present, scalp is clean
and dry. Hair is smooth and firm.
Pink tones should be seen,
normally 160 angle between nail
base and the skin, hard and
immobile, smooth and firm




4. head ,face, neck

Head




Face




Neck


Range of motion



Palpate the Trachea


Head symmetrically
rounded, erect, and in
midline. No lesions are
visible


Face is symmetric, oval in
shape. No abnormal
movements noted.


Neck nontender with full
ROM, symmetric without
masses. Lymph nodes non
palpable. Neck movement is
smooth and controlled
rotation

Trachea is midline. Thyroid
nonpalpable


Head size and shape vary especially
in accord with ethnicity, usually
symmetric, round, erect, and in
midline. No lesions are available.

Face is symmetric with around,
oval, elongated or square
appearance. No abnormal
movements.

Neck is symmetric with head
centered and without bulging
masses




Trachea is midline

5 . Eyes

Visual Acuity

Positions test



Eyelids & eyelashes,
eyeballs









Snellen Chart: with glasses
off vision is 20/50
Eye movement symmetric
throughout 6 directions


Eyes 2cm apart without
protrusion.Eyelashes are
evenly distributed. Eyelids
brown in color, without
edemaor lesions and freely
closeable bilaterally.
Eyeballs symmetric, without
protruding.
Bulbar&palpebral


Normal visual acuity is 20/20.

Eyes movement should be smooth
and symmetric throughout all 6
directions

The upper & lower lids close easily
and meet completely when closed.
Skin on both eyelids is without
redness, swelling or lesions.
Eyeballs are symmetrically aligned
in sockets w/o protruding or
sinking.

Bulbar &palpebral conjunctiva is
conjunctiva& sclera



Cornea & lens



Iris & pupil




Pupillary reaction to Light
Accommodation of pupils

conjunctiva is pale in color,
moist and smooth.Sclera is
white
Cornea is transparent, lens is
free of opacities


Iris is round, flat & evenly
colored. Pupil is round,
centered in iris, 3mm in size.

PEARRLA

Pupils constrict and
converge
clear, moist and smooth.
Underlying structures are clearly
visible. Sclera is white
The cornea should be transparent
with no opacities. Lens free of
opacities.

The iris is typically round, flat, and
evenly colored. The pupil is round
with regular border, is centered in
the iris. Pupils are normally equal in
size 3-5mm.
PEARRLA

The normal pupillary response is
constriction and convergence of the
eyes when focusing on a near
object.
3. Ears
Auricles



Auricle and mastoid
process

External auditory canal





Tympanic membrane











Whisper test
Webers test



Auricles are equal in size,
without deformity, lumps
and lesions. Skin is
thickened and waxy.
Auricles and mastoid
processes nontender

Bilateral Auditory canals
contain moderate amount of
dark brown, dry cerumen


Tympanic membrane is
difficult to view due to
cerumen.









Can clearly identifies words


No lateralization of sounds
to either ear

Auricles should be equal in size
bilaterally. Skin is smooth, with no
lesions, lumps or nodules.

Normally the auricle and mastoid
process are not tender.

A small amount of oderless
cerumen is the only discharge
normally present. Cerumen may be
yellow, orange, red, brown, gray, or
black and soft, moist, dry, flaky or
even hard.
The tympanic membrane should be
pearly, gray, shiny, and translucent
with no bulging or retraction. It is
slightly concave, smooth and intact.
A cone-shaped reflection of the
otoscope light is normally seen at 5
oclock in the right ear and at 7
oclock in the left ear. The short
process and handle of the malleus
and the umbo are clearly visible.
Whisper clearly identify
Vibrations are heard equally well in
both ears. No lateralization of
sound to either ear.
Air conduction is normally heard
longer than bone conduction
Rinne test AC is greater than BC in both
ears
sound.
4. Mouth
Lips

Teeth& gums







Buccal mucosa





Tongue





Hard and soft palates




Odor

Ovula



Lips dry , w/o lesions or
swelling
Upper part complete
dentures(false teeth),2
missing teeth in the lower
part, chalky white area in
the tooth surface
Gums are pale in color,
without inflammation or
bleeding
Buccal mucosa pale in color,
visible with saliva, no
redness, swelling



Darker in color,thickened,
no lesions, ulcers or nodules,
decreased tongue strength,
can distinguish bitter, sweet
and salty
Hard palate is pale in color
with wrinkle-like folds
Soft palates is red

No foul odor is noted

Ovula in midline and
elevates in phonation

Lips are smooth and moist without
lesions or swelling
Thirty two whitish teeth with
smooth surfaces and edges are
available. No decayed areas; no
missing teeth.
Gums are pink, moist, and firm with
tight margins to the tooth. No
lesions or masses.

It should appear pink in light-
skinned clients; tissue pigmentation
typically increases in dark-skinned
clients. In both, tissue is smooth
and moist without lesions.
Tongue should be pink, moist, no
lesion are present, no lesions, ulcers
or nodules are apparent, tongue
offers strong resistance, can
distinguish salty, sweet and bitter
taste
The hard palate is pale or whitish
with frim, transverse rugae. Soft
palates should be pinkish, movable,
spongy and smooth

No unusual odor or foul odor

The ovula is fleshy, solid structure
that hangs freely in the midline. No
redness of or exudate.
5. Nose Color of the nose is the
same as the rest of the face
darker brown, thickened
and waxy, symmetric,
patent, turbinates and
middle meatus pale pink,
without swelling, exudate or
lesions, nasal septum
midline without bleeding,
frontal and maxillary sinuses
nontender
Color is the same as the rest of the
face, smooth, symmetric, no
tenderness, client is able to sniff
through each nostril while other is
occluded, nasal mucosa is dark pink,
moist and free of exudates. Nasal
septum is intact and free of ulcers
or perforations. Turbinates are dark
pink. Frontal and maxillary sinuses
are nontender to palpation.
6. Thorax and lungs

Skin is depigmented,
dry,thickened with white
Skin color even. Scapulae are
symmetric and non protruding. No
straight lines patches,
auxillary respiratory muscles
and nasal flaring are not
observed, Scapulae are
symmetric and
nonprotruding.Thorax
expands bilaterally without
retractions or bulging.
Respirations even,
unlabored and regular
(20cpm). Vesicular breath
sounds heard in all lung
fields. No rales, rhonchi,
friction rubs noted.
Sitting, breathing easily with
arms in lap
Sternum is positioned at
midline & straight
Retractions not observed,
reported of joint pain &
epigastric pain.
use of accessory muscles and nasal
flaring are observed. Client reports
of no tenderness, pain or unusual
sensations.Skin and sucuatneous
tissue are free of lesions and
masses. Three types of normal
breath sounds may be auscultated-
bronchial, bronchovesicular and
vesicular.Noadventious sounds are
ausculatated.
7. Breast Breast small in size, round ,
and symmetrically
bilaterally. Skin is dark
brown with darker brown
areola, no dimpling. Free
movement in all positions.
Nipples are everted, no
discharged expressed. No
thickening or tenderness
noted. Lymph nodes
nonpalpable.
Breast can be a variety of sizes and
somewhat round and pendulous.
One breast may be normally be
larger than the other. Color varies
depending on the clients skin tone.
Texture is smooth without edema.
Areolas vary from dark pink to dark
brown. Small Montgomery
tubercles are present.Nipples are
nearly equal bilaterally in size and
are the same location on each
breast.Nipples are usually everted
with no signs of dimpling or
retraction. Breast should be
smooth, firm and elastic. No masses
should be palapated.
8. Heart No pulsations visible. Clear,
brief heart sounds
throughtout. No gallops,
murmurs, or rubs.
The jugular venous pulse is not
normally visible with the client
sitting upright. No blowing or
swishing or other sounds are
heard.Nopulsations or vibartions
are palpated in the areas of the
apex, left sternal border or
base.Normally no murmurs are
heard
9. Abdomen Abdomen is symmetric,
rounded, does not bulge
Abdominal skin may be paler than
the general skin, smooth, free of
when client raises head. Skin
color is dark brown, dry,
thickened and
shiny.Abdomen free of hair,
bruising and increased
vasculature. Umbilicus is
midline, recessed and
round.Bowel sounds low
pitched and gurgling at
14/min x4 quads.
lesions or rashes, umbilical is
midline at lateral line,recessed or
protruding no more than .5cm. and
is round or conical. Abdomen is flat,
rounded or scaphoid, symmetric,
does not bulge when raises head.A
series of intermittent, soft clicks
and gurgles are heard at a rate of 5-
30 per minute. Borborygmi may be
normally heard.
10. Musculoskeletal
Gait



Temporomandibular joint

Cervical, thoracic and
lumbar




Shoulders, arms and
elbows





ROM





Wrist








Hands and fingers



Uneven weight bearing is
evident. Client propels
forward. Posture slightly
stooped.
Decreased muscle strength.

Cervical and lumbar are
concave. Flexion of the
cervical spine is 45 degrees.
Extension of the cervical
spine is 45 degrees.
Shoulders symmetrically
round, dry, thickenedand
clients reported of joint
pain as she moves, elbows
are rough and hard

Decreased muscle strength,
painful and limited
abduction, adduction,
flexion and hyperextension

Symmetric,thickened and
waxy, no nodules noted,
have increased pain with
extension and flexion of the
wrist, decreased muscle
strength



Hand and finger are
symmetric, without nodules
but thickened and schlerotic
or stiff, tender, deformed
and distorted, limited in
motion, decreased muscle

Evenly distributed. Equal on both
sides. Posture erect, arms swing in
opposition.
Jaw protrudes and retracts easily.
The clients mouth opens and closes
smoothly.

Cervical and lumbar are concave
Flexion of the cervical spine is 45
degrees. Extension of the cervical
spine is 45 degrees.


Shoulders are symmetrically round,
no redness, swelling or deformity or
heat. Muscles are fully
developed.Client reports no
tenderness nor pain.


Extent of forward flexion should be
180 degrees; hyperextension 50
degrees; adduction 50 degrees and
;abduction 180 degrees. Client
should have full ROM against
resistance.
Wrist are symmetric, without
redness or swelling, nontender and
free of nodules Normal range of
motion are 90 degrees flexion; 70
degrees hyperextension; 55 degrees
ulnar devialtion; and 20 degrees
radial deviation. Client should have
full ROM against resistance.
Hands and fingers are symmetric,
nontender and without nodules.
Fingers lie in a straight line. No











Knees









Ankles and feet
strength






Knees symmetric,tendered
and warmth with a boggy
consistency, skin is
thickened and dry, inability
to extend knee fully,
decreased muscle strength
against resistance , reports
of pain on examination
Thickened, tendered, skin is
dry,with calluses,
decreased strength against
resistance and clients
reports of pain
swelling or deformities. Normal
range are 20 degrees of abduction,
full adduction fofingers(touching),
90 degrees of flexion, and 30
degrees of hyperextension. The
thumb should easily move away
from other fingers and 50 dgrees of
thumb flexion is normal. The client
has full ROM against resistance.
Knees symmetric, hollows present
on both sides of the patella, no
swelling or deformities, nontender
and cool, muscles firm, no
nodules.Normal ROM rmages 120
degrees to 130 degrees of flexion; 0
degress of extension to 15 degress
of hyperextension; Clients should
have full ROM against resistance.
No pin, healt, sweeling or nodules
are present, Skin is smooth and free
of corns and calluses. Clients should
have a full ROM against resistance.


























GORDONS FUNCTIONAL HEALTH PATTERN
BEFORE HOSPITALIZATION DURING HOSPITALIZATION
1. 1. Health
Perception
Health
Management
Pattern

Subjective:
Sumasakitnayungsikmuramgaisangb
uwanpero once kolangpinacheck up,
niresathanako ng
gamotininomkoyunperohindirinnam
antumatalab kaya tinigilkonalang
bale
sapagsususkanamanmedyonawawal
awalarinyungsakit as verbalized by
patient H.E.
Diagnosis: Ineffective self-health
maintenance related to current
illness as evidenced by not having
further checkup
Subjective: Nang parangsatinginko ay
lumalalayatayungsakitko, lumuwasna
kami samaynilasinamakoyunghipagko
para matingnanditosa hospital,
kasinararamdamankonarinnaparangtumi
tigasyungkatawankomagsimulasapaahan
ggangpaakyatnasya
Objective: Hypopigmentation was noted
to spread to face, neck
trunks and extremities, skin
is hardened and dry.
Diagnosis: Effective health seeking
behavior related to current
illness as evidenced by
prompting consult.
2. Nutritional-
Metabolic Pattern
S:
Datimatabaakomatakawkasiakokum
ain as verbalized by the patient
O: weigh of 70kg., height 55
D: Risk for Imbalanced nutrition as
evidenced by BMI of 27.34
S- ngayonditoakosa hospital
bumabanayungtimbangko at
nawawalannakasiako ng
ganasapagkainkasingapalagiakongnags
usuka as verbalized by the patient
O- weigh of 51kg., height 55
A- Patient H.As nutritional status has
been changed due to her confinement
and medical health condition.
D: Imbalanced nutrition, less than body
requirement related to current illness
as manifested by BMI of 19.92
3. Elimination
Pattern

S:
"Dumudumiakodalawangbesesara
waraw, at
S Hindi akomadalasdumumiditosa
hospital tsakayungpagihikorin ay
nabawasan,
tsakaarawarawakosumusukatalagatuwing
madalasnamanakongumihi as
verbalized by the patient

O: defecates 2 times daily without
experiencing discomforts, usually
morning and afternoon. Stool is
brown in color and is well
formed, voids 6-8 times a day,
urine is yellow in color. No pain
when voiding

haponas verbalized by the patient
O defecates once a day but not
everyday, stool is soft, is minimal in
amount and yellow to brown in color,
void 3-4 times without pain and
discomfort
A- Bowel -There was a change in the
frequency, consistency and amount
Bladder: there was a change in the
frequency and amount

D: Risk for electrolyte imbalance related
to less fluid intake and frequent vomiting
4. Sleep-Rest
Pattern

S: "Sa
bahayhindiakomakatulogmaayosd
ahilngasanararamdamankomasaki
tyungmga joints ko, halos
buongkatawantalagamakirottalag
a, kaya sagabipalgiakonagigising
as verbalized by the patient
O: dark circles around the eyes, feel
not rested and comfortable PS:
8/10
D: Disturbed sleep pattern secondary
to joint pain as manifested by
pain scale of 8/10

D: Insomnia secondary to pain as
manifested by restlessness
S:
"ngayonditoakosaospitalwalanatalaga
akongmagandangtulog,pakontinalang
ng pakontiyungtulogko ditto
O: Presence of dark circles around the
eyes , frequent yawning, patient has
increased restlessness and irritability.
A- Illness that causes pain or physical
distress can result in sleep problems.
People who are ill require more sleep
than normal and the normal rhythm &
wakefulness is often disturbed
(Fundamentals of nursing 7
th
edition by
Barbara kozier, et al.p 1117). There is
a total disruption of the sleep-wake
cycle because of the patients disease
D: Sleep deprivation related to prolonged
discomfort as manifested by malaise,
fatigue and decreased ability to function
5. Activity-Exercise
Pattern

Briskwalkingang exercise
kotuwingumaga,
mgaisangoraslangnamansaprobinsya,
S: ngayon, mabuti at me nagtuturoritosa
hospital ng kung anoangmakakabuti
para maibsanangnararamadamanko
kasonungnagsimula ng
tumigasyungmga muscle
kosapaataposnagsimulanarinsumakit,
palaginalangakonakahiga at di
konanagagawayungmgapangarawara
wna Gawain ko as verbalized by the
patient
O- decreased muscle strength,
inability to do daily activity living,
D: Impaired physical mobility related
to limited movement of the body or
of one or more extremities as
manifested by muscle aching and
joint pain
kaya kahitmedyomasakit pa ring
gumalaw ay
naglalakadakopapuntangbanyo para
maligomagisa,
nageexercisenarinakokahitpakontikont
ikatulad ng pagikot ng mgakamay,
tapos mag deep breathing exercise,
simple langperomakakatulongtalaga
para bumalikyung dating sigla ng
katawanko." as verbalized by the
patient
O: taken a short walk, and practiced deep
breathing exercise 10 cycles per hour
A- client is willing to adapt or to learn the
health teaching in able to perform
activities of daily living
D: Readiness for enhanced activity
exercise
6. Cognitive
Perception Pattern

S: mga 1 month ago ay
grabetalagayungsakitnanararamdam
ankobuongkatawan,
magsimulasakatawanpaakyat, kaya
umiiyaktalagaako as verbalized by
the patient

O: hardened skin, Pain scale of 9/10

D:Chronic Pain secondary to
schleroderma as manifested by Pain
scale of 9/10

S: "ditosa hospital nababawasanyung pain
kosagamotnabinibigaysa akin,
perohindikoparinkayangbumagonmagisa
nagpapaassist pa rinakokasi ng
masakitgumalawdahilditosa joint pain ko"
verbalized by the patient
O: hardened, thickened skin with straight
line white patches scattered in areas
of the thebody,fingers distorted, pain
scale 7/10
A- patient cannot do those things that
she usually do, she really needs an
assistance.
D: Alteration in comfort related to
current illness as manifested by facial
grimace whenever she moves
7. Self-Perception
Self-Concept
Pattern

S- Im a friendly person
madalasakongnakikihalubilosamgata
okasinganegosyanteako ng isda,
perosimulanungdumaposa akin
itongsakitnaito ay
nagkukulongakosakwarto ng
isambuwanhindiakonagpapakitasamg
a friends kokasinakitakosasalaminna
para biglatumandaangakinghitsura
as verbalized by the patient
O: skin is hardened and thickened
with straight white patches all over,
shiny, fingers distorted, brittle nails,
sudden weight loss
D: Disturbed body image related to
present illness as manifested by
thickened, shiny skin, fingers
distorted , and sudden weight loss
Situational low self-esteem related to
present illness as manifested by self
isolation

S: "sinabihankongayung doctor kona kung
pwedebaako I mercy killing nalangako" as
verbalized by the patient.
O: passivity, decreased appetite, sleep
pattern disturbance
A- Events or situations may change the
level of self concept over time, illness and
trauma can also affect the self- concept
(Fundamental of Nursing 7
th
edition by
Barbara Kozier p. 959 & 962)
Due to her present condition, there is a
change to the level of patient self-
perception and self-concept knowing that
her disease is rare and incurable, the
symptoms can prevented but it might be
present all the time.
D: Hopelessness related to prolonged
activity restriction and deteriorating
physiological condition as evidenced by
fatigue, malaise and change in physical
appearance
8. Role-
Relationship

S: malakasangkitakosa business
pagbebenta ng isda, at me
sarilikamingmgabangkataposdinadala
kosyasa manila kung saan mas
malakiat bultuhanangbentahan,
mabokaako kaya maramiakong
costumer, kaya
langnungnagkaroonnaako ng
sakitnaito,
S
Naawangaakosadalawakonganakkasisim
ulanungnagakasakitako ng ganito ay
hindikonasilanagagabayan, lao pa
ngayonmalayoakoditoakosa manila
nagpaconfine as verbalized by the SO
O:
D : Impaired parenting related to inability
to provide needs as primary care taker of
nagkukulongnaakosakwarto ,
ayawkonamunamakipagusapsamgaka
ibigan at mga costumer naming
kasibakanakahawaito or
pandirihanako as verbalized by the
patient
O: shy and minimal talking
D : Social isolation related to negative
self-perceptions and
unknowledgeable about her own
disease
children
9.Sexual Pattern

S: me asawaako at dalawaanganak
naming, malalkinarinsilayungisa ay
college na at yungisa ay highschool
as verbalized by the patient
O: married, 2 children
D: Active family Process
S
Dahilditosasakitko,atpalaginalangakonasa
hospital, hindikonamagagampanan pa
siguroyung role kobilangasawa as
verbalized by the patient
O: refrain from sexual activity
D:Sexual dysfunction related to present
illness as manifested by verbalization
10. Coping-Stress
Tolerance

S: walaakomakausapsabahay,
kasipalagirinwalayungasawakonag
hahanapbuhayiniiwanannalangnya
ako ng pagkainsaloob ng kwarto,
hindirinnilaakokinakausapsabahay
at inaasikaso, yunghipagko pa
angtinatawag para magalaga as
verbalized by the patient
O: on bed most of the time alone
D: Compromised family coping
related to insufficient, ineffective, or
compromised support from the
family members
S: nakakastress din
talagayunglagikanakahiga,
walakamagawataposganito pa
yungkalagayanko lifetime
komararamdamanito kaya
ngakinausapkodatiyungdoktorkoimerc
y killing nalangako,
walanarinnamanakongsilbirin, di
namakapaghanapbuhay, tapos di
konarinmaaalagaanmgaanakko as
verbalized by the patient
O: lying on bed, impulsive, lonely, fatigue,
decreased use of social support
A: According to Folkman and Lazaruz,
coping is the cognitive and behavioral
effort to manage specific external and/or
internal demands that are appraised as
taxing or exceeding the resources of the
person ( Fundamentals of Nursing by
Kozier page 1020) Due to his condition,
patient H.A. does not have an outlet to
divert his feelings.

D: ineffective coping related to
inadequate level of confidence in ability
to cope as manifested by verbalization
Risk for suicide related to situational
crises and inability to conserve adaptive
energies


11. value-Belief
Pattern
S:
"Matagalnaakohindinakakapagsimba
simulanungdumaposa akin
itongsakitnaito" as verbalized by the
patient
O: refrain from attending mass every
Sunday
D: Risk for impaired religiosity
related to illness as barriers to
practicing religion
S- Ngayonditosa hospital me nagbigaysa
akin ng book tungkolsaatingPanginoo,
basahinko raw ito raw ay food for the
soul nungsinimulana koi to basahin ay
nagibanarinyungpananawko bale
dapat faith langpalatalagakay God me
Awa angDiyosgagalingrinako at
hindikonarindapatisipin pa
angmganakakapa stress sa akin,
sisimulankonarinmagattend ng
misasaQuiapo at sasimbahan dun sa
Eastwood at lumapitke Padre Pio as
verbalized by the patient
O- Presence of Rosary and religious
booklet on bedside
D: Readiness for enhanced religiosity
related to ability to experience and
integrate meaning and purpose in life
through connectedness with a power
greater than oneself.


DIAGNOSTIC EVALUATION:

ECG: done July 23, 2014 @ 1:23 p.m.
Findings: Vent rate : 116 bpm
QRS duration : 80ms
QT/QTc : 316 / 439 ms
PR interval : 116 ms
P duration: 88 ms
RR interval : 517 ms
P-R-T axes: 58 55 13

Interpretation: Sinus tachycardia, Poor R-wave Progression V1-V3, Non Specific ST-T-Wave Changes,
Low voltage tracing
Interpreted by Cardiologist Dr.Ranulfo B. Javelosa Jr.


URINALYSIS:
done July 24, 2014 @ 12:28 p.m. by Med. Tech ALeth Sales and read by Pathologist Dr.Araceli Jacoba
COLOR RESULTS NORMAL VALUES
Turbidity Yellow Varying degree of yellow
Reaction Clear Clear
Specific gravity Acidic Variable, usually acidic
Protein 1.015 Variable
Sugar Negative Negative
RBC 0-1 hpf Negative
WBC(female) 0-5 hpf 0-2/hpf
Casts None
Bacteria None
Epithelial cells Few

INTERPRETATION:
WBC may indicate infections due to increase in disease fighting cells.


CBC

Test Result unit Normal Values
Hemoglobin 110 g/L 140-160
Hct 36 % 40-54
RBC 5.5 X1012/L 4.5 5.0
MCHC 30 % 32-37
MCH 20.0 Pg 27.5-33.2
MCV 65 fL 80-94
RDW 18.9 % 11-15
WBC 14.1 X109/L 5-10
Diff. Count
neutrophils 89 % 40-75
Stabs %
Lymphocytes 11 % 20-45
Monocytes %
Eosophils % 0-1
Platelet Normal X109L 150-440
MPV 8.6 fL 7.5 11.5



INTERPRETATION:
Low amount of hemoglobin in blood lowers the synthesis of erythropoietin, a hormone
secreted by the kidneys that increases the rate of production of red blood cells in response to
falling levels of oxygen in the tissues. The erythrocyte volume is lower than the normal value, it

may be due to less oxygen that binds with the iron portion to form oxyhemoglobin. Other
components of the blood are within the normal range.



BLOOD CHEMISTRY:
Done on July 24, 2014 @ 11:56 a.m. by Med. Techs Christine Cipriano& Maria Esperanza Cagurangan,
Pathologist Dr.JacobaAracelli

TEST RESULT NORMAL Range
UREA NITROGEN SUBSTC 2.29 mmol/L 3.2 6.8 mmol/L
CREATININE SUBSTC 57 unmol/L 44 106 umol/L
SODIUM 140 mmol/L 135 155 mmol/L
POTASSIUM 3.2 mmol/L 3.5 5.3 mmol /L
CPK - total 173 Iu/L 36 188 Iu/L




INTERPRETATION: The main cause of decrease in BUN are severe liver disease, anabolic state and
syndrome of inappropriate ADH.




UNIVERSITY OF THE EAST RAMON MAGSAYSAY
MEMORIAL MEDICAL CENTER
# 64 Aurora blvd, Quezon City
College of Nursing



CASE: GASTRITIS SECONDARY TO SCLERODERMA


Submitted By:
SUZETTE M. PIPO
Group A2
Surgical Ward

Submitted To:
Ms. ZandralineOng, MSN RN
Clinical Instructor Level III


July 30, 2014