PATIENT’S

PROFILE
 PATIENT ASSESSMENT

I. Patient profile
Name: “FIONA”
Age: 17 years old
Address: Lubi - lubi East Guinarona Dagami, Leyte
Occupation: Student
Date and time admitted: March 04, 2010 @ 3:10 pm
Attending Physician: Dr. Mary Antonette Picorro
Chief Complaint: Purpuric rash and fever
Diagnosis: Henoch – Schonlein Purpura
Date of interview: March 07, 2010 @ 3:15 pm
Source of Information: patient
Reliability: 90 – 95 %
 II. Health History
PRESENT ILLNESS
2 weeks PTA, patient experienced unproductive cough with
whitish mucous secretion accompanied with itching sensation of
the throat due to changes in weather, relieved by herbal plant
such as lagundi and home remedies such as increase fluid intake
and lemonade.
1 week PTA, patient noted a palpable rash at lower
extremities (both legs) assumed to have appeared after a
mosquito bite. Thereafter, she noted the rashes to be increasing
in number and now reaching the buttocks and back of trunk. No
other associated signs and symptoms noted. She decided to go to
a quack doctor in their barangay and was given an ointment
(name unable to recall) for the rashes.
 2 days PTA, after consulting with the quack
doctor her condition showed no signs of progress.
Still with rashes developed fever relieved by self
medications of paracetamol 500mf tablet but still did
not consult a physician
1 day PTA, fever persisted accompanied with
body malaise which prompted her to consult at
EVRMC and was advised to be admitted for further
examination.
PAST ILLNESS

Received complete immunization. Has not yet

experienced childhood illnesses such as measles,
mumps, and chicken pox. Has already experienced
common illnesses such as cough and colds, and fever.
Paracetamol 500mg given for fever, herbal (lagundi),
increase fluid intake, and lemonade as home remedies
for cough and colds.
Revealed no history of previous hospitalization nor
injury experienced.
No allergies to foods and drugs noted.
FAMILY HISTORY

Revealed history of DM on paternal side but denied

heredo familial disease on maternal side.
GYNECOLOGIC HISTORY

She had her menarche when she was in her

second year high school but cannot recall the
exact date. Usually lasts for one week with heavy
menstrual flow of dark red blood with clots
consuming 2 to 3 sanitary pads a day fully
soaked especially on first and second day.
Occasionally experience dysmenorrhea and
headache with no relief measures taken at home.
 
PSYCHOSOCIAL HISTORY

A non smoker occasionally drinks for at least 2

– 3 glasses of alcoholic beverages (tuba and
beer) per session with friends and classmate.
When facing stressful situation she usually
share it with her grandmother and follows her
advise.
Spend her leisure time at videoke at their
neighbor and watching TV at her favourite
shows (wowowee and primetime drama).
III. Reaction and Expectations

She was a little uncomfortable and could not sleep well

because of her condition. She expect to receive quality
care in order for her to be well and recover soon.
 Patterns of functioning
PATTERNS OF PRE – CLINICAL CLINICAL INSPECTION OTHER SOURCES
FUNCTIONING INSPECTION
1.Respiratory -has history of unproductive - RR: 24 cpm X-ray:
cough herbal meds. (lagundi) - no cough and colds Impression:
increased fluid intake and - with normal breath sounds Normal radiographic breath
lemonade serves as remedy sounds
- no history of PTB and
difficulty in breathing
- no history of asthma
- a non smoker

2.Circulatory -no history of hypertension - BP: 100/70 mmHg -X-ray:

- no history of dizziness, - PR: 82 bpm Impression:
Heart is not enlarge
palpitation and chest pain - presence of edema (non-
-with an IVF OF D5LR
pitting) and discolored part regulated @ 30 gtts/minute
( on both legs) -on I & O monitoring
- good capillary refill (less
than 2 seconds)
- no cyanosis
- no pallor
 Hematology
result Normal values significance
Hgb 127.0 g/l 120 - 160 Normal
Hct 0.41 % 0.36 – 0.47 Normal
erythrocytes 4.89mil/ul 4.2 – 5.4 mil/ul Normal

leukocytes 9.30mil/ul 4.5 – 10.0 mil/ul Normal

granulocytes 0.81 % 0.500 – 0.750 Increase

Infection
lymphocytes 0.16 % 0.200 – 0.350 Decrease
Immune problem
monocytes 0.03 % 0.020 – 0.060 Normal

Platelet count: 651 mil/ul 150 - 450 Increase:

May indicate polycythemia
or malignancy

Decrease may indicatemicrocytic

MCH 26.00 pg 27 – 31
cells,possible for IDA
Derease may indicate IDA or
MCHC 311 g/l 320 - 360
hemoglobinopathy
 Creatinine 49.0 umol/L 53-97 Low (possible
renal diseases )

TP (total CHON) 72.0 g/L 66-87 Normal

Albumin 44.1 g/L 40-55 Normal

Globulin 27.9 g/L 17-33 Normal

Na 132.4 mmol/L 135-148 Low (myxedema)

K 3.8 mmol/L Normal

Cl 102.2 mmol/L Normal

3.Food and fluid intake -usual food taken are rice, -skin is deep brown with -with IVF of D5LR regulated at
fish, and vegetables palpable Purpuric rashes, warm 30 gtts per minute
to touch, moist, good skin -patient is on I & O
-eat 3x a day
turgor -on DAT
-no food allergies -nails convex in shape
-No food preferences -pinkish conjunctiva, moist
-consumed 8 – 9 glasses of -no dentures
water per day -good appetite (eat 3x a day)
-food taken are rice, fish,
-occasionally drinks
vegetables, fruits, and bread
alcoholic beverages for at -consumed 5 – 6 glasses of water
least 2 – 3 glasses a day
-no NGT
-presence of abdominal pain
with PS: 7

4.Elimination -voids 3 – 4x a day with -Voids 2 – 3x a day with URINALYSIS:

yellowish to pale urine Macroscopic:
yellow urine approximately
approximately 1 ½ - 2 glasses Color: yellow
1-1/2 glass (as estimated by Transparency: turbid
(as estimated by patient)
-defecates every other day with
the patient) Specific gravity: 0.36
-defecates every other day pH: 5.0
yellow to brown stool
glucose: (-)
-seldomly experienced diarrhea, with yellow to green stool albumin: (+)
take diatabs as a relief measure -no diarrhea Microscopic:
-seldomly experienced
-no constipation Pus cells: 10 – 20
constipation, relieved by increase RBC: many
fluid intake Bacteria: many
Creatinine: 49.0
5.Regulatory mechanism -experienced fever -Temp: 38.4®C
associated with chills takes -febrile
paracetamol 500mg serves -skin is deep brown, moist
as relief measure and warm to touch
-has palpable Purpuric
rashes (reddish to brown)
@ left extremities, back of
trunk and buttocks area

6.Hygiene -takes a bath once a day -general appearance is unkept

-uses shampoo everyday -presence of palpable rashes
At the lower extremities, back of
-brushes teeth 3x a day
trunks, and buttocks
-changes clothes once a day -head is normocephalic, no
-no allergies to soap and lesions, no palpable masses
shampoo -hair is black, equally
distributed, presence of
dandruff, no pediculosis
-nails are long and dirty
-with halitosis
-Did not take a bath since
admission
7.Exercise and locomotion -she consider walking -stays lying on bed
household chores as her -limited movements from
exercise due to joint pain (such as
walking)
-decreased muscle strength
-neck:
No swelling, no
enlargement of thyroid
glands, no palpable masses

8.Rest and sleep -usually sleeps 8 – 9 hours -yawning

-sleeping time is 9pm or -presence of eye bags in
10pm and awakens 6am or both eyes
7am -number of hours sleep is 4 –
-does not take daytime naps 5 hours
-favorite sleeping position is -take daytime naps for 30
side lying minutes
-uses 8 pillows -has difficulty of sleeping
-no bedtime rituals due to pruritus
- Uses one pillow
 9.Communication and -right handed EYE:
-no eyeglasses Eyelashes equally distributed,
special senses whitish sclera, moist
-no hearing aid use
-no history of visual and lacrimation, pinkish and moist
conjunctiva, presence of eye
auditory disturbances
bags
- no speech disturbances
EARS:
-speaks in waray - waray
Pinna is in line with outer
cantus of the eye, no lesions,
no external canal discharges,
no ear ache
NOSE:
-no discharges
- no epistaxis

10.Sensory -no history of convulsion -conscious and oriented to

-no history of loss of time place, and person
consciousness
-no history of epilepsy

11.Pain and discomfort -does not take any medicine -has abdominal cramping
for pain if not severe (such pain (PS: 6)
as mild headache) only -has joint pain at shoulder,
applies VAPORAB or knees, and ankle (PS: 7)
ointment usually relieved by rest
-skin: pruritus
12.Reaction or diversion -fond of singing -resting and sleeping
videoke and watching -talking with her
TV mother and father

13.Religious life -goes to church -no religious medal

occasionally worn
-prays rosary
sometimes
14.Coping mechanism -usually shares her -feeling of discomfort
problems to her and slightly irritable
grandmother (due to joint pains and
-whenever she is pruritus)
frightened she just
sleep

15.Social occupations -do the household -Stays in her bed

chores most of the -seldomly talks to her
time room mates
-she wants to see her
father
 DRUG GENERAL SPECEFIC INDICATION CONTRAINDICA ADVERSE NURSING
ACTION ACTION TION REACTION RESPONSIBILITI
ES

sulbactam + antibiotic Bactericidal -treatment of -with allergies CNS: seizures Observe 10 Rs

ampicillin action against infections cause to penicillins CV: heart -assess history
750 mg IVTT sensitive by susceptible And failure of
q8h organisms; starins of cephalosporins GI: sore mouth, hypersensitivity
inhibits shigella, -use cautiously abdominal pain, and renal
synthesis of salmonella, S. with renal nausea and disorder
bacterial cell Typhosa, E.coli disorders vomiting, -assess culture
wall causing cell -skin and skin diarrhea of infected area,
death structure GU: NEPHRITIS skin color,
infections Hematology: lesion, CBC,
anemia Hematocrit,
Hypersensitivity urinalysis
: rash and fever
Local: pain,
phlebitis
 DRUG GENERAL SPECIFIC INDICATIONS CONTRAINDICATI ADVERSE NURSING
ACTION ACTION ONS REACTION RESPONSIBILITI
ES

Paracetamol antipyretics Inhibits the Mild pain Hypersensitivity GI: hepatic - assess overall
300g IVTT synthesis of Fever - use cautiously in failure, health status
q4h prostaglandins patient with hepatoxicity - assess type,
that may serve hepatic disease GV: renal location and
as mediators of failure intensity of pain
pain and fever Derm: rash, - assess fever,
urticaria note presence
of associated
signs
(diaphoresis,tac
hycardia,malais
e)
 DRUG GENERAL SPECIFIC INDICATIONS CONTRAINDICA ADVERSE NURSING
ACTION ACTION TIONS REACTION RESPONSIBILITI
ES
D5LR @ 30 Solution for - provides calories - Fluid - contraindicated Endo: inappropriate - assess hydration
gtts/min intravenous and maintenance replacement and with patient with insulin secretion status of the
infusion and for of fluid caloric delirium tremens (long-term patient receiving
F & E: hypokalemia,
replacement and supplementation use of solutions IV dextrose
hyphostamia,
maintenance of in patient who contraindicated in - Monitor I & O
hyposmagnesia, fluid
fluid therapy can’t maintain patient with -assess nutritional
overload,
adequate balance intracranial, Local: pain and status
intake and who are intraspinal irritation at IV site - Monitor IV site
restricted from hemorrhage CNS: confusion frequently for
doing so. CV: heart failure phlebitis and
with fluid overload infection
insusceptible patient - Check vital signs
GU: glycosuria, frequently report
osmoticdiuresis
adverse reaction
Respi: pulmonary
promptly
edema
- watch closely for
Skin: sloughing and
tissue necrosis signs and
symptoms of fluid
overload
 HEMATOLOGY
TEST RESULT NORMAL VALUES SIGNIFICANCE
Hgb 127.0 g/l 120 - 160 Normal
Hct 0.41 % 0.36 – 0.47 Normal
erythrocytes 4.89mil/ul 4.2 – 5.4 mil/ul Normal
leukocytes 9.30mil/ul 4.5 – 10.0 mil/ul Normal
granulocytes 0.81 % 0.500 – 0.750 Increase
Infection

lymphocytes 0.16 % 0.200 – 0.350 Decrease

Immune problem

monocytes 0.03 % 0.020 – 0.060 Normal

Platelet count: 651 mil/ul 150 - 450 Increase:
May indicate
polycythemia or
malignancy
MCH 26.00 pg 27 – 31 Decrease may
indicatemicrocytic
cells,possible for IDA

MCHC 311 g/l 320 - 360 Derease may indicate

IDA or
hemoglobinopathy
 URINALYSIS

Color Yellow normal

Transparency Turbid

Specific gravity 0.036 (1.005 – 1.030) decrease in

chronic renal
insufficiency diabetes
insipidus

PH 5.0 Decrease (acidic)

Glucose (-)
 Albumin (+) Indicate
microalbuminuria

Pus cells 10 – 20 May indicate UTI

RBC Many Increased may reflect tumor

stones, trauma glomerular
disorders, cystitis

Epithelial cells Few

Bacteria Many Determine presence of UTI

 Creatinine 49.0 umol/L 53-97 Low (possible renal
diseases )

TP (total CHON) 72.0 g/L 66-87 Normal

Albumin 44.1 g/L 40-55 Normal

Globulin 27.9 g/L 17-33 Normal

Na 132.4 mmol/L 135-148 Low (myxedema)

K 3.8 mmol/L Normal

Cl 102.2 mmol/L Normal

 NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES

There is tissue deposition of IgA

After 8 hours of nurse
Impaired tissue integrity related to
increase vascular permeability containing immune complexes patient intervention the
secondary to bacterial infection patient will be able to:
especially within the small
SUBJECTIVE:
vessels. The abnormal response -Prevent/ minimize
“may mga makatol ngan nanbubutol of the immune system is unclear occurrence of
ngadi hit akun mga paa ngan pablikbalik why it occurs, but it seems to complications
an akun hiranat” as verbalized by the represents an unusual reaction of
patient - maintain normal range
the body’s immune system that is
OBJECTIVE: of temperature
-palpable Purpuric rashes response to infection (either
- lower extremities edematous bacterial or virus). Small vessels
- demonstrate tissue
(especially feet) called capillaries in the skin are regeneration
-febrile
-warm to touch and moist skin
affected due to increase vascular
permeability resulting to skin
Vital signs rash which is most prominent
BP: 100/70 mmHg over the buttocks and behind the
PR: 82 bpm
lower extremities.
RR: 24 cpm
Temp: 38.4 ®C
PS: 7
 NURSING INTERVENTIONS RATIONALE EVALUATION

Independent After 8 hours of nurse patient

- Monitor vital signs note for elevated - provide baseline data changes usually
precedes fever and alteration of Lab
intervention the patient was
temperature and increase RR
- Assist patient for TSB studies able to:
- Encourage increase intake of fluids -helps lower elevated temp. - maintain normal range of
- Emphasize good hand washing -water therapy helps fight infection temperature with the help of
technique for all individual coming in -reduces occurrence of complications
(such as dermatitis)
TSB and paracetamol PRN as
contact with client
- instruct SO to prevent skin to skin -prevent adherence to surface and evidenced by body temp. of 37®C
surface contact encourages proper healing Goal met
- instruct SO to provide freshly -promotes circulation and tissue - prevent occurrence of
laundered bed linens. regeneration
-reduces swelling and promotes
complications as evidenced by
- keep skin free from pressure
- elevate lower extremities if circulation absence of signs and
possible/appropriate -irritation may affect the underlying manifestations of any
-avoidance of lotions or soap that may tissue which can alter in tissue complication such as
irritable the skin regeneration.
(dermatitis) therefore goal met
Dependent - partially demonstrate tissue
- sulbactam + ampicillin 750 mg IVTT - treatment for skin and skin structure regeneration due to lack of
q8h infectious medicine
-paracetamol 300 mg IVTT q4h PRN - for elevated temperature
-Useful in establishing individualized
Therefore goal partially met
Collaborative
-Refer to nutritional support team nutritional needs & identifying
appropriate routes
 NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES

Impaired physical mobility related In response to triggering event, the After 8 hrs of nurse – patient interaction
to joint paints antigen stimulus activates and series of nsg. interventions patient
Subjective: monocytes and the lymphocytes. IgA will be able to:
“diri gud aku nakakakiwa ngan form immune complexes with Verbalized reduce number of pain
scale from 7 to 4
nakakalakat hin maupay kay masakit antigens. The immune complexes
iton akun tiil pati iton akun kamot” build up and are redeposited in Maintain or increase strength and
As verbalized by the patient synovial tissue triggering the function of affected or compensatory
Objective: inflammatory reactions (joint body part through active or passive
-limited ROM effusion, pain, and edema) that can ROM exercises
-decreased muscle strength ultimately damage the involved
Maintain bodily function (particularly
-intolerance to activity and exercise tissue. When damage occurs injured
extremities) with absence or limitation
-facial grimace cells release chemical mediators
of contractures
-fatigue such as bradykinin, serotonin, and
-with the following vital signs: prostaglandin that affect the Prevent occurrence of prolonged bed
BP:100/70 mmHg exposed nerve endings of rest complications such as bed sores
PR:82 bpm nociceptors (pain receptors) and pneumonia
RR:24 CPM SOURCE:
Perform ADL’s within level of own
Temp:38.4®C Medical surgical nursing by
ability with safety
NPS:7 brunner and suddarts
Volume 2
Page: 1887-1888
 NURSING INTERVENTIONS RATIONALE EVALUATION

INDEPENDENT: -provide baseline data, changes on V/S After 8 hrs of nurse – patient interaction and
1.Monitor vital signs (esp. Temp and RR) occur if there is pain series of nsg. interventions patient was able
2.Monitor degree of joint pain (using pain -provides baseline data on the level of to:
scale) activity can patient tolerate Verbalized reduce of pain scale from 7 to
-maintains and improve joint function, 6 as evidenced by absence of facial
3.Assist with passive and active ROM and muscle strength and general stamina grimace therefore goal partially met
resistive exercises -strengthen shoulders and arms muscle Increase strength and function of affected
4.Encourage self care activities (eg. needed for walking
area as evidenced by participating and
Changing clothes) -promotes blood circulation especially to
increase tolerance in exercises such as
5.Encourage deep breathing exercises affected part
walking, therefore goals met
6.Encourage client to maintain upright and -maximize joint function and maintain
erect posture when sitting, standing, and mobility Maintain bodily function as evidenced by
walking -reduces fatigue and improves strength absence of contractures during
7.Maintain bed rest or chair rest when -relieves pressure on tissues and performance of ADL’s (e.g toileting)
indicated promotes circulation. And also prevents therefore goal met
8.Instruct SO to reposition patient shearing abrasions of skin Prevent occurrence of complications (bed
frequently -promotes joint stability and maintain sores and pneumonia) . As evidenced by
9.Instruct SO to position client with pillows proper joint position and body absence of bed sore and pneumonia.
COLLABORATIVE: alignment, minimizing contractures Therefore goal met.
1.Consult the physician or the occupational -useful in creating apprehensive Perform ADL’s within level of own ability
therapist and vocational specialist individualized activity or exercise
as evidenced by tooth brushing and
program
changing clothes without any assistance
therefore goal met
 NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES

Pruritus and hyper irritability

Sleep pattern disturbances related to
are related to large amounts of After 8hrs of nurse patient
pruritus and discomfort secondary to
histamine in the skin. This interaction the patient will be able
disease process
SUBJECTIVE: occurs in response to immediate to:
“danay dira aku nahingangaturog immunologic response between -minimize pruritus and discomfort
dara hit kakatol” specific antigen and antibody. -Obtain adequate sleep as evidence
As verbalized by the patient The interaction of foreign by :
OBJECTIVES: -No eye bags
antigen which specific
-presence of eye bags
antibodies causes subsequent -Minimize fatigue
-irritability
-yawning release of histamine and other
-weakness mediators.
-fatigue
-with the following vital signs: Med0-surg. Smeltzer et. Al
BP:100/70 mmHg Vol.2 pp 1970-1865
PR:82 bpm
RR:24 cpm
Temp:38.4 ®C
 NURSING INTERVENTIONS RATIONALE EVALUATION

INDEPENDENT:
After 8 hours of nurse patient
1. monitor vital signs -provide baseline
(Note for any changes beyond normal
interaction the patient was able to:
data(inadequate sleep may Minimize discomfort and pruritus
range)
affect vital signs) as evidenced by absence of
2. promote quiet and peaceful -reduces discomfort and scratching therefore goal met
environment by limiting visitor irritation and promotes Obtain adequate sleep as evidenced
(especially during resting time) adequate rest by 7 – 8 hours of sleep and absence
3.promote diversional activities of eye bags therefore goal met
-distract client attention instead
of focusing to itching
-helps hastens the feeling of
4. assist patient to assume being sleepy
comfortable position for rest or sleep
5.instruct patient to drink milk as
-helps acquire good sleep
indicated
6. advised wearing cotton next to the
skin rather than synthetic materials -synthetic materials can trigger
itching
PATHOPHYSIOLOGY
 Etiology: UNKNOWN
But may be due to unusual reaction of the body’s immune system in response to this
infection
(Due to previous infection of the throat or breathing passages)

Immune response
 
Antigen – antibody binding

 
Formation of immune complexes

IMMUNE COMPLEX
 
 In small vessels Redeposited in In intestinal In
(particularly in synovial tissue
capillaries ) epithelial cells glomerulus

Increased
Increased Ultimately
production of
damage the
vascular epithelial cells
involved tissue Irritation lining of the
permeability
glomerulus

Results in
Thickening of
• joint effusions glomerular filtration
•Urticaria Results to
• Flushing •Joint pain and membrane
skin rashes
•Pruritus edema
(palpable
Purpuric Scarring and loss of
rashes) glomerular filtration
Tissue damage and Increased membranes
inflammation of stomach and peristalsis
small intestines
Increased Decreased
hyperactive bowel GFR
Bleeding and
ulceration sounds
 Decreased GLOMERULAR
absorption NEPHRITIS

• Nausea and vomiting

Diarrhea •fever
•abdominal pain