Manila Tytana Colleges Manila Doctors College College of Nursing Pres. Diosdado Macapagal Blvd.

, Metropolitan Park, Pasay City

Nursing Process A case study on:

Acute Generalized Exanthematous Pustulosis

In Partial Fulfillment of Requirement for: Related Learning Experience

Submitted to: Ms. Minviluz Gerardino, RN, MAN Ospital ng Sampaloc

Submitted by: Group 1 Set B BSN SCN IV-02 CABATBAT, Jevi Clerchus Crighton CANALES, Kris Japheth CREANZA, Manelle DE CASTRO, Pia Marie DIDULO, Mary Ann

NURSING PROCESS Data Sheet Guide I. ASSESSMENT

A. General Data Patient s Initials: A. V. Address: Sampaloc, Manila Age: 55 y/o Sex: Male Date of Birth: September 29, 1955 Place of Birth: La Union Civil Status: Separated Occupation: Taxi Driver B. Chief Complaint Nung linggo ng gabi, bigla na lang nangangati ang buong katawan niya, pero wala pang nalabas na mga pulang pantal noon. Pagkaraan ng mga 2 araw, lumabas na ang mga pantal nya sa mukha, pulang pula sabay may lagnat pa siya hanggang sa kumalat na ng kumalat sa buong katawan nya yung pamumula at pangangati , as verbalized by the informant (sister) C. History of Present Illness A month prior to confinement (May 2011), the client suffered from his second mild stroke and he was rushed in Ospital ng Sampaloc where he was hospitalized and observed for several days. Upon being discharged, his physician prescribed several maintenance medicines to be taken for one month. His medication includes Amlodipine, Citicholine, Kalium Durule, Lorsartan and Allupurinol (unrecalled dosages). He was non compliant with the medication regimen. On Sunday evening of June 26, 2011, He felt itchiness all over his body but without any obvious signs on his skin. His sister gave him an unrecalled brand of ointment to be applied on his skin which she thought might help relieve the itchiness. According to the informant, it provided slight relief on the patient s part. After 2 days, (June 28, 2011), Aside from the itchiness that the patient felt, there were already obvious signs of illness, there were appearance of thick red rough patches all over his body. It first appeared on his face then it descends on his abdomen, arms and legs. He was also experiencing slight fever, (T=37.9C). His sister decided to rush him in the emergency room of Ospital ng Sampaloc, and was subsequently admitted. Several laboratories were done including Urinalysis and Blood Chemistry, and he is still under observation. D. Past History 1. 2. 3. 4. 5. 6. 7. Childhood Illness: unrecalled Adult Illness: Mild Stroke (December 2010 and May 2011) Immunization: cannot recall Previous Hospitalization: May 2011 (Ospital ng Sampaloc) Operation: none Injuries: none Medication/s taken prior to confinement: Amlodipine, Citicholine, Losartan, Kalium Durule, Allupurinol (unrecalled dosage)

Informant: L. V. (Sister) Date of Admission: June 28, 2011 (2:00pm) Order of Admission: Ambulatory

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Allergies: none

System Reviews 1. Health Perception-Health Management Pattern Over the years, Client s general health has always been good and favorable for him. He seldom gets cough or colds but whenever he got one, he wouldn t take any immediate actions, remedies or medications for it, instead he just let it subside until it s gone. Fortunately, Patient A.V. is positive that he is very much healthy for his age as also noticed by his sister. He can still work as a taxi driver to provide daily income for himself since all of his children have their own families and he is separated from his wife. He suffered from a mild stroke last December 2010 and just this recently, May 2011. He was rushed in Ospital ng Sampaloc and he was prescribed several medicines as his maintenance. This includes, Amlodipine, Citicholine, Kalium Durule, Losartan and Allupurinol (unrecalled dosages). He is not compliant with his medication regimen due to financial crisis. He doesn t have regular check ups but whenever he feels uneasy he doesn t hesitate to go the hospital to seek for medical advice. He is a regular smoker and a drinker. He smokes 2-3 cigarette packs a day and he is uncontrollable when it comes to alcoholic drinks. He hasn t met any accidents yet. At present, the client was hospitalized due to acute generalized exanthematous pulposis. According to the informant, his doctors presume that it is caused by one of his medications which is the Allupurinol but he is still under observation and the doctors are still searching for the true cause of his illness. He is feeling weak since the doctors put him on a diet restriction to find out if food might also be one of the reasons of this illness. He is also feeling stomach pain and he is having hard time to sleep which also makes him weak. He is also prescribed to take the following medications such as, Paracetamol 500 mg/tab every 6 hours if fever occurs (T= 38C), Hydrocortisone 25g/tab every 8 hours, Ranitidine 1 amp every 8 hours. The doctors also advised to do Normal Saline Solution compress on the affected parts three times a day for 10 minutes to provide relief for the itchiness. 2. Nutritional- Metabolic Pattern The patient s typical food intake is more on rice, egg, chickens and fishes. He seldom eats pork or meat. He prefers food that are prepared fried, sauted and soupy. He drinks 5-7 glasses of water every day, and he seldom drinks juices and soft drinks. He is a coffee person, he drinks at least 3-4 cups per day. He is uncontrollable when it comes to alcoholic drink. He doesn t take any food supplements. No observable weight gain for patient A.V. He has good appetite according to the informant. He wears dentures for his upper and lower teeth. At present, the client is on a restricted diet, as much as possible he should just take small meals and sips of water since he is still under observation with regards in finding the main reason for his illness. 3. Elimination Pattern The patient has no problem with elimination pattern. He is not constipated and has no problems with urine output. He urinates 6-8 times a day and he defecates at least once a day. He characterized his urine as yellow to orange in color, with no presence of blood in it. Meanwhile his stool is characterized as brown in color, no presence of blood and well formed. He never took any laxatives. He has no problems with extreme perspiration and odor. He provides himself good body hygiene. He regularly bathes himself, 3 times a day and does oral hygiene every meal.

At present, the client has slight difficulty when it comes to defecating and urinating since his food intake is limited. He only urinates 4-5 times a day. He is not defecating at the moment but doctors haven t prescribed medicine for it. 4. Activity- Exercise Pattern The patient sees to it that he has sufficient energy for his every day activity. He doesn t have any regular exercise. His only means of exercise is through walking around his home and around his community. He is fond of drinking alcoholic beverages with his neighbor friends which serves as his leisure activity. As of the moment, I can see that the patient doesn t have enough energy for activities. His movements are weak and slow. He is advised to have adequate rest. His recent attack of stroke affected the right side of his body part which makes him difficult in mobilization. 5. Cognitive- Perceptual Pattern The patient wears corrective lenses which only serve as his reading glasses. He doesn t have routine eye check-up. He still has a good hearing ability. Decision making for patient A.V. is hard, but most of the time, he makes firm and just decisions not only beneficial for him as well as for his children. He sees to it that he ll think twice before deciding, he weighs the pros and the cons. He is fair in any way. He learns easily through actual demonstration. The client uses Filipino language for communicating. According to the informant, he has good vocabulary level and has wide knowledge on things. He is very opinionated on things that are happening around him. 6. Sleep- Rest Pattern Although the patient lacks sleep, still he has sufficient energy in doing activities for his daily life, be it passive or active. He is used to having lack of sleep due to the nature of his work as a taxi driver. His usual sleeping hours is from 11PM until 5AM. During daytime, he is taking 30 minute naps usually after eating lunch. He has no difficulty and disturbances in his sleeping pattern. He doesn t have any sleeping problems and he doesn t use any sleeping aids. At present, the client lacks energy in doing things, his movements are a little weak and slow because of his illness. Yet this time because of being hospitalized, he has all the time to get enough rest and sleep. He is frequently seen lying on bed and sleeping to regain his strength. 7. Self- Perception Pattern The patient always feels good about himself, with a very bubbly yet disciplined personality. He is very much contented and happy with the way his life is going although there are some frustrations with the way his children run their lives. During conducting of this interview, the patient seems to be really weak. His sister answers for some of the questions. 8. Role- Relationship Pattern The client belongs to a nuclear type of family. He has 3 children but he only lives with one of his son, his daughter in law and grandchild. He is separated. Problems are handled and solved with cooperation among family members. Budgeting for daily needs is his only problem since he is providing for himself. Sexuality- Reproductive Pattern The patient is separated. He is also sexually inactive because according to him he is already contented with him having his children.

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His sister is the one who supports his ailing needs since his children already has their own families. 10. Coping- Stress Tolerance Pattern The client s stressor is the need to work as a taxi driver to provide himself daily income for his daily needs. Although sometimes he asks for the help from his children, yet most of the time his sister helps him in any way she can. He is into smoking, he smokes 2-3 cigarette packs per day which somehow serves as his stress reliever. He is also fond of drinking alcohol yet sometimes he becomes abusive and uncontrollable in taking it. 11. Values- Belief Pattern The client is a Catholic but he rarely attends mass. Although he is not that religious, He sees to it to thank the Lord for all the blessings and asking for guidance in every day life. He thinks communication and love will make the relationship with his family and with his siblings even stronger. The patient s values and beliefs seem to be a part of his life. He has the positive outlook in life that drives him to achieve and do what he wants and what should be done to make life more meaningful and healthy.

Family Assessment Name B. V. R. V. B. V. G. Heredo Maternal : None Paternal : None Relation Son Daughter in law Grand son Age 25 27 2 Sex M F M Educ. attainment Highschool Graduate College undergraduate N/A Occupation Contractual worker Employee (pawnshop) N/A