DEMOGRAPHIC DATA:

Name: VALANTES, Leonard Chester Quines

Age: 1 yr. 8 mos.
Birthday: May 22, 2008
Address: 72 Tram Ucab, Itogon, Benguet 09212728712
Religion: Roman Catholic
Next of Kin:
Occupation:
Latest Hospitalization Date:
Attending Physician: Dra. Bautista
Date of admission: January 28, 2010 2 :30 pm
CHIEF COMPLAINT
VOMITING WITH LOOSE BOWEL MOVEMENT
HISTORY OF PRESENT CONDITION
The onset of the present condition was about 8 hours prior to admission
when the patient had 10 episodes of vomiting of previously ingested food
and 2 episodes of loose bowel movement. There were no associated signs or
symptoms such as fever or diarrhea. The patient was noted to have poor oral
intake. The persistence of the child’s symptoms prompted the mother to
seek consult from the child’s pediatrician. The mother was advised admission
so the child was brought to this institution and was admitted.
GROWTH AND DEVELOPMENT

PHYSICAL GROWTH:

birth weight: 3.75 kg

present weight: 11.5 kg

DEVELOPMENTAL MILESTONES

The developmental milestones are at par with the child’s age.

SOCIAL – DEVELOPMENTAL BACKGROUND

The patient usually sleeps at 9 PM and wakes at 9 AM. He also takes

short afternoon naps. The patient interacts with all family members.
The mother claims that he has no disciplinary problems. He is not
toilet-trained.

IMMUNIZATIONS

According to the child’s parents, he has had all necessary

immunizations. The dates were unrecalled and no records were
available.

PAST MEDICAL HISTORY

 The patient was hospitalized at 3 days old for jaundice at SLU HSH.
There were no other childhood illnesses such as mumps, measles, or
chickenpox. He has no known allergy to any foods or drugs.

FAMILY HISTORY

The patient is the first and only child. The parents are well and appear
to be healthy. There is no history of asthma, hypertension, arthritis or
any cardiovascular disease.

SOCIAL – ENVIRONMENTAL HISTORY

The father is 28 years old, a Criminology graduate, and works as a

laborer. The mother is 22 years old, a Criminology graduate, and is a
housewife. They live in a non-congested neighborhood in a house
made of wood, cement and galvanized iron. Their house has 4 rooms
with 6 occupants. Their source of water for washing and cleaning
comes from a spring. Their drinking water is boiled for 10 minutes.
Their garbage is burned. Their toilet is flush type.

PAST PERSONAL HISTORY

PRENATAL HISTORY

The mother is 20 years old. Her OB score is G1P1 (1-0-0-1). She had
delayed menstrual cycle at 1 month age of gestation. She had a positive
pregnancy test result. She had her prenatal care at 2 months AOG with total
prenatal check up of 7 visits to the OPD. Given ferrous sulfate, Calcium
supplement, and multivitamins. At 6 months AOG, mother underwent
ultrasound revealing live, singleton, intrauterine pregnancy. She had her CBC
and Urinalysis is normal. There are negative exposure to VED’s , smoking,
radiation and had no alcohol intake during the pregnancy.

NATAL HISTORY

The patient was born via NSVD at Benguet General Hospital by an

obstetrician. Birth weight was 3.75 kg and birth length was unrecalled.
Patient had pink body, good cry and active limb movements upon birth. No
congenital malformations noted. No resuscitation done. AS and BS are
unrecalled.

NEONATAL HISTORY

Patient was breastfed after birth with good suck. There was no
paleness, negative cyanosis, negative jaundice noted on the 24th of life.
Umbilical stump fell off after 1 week without signs of infection.

REVIEW OF SYSTEMS

General: (-) febrile episodes, (-) weight loss, (-) weakness, (+) poor oral
intake, (-) easy fatigability, (-) incessant crying, (-) irritability
Skin: (-) dryness, (-) circumoral pallor, (-) pallor, no jaundice, no bruising, no
bleeding, (-) pruritus

Ears: no discharges, no hearing difficulty, (-) ear pains

Nose: no bleeding, (-) congestion, (-) cold, (-) nasal discharge

Head: no lesions, no trauma

Eyes: no tearing, no itching, no redness, no discharges,

GUT: (-) dysuria

Musculoskeletal: no trauma, no stiffening of extremities, able to ambulate

Hematologic: no hematomas, capillary refill of 1-2 seconds, no bruises

Nervous system: (-) convulsions

Endocrine system: (-) diaphoresis, (-) polydipsia, (-) polyuria

Respiratory: (-) cough, (-) cold, (-) posttussive vomiting, (-) shortness of
breath, (-) orthopnea

Cardiac: (-) edema, (-) easy fatigability, (-) cyanosis

GIT: (-) abdominal pain, (-) vomiting, (-) diarrhea, (-) constipation, (-)
flatulence, (-) loss of appetite

Mouth: lips and buccal mucosa are moist

Chest: symmetrical, no lesions

Lungs: symmetrical chest expansion, no lagging, (-) bibasal crackles, (-)

wheezes

Heart: normal late, regular rhythm

Abdomen: direct tenderness, no masses palpated

Genitalia: grossly male

Extremities: no gross deformities, pink nail beds, full and equal pulses, good
capillary refill

Motor: active limb movements

Sensory: Reacts to soft touch

Reacts to pain

PHYSICAL EXAMINATION

General Appearance: awake, afebrile, not in cardiorespiratory distress

Vital Signs: PR: 113 bpm

RR: 26 cpm
 TEMP. : 37 C

Skin: no pallor, no cyanosis, no jaundice, warm to touch with good skin

turgor

Anthropometric measurements: weight > 11.5 kgs

Head: normocephalic, no trauma, normal hair distribution, no gross

deformities

Eyes: pink palpebral conjunctiva, no abnormal discharges, no sunken

eyeballs

Ears: normally set, no lesions or deformities, no abnormal discharges

Nares: patent with no nasal flaring, no nasal discharge

Neurological:

Cerebral function: Patient is conscious.

Cerebellar function: no nystagmus

GORDON’S FUNCTIONAL PATTERNS

• Health Perception-Health Management
The mother understands the advantages of breastfeeding to the
nutrition of the child. She addressed the child’s condition by
feeding the child to replenish lost nutrients.
• Nutritional-Metabolic Pattern
The patient’s present weight is 11.5 kgs. He has no known
allergies to any food or drug. The patient is breastfed and is able
to tolerate solid food. He has not taken supplements before
being admitted at this institution.
• Elimination

The patient is not toilet trained. The patient does not experience
any kind of discomfort when urinating or defecating.
• Activity- Exercise
Patient is able to ambulate and perform ADLs such as eating,
going to the bathroom, standing or sitting without assistance.
There is a splint placed on the left hand to avoid strain on the
insertion site to prevent dislodging the needle.
• Cognitive- Perceptual
The patient is alert and no irritability was noted. He is aware of
the time, place and the people around him. He is able to alert his
mother with regards to his condition such as thirst, pain or when
needs to have his diaper changed. The child’s developmental
milestones are at par with age.
• Sleep-Rest
The patient is fully awake and active. The mother’s has no
complaints with regards to whether the child experiences lack of
sleep or rest. The child takes afternoon naps.
 • Sexuality- Reproductive Pattern
The patient’s mother has an OB score of G1P1(1001). She and her
husband are currently using no family planning method but are
trying to put a space of 2-3 years between children.

• Coping Stress Tolerance

The patient has a stable support system of family members and
helper.

• Value Belief
The patient is baptized as a Roman Catholic. His parents are also
Roman Catholics. They are active members in the Church.

DIAGNOSTICS:

DIAGNOS FINDINGS NORMAL RESULTS INDICATION

TIC
PROCEDU
RE
URINALYSIS Color: light yellow >clear to yellow The results are
indicative urinary
Reaction: acidic >
tract infection.
Appearance: slightly >
turbid
>1.006- 1.030
Specific gravity: 1.010
>(-) albumin
(-) albumin
> (-) sugar
(-) sugar
>(-) pus cells
Pus cells: 0-1/ hpf
>0-2/ hpf
Red blood cells: 0-1/
>0-2/ hpf
hpf
>0-2 /hpf
Mucus threads:
occasional >(-) crystals
Epithelial cells: >(-) crystals
occasional
>(-) bacteria
(-) crystals
>(-) amorphous
(-) cysts urates
Bacteria : occasional >(-) yeast cells
 Amorphous urates:
occasional

(-) yeast cells

HEMATOLO Erythrocytes: 0.36 >0.37 – 0.47 The results does
GY not indicate any
Hemoglobin: 121 > 110 - 150
presence of
Leukocytes: 8.47 excess of
deficiency in
Segmenters: blood volume or
0.79 components.
Lymphocytes:
0.21

Normocytic

Normochromic
PARASITOL Color: green brown > dark brown The results do
OGY not indicate any
Consistency: soft >semi formed and
abnormalities in
soft
(-) pus cells the patient’s
>(-) pus cells stool.
(-) red blood cells
>(-) red blood cells
(-) yeast cells
>(-) yeast cells

DRUG STUDY:

A. GENERIC NAME: Bacillus Clausii

BRAND NAME: Erceflora
CLASSIFICATION: anti-diarrheal
MECHANISM OF ACTION: replaces lost normal flora in the GIT
SIDE EFFECTS: may cause constipation when taken in excess
NURSING CONSIDERATIONS: this drug may be given even if patient
has not eaten.
May be mixed with milk or water
when administered
B. GENERIC NAME: Ascorbic Acid
BRAND NAME: Ceelin Plus
CLASSIFICATION: vitamis, water- soluble vitamins
MECHANISM OF ACTION: used in biochemical reactions in the body
SIDE EFFECTS: CNS> drowsiness, nausea and vomiting, headache
NURSING CONSIDERATIONS: Best if taken with juices.

C. GENERIC NAME: Amikacin sulfate

BRAND NAME: Amikacin
CLASSIFICATION: antibiotic
 MECHANISM OF ACTION: bacteriostatic; binds to the bacterial 30S
ribosomal subunit, causing misreading of mRNA and leaving the
bacterium unable to synthesize proteins vital to its growth.
SIDE EFFECTS: Kidney damage and hearing loss
NURSING CONSIDERATIONS: serum creatinine levels should be
monitored.
Monitor for hypersensitivity.
Report immediately any change in
hearing acuity, ringing or roaring in ears, alteration in balance,
vertigo, feeling of fullness in head; pain, tingling, or numbness of
any body part; or change in urinary pattern or decrease in urine

NCP PROPER
O
➢ “ Pwede na daw kaming umuwi sabi ng doktor.” as verbalized by the
mother.
➢ With initial vital signs of T: 37C ; RR: 26 cpm ; PR: 113 bpm
➢ patient able to ambulate without assistance
➢ no episode of vomiting noted
➢ with good oral intake and good appetite; on breastfeeding with good
suck
➢ able to tolerate solid foods
➢ with good skin turgor and moist capillary refill
➢ excitement noted on patient and significant others
Goal: The client will be not experience any recurrence of the condition.
LTO: After 8 hours of nursing interventions, the client’s significant other/s will
be able to verbalize desire for wellness and how to prevent any recurrence of
the condition.
STO: After 4 hours of nursing interventions, the client will signs indicative of
his readiness for an improved condition and discharge.
 PATHOPHYSIOLOGY OF ACUTE GASTROENTERITIS (BACTERIAL)
with some DEHYDRATION

ACUTE GASTROENTERITIS (BACTERIAL) with some DEHYDRATION

Gastric irritation

Acid reflux

Risk for fluid and Risk for fluid

electrolyte volume deficit
imbalance r/t fluid r/t episodes of
loss vomiting
Vomiting

Ingestion of Ingestion of
Ingestion of
Bacillus Clausi (Erceflora) Amikacin (Aminoglycoside)
Ascorbic Acid & Zinc

Return of Normal Flora in Destruction of

Boosting of the
 the GIT Infectious Bacteria in the body
Immune System

READINESS FOR FLUID BALANCE

Saint Louis university

College of nursing
Baguio city

Nursing care plan

Patient: valantes, leonard chester

Submitted by:
Milar, krizza s.
Ocampo, ira kei B.

Bsn ii-18 a
Sir lee nino Lagarto
Clinical instructor