S> Fluid volume deficit, S> “Pasa ang kanang Impaired skin

“Naglulungad vomitus related to braso ng baby ko” as integrity related to

ang baby ko” gastric distention verbalized by the mechanical factors
as verbalized secondary to the mother. as evidenced by
by the mother. narrowing of the violet spots or
duodenum as O> violet spots or discoloration in
O> increased evidenced by discoloration in the arm the arm.
salivation presence of blood >disruption of skin due
> ineffective stained vomitus. to puncture of the needle
feeding > poor skin turgor
> decrease > crying when being
skin turgor touched
> Lab results:
>inconvenient ●Total bilirubin=5.94
sucking umol/L
> poor Rv: 0.0-21.0
sucking reflex umol/L
> milk reflux ●Direct bilirubin=
when sucking 3.89umol/L
> small Rv: 0.021.o umol/L
amount of milk ●Indirect Bilirubin=
per meal at 2.05umol/L
least 10 cc Rv: 0.0-3.42umol/L
> vomited 8x/ ●PTT=12.9(11.5secs)
shift to a bottle Rv: 10-15secs
greenish color ●APTT=26.4(32.0
of 100cc/day secs)
> Previous 2.3 Rv: 26.1-36.3 secs
Kg ●Albumin=25.20g/L
> Present 2.8 Rv: 38.54g/L
Kg

S>”habang Ineffective S>” Hindi siya Altered urinary

tumatagal ang health umiihi kaya elimination pattern
daming maintenance nilagyan na siya ng related to decrease
nadadiagnose na related to lack of sunda” as bladder muscle
sakit sa anak ko”, as access to verbalized by the tone secondary to
verbalized by the adequate patient’s mother. dehydration
patient’s mother healthcare
services as O >with straight
O>crying evidenced by catheter connected
>Restless observed to small bedside
>with incision in inability in bottle draining to a
the right upper meeting basic dark yellow output
abdomen health needs. > w/ swollen
>with slanting genitalia
eyes >w/ urine output
>written diagnosis of 25cc/day
as follows: (normal urine
●Sepsis output 48-
Neonatorum 72ml/day)
●Down’s Syndrome > with increase
●s/p creatinine result:
Exlap,Duodeno- 241.10/2.72
duodenostomy for umol/L
Duodenal Atresia (Rv: 53.1-
● Congenital Heart 115.0 umol/L
Disease )
>BUN result:
19.03 umol/L
(Rv: 2.5-7.2
umol/L)
>2 days NPO
sept. 5 and 6,2009
>Urinalysis
result:
-color= dark yellw
Rv: pale yellow
-specific
gravity=1.010
Rv: 1.003-1.035
-character=turbid
Rv: clear
-squamous
epithelial cell=few
Rv: none
-pH reaction=5.0
Rv: 7.35-7.45

S: “Isinusuka niya ang Altered S:”Konti lang ang Altered Bowel

iniinom niyang gatas”. nutritional naidudumi niya”as elimination pattern
As verbalized by the Imbalanced verbalized by the related to metabolic
mother related to mother. disorder as
inability to evidenced by hard
O: >with right upper consume food O:>irritable formed stool and
abdominal incision as evidenced >restless straining upon
(duodeno- by inadequate >infrequent passage defecation
duodenostomy) food intake of stool
>Restless >Dry skin
>Lethargic >noted urge in
>Continued vomiting defecation
even when infant has >Distended
been feed for several abdomen upon
hours palpation
>OGT connected to a >red peri anal skin
bed side bottle draining upon inspection
to a greenish output >constant dribbling
>poor muscle tone of soft stool.
>pale conjunctiva >abdominal
>wt of 2.3 from 2.9 kg dullness upon
>total intake=5cc/hr palpation
> total vomitus= >with hard stool
100cc/day like small sticky
> vomiting 8x pellets green-
greenish color brownish in color
>Potassium=3.95 Rv: soft and
Rv: 3.5-5.5 mustard yellow in
>Sodium=138.5 color to yellow with
Rv: 135-145 green specks.
>Calcium=2.65mmol/L
Rv: 2.15-
2.57mmol/L

O>unsustained Ineffective feeding

sucking pattern related to
>irritable reflux secondary to
>restless disease process
>continued
vomiting even
infant has not been
fed for several
hours
>OGT connected to
a bedside bottle.
>with a wt .of 2.3
kg from 2.9 kg.