Question

CLINICAL SCENARIO:

NURSING HEALTH HISTORY

Patient’s Profile

Name: Patient X
Age:    18
Date of birth:             April 3, 2000

Sex:    Female:

Height: 5’1 ft.
Weight: 48. 4kg

Date of Admission/ Time of Admission: August 19, 2020 7:00 AM

Allergy: No allergy to food and medication

Initial Diagnosis:

Measles, Pregnancy Uterine 33 5/7 weeks AOG G1P0 with Intestinal Complications (AGE)

Chief complaint:

Fever and productive cough

History of Present Illness:

The client was admitted to the San Lazaro Hospital last August 4, 2020. 2 weeks prior to consultation: (+) undocumented fever, intermittent, no other associated symptoms no consultation done, no medications taken. 1 week PTC: (+) onset of productive cough (yellow mucus), colds, no fever or rashes, no consult done, no meds taken. Interval history revealed persistence of cough and colds until 1 day (+) rashes, non-pruritic on abdomen which spread to the trunk and face. Sought consult and was prescribed vitamins and sent home.

Past Medical/ Personal and Social History:

No previous hospitalizations and surgeries.

Past Medical History:

(-) PTB
(-) Diabetes Mellitus (-) Asthma
(-) Hypertension
(-) Cancer
(-) allergy

Family History:

(-) Hypertension (-) Diabetes
(-) Cancer
(-) PTB

(-) Asthma

Admission Order

The patient was admitted on August 19, 2020 at 7:00 am with a chief complaint of fever and productive cough. Client was admitted to Emergency Room. Consent was secured for admission. Client was the transferred to Adult Female Ward. Patient received with IVF D5LR 1L regulated at 150cc/hr. Client’s vital signs are (BP - 100/70 RR - 25 T - 38.3 HR - 116 O2 saturation - 95%) There is a presence of fever with macula-papular rash on the patient with productive cough (whitish to yellowish mucus secretion). The patient also showed sign of body weakness, poor appetite, abdominal pain and defecates a mushy consistency stool. Physician ordered for CBC, BT, Measles IgG, IgM, CXR-PA view, Serum Creatinine, Na, K, SGPT,

SGOT, and Stool exam. Paracetamol 1 tab PRN for fever >37.8, Hexetidine 10 ml for oral gargle was given. Performed tepid sponge bath. Encouraged to increase fluid intake. Maintained high back rest. Advised the watcher not to leave the client unattended. Kept monitored the safety of the client by maintaining side rails up. Vital signs monitored q4 and recorded. Intake and Output monitored. Watched out for (WOF) any signs of respiratory distress such as dyspnea or increased respiratory rate. The following day, client was seen awake and lying in bed. Client’s vital sign are (BP- 90/60 RR-23 T- 36.7 HR-97 O2 sat- 97%). Client still manifested maculopapular rash with body malaise. Cough still productive with crackles heard on both upper lung area. IVF D5LR 1L regulated at 150cc/hr was started. Noted and referred Physician’s order for Isoxsuprine 10mg/tab, 2tabs PO TID and Dexamethasone 6mg/amp TIV q6 x4 doses. . IVF PNSS 1L at 110cc/hr to follow. Advised not to scratch the skin to prevent skin integrity impairment. Maintained HOB elevation at 30-40 degrees. Provided a quiet and calm environment. Instructed the watcher not to leave the patient alone. Kept monitored the safety of the client by maintaining side rails up. Instructed dietary intake as tolerated. Vital signs monitored q4 and recorded. Intake and Output monitored. WOF vaginal bleeding and refer to the staff nurse immediately. Client was seen awake and lying in bed. Client’s vital sign are (BP 100/60 RR-22 T-36 HR-85 O2 sat95%). Client manifested conjunctivitis and still showed presence of rash in the skin. Cough still productive. Acetylcysteine 600mg 1-tab dissolve in 50cc water ODHS were given. Patient was ordered for discharge. Noted and instructed the patient regarding the following home medications ordered by the Physician, Co-amoxiclav 625 mg 1tab TID for 7 days, Hexetidine gargle 10ml TID, Multivitamins 1tab OD and B-Complex 1tab OD. Encouraged client to increase oral fluid intake. Advised to follow-up to OPD after 1 week. Vital signs monitored and recorded.

1. Complete the Gordon’s Functional Health Pattern of your client based on the history and the chart by answering the box of during hospitalization. What statements will your patient will tell you, can also base your answer in your experience during your duty in the hospital.

Health Perception and Health Management
Prior to Admission : She claimed she doesn't get sick often. Every time she had a fever and cough before her pregnancy, her mother just gave her paracetamol and lagundi capsule as medication. She reported that she does not have a complete vaccination record. She claimed she does not smoke and drink alcohol or use any illegal drugs.	During Hospitalization
2. Nutritional and Metabolic Pattern
According to the client, she usually ate rice, vegetables, and meat for breakfast, lunch and dinner. She claimed she has a good appetite.
3. Elimination Pattern
She claimed that she defecated once a day with brown and formed stool. She had not experienced any difficulties in defecation and she never used any laxatives and stool softeners. She said she urinated 3 times a day with yellow urine and has no foul smell. And She did not experience any difficulties in voiding
4. Activity-Exercise Pattern
She did not usually exercise except for household chores.
5. Sleep-Rest Pattern
She went to bed at 9 pm and wakes up 10 am and takes a nap from 3pm- 4pm.
6. Cognitive-Perceptional Pattern
According to the client, she does not have any problems in hearing, sight as well as memory.
7. Self-Perception/Self-Concept Pattern
She rarely go out to socialize with other people.
8. Role Relationship Pattern
The Client’s permanent address is in Antipolo Rizal. She stays together with her live in partner and her family.
9. Sexually Reproductive Pattern
The client is sexually active. She had one sexual partner.
10. Coping/Stress Tolerance
Client talked to her mother whenever she felt anxious. According to the client, watching K drama was her way to alleviate stress.
11.Value / Belief Pattern
Client is a Roman Catholic but her family rarely goes to church every Sunday.

2.         Make at least 2 days course in the ward based on the admission order and some activities happened in the ward. (reflect on your experiences in the ward)

Answer 1

Answer 1:The statements that the patient will tell during hospitalization (with reference to the Gordon’s Functional Health Pattern) based on the history,patient chart and my experience during the duty in the hospital are given below:

1.Probable patient statement for health perception and Management

a]. she normally keeps good health but since last 20 days she has hardly felt good.

b] she has felt tired, quite sick and uneasy most of the times since two weeks.

c]. She thinks with pregnancy her body has changed and things are not the same with her as before.

2.Patient statements to nutritional-Metabolic pattern.

a)She doesn't feel much hungry and her stomach hurts

b) She would prefer to have a little chilled juice ;her throat hurts from coughing.

3.Probable patient statement to elimination pattern

a) She had a very mushy stool this morning,

b)She never experienced this kind of stools before .

c)Her urine was dark yellow and little in quantity this morning.

4.Probable patient statements for activity and exercise pattern :

a)She felt quite breathless while going to the washroom today morning.

b) She feels a little better to breathe when she is sitting up in the bed

5.probable patient statements for sleep and rest patterns:

a)She found it difficult to sleep at night .Her eyes were hurting and her rashes itched.

b)She prefers to rest with the head end of my bed up. That makes her feel a little less uneasy

c) She wishes she could sleep better.

6. probable patient statements for cognition and perception pattern

a)She can remember every detail since she got sick and and how tired she has been  since then.

7. probable patient statement for self-perception /self concept patterns

a) She doesn't go out often but the hospital makes her feel sick and she feels like going out.

b)She doesn't see how she could have got this infection from someone else,she hardly socializes and in her family all are fine;nobody is sick.

c) She wonders if the the thing that she got the rash and the fever would spread to others she meets and to her kid.

8. probable patient statements for Role relationship pattern

a} She fears the rash and  the fever will spread to her live in  partner and his family once she gets home.

9.probable statement for Sexually Reproductive Pattern

a} She doesn't think she will be able to sleep with her partner while she has this rash and cough.

10.probable statement for Coping/Stress Tolerance

a) she loves talking to her mother; it makes her feel better but the cough doesn't allow her to speak much

b)She hasn't watched TV for last 5 days ;felt very sick to watch.

c)She  wishes she could get to see the K drama series here in the ward; it helps her feel better

11..probable statement for Value / Belief Pattern

a) She says that her Family rarely goes to church but somehow her sickness makes her feel like going to church to pray

         Make at least 2 days course in the ward based on the admission order and some activities happened in the ward. (reflect on your experiences in the ward)

answer2:The 2 -day course in the ward based on the admission order and some activities that happened in the ward based on my experiences is briefed below:

day 1 course:

The patients vital parameters were checked,charted and she was given tepid bath sponge. She was quite comfortable at the end of sponging.The medicines and diet as prescribed were given were given She was a worried if the measles that she has would have any effect on her baby. Patient education and counselling about the the measles having medical complications for her was given and reassurances given.The risk of preterm delivery was explained.. She hardly ate anything and asked if she could get some chilled juice to drink as she felt sore in the throat. She was advised that some warm liquids like warm soup or warm porridge would help her to feel better than chilled juice. Patient also sought help for itching. She complained  severe itching especially in the skin over the abdomen. Physician consultation was sought and calamine lotion dabbed with cotton pad on the rashes. She also complainted of abdominal pain and asked if she could get some medicine for the pain.Physician consultation was sought for the same. She was advised to keep the kick count of the babys' movements and the same was confirmed from her at the end of the shift. She was educated that at least 10 movements  in 2 hours would mean that her baby is doing well and that she should keep alert if the movements decrease.She should also inform if she has any vaginal bleed.she was informed that the gynaecologist would see her after this shift.

Day  2 course

The patient was up in the bed lying wide awake at the beginning of the shift. She said that she had not slept well at night and complained that the cough irritated her, also the rashes. Her vitals were taken and the lungs auscultated. There were basal crackles heard in the lungs but her fever was better;temperature normal .Patient was given hexetidine gargles. and injections and tablets as advised by the physicianShe did feel like eating a little and felt some appetite for breakfast. She inquired if there was any chance that she would have an early delivery and what would happen to her baby if she delivered early. She was counseled that she had been given injection dexamethasone for her baby's lung maturity if she delivers early and in any event that she should have any vaginal bleeding she should inform immediately.She was educated about the possibility of a premature labour. The patient was quite apprehensive about this and wondered if she could have her mother to see her so that she could discuss the same with her and feel better.Her mother was called and message conveyed.She said she found it difficult to drink the tablet(n-acetylcysteine) that was dissolved in the water and asked if she could take it without dissolvingShe also wanted to know how long it will take for the rashes and the cough to settle and whether she could use the lagundi capsule as medication which her mother usually gave her.She was informed that the same  would be discussed with her doctor and she would be kept informed.