I. INTRODUCTION II.

Chief Complaint
Abdominal pain and vomiting III. PATIENTS PROFILE NAME: Romney Farmantier Panaligan Aumentado Address: 2174 Malungay St. Ph. 4 Brgy. CAA, Las Pinas City 1740 Age: 2 years old Sex: Male MArital Status: Single Occupation: None Religion: Catholic Health Care Financing: Private Resources Usual Source of Medical Care: Health Center, District hospital.

IV.Nursing History
1. History of present illness.

Patient was apparently well until night PTA when after eating rice and sotanghon soup suddenly had 4 episodes of vomiting of previously ingested food to blood streaked content. this was associated with 1 episode of loose stool, watery, non-blood streaked, nonfoul smell. this prompted consult at ER to subsequently.

2. Past Medical History.

a. Injuries or accidents N/A b. Hospitalizations and operations ~ This is the first time that the patient has been hospitalized. c. Immunization BCG: / / at birth / / school entrance DPT: / / 1st dose / / 2nd dose OPV: / / 1st dose / / 2nd dose AMV: / / Hepatitis B vaccine:/ / 1st dose / / 2nd / / 3rd d. Allergies: / / 3rd dose / / 3rd dose

/ / food, specify:___N/A__________________ / / drugs, specify:___ N/A ________________ / / chemicals, specify: __ N/A ______________ / / environmental allergies, specify: __ N/A____

3. Family History of Illness According to the patient's mother, there were no occurence of hereditary diseases such as diabetes, hypertension, cancer. 6. GORDONS FUNCTIONAL HEALTH PATTERNS

6.1 HEALTH-PERCEPTION AND HEALTH MANAGEMENT PATTERN

6.1.1 Perception of own health and well-being? 6.1.2 How does he keep self healthy?

Wasnt able to answer due to underlying condition

According to mother, they were giving nutritious and healthy food and patient is taking vitamins such as CEELIN and NUTRILIN. 6.1.3 Understand and aware The diagnosis and were of diagnosis ang explained well to the prognosis? patients parents. 6.1.4 Complies with treatment regimen? If not, reasons for not complying? 6.1.5 Plans for faster recovery? They follow and comply with the treatment regimen.

The mother said that they were following doctors orders for the patients faster recovery.

6.2

NUTRITIONAL-METABOLIC PATTERN

6.2.1 Appetite in general? Usual eating pattern? Likes? Dislikes? Dietary Restrictions? 6.2.2 Effects of illness and hospitalization to appetite and nutritional intake? 6.2.3 24-hour diet recall

Chocolates and fatty foods were retricted to patient. He has good appetite and taking vitamis like nutrilin and ceelin. According to mother, the patient has better appetite in home compare when he was admitted to the hospital. DINNER slice of watermelon cup of rice 1 piece of chicken 1 bottle of milk 1 glass of water BREAKFAST 1 bottle of milk 2 glass of water bottle of Gatorade Lunch 2 glass of water bottle of Gatorade 1 bottle of milk cup rice cup vegetables 1 slice of fish

6.2.4 Weight loss or gain?

The patient gained loss.

6.2.5 Uses vitamins or supplements, slimming aids?

The patient takes Ceelin and Nutrilin.

6.3

ELIMINATION PATTERN

6.3.1 Urination (frequency, urine characteristics, discomforts felt) 6.3.2 Defecation (frequency, stool characteristics, discomforts felt) 6.3.3 Effects of illness and hospitalization to urination and defecation patterns? 6.3.4 Last urination and bowel movement? 6.3.5 Use of laxatives or diuretics?

According to patient's mother, patient urinates less than 10 times a day with clear, amber colored urine and with no disccomfort. Patient also defecates once a day. His stool is from watery to yellow semiformed shape with no discomfort felt. None.

Last urination and bowel movement were after lunch,November 23, 2010. None

6.4

ACTIVITY- EXERCISE PATTERN

6.4.1 Ability to perform activities if daily living (ADLs)? 6.4.2 Type of exercise? Frequency? 6.4.3 Tires easily? 6.4.4 Occasions of dizziness, shortness of breath? Trigers? 6.4.5 Perceived benefit of exercise

The patient was not able to perform ADLs upon confinement. He is playing with toys as tolerated. He does not tires easily. There were no occasions of dizziness and shortness of breath. According to the mother, the child is exercising through playing, patient keeps his bone and muscle healthy.

6.4.6 Use of energy-giving supplements 6.4.7 General mobility since hospitalized? 6.4.8 Effects of illness and hospitalization to general mobility and self-care?

None Limited movements Patient experienced weakness and limited movement upon admission.

6.5

SLEEP-REST PATTERN

6.5.1 Usual hours of sleep? Intermittent or continuous? 6.5.2 Sleeping problems? Describe 6.5.3 Use of coffee, tea, cafeinated beverages and alcohol? Amount per day? 6.5.4 Difficulty falling asleep? 6.5.5 Wakes up during the night? How often? 6.5.6 Feels rested after sleep? 6.5.7 Snoring? Sleepwalking? Sleep apnea? 6.5.8 Use of sleeping aids or medications? 6.5.9 Effects of illness and hospitalization to sleeping pattern?

According to patient's mother, pt is taking nap on afternoon for 2 hours and 10 hours of continuous sleep at night Patient has no sleeping problems. None

None No. No None None

None

6.6

COGNITIVE-PERCEPTUAL PATTERN

6.6.1 Sensory deficits? 6.6.2 Memory lapses? 6.6.3 Pain perception (tolerance, threshold) 6.6.4 Ability to understand instructions? 6.6.5 Learning patterns? 6.6.6 Use of pain medication? 6.6.7 Effects of illness and hospitalization to memory and perception?

No sensory deficits. No memory lapses. Wasnt able to assess due to underlying condition The patient does not totally understand all instructions. None.

None

6.7

SELF-PERCEPTION AND SELF-CONCEPT PATTERN

6.7.1 Description of personal characteristics. 6.7.2 How does she see self as a person? 6.7.3 Feeling about appearance? 6.7.4 Effects of illness and hospitalization to selfconcept?

Wasnt able to assess due to immaturity. Wasnt able to assess due to immaturity. Wasnt able to assess due to immaturity. Wasnt able to assess due to immaturity.

6.8

ROLE-RELATIONSHIP PATTERN

6.8.1 Roles and responsibilities in the family? 6.8.2 Relationship with spouse/partner/significant others? 6.8.3 Availability of support persons? 6.8.4 Significant persons?

The patient is a child. There is no change in relationship of the child to his parents, according to mother. His family always visit her in the hospital. There are always available. There is no effect of illness and hospitalization to relationship of the patient to his family, according to the mother.

6.8.5 Effects of illness and hospitalization to role performance and relationships with significant persons?

6.9

COPING AND STRESS TOLERANCE PATTERN

6.9.1 Usual stressors? 6.9.2 Coping strategies? Effective? 6.9.3 Feelings about ilness? Coping? 6.9.4 Stresses with illness and hospitalization? Coping?

Wasnt able to assess due to immaturity. Wasnt able to assess due to immaturity. Wasnt able to assess due to immaturity. Wasnt able to assess due to immaturity.

6.10 VALUE-BELIEF PATTERN

6.10.1 Important religious practices? 6.10.2 Perceived help of faith? 6.10.3 Ways that could support spirit? 6.10.4 Effects of illness and hospitalization to faith and belief? V. PHYSICAL EXAMINATION
III. Physical Assessment SYSTEM A. Vital Signs WHAT TO ASSESS

Wasnt able to assess due to immaturity Wasnt able to assess due to immaturity Wasnt able to assess due to immaturity Wasnt able to assess due to immaturity

ACTUAL FINDINGS Temp: PR: RR: BP: 110/80 mmHg

Temperature, pulse, respiration, BP

B. Integumentary 1. skin Color, odor, temperature, moisture, texture, thickness, mobility, turgor, vascularity, swelling, rashes uniform skin color warm to touch axillae is moistened Has good skin turgor Has no lesions, swelling and edema on skin

2. hair

Distribution, thickness, texture lubrication, scalp characteristics

Evenly distributed black hair Thin, oily hair No infection and infestations in the scalp No dandruff Variable/uneven distribution of body hair

3. nails

Nail bed color, consistency, thickness, shape texture, angle between nail and nail bed, capillary refill

Smooth texture Pink nail beds Convex curvature with nail plate having an angle of about 160 Intact epidermis/tissues surrounding nails Capillary refill less than 2 seconds

C. Head and Neck 1. head Size, shape, contour Rounded, normocephalic,and symmetrical frontal, parietal and occipital prominences Smooth No nodules or masses Symmetrical facial movements

20/200 on both eyes -as verbalized by the patient Diminished

2. eyes

Visual acuity, extra ocular movt, visual fields, position and alignment

peripheral vision Both eyes coordinated in movement Hair evenly distributed, skin intact Symmetrically aligned, equal movement

Eyebrows: symmetry, movement, extension, quantity of hair

Equally distributed, curled slightly outward Lids close symmetrically 17 blinks per minute No discharge and discoloration Transparent; capillaries present; smooth and pink conjunctiva; white sclera Pupils round, equal in size Black in color Arcus senilis present Patient blinks when cornea is touched Illuminated pupil constricts Nonilluminated pupil constricts when the other pupil is illuminated Reactive to accommodation Same color as facial skin; symmetrical; smooth in texture Pinna recoils after it

Eyelashes: distribution,

Eyelids: position and movt, color

Conjunctiva: color

Pupils: equality, shape, reaction to light, accommodation

is folded Dry yellowish cerumen

Auricle: position, size, shape, texture

Uniform in color, symmetric and straight, smooth in texture

Has discharge No tenderness; both

3. ears External auditory canal: discharge of cerumens color, consistency

nares are patent for air; symmetric in shape

Pink in color; No lesions Not palpable and

tender

External nose: shape, symmetry, texture, skin color

Uniform dark red color;

Nares: shape symmetry, discharge soft, smooth and dry texture; symmetric in contour and able to purse lips

4. nose Mucosa: color, discharge

No teeth and using

dentures Central position; uniform pink in color; moist and raised papillae/taste buds; thin whitish coating; moves freely and no tenderness

Sinus: texture

Uniform dark red in

Lips: color, texture, hydration, contour color; moist and firm in texture

Pink and smooth posterior wall; moist in texture Same color as of buccal mucosa and floor of the mouth Dark red, smooth Glands ascends during swallowing but it is not visible Not palpable

Teeth: position, color, hygiene Tongue: color, position, texture, coating, mobility

5. mouth

Gums: color, texture

Pharynx: color, hydration

Salivary Glands

Palate Thyroid Gland

Lymph Nodes

6. Neck D. Thorax and Lungs Posterior Thorax Shape, symmetry Chest excursion or movement Chest symmetric Full and symmetric excursion Skin intact, uniform temperature

Anterior Thorax E. Breast and Axillae RR Rhythm Size, symmetry, skin color, contour, shape

Effortless respirations Breasts even with the chest wall Skin uniform in color skin smooth and intact moistened axilla Some moles, without birthmark Oval and bilateral

Moles and other markings Areola: size,

shape, surface characteristics

areola, browncolored Rounded, equal in size

Nipples: size, shape, color, direction, surface characteristics and discharge

F. Abdomen

Skin

Contour, symmetry

Post-operative surgical incision with dressing at right upper quadrant Uniform color; no tenderness; flat rounded (convex); Midline and circular in shape; darker in color compared to the abdomen Symmetric contour movements caused by respirations

Umbilicus: position, shape, color

G. Neurologic

Normal respiratory movement Level of consciousness: language, response to stimulation, intellectual function, abstract thinking, ability to perform simple arithmetic calculations, make judgment

Client is awake and oriented to person, time and place.

ANATOMY AND PHYSIOLOGY

DIGESTIVE SYSTEM
Digestion is the process by which food broken down so that it can be used by the body. The digestive system begins in the mouth. The digestive tract is a long tube running from the mouth to the anus. In a living body it is contracted to twelve to fourteen feet (12-14 ft). Digestion begins in the oral cavity. Food enters the mouth and then mastication takes place. Mastication begins the process of mechanical digestion, in which large food particles are broken down into smaller ones. The teeth crush or tear the food into small pieces. The tongue, large muscular organ, moves food in the mouth and, in cooperation with the lips and cheeks, holds the food in place during mastication. It also plays a major role in the process of swallowing. The tongue is a major sensory organ for taste, as well as being one of the major organs of speech. During chewing, much greater quantities of saliva are secreted by three pairs of extrinsic salivary glands, namely the parotid glands (located under the skin anterior to each earlobe), the submandibular glands (located under the base of the tongue), and the sublingual glands (located in the floor of the mouth). Saliva is a watery fluid containing several components including lysozyme, an enzyme that kills bacteria, and salivary amylase, an enzyme that begins the digestion of starch. Once the food is chewed and softened in the mouth, the tongue rolls it into a ball or bolus and then pushes the bolus to the throat to be swallowed. As the food passes to the pharynx or throat, the epiglottis is tipped posteriorly so that the opening in the larynx is covered, preventing food from entering the larynx. The food then passes into esophagus. Esophagus is a muscular tube connecting the mouth with the stomach. Like a stretchy pipe that's about 10 inches (25 centimeters) long. The esophagus moves the food to the stomach by a serious of muscular contractions called peristalsis. Peristalsis is the wavelike contraction of muscles that move food through the digestive system. This takes about 2 or 3 seconds. The lower end of the esophagus, which passes through a hole in the diaphragm to meet the stomach within the abdominal cavity, has a lower esophageal (or cardiac) sphincter which briefly relaxes to allow the bolus of food to enter the stomach.

As the food enters the stomach, muscle contractions begin to twist, turn, and churn the food. The twisting, turning, and churning of food in the stomach are part of mechanical digestion. The stomach is a muscular sac that is located in the upper left portion of the abdominal cavity. The inner lining of the stomach wall contains millions of tiny gastric glands that secrete gastric juice, which dissolves the food to form a thick liquid called chyme. Gastric juice contains several substances including hydrochloric acid, intrinsic factor (which is essential for the intestinal absorption of vitamin B 12) and pepsinogen (an inactive protein -digesting enzyme). The hydrochloric acid has several functions including destroying ingested bacteria, and converting pepsinogen into its active form, pepsin, in order to initiate the digestion of protein. At the lower end of the stomach is the pyloric sphincter, a valve through which chyme must flow to enter the small intestine. 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. The small intestine is a long, coiled organ about one inch in diameter. The small intestine is 6 meters in length. It consists of three segments named the duodenum, jejunum and ileum. During this time, the liver releases bile into the small intestine. The bile enters the small intestine through the bile duct. The liver filters out harmful substances or wastes, turning some of the waste into more bile. Bile prepares the fats for digestion; it helps to absorb fats into the bloodstream. And the gallbladder serves as a warehouse for bile, storing it until the body needs it. Pancreatic juice, secreted by the pancreas, contains enzymes that break down sugars and starches into simple sugars, fats into fatty acids and glycerol, and proteins into amino acids. The pancreatic juice enters through pancreatic duct. The walls of the small intestine release enzymes that complete the digestion of all three basic nutrients. In the walls of the small intestine are millions of small projections called villi. These villi increase the small intestine capacity for absorption. Digested food is absorbed into these blood vessels and carried to all body cells. Food may spend as long as 4 hours in the small intestine and will become a very thin, watery mixture.\ 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 waterabout 6 liters (1.6 gallons) dailyas 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 feceswaste material that consists largely of undigested food, digestive juices, bacteria, and mucusuntil 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.

BIBLIOGRAPGY: Saladin, Kenneth S. Anatomy & Physiology: The Unity of Form and Function, 2nd ed. New York: McGraw-Hill, 2005 : Rod R. Seeley, et al, Essentials of Anatomy and Physiology, 6th ed. New York: McGraw-Hill, 2007.