ST.

ALEXIUS COLLEGE
City of Koronadal
College of Nursing

DATABASE: PATIENT HISTORY AND NURSING INTERVIEW

HEALTH ASSESSMENT I

Biographical Data

Name: Mr. Bata Batuta

Age: 3 years old
Address: Purok San Antonio, San Roque, Koronadal City, South Cotabato
Bithdate: September 27, 2007
Birthplace: South Cotabato, Provincial Hospital, Koronadal City
Gender: Male
Civil Status: Single
Religion: Roman Catholic
Nationality: Filipino
Contact Person:

Name: Mr. Tatay

Address: Purok San Antonio, San Roque, Koronadal City, South Cotabato
Relationship to Patient: Father

Chief Complaint:
Main Problem:
Loose bowel movement (LBM) and vomiting
Course of Present Illness:

Onset and Duration

November 21, 2010, at around 10:00 A.M., Mr. Bata Batuta experienced
loose bowel movement (LBM) 6 times and vomiting 7 times. At around 2:34 P.M.
that same day, he was admitted to The Doctors’ Clinic and Hospital, Inc._________

Sign and Symptoms

Loose bowel movement, vomiting, abdominal pain, hyperactive bowel
sounds, dehydration

Medication
 Metoclopromide 2 mg IVTT for 2 dose every 8 hours;
 Paracetamol 120 g 6 mL orally every 4 hours for fever;130 g IVTT every 4
hours for fever=39C;
 Ampicillin 250 mg IVTT every 6 hours ANST(after negative skin test)(-)
 Dicycloverine Hydrochloride (Relestal) 5 mL orally TID

Initial Intervention
 Provocative (action/position)
Palliative (action/position)
Understanding of an illness
Mr. Bata Batuta is not old enough to understand his condition. But his parents
do understand that he is experiencing loose bowel movement and vomiting because
because he always

Past Health History

A. Childhood Illnes
Mr. Bata Batuta sometimes experiences flu and colds. But he has no history of any
serious illnesses.
B. Surgeries
No history of surgeries.
C. Injuries
Experienced falling over, but only had a few scratches and bruises.
D. Hospitalization
No previous history of hospitalization.

E. Medication (prescribed or maintenance)

Multivitamins only.
F. Allergies
No known allergy to fluids and drugs.
G. Immunization Status
Complete Immunization status.

Family History

Maternal Side: ____________________________________________________________

Paternal Side:_____________________________________________________________

Psychosocial Profile

A. Health Practices and Health Beliefs

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________________________

B. Typical Day

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 C. Nutritional Pattern
According to his mother, he eats moderately. He is fond of eating sweets but is still
eating vegetables, fruits and meat. He drinks 2 glasses of milk a day.

D. Activity/Exercise

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________________________

E. Sleep/Rest Pattern

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________________________

F. Personal Habits

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G. Socio-economic Status

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________________________

Summary of the Interview:

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_____________________________
Interviewer

Jtoraño,rn-2009

ST. ALEXIUS COLLEGE

 City of Koronadal
College of Nursing

HEALTH ASSESSMENT II

Name: Mr. Bata Batuta Ward No. /Room No.:

Age: 3 years old Department:
Sex: Male Civil Status: Single
Address: Purok San Antonio, San Roque, Koronadal City, South Cotabato
Nationality: Filipino
Religion: Roman Catholic
Diagnosis: Acute Gastroenteritis with some dehydration
Date of Admission: November 21, 2010
Time of Admission: 2:34 P.M.
Blood Type: Type “O”
Allergies (specify in Red Ink): None

Mental State Activities Bladder/Bowel

Conscious Ambulate With I & O monitoring
 Drowsy  Dangle/Sit-up  Urinary Incontinence
 Unconscious  Bed Rest with toilet Privilege  Foley Catheter
 Comatose  Complete Bed Rest  Colostomy
Mood and Affect Hygiene and Comfort Diet and Nutrition
 Calm  Oral Care  NPO
 Anxious  Perineal Care  Clear Liquid
 Soft/Full
 Computed/Osteorized
 Appetite
• Ability to eat
Motor Status Bed Bath Tubes
Normal  Partial  Thoracostomy
 Slurred speech  Complete  Tracheostomy
 Hemiplegia  Penrose
Grooming
 Paraplegia
 Paresis Good
 Fair
 poor
Other Information

Height: _3 feet_ Weight: 13 kilograms

Temp: __38.5 ْ C___ CR: _128 bpm___ RR: ___32 cpm____

___Patricia Nadine M. Sarcadio___

Assessor
 ST. ALEXIUS COLLEGE
City of Koronadal
Instruction: College of Nursing
Use “N” to indicate “NORMAL” condition.
Use “A” to indicate “ABNORMAL” conditionNURSING REVIEW CHART
Indicate your comments on the column for SIGNIFICANT DATA
“SIGNIFICANT DATA”
Name:_________________________________ Room Number: __________ Date: ________

Head __N__
Skin __A__
poor skin turgor, dry skin
Lymph __A__
Eyes __N__ ______________________
Ears __N__ ______________________
Nose __N__ ______________________
Mouth __A__ ___________________dry
Neck __N__ lips_________
Breasts __N__ ______________________
Chest ______________________
Inspection __N__ ______________________
Palpation __N__ ______________________
Percussion __N__ ______________________
Auscultation __N__
______________________
Cardiovascular System
Pulses ______________________
Carotid __N__ ______________________
Brachial __N__ ______________________
Radial __N__ ______________________
Polpliteal __N__ ______________________
Dorsalis Pedis __N__ ______________________
Posterior Tibial __N__ ______________________
Heart ______________________
Inspection __N__ ______________________
Palpation __N__ ______________________
Percussion __N__
______________________
Auscultation __N__
Kidney _____ _______bowel
Abdomen __A__ sounds_______
Genitalia __N__ ______________________
Back and spine __N__ ______________________
Rectum __N__ ______________________
Extremities __N__ ______________________
Bones and joint __N__ ______________________
Neurologic ______________________
Behavior __N__
N__ ______________________
Mental Status __N__ ______________________
Reflexes __N__
____
Motor Coordination __N__
 ST. ALEXIUS COLLEGE
City of Koronadal
College of Nursing

ANATOMY and PHYSIOLOGY

The digestive system consists of two linked parts: the alimentary canal and the accessory
digestive organs. The alimentary canal is essentially a tube, some 9 meters (30 feet) long, that
extends from the mouth to anus, with its longest section- the intestines- packed into the abdominal
cavity. The lining of the alimentary canal is continuous with the skin, so technically its cavity lies
outside the body. The alimentary ‘tube’ consist of linked organs that each play their own part in
digestion: mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The
accessory digestive organs consist of the teeth and tongue in the mouth; and the salivary glands,
liver, gallbladder, and pancreas, which are all linked by ducts to the alimentary canal.
STOMACH
It is a J- shaped enlargement of the GI tract directly under the diaphragm in the epigastric,
umbilical and left hypochondriac regions of the abdomen. When empty, it is about the size of a
large sausage; the mucosa lies in large folds, called RUGAE. Approximately 10 inches long but
the diameter depends on how much food it contains. When full, it can hold about 4 L (1 galloon) of
food. Parts of the stomach includes cardiac region which is defined as a position near the heart
surrounds the cardio-esophageal sphincter through which food enters the stomach from the
esophagus, fundus which is the expanded part of the stomach lateral to the cardiac region; body
is the mid portion; and the pylorus a funnel shaped which is the terminal part of the stomach. The
pylorus is continuous with the small intestine through the pyloric sphincter, or valve.

With the gastric glands lined with several secreting cells the zymogenic (peptic) cells
secrete the principal gastric enzyme precursor, pepsinogen. The parietal (oxyntic) cells produce
hydrochloric acid, involved in conversion of pepsinogen to the active enzyme pepsin, and intrinsic
factor, involved in the absorption of Vitamin B12 for the red blood cell production. Mucous cells
secrete mucus. Secretions of the zymogenic, parietal and mucus cells are collectively called the
gastric juice. Enteroendocrine cells secrete stomach gastrin, a hormone that stimulates secretion
of hydrochloric acid and pepsinogen, contracts the lower esophageal sphincter, mildly increases
motility of the GI tract, and relaxes the pyloric sphincter. Most digestive activity occurs in the
pyloric region of the stomach. After food has been processed in the stomach, it resembles heavy
cream and is called CHYME. The chyme enters the small intestine through the pyloric sphincter.

SMALL INTESTINE

Most digestion, as well as absorption of digested food, occurs in the small intestine. This
narrow, twisting tube, about 2.5 cm (1 in) in diameter, fills most of the lower abdomen, extending
about 6 m (20 ft) in length. Over a period of three to six hours, peristalsis moves chyme through
the duodenum into the next portion of the small intestine, the jejunum, and finally into the ileum,
the last section of the small intestine. During this time, the liver secretes bile into the small
intestine through the bile duct. Bile breaks large fat globules into small droplets, which enzymes in
the small intestine can act upon. Pancreatic juice, secreted by the pancreas, enters the small
intestine through the pancreatic duct. Pancreatic juice contains enzymes that break down sugars
and starches into simple sugars, fats into fatty acids and glycerol, and proteins into amino acids.
Glands in the intestinal walls secrete additional enzymes that break down starches and complex
sugars into nutrients that the intestine absorbs. Structures called Brunner’s glands secrete mucus
to protect the intestinal walls from the acid effects of digestive juices.
 The small intestine’s capacity for absorption is increased by millions of fingerlike
projections called villi, which line the inner walls of the small intestine. Each villus is about 0.5 to
1.5 mm (0.02 to 0.06 in) long and covered with a single layer of cells. Even tinier fingerlike
projections called microvilli cover the cell surfaces. This combination of villi and microvilli
increases the surface area of the small intestine’s lining by about 150 times, multiplying its
capacity for absorption. Beneath the villi’s single layer of cells arecapillaries (tiny vessels) of the
bloodstream and the lymphatic system. These capillaries allow nutrients produced by digestion to
travel to the cells of the body. Simple sugars and amino acids pass through the capillaries to enter
the bloodstream. Fatty acids and glycerol pass through to the lymphatic system.
LARGE INTESTINE
A watery residue of indigestible food and digestive juices remains unabsorbed. This
residue leaves the ileum of the small intestine and moves by peristalsis into the large intestine,
where it spends 12 to 24 hours. The large intestine forms an inverted U over the coils of the small
intestine. It starts on the lower right-hand side of the body and ends on the lower left-hand side.
The large intestine is 1.5 to 1.8 m (5 to 6 ft) long and about 6 cm (2.5 in) in diameter.
The large intestine serves several important functions. It absorbs water— about 6 liters (1.6
gallons) daily—as well as dissolved salts from the residue passed on by the small intestine. In
addition, bacteria in the large intestine promote the breakdown of undigested materials and make
several vitamins, notably vitamin K, which the body needs for blood clotting. The large intestine
moves its remaining contents toward the rectum, which makes up the final 15 to 20 cm (6 to 8 in)
of the alimentary canal. The rectum stores the feces—waste material that consists largely of
undigested food, digestive juices, bacteria, and mucus—until elimination. Then, muscle
contractions in the walls of the rectum push the feces toward the anus. When sphincters between
the rectum and anus relax, the feces pass out of the body
 ST. ALEXIUS COLLEGE
City of Koronadal
College of Nursing

PATHOPHYSIOLOGY

PREDISPOSING FACTORS PRECIPITATING FACTORS

Ingestion of Bacteria

Increased of WBC in response to Invasion of bacteria at

infection intestine

Bacteria damages some intestinal

villi
37.6 °C Elevation of body temperature to
fight bacteria
Disruption of bowel movement

Insensible water loss Food incompletely digested

Food molecules become osmotic

agent

Osmotic agents attracts water,

potassium, and intestinal fluids

Water, potassium, and Potassium

Dehydration intestinal fluids is passed loss causes
through a loose watery stool muscle
weakness

ACUTE GASTROENTERITIS
ST. ALEXIUS COLLEGE
City of Koronadal
College of Nursing

DOCTOR’S ORDER
 Date/ Time Doctor’s Order Rationale
November 21,  Admit  For further evaluation and management
2010  Secure Consent  Serves as a legal basis that covers full
explanation of procedures to be performed
CR=128 bpm  TPR every shift  Serves as baseline data. To monitor any
Temp = 38.5 ۫C abnormalities and variation of patient vital signs
Weight = 13
kilograms  NPO to prevent vomiting. Then DAT for proper
 NPO(nothing by mouth)
for 3 hours then DAT nutrition.
Vomited 7 (Diet as tolerated)
times  Complete Blood Count - determines number,
 Request CBC, Urinalysis,
(+) abdominal variety, percentage, concentrations, and quality
and Fecalysis
pain of blood cells. it is used as a broad screening
check for anemia, infection, and many other
diseases.
 Urinalysis - Determine the renal function and
specific gravity for proper hydration and to
provide information and any pathologic
changes in urinary tract as well as other part of
the body
 Fecalysis- Evaluates stool color, consistency,
parasite identification and detection of gastro
-intestinal problems.

 D5.3NaCl 500cc to run @  Hypertonic solution which is used to replace

65 mgtts fluids and electrolytes lost during vomiting and
LBM.
 IVF to follow D5LR 500  Hypertonic solution which is used to replace
cc to run @ SR(same fluids and electrolytes lost during vomiting and
rate) LBM.

 Relestal 5 mL TID (three 

times a day)
 Paracetamol 120g 6mL  Antipyretic used to relieve fever
every 4 hours for fever
 Paracetamol 130g then  IV route provides faster relief to fever than oral
IVTT for fever 39 ۫C every route.
4 hours
 ST. ALEXIUS COLLEGE
City of Koronadal
College of Nursing

LABORATORY TESTS and DIAGNOSTIC PROCEDURE RESULTS

1. Urinalysis
Appearance
Date Result Normal values Implication
October 04, 2010 Clear Clear to slightly Normal
easy

Color
Date Result Normal values Implication
October 04, 2010 Yellow Pale, straw-colored Normal
to amber colored

Reaction pH
Date Result Normal values Implication
October 04, 2010 5.0 4.5 – 8.00 Normal

2. Fecalysis
Color
Date Result Normal values Implication
October 04, 2010 Brown Brown Normal

Consistency
Date Result Normal values Implication
October 04, 2010 Watery Formed, soft, Indicates irritation of
semisolid, moist the GI tract

Constituents
Date Result Normal values Implication
October 04, 2010 No intestinal No intestinal
parasite seen parasite
Remarks: Moderate – bacteria

Hematology
09-28-09

Exam Result Normal Value Implications

Hemoglobin 136 135-180g/L Normal

Hematocrit 40.90 42-52 vol% Decrease

RBC 5.48 4.50-6 x 10 12/L Normal

WBC 24.05 4.5-11 x 10 9/L Increase

.
Segmented
Neutrophils 0.70 0.50-0.70

Lymphocytes 0.14 0.25-0.40 Decrease

Monocytes 0.10 0.25-0.40 Decrease

 ST. ALEXIUS COLLEGE
City of Koronadal
College of Nursing

DRUG STUDY

Name of Drug Date Classification Mechanism of Action Specific Indication Side Effects Nursing Precaution
Ordered
 ST. ALEXIUS COLLEGE
City of Koronadal
College of Nursing

NURSING CARE PLAN

Assessment Nursing Diagnosis Objective Evaluation Nursing Interventions and Rationale Evaluation
Criteria
 ST. ALEXIUS COLLEGE
City of Koronadal
College of Nursing
DISCHARGE PLAN

The medical discharge plan includes the prescription of medication for continuing care and
recovery and schedule for next clinic visit. The discharge plan goal is to relieve symptoms and
prevention of complication.

Patient’s Education and Health Maintenance

• Encourage the patient to follow medication regimen as directed
• Home Medication:
 Lanoxin 0.25g 1 tab O.D
 Vastarel MR 1 tab BID

Nursing Discharge Plan

M – edication

Intake of appropriate vitamin supplement and diuretics to increase protection mechanism of the
immune system and decreases renal vascular resistance and may increase renal blood flow,
respectively.

E – conomic

The use of nonpharmacotherapy such as drinking plenty of water will promote increase plasma in
blood to increase immunity and proper hygiene and promotion of cleanliness at home and work
area.

T – reatment

Management of such condition would be through hydration and doing control measures to
eliminate vector by promoting cleanliness in the environment through proper disposal of rubber
tires, changing of water of lower vases once a week, destruction of breeding places of mosquito
and residual spraying with insecticides.

H – ygiene

Advise to follow proper body hygiene and to maintain cleanliness on surroundings. This would
prevent additional cases of DHF.

O – ut Patient/ Follow-up
Any odd signs such as fever, petechiae, recurrence of fever,etc. must be immediately reported to
the physician.

D – iet

Instruct to eat foods that are low fat, low fiber, non-irritating and non-carbonated.
Cover Page
Table of Contents
Introduction
Health Assessment I
Health Assessment II
Nursing Review Chart
Anatomy and Physiology
Pathophysiology
Doctor’s Orders
Laboratory Tests/Diagnostic Procedures
Drug Study
Nursing Care Plan
Discharge Plan
Bibliography