Medical Ward
Medical Ward
Medical Ward
GENERAL OBJECTIVES:
After 3 days of exposure at medical ward students from CTS-CN will be able to
SPECIFIC OBJECTIVES:
1.1 ASSESMENT
2
a. Patient’s History
• Patients Profile
Name: B, F.G.
Age: 22
Sex: Female
Civil Status: Single
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: June 25, 2009
Time of Admission: 7:00 pm
Case Number: 2190
Ward: Medical Ward
Bed Number: 310 A
Chief Complaint: - On and off fever for 3 days
- Vomiting after meals
- Tonsillitis
Impression: Urinary Tract Infection
Genogram
legend:
Male - Paternal Maternal
Female -
Hypertensive
Deceased -
PATIENT on and
off fever,
vomiting and
tonsillitis
b. Gordon’s 11 Functional Health Pattern
1. Pattern of Health Perception and Health Management
Ms. B, F.G describes herself as good, fine and no problem but since she was
admitted she said that it’s fair. She doesn’t have any regular physical examination and
exercise program, she completed her immunization. She drinks vitamins (Multivitamins +
Iron) every day and she wanted to have anti-flu vaccine. She cooperates well and took her
prescribed medicines on time.
2. Nutritional – Metabolic Pattern
She usually eats three times daily and with snacks. Her meal consists of rice,
vegetables, fish and meat. She usually drinks 4-6 glasses of water per day. During her stay
at the hospital, DAT diet was ordered, and the patient drinks a lot of water every day and
minimized intake of sweets.
3. Elimination Pattern
She has no problem regarding her defecation and she usually defecates
every morning around 5 – 7 am every other day, also consist of tan color with small light
yellow and not so sticky. She usually urinates 2-3 times a day and feels pain upon
urinating and has dark pale yellow. During her stay at DICGH, patient verbalized “dili
nakaayo sakit inig pangihi pero sige ko balik2 sa CR”. She doesn’t use any assistive device
in order to defecate and urinate well.
4. Pattern of Activity and Exercise
4
Ms. B, F.G said that she usually goes to work every day and walked towards her
work place. She does many things in order to burn calories and fats like work outs. Since
Ms. B, F.G was hospitalized she has limited work due to her present condition.
5. Cognitive – Perceptual Pattern
Patient has no problem or any deficit in sensory perception and has no complaints
of vertigo, insensitivity to cold and heat during her stay. She was able to talk and
communicate well and write well.
6. Pattern of Sleep and Rest
She usually sleeps at around 10:30 – 12 midnight and usually wakes up at 5:30 am
and in afternoon she usually sleeps 1 – 2 hours. When she wakes up, she usually does her
daily chores. She doesn’t use any assistive device in order to sleep and rest well. During
her stay her rest pattern was altered due to her present condition and uncomfortable
environment. Also she was monitored every four hours as ordered by the doctor.
7. Role – Sexuality Reproductive Pattern
Ms. B, F.G hasn’t used any kinds of contraceptives. Patient complaints due to pain in
urinating, she has normal menstrual cycle (2-3 days).
8. Pattern of Self – Perception and Self Concept
Patient is very concerned about getting well and has positive outlook in her life. As
what I observed, Ms. B, F.G responded and reported what she feels during her illnesses
and asks what are the other ways to cure her.
9. Relationship Pattern
She has good family relationship and has good relationship towards the medical
team. She was the youngest among their siblings. She was loved by her family to take
care of her. She can speak clearly.
10. Pattern of Coping and Stress Tolerance
She said whenever she had stressors in life she usually watches movies with her
family and sometimes she sleeps to relieve stress. Now the only thing she can do is to
sleep due to her present illnesses.
11. Pattern of Values and Beliefs
She usually prays everyday, during and after eating meal. She has a strong faith in
God and she goes to church every Sunday. Ms. B, F.G is respectful, patient and courteous.
c. Review of Systems (Draw the anatomical position of the human body anterior
and posterior, then mark the affected area)
Anterior Posterior
TONSILITIS
5
URINARY TRACT
INFECTION
1) Integumentary System
a. Skin: patient has light brown skin; smooth and warm (38.8°c); (-) (dry)
moisture; no presence of lesions and scar noted.
b. Hair: she has black hair; thick and straight; no lice noted.
c. Scalp: her scalp was symmetrical; no presence of lesions and scar noted.
d. Nail: her nails were symmetrical; good capillary refill in 1-2 seconds; long
nails; clean.
3) Eyes
Her both eyes were symmetrical and she can clearly see and read near or far;
brown color eyes; no signs of irritation nor inflammation seen; (+) PERRLA (pupil
equally round reactive to light accommodation).
4) Ears
Both of her ears were in line with the eye level; symmetrical; no amount of
serum discharges noted; no signs of inflammations and lesions noted. Patient can
hear clearly.
7) Respiratory System
I- her thoracic part was equal and symmetrical.
P- intercostals spaces of the patient were even.
P- (+) resonance.
A- normal breath sounds; 21 cpm.
8) Cardiovascular System
I- (-) palpitations.
P- non tender.
P- (+) resonance.
A- (-) murmur sounds; 110/60 mmHg.
Pulse sites
Radial - 78 bmp
9) Breast
I-her breasts were symmetrical; no lesions and deformities noted; no discharges
noted; nipples were not
inverted.
P- no tenderness;
10) Abdomen
I- equal color; smooth texture; no deformities noted; no inflammations and lesions
noted.
A- bronchovesicular sound found at the mid part of 1st - 2nd interspaces on the
anterior chest and in medium pitch.
7
P- according to the patient she hasn’t noted lumps and masses.
P- Not performed
1.4 PATHOPHYSIOLOGY
• UTI (urinary tract infection) is a bacterial infection that affects any part of the urinary
tract. The main cause agent is Escherichia coli. Although urine contains a variety of
fluids, salts, and waste products, it does not usually have bacteria in it. When bacteria
get into the bladder or kidney and multiply in the urine, they may cause a UTI.
MANIFESTATIONS
• Dysuria (painful urination)
• Urgency (the need to urinate
• without
Schematic
delay)Diagram
• Increased frequency of
urination UTI
• Suprapubic tenderness, (URINARY TRACT
PREDISPOSING FACTORS INFECTION)
pelvic discomfort especially DISEASE CONDITION
CAUSE
• Improper Hygiene Bacteria called
pre- and immediately
• Low intakeOccurs
of water and of Urethritis - The inflammation and Escherichia Coli lived in
postvoid. in 20%
vitamins infection is limited to the urethra. the bowel (colon and
women with uncomplicated
• Children and Adults Cystitis - Results from an irritation around the anus0).
UTI.
•• Patient with AIDS and of the lower urinary tract mucosa.
Small volume voiding. • Poor Hygiene
Hemorrhagic Cystitis -
• Increased numberwho
Diabetes / People take
of white • Sexual Intercourse
immunosuppressant Characterized by large quantities
blood cells in the urine
medication. of visible blood in the urine. It can
(pyuria)
be caused by an infection
•• One of the most
Suprapubic common
tenderness REPRODUCTIVE
(bacterial or adenovirus types 1-
• sources of infection
Urinary urgency andis SYSTEM
47) or as a result
ORGAN of radiation,
AFFECTED
frequency may be present or cancer chemotherapy, or
absent. immunosuppressive medication.
• Fever Hemorrhagic cystitis is often
• Flank pain and tenderness confused with glomerulonephritis,
(back pain) but hypertension and abnormal
• Costovertebral angle renal function are absent in MANIFESTATIONS (PATIENT)
MANIFESTATION
• hypothermia, poor
appetite, lethargy,
change in mental
status.
• Chills, Flank Pain,
Nausea and Vomiting.
• Cloudy, Bad Smelling
and Blood in urine.
• Delirium
COMPLICATIONS
- Sepsis - Septic Shock -
Pyelonephritis
- Damage of Kidneys - Renal
Hypertension
DEATH
• The basic pathophysiology is that once bacteria enter the bladder, local defense
mechanisms in the bladder break down and the bacteria invade the bladder
mucosa and begin to multiply. The bacteria that have lodged in the mucosa cannot
be eliminated by urination. Inflammation also occurs; it is the general response to
any bacterial invasion which results in vascular permeability. Because of the
vascular permeability, bacteria that have invaded the bladder mucosa are able to
escape into the blood stream and this is the actual start of septicemia. Once the
bacteria enters the blood stream they release endotoxins and the symptoms of
bacteremia are produced.
12
o ο ο Diabetic
o Alteration in
o ο ο Tonsillitis
thermoregulations related to
o ο ο Fever (38.8°C)
illness as manifested by fever
38.8°c and warm skin.
13
o ο ο Vomiting (40ml/day)
Gordon’s 11 Functional Health Pattern
o ο ο Stress / Restless
o ο ο Pain in Urinating at a scale of 9
o ο ο Limited Exercise Pattern
Diagnostic Exam
o ο ο (+) Protein
o ο ο WBC increases