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,
fish, and vegetables
-eat 3x a day
-no food allergies
-No food preferences
-consumed 8 – 9 glasses of
water per day
-occasionally drinks
alcoholic beverages for at
least 2 – 3 glasses
4.Elimination -voids 3 – 4x a day with
yellowish to pale urine
approximately 1 ½ - 2 glasses
(as estimated by patient)
-defecates every other day with
yellow to brown stool
-seldomly experienced diarrhea,
take diatabs as a relief measure
-seldomly experienced
constipation, relieved by increase
fluid intake
-skin is deep brown with -with IVF of D5LR regulated at
palpable Purpuric rashes, warm 30 gtts per minute
to touch, moist, good skin -patient is on I & O
turgor -on DAT
-nails convex in shape
-pinkish conjunctiva, moist
-no dentures
-good appetite (eat 3x a day)
-food taken are rice, fish,
vegetables, fruits, and bread
-consumed 5 – 6 glasses of water
a day
-no NGT
-presence of abdominal pain
with PS: 7
-Voids 2 – 3x a day with URINALYSIS:
Macroscopic:
yellow urine approximately
Color: yellow
1-1/2 glass (as estimated by Transparency: turbid
the patient) Specific gravity: 0.36
-defecates every other day pH: 5.0
glucose: (-)
with yellow to green stool albumin: (+)
-no diarrhea Microscopic:
-no constipation Pus cells: 10 – 20
RBC: many
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
Independent
- Monitor vital signs note for elevated
temperature and increase RR
- Assist patient for TSB
- Encourage increase intake of fluids
- Emphasize good hand washing
technique for all individual coming in
contact with client
- instruct SO to prevent skin to skin
surface contact
- instruct SO to provide freshly
laundered bed linens.
- keep skin free from pressure
- elevate lower extremities if
possible/appropriate
-avoidance of lotions or soap that may
irritable the skin
Dependent
- sulbactam + ampicillin 750 mg IVTT
q8h
-paracetamol 300 mg IVTT q4h PRN
Collaborative
-Refer to nutritional support team
RATIONALE
- provide baseline data changes usually
precedes fever and alteration of Lab
studies
-helps lower elevated temp.
-water therapy helps fight infection
-reduces occurrence of complications
(such as dermatitis)
-prevent adherence to surface and
encourages proper healing
-promotes circulation and tissue
regeneration
-reduces swelling and promotes
circulation
-irritation may affect the underlying
tissue which can alter in tissue
regeneration.
- treatment for skin and skin structure
infectious
- for elevated temperature
-Useful in establishing individualized
nutritional needs & identifying
appropriate routes
EVALUATION
After 8 hours of nurse patient
intervention the patient was
able to:
- maintain normal range of
temperature with the help of
TSB and paracetamol PRN as
evidenced by body temp. of 37®C
Goal met
- prevent occurrence of
complications as evidenced by
absence of signs and
manifestations of any
complication such as
(dermatitis) therefore goal met
- partially demonstrate tissue
regeneration due to lack of
medicine
Therefore goal partially met
 NURSING DIAGNOSIS SCIENTIFIC ANALYSIS
Impaired physical mobility related In response to triggering event, the
to joint paints antigen stimulus activates
Subjective: monocytes and the lymphocytes. IgA
“diri gud aku nakakakiwa ngan form immune complexes with
nakakalakat hin maupay kay masakit antigens. The immune complexes
iton akun tiil pati iton akun kamot” build up and are redeposited in
As verbalized by the patient synovial tissue triggering the
Objective: inflammatory reactions (joint
-limited ROM effusion, pain, and edema) that can
-decreased muscle strength ultimately damage the involved
-intolerance to activity and exercise tissue. When damage occurs injured
-facial grimace cells release chemical mediators
-fatigue such as bradykinin, serotonin, and
-with the following vital signs: prostaglandin that affect the
BP:100/70 mmHg exposed nerve endings of
PR:82 bpm nociceptors (pain receptors)
RR:24 CPM SOURCE:
Temp:38.4®C Medical surgical nursing by
NPS:7 brunner and suddarts
Volume 2
Page: 1887-1888
OBJECTIVES
After 8 hrs of nurse – patient interaction
and series of nsg. interventions patient
will be able to:
Verbalized reduce number of pain
scale from 7 to 4
Maintain or increase strength and
function of affected or compensatory
body part through active or passive
ROM exercises
Maintain bodily function (particularly
extremities) with absence or limitation
of contractures
Prevent occurrence of prolonged bed
rest complications such as bed sores
and pneumonia
Perform ADL’s within level of own
ability with safety
 NURSING INTERVENTIONS
INDEPENDENT:
1.Monitor vital signs
2.Monitor degree of joint pain (using pain
scale)
3.Assist with passive and active ROM and
resistive exercises
4.Encourage self care activities (eg.
Changing clothes)
5.Encourage deep breathing exercises
6.Encourage client to maintain upright and
erect posture when sitting, standing, and
walking
7.Maintain bed rest or chair rest when
indicated
8.Instruct SO to reposition patient
frequently
9.Instruct SO to position client with pillows
COLLABORATIVE:
1.Consult the physician or the occupational
therapist and vocational specialist
RATIONALE
-provide baseline data, changes on V/S
(esp. Temp and RR) occur if there is pain
-provides baseline data on the level of
activity can patient tolerate
-maintains and improve joint function,
muscle strength and general stamina
-strengthen shoulders and arms muscle
needed for walking
-promotes blood circulation especially to
affected part
-maximize joint function and maintain
mobility
-reduces fatigue and improves strength
-relieves pressure on tissues and
promotes circulation. And also prevents
shearing abrasions of skin
-promotes joint stability and maintain
proper joint position and body
alignment, minimizing contractures
-useful in creating apprehensive
individualized activity or exercise
program
EVALUATION
After 8 hrs of nurse – patient interaction and
series of nsg. interventions patient was able
to:
Verbalized reduce of pain scale from 7 to
6 as evidenced by absence of facial
grimace therefore goal partially met
Increase strength and function of affected
area as evidenced by participating and
increase tolerance in exercises such as
walking, therefore goals met
Maintain bodily function as evidenced by
absence of contractures during
performance of ADL’s (e.g toileting)
therefore goal met
Prevent occurrence of complications (bed
sores and pneumonia) . As evidenced by
absence of bed sore and pneumonia.
Therefore goal met.
Perform ADL’s within level of own ability
as evidenced by tooth brushing and
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