Review of Systems Skin Last Feb. 2007, Mr.

X has experienced boils on his left leg with a scar formation. Head Mr. X was complaining of being light headed occurring after drinking alcohol. Eyes Mr. X was not complaining of any visual changes and had never used eye glasses until now. Ears Mr. X was not complaining of pain, hearing changes without any discharges. Nose Mr. X was not complaining of any nasal discharges or any obstruction in the nose. Throat This august 2008, Mr. X had experienced difficulty of swallowing, sore throat, and regurgitation. Respiratory This August 2008, Mr. X complaints of difficulty of breathing. Cardio The patient was not complaining of chest pain. Gastro This august 2008, Mr. X experienced abdominal pain, loss of appetite, dysphagia of solid foods, and regurgitation. Genitourinary The patients urine output decrease with a dark yellow in color, and had not experienced UTI. Musculo-skeleto Mr. X experienced weakness and had limitations in performing his ADLs.

Demographic Data Mr. X is a 31 year old male, presently residing at Sta. Ignacia, Tarlac. Mr. X is married and lives with his family with two children and his wife. They are Roman Catholic. He was admitted on August 22, 2008 with a chief complaint of abdominal pain under the service of Dr. R. Present Health History Thirteen hours prior to consultation, Mr. X had an alcohol binge. Five hours prior to consultation Mr. X started having vomiting, abdominal pain on epigastric area, and diarrhea. Two hours prior to consultation Mr. X is sought to consult to a private hospital seen and examined and diagnosed alcohol intoxication. Past Medical History Mr. X stated that he has been immunized with BCG, Tetanus Toxoid, Measles, and Polio Vaccines. Family Health History Mr. Xs mother is known of having hypertension and his father is known of having a Pulmonary Tuberculosis. Social History Mr. X was a former carpenter and lives with his family. Their house is situated in a slum-like neighborhood and is within close proximity with Barangays road network and Local Health Unit. Their house is made up of sawali, has adequate space for the entire family members and has no problem with the house ventilation. They get their water from the water pump which is going to be used for both drinking and washing purposes. Garbage is thrown in a sack and is collected by a garbage truck weekly. They used pail-system for their toilet. Mr. X is alcoholic, drinking for about an average of two to three times a week. Based on Mr. X he is eating three meals per day and he is fond of eating fatty foods.

Nursing Diagnosis Alteration in Comfort; Acute Pain related to Hyperperistalsis

Intervention 1. Encouraged client to report feeling of discomfort or pain 2. Assess or instruct to report of abdominal cramping or pain, noting location, duration, intensity, investigate and report changes in pain characteristics 3. Review factors that aggravate or alleviate pain 4. Observe and record abdominal distention, increased temperature, decreased BP

Rationale 1. May try to tolerate pain rather than request analgesics 2. Colicky intermittent pain occurs with Crohns predefecation pain frequently occurs in with urgency, which may be severe and continuous 3. May pinpoint precipitating or aggravating factors or identify developing complications

Nursing Diagnosis Fluid Volume Deficit related to Excess Losses through

Intervention 1. Encouraged client to report feeling of discomfort or pain 2. Assess or instruct to report of abdominal cramping or pain, noting location, duration, intensity, investigate and report changes in pain characteristics 3. Review factors that aggravate or alleviate pain 4. Observe and record abdominal distention, increased temperature, decreased BP

Rationale 1. May try to tolerate pain rather than request analgesics 2. Colicky intermittent pain occurs with Crohns predefecation pain frequently occurs in with urgency, which may be severe and continuous 3. May pinpoint precipitating or aggravating factors or identify developing complications

CUES S: wala akong ganang kumain as verbalized by the pt. O: >weight loss >poor skin turgor >sunken eyes

NURSING DIAGNOSIS imbalanced nutrition less than body requirements R/T loss of appetite as evidenced by weight loss

SCIENTIFIC EXPLANATION >Due to malabsorption of nutrients in the gastro intestinal tracts predisposes the pt. to dehydration; factors may include are loss of appetite, nausea and vomiting that leads the pt. to loss an adequate caloric and protein requirements loss of fluid, nutrients and minerals

PLAN/GOAL

NURSING DIAGNOSIS >after series windependent: of proper w nursing >weight daily intervention the pts body requirements will be able to regain h >Encourage bed rest and limited activity during acute phase of illness

RATIONALE

>Provides information/ effectiveness of therapy

EXPECTED OUTCOME >After series of proper nursing intervention thepts body requirements will regain

>Decreasing metabolic needs aids in preventing caloric depletion and converse energy >for monitoring purposes and to detect the possible dehydration >To meet increase metabolic demands >to determine what information to provide in the client >To prevent further dehydration

>monitor intake and output collaborative mngt.. >Provide more nutrients and vitamins to the client >Ascertain understanding of individual nutritional needs >Instruct the client about the need for a well balanced diet other collaborative:

>Keep patient n NPO as indicated >Intravenous total parenteral nutrition

>

>Resting the bowel decreases peristalsis and diarrhea limiting malabsorption/ loss of nutrients >this regimen rest the GI tract completely while providing essential nutrients short term TPN is indicated during periods of disease exacerbation when bowel rest is needed