Assessment Final

II. Assessment

A. General Assessment Tool

I. GENERAL INFORMATION

Name: E.M.Age: 30 yrs. old Birthday: December 21, 1979Sex: Male Civil Status: Single Religion: Roman Catholic Occupation: Farmer Address: Rizal, Claveria, Misamis OrientalInformant: M.V. and E.M. Relation: elder sister and patient himself Admission Date: July 13, 2010 (Tuesday) Time of Admission: 11:00 PM Chief Complaint: Change in sensoriumAttending Physician: Dr. Sarmiento Diagnosis/ Impression: Hepatic Encephalopathy secondary to hepatitis B Infection

History of Present Illness: Last July 1, 2010, patient complained of intermittent epigastric pain with a

pain level of 7/10 with 10 as the most painful and loss of appetite but tolerated his condition.

On July 5, 2010, he still complained of loss of appetite, and on and off epigastric pain that radiated to the right upper quadrant as well as hematemesis. Patient’s elder sister administered antacids (Kremil-S, 1 tab, 500 mg) since she suspected that the patient might be suffering from hyperacidity. His wife also applied efficascent oil all over his back and his abdomen after suspecting that the patient has “panuhot”.

On July 9, patient still suffered from the same complaints which prompted them to seek medical advice in Claveria Public Hospital. He was told by the physician that he might be suffering from ulcer and that he needed further evaluation and follow-up visits in the hospital. He was given cimetidine and antacids (Al (OH) 3) and was allowed to rest at home.

On July 12, he complained of feeling worse, as he experienced blurred vision and tends to forget the things that he is doing (e.g. why he is opening the door, why he is holding a paper). According to his wife and sister, the patient’s affect became flat and appeared clueless of what he was saying or doing.

1 day P.T.A., his epigastric pain worsened and chose not to eat the whole day. He then vomited in the evening; vomitus was brownish with blood streaks and was approximately 60 cc. In the morning of July 13, his wife tried to get him up from bed but he was too weak to do so and he felt nauseated and dizzy. They rushed him to Claveria Public Hospital but the physician was unable to diagnose the patient’s

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condition due to inadequate resources. He was referred to Northern Mindanao Medical Center, hence, their current admission. Food and Drug Allergy, please specify: No known drug or food allergies

Past Major Illness, Operation, and Hospitalization:Last November 2008, patient was hospitalized in Claveria Public Hospital with

a chief complaint of high grade fever and was diagnosed with Urinary Tract Infection.

Vital signs: July 14,

2010July 15,

2010July 16, 2010

July 17, 2010

September 3, 2010

HR- 86 bpm

HR- 61 bpm

HR- 73 bpm

HR- 90 bpm

HR- 80 bpm

RR- 16 cpm

RR- 16 cpm

RR- 15 cpm

RR- 21 cpm

RR- 18 cpm

Temp- 36.3 0C

Temp- 36.6 0C

Temp- 37 0C

Temp- 37 0C

Temp - 37 0C

BP- 120/80 mmHg

BP- 120/80 mmHg

BP-130/80 mmHg

BP- 130/80 mmHg

BP- 120/80 mmHg

July 14, 2010 July 17, 2010 September 3, 2010Weight: 50kg Weight: 52kg Weight: 59kgHeight: 5’6“ Height: 5’6“ Height: 5’6“

II. ACTIVITY/REST

July 14, 2010 July 17,2010 September 3, 2010Usual activities:

“Magdaro, manigway. Magsige ra gyud na siya og trabaho.” as verbalized by S.O.

“Halos naa rako sa uma gatrabaho tibuok adlaw. Diri sad sa ospital kay sige ra ug higda ug lingcod.” as verbalized by patient.

“Ga-stand by rako diri balay pagka-uli gikan ospital. Mga isa ka semana ayha ko naka jogging-jogging ug baklay-baklay sa gawas sa balay. Ug human sa tulo ka semana kay nakahinay-hinay nako og sugod sa trabaho. Karon kay nakabalik na gyud ko sa akong mga

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kasagara na trabaho sa umahan.” as verbalized by patient.

Usual leisure time activities:

“Hilig na siya og magbasketball, maglaag, magtan-aw og tv.“ as verbalized by S.O.

“Ay, maglaag-laag, basketball og standby sa balay kung way himuon… Diri sa ospital, magsturya2x lang sa mga parente kay wala gyuy lain lingaw” as verbalized by patient.

“Basketball2x gihapon usahay ug magtan-aw t.v sa gabii.” as verbalized by patient.

Limitations imposed by condition:

“Dili na siya makahimo sa iyang trabaho kay pirme nalang mag-lain iyang ginhawa.” as verbalized by S.O.

“Gatrabaho pa man hinuon ko tong sakit akong tiyan pero atong dominggo nga gahanap-hanap na akong panan-aw og dali nako makalimot, wala na gyud ko naka-adto ug uma ug wala nako kabalo ug unsa na akong mga gipanghimo. Na hospital pa gyud ko samot nga wala gyud ko nakatrabaho. Pirme rako diri sa katri kay nakacatheter pa man ko og medyo luya pasad ko.” as verbalized by patient.

“Okay naman ko makatrabaho nako balik ug tarong ug makalaag-laag nasad ko. Pero dili sad ko gapalabi kay mahadlok sad ko nga basin ma-unsa pa lang ko” as verbalized by patient.

Usual sleep pattern:

“Sa una mga alas-dyes na siya matulog sa gabii ug mumata dayun mga alas singko para magtrabaho na dayun. Pero tong lain na iyang ginabati-on mga

“Ga sige rako ug tulog diri sa hospital kay medyo luya pasad akong pamati. Mga alas-syete tulog nako ug maka-mata rako pag magkuha napud ug bp or maghatag

“Wala man pud koy problema sa akong pagtulog karun. Matulog ko mga alas otso dayun mumata mga alas kwatro o alas singko.” as verbalized by

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alas syete pa lang tulog na ug mumata mga alas otso sa buntag.” as verbalized by SO.

tambal.” as verbalized by patient.

patient.

Naps: “Na mag sige ra gyud ug tulog sa udto katong nagsakit na siya.” as verbalized by SO.

“Sa una tong wala pako nagsakit usahay rako makatulog sa udto o hapon pero karun sa ospital mag sige ra gyud ko ug tulog. Ganiha buntag mga duha or tulo ka oras dayun mata-mata nasad... taud2x balik nasad ug tulog.” as verbalized by patient.

“Tibuok adlaw naa man ko sa uma. Makauli ko sa balay mga alas unsi. Usahay makatulog gamay ug mga usa ka oras dayon balik nasad sa uma.” as verbalized by patient.

Aids: “Wala man, makatulog mana diretso.” as verbalized by SO.

“Wala man.” as verbalized by patient.


Difficulty sleeping:

“Wala man pud na siya nagreklamo nga lisod itulog. Mag sige naman hinuon ug tulog.” as verbalized by SO.

“Wala man sad.” as verbalized by patient.


Feeling on awakening:

“Dili sad gyud ko kaingun pero murag gikapoy man gihapon.” as verbalized by SO.

“Okay ra pero luya-luya gamay.” as verbalized by patient.

“Maayo man akong pamati. Wala man pud koy lain nga gabation.” as verbalized by patient.

Objective:July 14 & 15, 2010Observed response to activity: Patient was not able to perform any activity.Posture: Patient was unable to stand as he remained in bed.Others/Comments: Patient was stuporous and responds in vigorous and painful stimuli (e.g. pin prick, face tapping). Upon waking up, patient stares blankly in one direction and does not follow verbal instructions (e.g. follow the light with the eyes, raise arms, and flex legs…). Patient does not respond verbally to questions or instructions.

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July 17, 2010Observed response to activity: Patient was able to perform activities such as active range of motion exercises and was able to sit up on bed.Posture: Patient was slouching.Others/Comments: Patient moved slowly. He responded to certain stimuli such as follow the light with the eyes, raise arms, and flex legs.

September 3, 2010 (home visit)Observed response to activity: Patient able to walk 10-12 ft. away from S.N. HR, RR & BP remained the same & remained stable.Posture: Pt. able to stand & sit erect.

III. CIRCULATION

July 14, 2010 July 17, 2010 September 03, 2010

History of hypertension

“Wala pud ko kabalo kung nahigh blood naba ni siya.” as verbalized by S.O.

“Sukad2x sa akong pagkabata wala man pud ko gi-high blood.” as verbalized by patient.

“Katong naa pa ko sa ospital usahay ingnan ko sa mga nurse nga taas akong B.P. dayun mu-naog napud.”As verbalized by patient.

Heart trouble “Wala man sad na siya nagreklamo.” as verbalized by S.O.


“Wala man sad nagsakit akong dughan.” as verbalized by patient.

Ankle/leg edema “Wala man sad ko nakamatikod nga nanghupong siya.” as verbalized by S.O.

“Murag medyo ni dako akong duha ka tiil. Karun pa sad ni nabantayan sa akong igsoon” as verbalized by patient.

“Pag-gawas namo sa hospital pareha ra kadako atong ulahi ninyong adto pero pag-abot namu diri sa balay mas gidako siya ug nagdako pud akong tiyan” as verbalized by patient.

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Slow healing “Wala man pud.” as verbalized by the S.O.

“Wala man sad ko nakamatikod nga dugay maayo akong samad.” as verbalized by patient.

“Wala pasad ko nasamad pag-uli nako diri sa balay” as verbalized by patient.

Claudication “Wala man pud siya nag-ingun o nagreklamo.” as verbalized by the S.O.

“Wala man pud” as verbalized by patient.

“Wala man gihapon” as verbalized by patient.

Cough/hemoptysis “Wala man sad siya gi-ubo. Wala pasad na siya nagreklamo nga dunay dugo iyang ubo” as verbalized by the S.O.

“Wala man pud ko gi-ubo karun” as verbalized by patient.

“Wala man sad koy ubo” as verbalized by patient.

Extremities/numbness

“Wala man pud.” as verbalized by the S.O.

“Wala man sad maminhod akong kamot ug tiil.” as verbalized by patient.

“Wala man pud” as verbalized by patient.

Objective:July 14, 2010 July 15, 2010 July 16, 2010 July 17, 2010 September 3,

2010Blood

PressureLyingL-120/80 mmHg

Sitting Not assessed

Standing Not assessed

Pulse

Blood Pressure

Lying L-120/80 mmHg

Sitting Not assessed

Standing Not assessed

Pulse

Blood Pressure

Lying L-130/80 mmHg

Sitting L- 120/80 mmHg

StandingNot assessed

Pulse

Blood Pressure

Lying L-130/80 mmHg

Sitting L- 130/80mmHg

StandingL- 120/80mmHg

Pulse

Blood Pressure

LyingR- 120/90 mmHg

Sitting- L-120/90 mmHg

Standing R-120/90 mmHg

Pulse

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Pressure: 40-50 mmHgPMI: 5th ICS, left sternal border, midclavicular line




Pressure: 40 mmHgPMI: 5th ICS, left sternal

border, midclavicular

line

Objective Data

July 14, 2010

July 15, 2010

July 16, 2010

July 17, 2010

Sept 3, 2010

Heart Rate 87 bpm 66 bpm 73 bpm 90 bpm 80 bpmSounds S1 – S2

notedS1 – S2

notedS1 – S2

notedS1 – S2

notedS1 – S2

notedRhythm Regular Regular Regular Regular Regular

Pulse Site July 14, 2010

July 15, 2010

July 16, 2010

July 17, 2010

Sept 3, 2010

Carotid 87 bpm 66 bpm 73 bpm 90 bpm 80 bpm

Brachial 85 bpm 63 bpm 69 bpm 91 bpm 81 bpmRadial 86 bpm 61 bpm 73 bpm 90 bpm 80 bpm

Dorsalis Pedis

82 bpm 58 bpm 69 bpm 88 bpm 79 bpm

Popliteal 83 bpm 58 bpm 71 bpm 89 bpm 80 bpmTemporal 86 bpm 60 bpm 73 bpm 90 bpm 81 bpm

Breath Sounds:July 14, 2010 July 15, 2010 July 16, 2010 July 17, 2010 Sept 3,2010Clear Breath

SoundsClear Breath

SoundsClear Breath

SoundsClear Breath

SoundsClear Breath

sounds

Jugular vein distention: none notedExtremities: Temperature: Warm to touch Color: Brown

July 14, 2010 July 15, 2010 July 16, 2010 July 17, 2010 Sept 3, 2010Temp - 36.3 0C Temp - 36.6 0C Temp - 37 0C Temp - 37 0C Temp-37 0C

Objective Data

July 14, 2010

July 15, 2010

July 16, 2010

July 17, 2010

Sept 3, 2010

Capillary Refill:

< 2 seconds

< 2 seconds

< 2 seconds

< 2 seconds

4 seconds

Vascular Bruit:

None noted

None noted None noted None noted None noted

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Homan’s Sign:

(-) (-) (-) (-) (-)

Varicosities: No varicositie

s noted

No varicosities

noted

No varicosities

noted

No varicosities

noted

No varicosities

notedColor of Nail

Beds:Yellow Yellow Yellow Yellow Yellow

Lips: Pale and dry

Pale and dry

Pale and dry

Pale and dry

Pale and dry

Oral Mucous Membranes:

Moist, intact,

color of membrane

s under the tongue

is yellowish

Moist, intact, color

of membranes under the tongue is yellowish







Sclera: Icteric Icteric Icteric Icteric Icteric

IV. EGO INTEGRITY

July 14, 2010 July 17, 2010September 3,

2010

Report of stress factors:

“Kwarta ramay permi gaproblemahon ana.” As verbalized by S.O.

“Usahay maproblema sa atong kapobrehon samot na karun nga na ospital pajud..” As verbalized by patient.

“Mahadlok kog huna-huna nga ni-ingon ang doctor nga wala na ni ka-ayuhan akong sakit pero okay raman gihapon, salamat sa Diyos.” As verbalized by patient.

Ways of handling stress:

“Magjoke2x rana. Wala gyud na siyay libog, magkatawa2x rana permi, iya nalang dayun idala sa katawa bah.” As verbalized by S.O.

“Lingaw-lingaw uban ang pamilya … isturya-isturya. Pasalamat sad gyud ko kay gatabang sa ako akong mga igsoon” As verbalized by patient.

“Dili nalang huna-hunaon ug padayon og ginhawa.” As verbalized by patient.

Financial concerns:

“Na problema gyud na. Ambot aha pa gani mi mangita ug

“Galisod gyud mi karon. Wa gyud mi ikapalit aning

“Igo-igo ra gyud makakaon sa tulo ka adlaw ug

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pangbayad diri. Perti gyung lisuda biya namo mam. Naa pa iyang pamilya nabiyaan didto sa Claveria” As verbalized by S.O.

gipangresita nga tambal.” As verbalized by patient.

gapaningkamot gyud og trabaho karon kay wala gyuy lain magbuhi sa akong pamilya.” As verbalized by patient.

Relationship status:

“Buotan man kaayu na siya, wala gyud na siyay problema sa iyang asawa, pamilya ug mga igsoon. Wala pud na siyay kaaway. Si-aw man gud kaayu na siya ug jokeron bah.” As verbalized by S.O.

“Okay ra man sad akong relasyon sa akong pamilya. Wala man sad koy kaaway. Mas na close na hinuon gyud ko karun sa akong mga igsoon.” As verbalized by patient.

“Okay ra man. Pasalamat lang gyud ko nga naa akong pamilyagasuporta og gasabot sa akong kahimtang.” As verbalized by patient.

Lifestyle:

“Aktibo gyud kay sige raman na ug trabaho ug lakaw” As verbalized by S.O.

“Karun kay naa ra gyud ko pirme sa katri gahigda-higda, lingkod2x.” As verbalized by patient.

“Dili ko mahimutang kung wala koy buhaton. Medyo lihok gyud ko.” As verbalized by patient.

Recent Changes:

“Medyo na laylo lang gyud siya sa iyang mga gapangbuhaton tungod sa iyang sakit” As verbalized by S.O.

“Sa una kay lihok gyud kayo ko. Karon sige ra og higda ug naa ra gyud sa katri.” As verbalized by patient.

“makabalik nako sa akong trabaho pero gabantay gyud gihapon ko kay basin magdaot nasad ko.” As verbalized by patient.

Feelings of Helplessness/ Hopelessness:

“Wala man pud”. As verbalized by S.O.

“Wala man.” As verbalized by patient.

“Wala pud. Ga-salig lang gyud ko sa Ginoo nga matas-an pa gyud akong kinabuhi.” As verbalized by patient.

Powerlessness:“Wala.” As verbalized by S.O.



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Objective:

Emotional StatusObjective

DataJuly 14,

2010July 15,

2010July 16,

2010July 17,

2010Sept 3. 2010

Observed Physiologic Response:

Not assessed (patient

was Stuporous)

Not assessed (patient

was Stuporous)

Calm Calm Calm

Other comments: Upon first day of assessment patient most of the time was asleep and when aroused by vigorous stimuli, he cannot respond verbally and does not obey command/ instructions. Assessment was done through interviewing the family members during the first day.

V. ELIMINATION


Usual bowel pattern:

“Kada-adlaw na siya gakalibang.” As

verbalized by S.O.

“Dili man pareha maam. Usahay ika-

isa, ika-duha usahay pud, dili ko kalibang sa usa ka adlaw. Pero diri sa ospital wala pako

kalibang gikan kagahapon.” As

verbalized by patient.

“Mga ka isa o kaduha sa usa ka adlaw. Dili man pareha adlaw-

adlaw.” As verbalized by

patient.

Usual character of stool:

“Brown, tibuok man” As verbalized by

S.O.

“Tong wala pako na-ospital. Brown

dili pud gahi kaayu og dili pud basa.” As


“Ay, okay ra man. Brown ug dili gahi og dili pud basa.” As verbalized by

patient.

Last Bowel Movement:

“Ingun sa iyang asawa kay atong

dominggo pana siya nakalibang kay

halos wala naman pud lagiy

gakaonon.” As verbalized by S.O.

“Nah,wala nako nakahinumdum

ma’am.” As verbalized by

patient.

“Kagahapon. As verbalized by

patient.(referring to

September 2)”

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Laxative use:

“Wala man siya gagamit.” As

verbalized by S.O.; Laxative aid was

ordered and administered on

July 14, 2010 (Lactulose, 30 mL

every 2 hours, restart with BM then

30 mL TID)

“Wala pa sad ko sukad-sukad naka

tumar.” As verbalized by

patient.

“Wala man.” As verbalized by

patient.

History of bleeding:

“Wala man pud.” As verbalized by S.O.


patient.

“Wala.” As verbalized by

patient.

Hemorrhoids:“Wala pud siya nagreklamo” As

verbalized by S.O.


patient.

“Wala man sad” As verbalized by

patient.

Constipation:

“Ingun sa iyang asawa kay atong

dominggo pana siya nakalibang kay

halos wala naman pud lagiy

gakaonon.” As verbalized by S.O.

“Wala pa ko kalibang sugod tong

Nakamata ko gahapon.” As verbalized by

patient.

“Makalibang na ko ug tarong karon.” As verbalized by

patient.

Diarrhea:“Wala sad.” As

verbalized by S.O.“Wala man.” As verbalized by

patient.


patient.

Usual voiding pattern:

“Wala man pud siya nagreklamo nga

lisud iihi o sakit iihi. Katong una namong pagpacheck-up sa

Claveria, yellow ang color sa iyang ihi ug

sakto ra man sad daw kadaghanon,” As verbalized by

S.O.

“Usahay kaduha sa buntag og sa

hapon, katulo dayon sa gabi.i pero diri sa

ospital kay nakacatheter man ko.” As verbalized

by patient.

“Dili pareha usahay mga ika pito sa usa ka

adlaw, usahay ika-walo.” As


Incontinence:“Wala.” As

verbalized by S.O.“Wala.” As



patient.

Urgency:“Wala.” As

verbalized by S.O.“Wala.” As



patient.Retention: “Wala.” As “Wala.” As “Wala.” As

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verbalized by S.O. verbalized by patient.


Pain/Burning/Difficulty in

voiding:

“Wala man pud daw sakit.”

As verbalized by S.O.

Wala.” As verbalized by

patient.

Wala.” As verbalized by

patient.

History of kidney/bladder disease: “Na-admit siya sa 2008 kay gi U.T.I. pero kas-a rasad to.”(And there were no verbalizations regarding treatment.)

Objective:

Abdomen July 14, 2010 July 17, 2010 September 3, 2010Tender: non tender non tender non tender

Palpable mass: none None NoneSoft/Firm: Firm Firm Firm

Size/Girth:27 ½ inches 27 ½ inches 30 inches

Bowel Sounds:

Hypoactive, irregular, gurgling sounds; (UR: 6,

UL: 5, LR: 4, LL:4)

Hypoactive, irregular, gurgling sounds; (UR: 6,

UL: 5, LR: 4, LL:4)

Normal, high pitched gurgling noises;

((UR: 16, UL: 15, LR: 15, LL:20)

Bladder palpable:Bladder not

palpableBladder not

palpableBladder not palpable

Distension of Bladder:

Not Distended Not Distended Not Distended

Others/Comments: Patient has a condom catheter attached to a urobag and is draining well to

an amber-colored urine at 450 cc level (Inserted by Dr. Echalico on 07/13/10; 11:30 pm) upon first day of assessment up to last day of assessment and still had the condom catheter until July 18, 2010

Patient verbalized during home visit that he was only able to defecate on July 18, 2010

VI. FOOD/FLUID

July 14, 2010 July 17, 2010 September 3, 2010Usual diet (type):

S.O. verbalized, “kasagara gakan-on niya kay bulad, isda ug mga utan. Kung makakaon ug karne usahay rasad kaayo

“Ginapa-agi raman ang murag lugaw diri sa akong ilong. Pero ingun man to si doctor nga puede na ni tantangon.” As

“Halos gulay gyud o mga de lata nga sud-an ug kan.on akong gakan-on. Makakaon usahay ug karne kung naa.”

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kay mahal sad.” .

verbalized by patient

As verbalized by patient

Number of meals daily:

S.O. verbalized, “katulo sa isa ka adlaw”

“Murag isa man tingali sa buntag dayun isa sa gabii gahapon diri gi-agi sa tubo sa akong ilong. Nakalimot man ko.” As verbalized by the patient

“Katulo sa isa ka adlaw. Usahay makasnak2x ginagmay sa hapon” As verbalized by patient

Last meal /intake:

“Katong gipa-agi sa iyang ilong nga murag lugaw pero gisuka rasad lagi niya” as verbalized by the S.O.

“Lugaw ganiha buntag” As verbalized by patient

“Ganiha pani-udto kay kan.on ug de lata nga sardinas.” As verbalized by patient

Loss of appetite:

“Mga sugod atong July permi rana siya walay gana. Ug ato laging mga lunes ug martes kay halos wala nay gakaonon kay sakit daw iyang tiyan ug ginasuka ra pud niya.”

“Katong wala pako na-ospital permi rako walay gana pero karun akong pamati gyud kay perting gutoma”As verbalized by patient

“Wala naman hinuon, nibalik naman akong gana sa pagkaon”As verbalized by patient

Nausea/ Vomiting:

“Atong lunes nagsuka na siya sa balay ug nagreklamo siya sa buntag sa martes nga kasuka-on daw siya” as verbalized by S.O.

“Wala naman hinuon ko nagsuka ug dili naman sad ko kasuka-on”As verbalized by patient

“Wala naman ko nagsuka, ug dili na pud ko makafeel ug kasukaon”As verbalized by patient

Dentures:

S.O. verbalized, “wala man siyay pustiso”

“Wala.” As verbalized by patient.


Allergy/ Food Intolerance:

S.O. verbalized, “wala man”



Heartburn/ Indigestion:

“Permi na siya magreklamo nga sakit iyang kuto-

“Medyo ga-lain akong kuto2x, tingali tungod kay

“Usahay maglain akong tiyan ug kuto2x labi na gikan

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kuto, tingali sad kay permi siya walay gana ug halos wala nay kaonon” As S.O. verbalized

paminaw nako gutom kaayo ko.” As verbalized by patient.

ko magtrabaho o tunga2x sa akong pagtrabaho. Mawala raman sad pagmakapahuway na ug matrapuhan ang akong singot” As verbalized by patient.

Mastication/ swallowing problems:

S.O. verbalized, “wala man”



Changes in weight:

“Nagniwang na siya karun. Katong wala pa na siya’y gibati tambok2x pana siya. Dili lang sad gyud ko kaingun kung unsa siya kabug-at sa una.” As S.O. verbalized

“Medyo nagniwang ko karun pero sa una mga 55 kilos gyud ko” As verbalized by patient.

“Pag-abot nako diri sa balay gikan ospital, nitambok gyud ko kay nanghupong man sad ko sa akong kamot ug tiil. Mga 64 kg ko tong nagpacheck-up ko sa ospital diri sa claveria” As verbalized by patient.

Diuretic use: S.O. verbalized, “wala man.”

“Wala man ko gagamit” As verbalized by patient.

“Naginom ko atong Lasix kay nagdako akong tiyan, ni 36 inches gud to kadako pag-abot diri balay pero nawala ra dayun mga ikatulong semana sa agosto” As verbalized by patient.

Others/Comments: Upon first day of assessment, Patient has an NGT(French 16) at his left

nostril (Inserted by Dr. Echalico on 07/14/10; 12:05 AM) Physician ordered on July 14, 2010: 0F- 2200 kcal (110 gm CHON, 275

carbohydrates, 73 gm fat, 4 gm NaCl) in 4 equal feedings Patient vomited thrice upon first day of assessment

- Patient vomited right after being fed via NGT; vomitus was yellowish in color; approximately amounting to 240 cc.

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- Patient vomited right after being transferred from the E.R. to the Male Medical Ward; vomitus was greenish in color with blood streaks approximately amounting to 180 cc.

- Patient vomited for the third time after being given second feeding via NGT; vomitus was yellowish in color approximately amounting to 240 cc.

Patient able to progress to soft diet on July 18, 2010 Patient able to resume usual diet pattern upon arriving at home

Objective Data

July 14, 2010

July 15, 2010

July 16, 2010

July 17, 2010

September 3, 2010

Skin turgor:Good and resilient

Good and resilient

Good and resilient

Good and resilient

Good and resilient

Mucous membranes:

moist, intact but

yellowish in color

moist, intact but

yellowish in color

moist, intact but

yellowish in color

moist, intact but

yellowish in color

moist, intact but

yellowish in color

Edema: none noneMild edema (+1) on both

feet

Mild edema (+1) on both

feet

Bipedal pitting edema

Thyroid enlarged:

Not Enlarged

Not Enlarged

Not Enlarged

Not Enlarged

Not Enlarged

Halitosis:Bad odor

notedBad odor

notedBad odor

notedBad odor

notedMild odor

noted

Appearance of tongue:

moist, pink- intact

moist, pink- intact

moist, pink- intact

moist, pink- intact

moist, pink- intact

Height: 5’6”


BMI:17.79; classified as

underweight18.5; within normal

range for BMI

20.99; within normal range for

BMI

Body Build:ectomorph;

decreased amount of fat and muscles

ectomorph; decreased amount of fat and muscles

Endomorph

Hernia/ masses:None None None

Condition of teeth/gums:

Patient has a set of complete teeth—most are yellowish in color. The gums



20

are pinkish, intact and without lesions. The back of the tongue is yellowish and bad odor noted from the mouth.

are pinkish, intact and without lesions. The back of the tongue is yellowish and mild odor noted from the mouth.

are pinkish, intact and without lesions. The back of the tongue is yellowish and mild odor noted from the mouth.

Intake and Output Record: (Refer please to appendices)

VII. HYGIENE


Activities of Daily Living

(Independent/Dependent):

Dependent Dependent Independent

Equipment/ prosthetic devices

required:

None None None

Assistance provided by:

Elder sisters and elder brother

Elder sisters and elder brother

Assistance may be provided by his wife

Others/Comments:

Upon assessment, patient is stuporous – responds to vigorous stimuli but not able to talk and make movements purposefully. Patient is not able to feed, dress and take care of himself as he laid in bed all through out the day.

Patient is fully conscious but still needs assistance as he has not regained his full normal strength

Patient is already able to perform activities of daily living independently

21

Objective:Objective

DataJuly 14,

2010July 15,

2010July 16,

2010July 17,

2010Sept. 3,

2010

General Appearance:

unkempt, with long dirty nails, dry and cracked soles

unkempt, with long dirty nails, dry and cracked soles

Well-kept with short clean nails; able to endure some activities

Well-kept with short clean nails; able to endure ambulating

Untidy with long dirty nails as he came from a heavy day’s work in the farm

Manner of Dress:

Appropriate; wore t-shirt and shorts





Body Odor:Has some body odor

Has some body odor

Less body odor

No body odor

Some body odor

Condition of Scalp:

With dandruff but no lesions noted





Presence of Vermin:

No infestations noted





Others/Comments:

Patient was not able to take a bath due to his condition but assisted by his family members and student nurses with hygienic measures such as changing of clothes as necessary

Patient still not able to take a bath but assisted by his SO with hygienic measures such as sponge bath

Patient still not able to take a bath but assisted by his SO with hygienic measures such as sponge bath

Patient still not able to take a bath independently but assisted by his SO with hygienic measures such as sponge bath

Patient takes a bath everyday and is able to change his clothes indepen-dently

22

VIII. NEUROSENSORY


Fainting spells/ dizziness:

S.O. verbalized, “nagreklamo lagi siya nga gakalipong daw siya atong martes (July 13, 2010 pero dili mana siya permi gyud gakalipong sa una.”

Dependent“Usahay malipong ko kung kali kot mutindog” as verbalized by patient

Independent“wala man ko gakalipong diri sa balay..”as verbalized by patient

Headache:

“wala man, gakalipong lang siya.” As verbalized by S.O.

“wala man koy gibati na labad sa ulo” as verbalized by patient

“wala napud nagsakit akong ulo” as verbalized by patient

Weakness (location):

“nagluya gyud siya sugod atong mga lunes (july 12, 2010), murag tibuok lawas niya dili niya ma-alsa. Maayo karun kay murag sige siya ug tulog diri sa hospital pero gakabalaka sad mi kay dili man pud makamata ug sturya ug tarong”As verbalized by S.O.

“luya pa gyud akong gibati ug dili pa nayo malihok ug tarong akong lawas” as verbalized by patient

“mga tulo ka semana human ko gi gawas sa ospital pa gyud ko ayha nabaskog balik.. wala naman hinuon ko nagluya karon” as verbalized by patient

Eyes: Vision loss: Right/Left:

nagreklamo to siya nga hanap2x daw iyang panan-aw. Wala sad mi kabalo nganu to, nikalit raman” As verbalized by S.O.

“makakita nako pero dapat kanang naa sa duol lang kay hanaphanap na kung mga upat ka metro ang ka layo” as verbalized by patient

“atong wa pako nagdaot, makaklaro man gyud ko sa layo pero karon kay maglisod nako” as verbalized by patient

Last examination:

S.O. verbalized, “sukad wala pasad mi nakapacheck-up sa iyang mata”

“wala pako sukad naka pa check-up” as verbalized by patient

“plano nako mapatan-aw sa doctor puhon unta” as verbalized by patient

23

Glaucoma:S.O. verbalized, “wala man pud siyay glaucoma.”

“wala man koy glaucoma” as verbalized by patient

“wala” as verbalized by patient

Cataract:S.O. verbalized, “wala man pud na siyay cataract.

“wala man pud koy cataract” as verbalized by patient

“wala man” as verbalized by patient

Sense of smell:

S.O. verbalized, “okay raman sad tingali kay wala man siyay gireklamo nga dili siya isimhot.”

“okay raman” as verbalized by patient

“wala may problema” as verbalized by patient

Epistaxis:

S.O. verbalized, “wala pasad sukad nagsunggo.”



Others/Comments: S.O. verbalized, “Limtanon nasad kaayu siya ug murag wala siya sa iyang kaugalinon bah…

Kung magsturya mi usahay kay mawala siya sa passing (out of topic).” (referring to patient’s status prior to admission)

Patient verbalized upon home visit “usahay makalimot ko sa ginagmay na butang pero pagkadugayan mahidomdoman rasad nko balik.”

Objective:Objective

DataJuly 14,

2010July 15,

2010July 16,

2010July 17,

2010September

3, 2010

Mental Status:

Stuporous; Not oriented

to time, place, and

person

Stuporous; Not oriented

to time, place, and

person

Drowsy; but oriented to time and

place and person

Alert and fully

conscious; Oriented to time, place and person

Alert and fully

conscious; Oriented to time, place and person

Affect: Flat Flat Appropriate Appropriate AppropriateDelu-sions:

No delusions reported





Hallu-cinations:

No hallu-cinations reported





Memory: Recent: Not Accessible

Remote: Not Accessible

Recent: Not Accessible

Remote: Not Accessible

Recent: Accessible

(able to remember

Recent: Accessible

(able to remember

Recent: Accessible

(able to remember

24

who visited him in the afternoon)

Remote: Not accessible

student nurse who

took care of him in the morning)Remote:

Accessible(able to

remember his own birthday)

what his lunch was)Remote:

Accessible(able to

recall wife’s birthday

Speech Pattern:

Patient unable to

verbally co-mmunicate

Patient unable to


Slurred (inaudible

and difficult to

understand)

Under-standable;

clear; spontaneous

And loud enough to

hear

Under-standable;

clear; spontaneous

And loud enough to

hear

Cong-ruence:

Patient unable to


Patient unable to


Congruent in content and

context (although it took time to

fully understand his words)


context


context

Pupil Size/Reaction:

OS and OD: 2mm, pupil

equally round and reactive to light and

acco-mmodation



acco-mmodation



acco-mmodation



acco-mmodation



acco-mmodation

Facial Droop:

None noted None noted None noted None noted None noted

Swallowing:

Swallowing is not

impaired but strict

aspiration precaution

due to altered mental

Swallowing is not

impaired but strict

aspiration precaution

due to altered mental

No difficulty in swallowing

noted


noted


noted

25

status. status.

Handgrip/Release:

Patient not able to perform handgrip

Patient not able to perform handgrip

Left: weak handgrip

Right: weak handgrip

Left: strong handgrip

Right: strong handgrip

Left: strong handgrip

Right: strong handgrip

Posturing:Not able to

stand/sitNot able to stand/ sit

SlouchingSlouching Erect

Paralysis:No paralysis

notedNo paralysis

notedNo paralysis

notedNo paralysis

notedNo paralysis

noted

Glasses: None prescribed. Contacts: None Hearing aids: NoneOthers/Comments:

Patient is stuporous and responds in vigorous and painful stimuli (e.g. pin prick, tapping his face). Last July 14, 2010.

Upon waking up, patient stares blankly in one direction and does not follow verbal instructions (e.g. follow the light with the eyes, raise arms, and flex legs…). Last July 14, 2010.

Patient does not respond verbally to questions or instructions but after physician’s assessment in the E.R., patient suddenly made a moan-like sound for about 30 seconds. Further assessment was done by the physician patient but he did not respond and continued to stare blankly in one direction.

July 14, 2010 July 17, 2010 September 3, 2010Babinski Reflex: (-) (-) (-)

Kernig’s sign: (-) (-) (-)Brudzinki’s reflex: (-) (-) (-)

Deep Tendon Reflex:

+2 + 2 +2 +2

+ 2 + 2

+2 + 2

+ 2 + 2

*test for DTR was done by the physician on July 14, 2010 as observed by SN in the ER.*DTR of July 17, 2010 is equal to +2 in both elbows and patella.

26

July 17, 2010 September 3, 2010Aterexis positive negative

Glascow Coma Scale:

July 14, 2010

July 15, 2010 July 16, 2010 July 17, 2010 September 3, 2010

Motor Response:

5(localizes

painful stimuli)

5 (localizes

painful stimuli)

6(obeys simple

response)

6(obeys simple

response)

6(obeys simple

response)

Verbal Response:

2(incompreh

ensible sounds)

1(no verbal response)

5(oriented)

5(oriented)

5(oriented)

Eye-Opening:

2(in

response to pain)

2(in response

to pain)

3(in response

to sound)

4(spontaneous)

4(spontaneous)

Total: 9 8 14 15 15

SPERM:

DATE Sensorium Pupil Eye movement

Respiration Motor response

July 14 Stuporous 2mm 2 (in response

to pain)

16cpm 5(localizes painful stimuli)

July 15 Stuporous 2mm 2 (in response

to pain)

16cpm 5(localizes painful stimuli)

July 16 Drowsy 2mm 3 (in response

to sound)

15cpm 6(obeys simple

commands)July 17 Alert and

fully conscious

2mm 4 (spontaneous)


commands)September 3

Alert and fully

conscious

2mm 4 (spontaneous)


commands)

27

Handwriting:

Signature on July 16, 2010

Signature on July 17, 2010

Signature on September 3, 2010

*Patient verbalized on July 16, 2010, “Hala, dili ko kasulat ug tarung… Ambot nganu... Murag gakurog akong kamot, dili ko kasabot…”*Patient verbalized on July 17, 2010, “Arang-arang na akong pagsulat… Inani gyud ang dapat itsura gahapon sa akong signature”*Patient verbalized on Sept. 3, 2010, “Okay na akong pagsulat karun, dili na maghiwi2x…”

IX. PAIN/COMFORT

Others/Comments: Assessment for pain was not done as patient was not able to verbalize any

discomfort. Patient was not able to respond purposefully upon assessment.

28

Patient’s vital signs were within normal range upon assessment. Patient did not complain of pain in the third and fourth day of assessment

where he was already able to verbally communicate. Patient did not complainof any experience of pain upon assessment on July

17, 2010. There were no complaints of pain upon home visit.

X. RESPIRATION

SubjectiveJuly 14, 2010 July 17, 2010 September 3, 2010

Cough/sputum:

S.O. verbalized, “wala man sad siya gi-ubo. Wala pasad na siya nagreklamo

nga dunay dugo iyang ubo”

“wala man ko giubo” as


“wala man koy ubo” As verbalized by

patient.

Smoker:”Panalagsa raman

kaayu” as verbalized by SO

“nay adlaw nga tulo ka stick naa puy adlaw nga isa ka

kaha akong mahurot.. pero

karung semanaha wala ko naka

panigarilyo.” As verbalized by

patient.

“mga isa o duha ka stick nalang ug gina-antus nako nga sa

isa ka adlaw dili gyud manigarilyo.” As verbalized by

patient.

Pack per day:

S.O. verbalized, “mga isa raman o duha ka kaha sa

isa ka adlaw ”

“dili permanente pero naay mga

adlaw nga maka hurot kog isa. mga 3 tingali ka adlaw sa isa ka semana” As verbalized by

patient.

“dili na gaabot ug isa ka kaha karon” As


Brand:

S.O. verbalized, “Philip, Champion, Hope... Bisan unsa

man”

“kasagara fortune nga red pero kung walay fortune bisan

unsa raman.” As verbalized by

patient.

“fortune nga pula ug kung wala, mark

nalang” As verbalized by

patient.

Number of years: “adtong dise otso pa siya ” as

verbalized by S.O.

“nagsugod kog sigarilyo tong

namatay si papa mga disi otso ko”

“mga 12 na ka tuig” As verbalized by

patient.

29

As verbalized by patient.

Use of respiratory aids:

“naa siyay oxygen.” As verbalized by

S.O.

“kaning oxygen sa akong ilong” As verbalized by

patient.

“wala na naman koy gamit2x anang

oxygen” As verbalized by

patient.

Others/Comments:

Objective

Objective DataJuly 14,

2010July 15,

2010July 16,

2010July 17,

2010September

3, 2010Respiratory

Rate:16 cpm 16 cpm 15 cpm 21 cpm 18 cpm

Depth:

Equal Bilateral Chest

Expansion; Deep


Expansion; Deep


Expansion; Deep


Expansion; Deep


Expansion; Deep

Symmetry: Symmetric Symmetric Symmetric Symmetric SymmetricUse of

Accessory Muscles:

Yes, abdominal muscles





Nasal Flaring:Mild nasal

flaring notedMild nasal

flaring noted

Mild nasal flaring noted

Mild nasal flaring noted

No nasal flaring noted

Fremitus:

Not assessed as patient not

able to verbally

communicate

Not assessed as patient not

able to verbally

communicate

Tactile fremitus noted on both lung

fields


fields


fields

Breath Sounds:Clear,

vesicular lung fields

Clear, vesicular

lung fields

Clear, vesicular

lung fields

Clear, vesicular

lung fields

Clear, vesicular

lung fieldsCyanosis: Acyanotic Acyanotic Acyanotic Acyanotic Acyanotic

Clubbing of Fingers:

None None None None None

Sputum Characteristics:

None None None None None

30

XI. SAFETY


2010

Allergies/ sensitivity:

S.O. verbalized, “wala mana siyay

allergy.”

Patient verbalized, “wala man pud

koy nahibal-an na allergic ko”

Patient verbalized, “wala man.”

History of STD (date/type):

S.O. verbalized, “wala man”.

Patient verbalized, “wala man pud ko na-abunuhan ug

dugo.”

Patient verbalized, “sukad2x wala gyud ko kabalo

nga naakoy hep B. Ingun ang doctor pwede daw nako

ni makuha sa pakighilawas”

Blood transfusion/number:

S.O verbalized, “wala paman sad na siya sukad na-

abunuhan ug dugo”



History of accidental injuries:

S.O. verbalized, “nahulog to siya

sa kabayo sa una pero wala raman

siya na-unsa. Naligyas sad daw na siya pagdula

ug basketball tong mga unang

semana sa july.”

Patient verbalized, “sa una nahulog

ko sa kabayo pero bata pako

ato..mga 12 pako. napi-ang ko ato sa

kamot pero gipahilot ra dayon. Wala man pud ko

naligyas tong nagbasketball ko.”

Patient verbalized, “wala man gikan tong na-ospital

ko.”

Fractures/ dislocations

S.O. verbalized, “wala man pud.”

Patient verbalized, “wala.”


Arthritis/ unstable joints

S.O. verbalized, “wala man na siyay arthritis.”

Patient verbalized, “wala man pud koy arthritis.”


Back problemsS.O. verbalized, “wala pud man

siya nagreklamo”

Patient verbalized, “wala may sakit

akong likod.”

Patient verbalized, “wala man koy

nabatian nga na sakit akong likod.”

Change in moles“wala mi ka matikod.”

Patient verbalized, “wala ko

kabantay.”


Enlarged nodes S.O. verbalized, “wala man sad.”

Patient verbalized, “wala man koy

namatikdan nga

Patient verbalized, “wala man ko nalusayan.”

31

gilusayan ko.”

ProsthesisS.O. verbalized, “wala man sad.”



Ambulatory deviceS.O. verbalized,

“dili man siya gasungkod.”

Patient verbalized, “dili man ko ga-

sungkod.”

Patient verbalized, “dili man ko

kailangan ug sungkod.”

Expression of ideation of violence (self/others): S.O. verbalized “buotan man kaayu na siya, wala gyud na siyay problema sa iyang asawa, pamilya ug mga igsoon. Wala pud na siyay kaaway. Si-aw man gud kaayu na siya ug jokeron bah.”

Objective:Temperature:

July 14, 2010 July 15, 2010 July 16, 2010 July 17, 2010September 3,

2010Temp - 36.3 0C Temp - 36.6 0C Temp - 37 0C Temp - 37 0C Temp - 37 0C


2010

Diaphoresis:Mild diaphoresis

notedMild diaphoresis

notedNone

Scars: None None NoneRashes: None None None

Ulcerations: None None NoneBlisters: None None NoneBurns,

degree/percent:None None None

Laceration: None None NoneEcchymosis: None None None

General Strength:

July 14, 2010 July 15, 2010 July 16, 2010 July 17, 2010September 3,

2010Not able to

move purposefully and actively; remained in

bed the whole day

Not able to move

purposefully and actively; remained in

bed the whole day

Mild Weakness

noted

Mild Weakness

noted

Regained energy and strength to

normal

July 14, 2010 July 17, 2010 September 3, 2010Gait: Not assessed as

patient was not Not assessed as patient was

Steady normal gait

32

able to stand and move out of bed

not able to stand and move

out of bedParesthesia/paralysis: None None None

XII. SEXUALITY

July 14, 2010 July 17, 2010 September 3, 2010Sexually active: “Uo.” As

verbalized by S.O.

“Uo pero medyo laylo tong

nagsugod ko og bati ug karon nga naa sa ospital.” As


“Uo.” As verbalized by patient.

Breast cyst/lump/discharges:


S.O.

“Wala man sad karon.” As



patient.

Testicular/Prostate problem:

“Wala man siya nagreklamo.” As

verbalized by S.O.


patient.

“”Wala man pud.” As verbalized by

patient.

Practiced Self-examination:

“Wala man. Dili man pud tingali siya mag ingon kung gina himo

niya.” As verbalized by

S.O.

“Dili ko kabalo unsaon na.” As verbalized by

patient.

“Dili gihapon.” As verbalized by

patient.

Last proctoscopic/Prostate

examination:

“Wala pasad sukad.” As

verbalized by S.O.


patient.

“Wala pako nakapa exam.” As


Birth Control: “Naay I.U.D. iyang asawa.

Nagpabutang to siya paghuman ug anak atong

ikaduha nila nga anak.” As

verbalized by S.O.

“Naay I.U.D. akong asawa.”

As verbalized by patient.

“Naay I.U.D. akong asawa” As


33

Others/Comments: Physical assessment of patient’s reproductive area was not done due to S.O.

refusal and patient’s (4th day of assessment; where patient was already able to communicate clearly and spontaneously) refusal to conduct testicular examination.

Patient verbalized (4th day of assessment), “Okay raman among relasyon, mayo rasad (referring to sexual activities with wife)…”

Patient verbalized (4th day of assessment), “wala man puy gagawas nga lain sa akong kinatawo…”

Patient verbalized (4th day of assessment), “gituli ko atong grade 2 paman.”

XIII. SOCIAL INTERACTIONS

July 14, 2010 July 17, 2010 September 3,2010Marital Status S.O.

verbalized, “Buotan man kaayu na siya, wala gyud na siyay problema sa iyang asawa.”

“Okay raman, makamingaw kay wala siya diri.” as patient verbalized.

“Okay ra kayo, naa gyud siya

gaatiman nako.” as verbalized by the

client.

Living with “Iyang asawa ug duha ka anak.” as verbalized by S.O.

“Kami ra sa akung asawa sa balay ug among anak dayon

silingan ra nako akong igsoon.” As

verbalized by client.

“Uban naku karon ang akung asawa ug mga anak” As

verbalized by client.

Concerns/stresses

“Kwarta raman na ilang gaproblemahon pero dili gyud kaayu na sila ga-away kay kung masuko natong asawa permi raman niya pakatwa.on… SI-aw man gud kaayu ni akong manghud, jokeron bah” as verbalized by S.O.

“Usahay di pa kayo ko katarong ug

sturya ug katarong ug halubilo sa

akong parente.” As verbalized by

client.

“Okay na kayo, maayo na kayo

akong relasyon sa akong pamilya ug

silingan” As verbalized by

client.

Extended Family “Wala man, naa rami sa ilang tapad

“Kami ra gyud sa akung asawa ug

“Akung ugangan na babae ug

34

nga balay.” as verbalized by S.O.

mga anak sa among balay pero karon kay akong mga igsoon ang ga-atiman nako.” as verbalized by

the client.

bayaw.” as verbalized by the

client.

Other support person

“Iyang asawa ug kami iyang mga

igsoon.” as verbalized by S.O.

“Akong mga igsoon.” as

verbalized by the client.

“Akong asawa ugangan ug bayaw.” as


Role within family structure

“Siya gyud na kauban sa iyang

asawa ang gadesisyon sa

pamilya. Siya pud gapanginabuhi para nila.” as

verbalized by S.O.

“Kami duha gyud ga desisyon sa

akong asawa, pero karon kay akong

mga igsoon ang ga desisyon para kanamu.” as

verbalized by the patient

“Kami sa akung asawa ang ga desisyon.” as


Report problems related to

illness/condition

“Usahay matingala nalang na iyang asawa kay dili siya makahinodom ug makalimot siya dali. Pero gi-ingnan niya iyang asawa daan nga sabton lang sa siya kay dili gyud daw niya gatuyu-on nga makalimot siya.” as verbalized by S.O.

“Medyo dili pa gyud ako katarong ug halubilo sa mga

tao sa akong palibot kay

mawala-wala pa ko sa akong

ginasturya usahay.” as

verbalized by the client”wala naman

mayo na akong paminaw” as

verbalized by the client

“Wala naman mayo na akong paminaw.” as verbalized by the client

XIV. TEACHING/LEARNING

Subjective:Dominant language (specify):S.O. verbalized,”Bisaya”Literate: S.O. verbalized, “Oo, makasulat na siya ug makabasa gamay.”Educational level: S.O. verbalized, “Elementary, grade 3 raman siya taman.”Health beliefs/practices: S.O.verbalized, “Gagamit mi ug mga herbal, banaba, mangga, sambong, bayabas, tawa2x.. ug haplas2x dayun-efficascent oil, shane…”

35

Familial risk factors: ( / ) Diabetes – Eldest Sister( ) TB( / ) Heart Disease – Elder Brother( ) Stroke( ) Hypertension( ) Epilepsy( ) Renal Disease( / ) Cancer – Eldest Sister (Liver Cancer) and Mother (Breast Cancer)( ) Mental Illness( ) Substance AbuseOthers; ( / ) Hepatitis B – Elder BrotherComments:

S.O. verbalized, “Wala sad mi kabalo nganung nagkahepatitis to akong isa ka igsoon. Siya raman pud, wala may hepatitis iyang asawa ug mga anak. Ambut pud lagi aha na ni E.M. nakuha nga sakit.”

Patient verbalized upon home visit, “wala man gyud mi nagka-uban sa akong kuya mga 1 year old pa lang ko kay nagbalhin na sila sa bukidnon. Wala pud ko katambong sa iyang lubong kay namatay man daw to siya tungod sa hepa."

SO verbalized upon home visit “Ni gawas mi sa hospital kay ingon man to ang doctor nga dili na siya ma uli-an so mypag mu uli nalang mi. Dili pud mi mu tuo nga naa siyay Hepa B kay wala man to sa iyang ultrasound pero okay raman siya karon, pasalamat sa Diyos.”

Patient verbalized, “Lima ka adlaw rako naka-inom atong aminoleban pero wala na dayun kay perting mahala sa mga tambal.”

Use of alcohol (amount/frequency): S.O.verbalized, “Gainum, kanang naay okasyon raman sad.” Last July 14,

2010. Patient verbalized ”Wala man gyud ko niinom og dili na gyud kay mahadlok

nako basin ma-unsa ko.” Last September 3, 2010.

Others/Comments: Patient is an occasional drinker; He drinks 5-6 bottles of Beer and 6-7 glasses of rhum (e.g. Tanduay, Fighter, San Miguel Beer and Beer na Beer) when there’s occasion (2-3 times in a month); He started drinking at the age of 18.

36

Prescribed drugs/medications:

Medications Indications1. Essential Forte (1 cap TID per

NGT)fatty degeneration of the liver, hepatitis

(including toxic hepatitis)2. Lactulose (30 mL per NGT) portal-systemic encephalopathy in

patients with hepatic disease, Constipation

3. Metoclopramide (1 amp IVTT every 8 hours)

decreased nausea, vomiting

4. Ranitidine (50 g IVTT EVERY 8 hours)

antiulcer agent/ prophylaxis for ulcer

5. Aminoleban (500 mL every 12 hours)

used as general nutrients; enteral/nutritional

6. Metronidazole (500 mg IVTT EVERY 6 hours)

treatment of anaerobic infections: intra-abdominal infections

7. Citicoline (+6m q12°) signs and symptoms of cerebralinsufficiency e.g. dizziness, memory

loss, poor concentration, disorientation

8. Mannitol (20 mL IV bolus, STAT) increased intracranial or intraocular pressure; toxic overdose

9. Vitamin K ( 1 amp, IVTT) prevention of bleeding; treatment and prevention of hypoprothrombinemia

10.Omeprazole (40mg 1cap OD po) Reflux esophagitis

11.Paracetamol (500 mg 1 tab now) Fever

37

http://www.mims.com/Page.aspx?menuid=companionhome&ID=3158

B. Body Maps. (Illustrate in the body map how your patient looks-like. E.g. tubes inserted bruises, surgical incisions, physical abnormalities, affected areas.

DAY 1: July 14, 2010 (Tuesday; 11:00 AM and 3:00 PM)

38

Stuporous — change in sensoriumNGT on left nostrilOxygen inhalation @ 2 L/min via nasal cannulaIVF of PNSS 1L @ 30 gts/min

Condom Catheter attached to urobag

DAY 2: July 15, 2010 (Thursday; 3:30 PM)

Patient still was not able to defecate during the dayPatient still stuporous and does not respond verbally and does not obey simple

commandPatient complains of dizziness when ambulating and a feeling of general

weaknessPatient is being fed through the nasogastric tubePatient vomited twice during the day; vomitus was yellowish in color;

approximately amounting to 550 cc all in all

.

39

Stuporous — change in sensoriumNGT on left nostrilOxygen inhalation @ 2 L/min via nasal cannulaIVF of D5W 1L @ 30 gts/min


Day 3: July 16, 2010 (Friday, 12:30 PM)

Patient was not able to defecate

during the shiftPatient was already arousable by verbal stimuliPatient was able to respond verbally although speech is slurred and difficult to

understandPatient still cannot retrieve remote memories and some recent memoriesPatient not oriented to time and placePatient able to follow/obey simple commands/instructions (e.g. flex the knee,

make a fist)Patient was able to sit up but not yet able to endure standingPatient is being fed through the nasogastric tubePatient vomited after being transported to the examination room (For

ultrasound); vomitus was yellowish in color; approximately amounting to 200 cc all in all

Patient was able to see clearly and read; but not able to write his own signature properly

Day 4: July 17, 2010 (Saturday, 11:00 AM)

40

Drowsy—able respond verbally and activelyNGT on left nostrilOxygen inhalation @ 2 L/min via nasal cannulaIVF of D5NSS 1L @ 30 gts/min


Patient was not able to defecate.Patient is fully conscious and able to ambulate independently.Patient was oriented to time, place and person.Patient able to verbally and actively respond to command/instructions.Patient’s handwriting was better and was readable.Patient is being fed through the nasogastric tube.Patient is already allowed to take sips of water.Patient did not vomit for the whole day.

Day 5: (September 3, 2010) Friday 3:00pm

41

Fully conscious—able to respondNGT on left nostrilOxygen inhalation @ 2 L/min via nasal cannulaIVF of D5NSS 1L @ 30 gts/min


Bipedal mild edema

Patient was able to defecate. Patient was fully conscious and able to ambulate independentlyPatient was oriented to time, place and personPatient able to verbally and actively respond to command/instructionsPatient’s handwriting was better and was readablePatient was able to eat food as tolerated.Patient is already allowed to drink water.Patient did not vomit for the whole day.

42

Fully conscious—able to respond

Complaints of near-sightedness

Complaints of increase of abdominal size

Bipedal edema noted

Documents

Assessment Final