I. INTRODUCTIONScleroderma is a connective tissue disease that involves changes in the skin, blood vessels, muscles, and internal organ.It is a chronic, progressive autoimmune disorder where inflammation and the overproduction of collagen accumulate in the body. It can cause swelling or pain in muscles and joints.There are two main types of Scleroderma- Systemic and Localized. Systemic Scleroderma may affect multiple systems such as the integumentary, cardiopulmonary, vascular, gastrointestinal, genitourinary, or musculoskeletal. There are three forms of Systemic Scleroderma. With Diffuse Scleroderma skin thickening occurs more rapidly and involves more skin areas than in limited. In addition, people with diffuse scleroderma have a higher risk of developing sclerosis or fibrous hardening of the internal organs.Sine Scleroderma involves organ fibrosis with no skin involvement. With Limited Scleroderma (CREST syndrome) skin thickening is less widespread, typically confined to the fingers, hands and face, and develops slowly over years. Internal problems occur, but they are less frequent and tend to be less severe than in diffuse scleroderma. The limited symptoms of Schleroderma are referred to as CREST, Calcinosis(calcium deposits in the skin), Raynauds Phenomenon (spasm of blood vessels in response to clod or stress in the hands or feet), Esophageal Dysfunction (acid reflux and decrease in motility of esophagus),Schlerodactyly (Thickening & tightening on the fingers and hands) and Telangiectasias (dilation of capillaries causing redmarks on surface of the skin or depigmentation). Nearly everyone who has scleroderma experiences a hardening and tightening of patches of skin. These patches may be shaped like ovals or straight lines. The number, location and size of the patches vary by type of scleroderma. Skin can appear shiny because it's so tight, and movement of the affected area may be restricted. One of the earliest signs of scleroderma is an exaggerated response to cold temperatures or emotional distress, which can cause numbness, pain or color changes in the fingers or toes. Called Raynaud's phenomenon, this condition also occurs in people who don't have scleroderma. In addition to acid reflux, which can damage the section of esophagus nearest the stomach, some people with scleroderma may also have problems absorbing nutrients if their intestinal muscles aren't moving food properly through the intestines. Rarely, scleroderma can affect the function of the heart, lungs or kidneys. These problems can become life-threatening.Based on the said symptoms the current disease that patient H.A. have is most likely as Systemic Limited Scleroderma in which fatigue or excessive weight loss, digestive difficulties and nutrient deficiencies are common and the symptoms of CREST are present.Her skin is shiny and tightened with visible straight line white patches in some areas, fingertips distorted. She is suffering from epigastric and joint pain, accompanied with heartburn and vomiting. The attending physician explained that symptoms of heartburn will not disappear because ofswelling of the esophagus, the tube between the throat and stomach and esophageal injury from acid exposure. It will only manage by reducing the symptom by taking proton pump inhibitors.There is no cure, but various treatments can control symptoms and complications.The current best evidence that can be beneficial is Physical Therapy Management. Physical therapists can design a program of regular stretching and gentle exercise to help manage pain, improve strength, improve or maintain mobility, minimize joint contracture improve circulation,enhance or maintain performance of activities of daily living in order to encourage independence. In addition, an appropriate level of exercise can promote relaxation and a sense of well-being. And yet, Patient H.A. is currently undergoing Physical therapy

II. DEMOGRAPHIC

II.A PATIENT PROFILEName: H.A.Current Address: #3855 R. De Santos, Sta. Mesa, ManilaPrevious address: Aparri, Cagayan ValleyGender: FemaleAge: 40 years oldBirthdate: October 23, 1973Status: MarriedEducational Attainment: 2nd year College, undergraduateOccupation: BusinesswomanNationality: FilipinoEthnicity: IlocanoReligion: Roman CatholicSource of income: Owned Business with husbandLiving environment: Bungalow, owned, 4 occupants, Barangay

II. B. Chief Complaint: Abdominal epigastric pain and joint pain for 1 month, Admitting Diagnosis: Steroid Induced GastritisAdmitting Physician: Dr. R. RamosDate of admission: July 23, 2014 @ 2:36 p.m.

III. B. PRESENT ILLNESSOne month prior to admission, patient noted sudden onset of epigastric pain (Pain scale 8/10) and generalized body pain, and sought consult to physician and was prescribed Decilon 500mg. Pain was not relieved by medications after taking it three times a day. Pain was slightly relieved by vomiting.Two weeks prior to admission, epigastric pain was still noted, since onset of symptoms was noted after intake of Decilon, Patient opted to discontinue medication. However despite this change pain still persisted.On the day of admission, patient was still noted to have epigastric pain and being referred due to multiplepigmented macules some scattered into patches with areas of normal skin all over the body, positive tapering of digits and taut and hardened skin thus also prompting consult followed by admission.

II. C. PAST MEDICAL HISTORYPatient had hypothyroidism and undergone operation in thyroidectomy last 2012. On May 2014 she was diagnosed case of Scleroderma that initially presented as thickening of the skin.II. D. FAMILY HISTORY The mother of the patient had breast cancer and her father had laryngeal cancer. Her sister had goiter.II. E. SOCIAL HISTORYPatient H.E. is a neither non-smoker nor alcoholic drinker. Has casual relationship with her neighbors.II. F. DEVELOPMENTAL TASKPatient H.A. is 40 years old, married and has 2 children, her developmental task is to establish a sense of generativity versus stagnation. People under this task extend their concern from just themselves and their families to the community and the world. They are self- confident and better able to juggle their various lives (mother,church member, gourmet cook). But people without this sense become stagnated or self-absorbed. Due to her condition she cannot perform most of the functions of being motherhood.

II. G. PREVIOUS MEDICATIONS: Levothyroxine 50 m once daily for Hypothyroidism(2013) , Penicillamine 250mg once daily and Prednisone 10mg/mg 1 tab Once daily for Scleroderma(2014)and Decilon 500 mg TID (.03/kg/day)

GENOGRAM KEYIII. GENOGRAM

= Client

=Deceased( BreastCancer ) 55 y(Laryngeal Cancer ) 57 y

=Deceased

= Female

= MaleA/W45goiterA/W47A/W51A/W54A/W57

A/W45Client 40

A/W = Alive & Well( ) =Cause of death

A/W14A/W17

PHYSICAL ASSESSMENT:

Assessment FindingsNormal findings

1. General SurveyHeight: 55Weight: 51 kg.RR: 30 cpmPR: 124 bpmTemp: 36.7 CBP: 110/70

2. Mental status and Level of consciousness Clients level of consciousness

Posture and body movement

Behaviour and affect

Dress and grooming

Facial expressions

Speech

Client is alert and oriented to time and date. Client responds appropriately.

Slumped posture

Client follows through instructions. Mild anxiety is present

Dress is neat and clean, appropriately dressed according to weather

Facial expression symmetric & correlate with mood( smiles and frowns appropriately)Speech is clear & appropriateAlert & oriented to what happening at the time of interview & physical assessment

Appears to be relaxed and back erect when standing or sittingCooperativeMild to moderate anxiety may be normal in a client who is having physical assessment

Dress is appropriate for occasion & weather

Maintains eye contact, smiles and frowns appropriatelySpeech is in moderate tone, clear, with moderate pace, and culturally appropriate

3. Skin, Hair, Nails

Skin:Dark brown, warm to touch, excessively dry, waxy, thickened and tightened with straight line white patches, diffuse DE pigmented macules.Scalp & hair: Black in color, straight, thin & dry in texture evenly distributed, No scalp or Flaking.Nails:Pale in color , thickened, 180 angle, and greater than 2 seconds capillary nail bed refillhairhairReveals evenly colored skin tones without unusual or prominent discolorations, smooth without lesions, normally thin, Skin pinches easily and immediately return to its original position.Natural hair color varies in race. Color is determined by the amount of melanin present, scalp is clean and dry. Hair is smooth and firm.Pink tones should be seen, normally 160 angle between nail base and the skin, hard and immobile, smooth and firm

4. head ,face, neck

Head

Face

Neck

Range of motion

Palpate the Trachea

Head symmetrically rounded, erect, and in midline. No lesions are visible

Face is symmetric, oval in shape. No abnormal movements noted.

Neck nontender with full ROM, symmetric without masses. Lymph nodes non palpable. Neck movement is smooth and controlled rotation

Trachea is midline. Thyroid nonpalpable

Head size and shape vary especially in accord with ethnicity, usually symmetric, round, erect, and in midline. No lesions are available.

Face is symmetric with around, oval, elongated or square appearance. No abnormal movements.

Neck is symmetric with head centered and without bulging masses

Trachea is midline

5 . Eyes

Visual Acuity

Positions test

Eyelids & eyelashes, eyeballs

conjunctiva& sclera

Cornea & lens

Iris & pupil

Pupillary reaction to Light Accommodation of pupils

Snellen Chart: with glasses off vision is 20/50Eye movement symmetric throughout 6 directions

Eyes 2cm apart without protrusion.Eyelashes are evenly distributed. Eyelids brown in color, without edemaor lesions and freely closeable bilaterally. Eyeballs symmetric, without protruding.Bulbar&palpebral conjunctiva is pale in color, moist and smooth.Sclera is whiteCornea is transparent, lens is free of opacities

Iris is round, flat & evenly colored. Pupil is round, centered in iris, 3mm in size.

PEARRLA

Pupils constrict and converge

Normal visual acuity is 20/20.

Eyes movement should be smooth and symmetric throughout all 6 directions

The upper & lower lids close easily and meet completely when closed.Skin on both eyelids is without redness, swelling or lesions.Eyeballs are symmetrically aligned in sockets w/o protruding or sinking.

Bulbar &palpebral conjunctiva is clear, moist and smooth. Underlying structures are clearly visible. Sclera is whiteThe cornea should be transparent with no opacities. Lens free of opacities.

The iris is typically round, flat, and evenly colored. The pupil is round with regular border, is centered in the iris. Pupils are normally equal in size 3-5mm. PEARRLA

The normal pupillary response is constriction and convergence of the eyes when focusing on a near object.

3. Ears Auricles

Auricle and mastoid process

External auditory canal

Tympanic membrane

Whisper test Webers test

Rinne testAuricles are equal in size, without deformity, lumps and lesions. Skin is thickened and waxy.Auricles and mastoid processes nontender

Bilateral Auditory canals contain moderate amount of dark brown, dry cerumen

Tympanic membrane is difficult to view due to cerumen.

Can clearly identifies words

No lateralization of sounds to either earAC is greater than BC in both earsAuricles should be equal in size bilaterally. Skin is smooth, with no lesions, lumps or nodules.

Normally the auricle and mastoid process are not tender.

A small amount of oderless cerumen is the only discharge normally present. Cerumen may be yellow, orange, red, brown, gray, or black and soft, moist, dry, flaky or even hard.The tympanic membrane should be pearly, gray, shiny, and translucent with no bulging or retraction. It is slightly concave, smooth and intact. A cone-shaped reflection of the otoscope light is normally seen at 5 oclock in the right ear and at 7 oclock in the left ear. The short process and handle of the malleus and the umbo are clearly visible.Whisper clearly identifyVibrations are heard equally well in both ears. No lateralization of sound to either ear.Air conduction is normally heard longer than bone conduction sound.

4. Mouth Lips

Teeth& gums

Buccal mucosa

Tongue

Hard and soft palates

Odor

Ovula

Lips dry , w/o lesions or swellingUpper part complete dentures(false teeth),2 missing teeth in the lower part, chalky white area in the tooth surfaceGums are pale in color, without inflammation or bleedingBuccal mucosa pale in color, visible with saliva, no redness, swelling

Darker in color,thickened, no lesions, ulcers or nodules, decreased tongue strength, can distinguish bitter, sweet and salty Hard palate is pale in color with wrinkle-like foldsSoft palates is red

No foul odor is noted

Ovula in midline and elevates in phonationLips are smooth and moist without lesions or swellingThirty two whitish teeth with smooth surfaces and edges are available. No decayed areas; no missing teeth.Gums are pink, moist, and firm with tight margins to the tooth. No lesions or masses.

It should appear pink in light-skinned clients; tissue pigmentation typically increases in dark-skinned clients. In both, tissue is smooth and moist without lesions.Tongue should be pink, moist, no lesion are present, no lesions, ulcers or nodules are apparent, tongue offers strong resistance, can distinguish salty, sweet and bitter tasteThe hard palate is pale or whitish with frim, transverse rugae. Soft palates should be pinkish, movable, spongy and smooth

No unusual odor or foul odor

The ovula is fleshy, solid structure that hangs freely in the midline. No redness of or exudate.

5. NoseColor of the nose is the same as the rest of the face darker brown, thickened and waxy, symmetric, patent, turbinates and middle meatus pale pink, without swelling, exudate or lesions, nasal septum midline without bleeding, frontal and maxillary sinuses nontenderColor is the same as the rest of the face, smooth, symmetric, no tenderness, client is able to sniff through each nostril while other is occluded, nasal mucosa is dark pink, moist and free of exudates. Nasal septum is intact and free of ulcers or perforations. Turbinates are dark pink. Frontal and maxillary sinuses are nontender to palpation.

6. Thorax and lungs Skin is depigmented, dry,thickened with white straight lines patches, auxillary respiratory muscles and nasal flaring are not observed, Scapulae are symmetric and nonprotruding.Thorax expands bilaterally without retractions or bulging. Respirations even, unlabored and regular (20cpm). Vesicular breath sounds heard in all lung fields. No rales, rhonchi, friction rubs noted.Sitting, breathing easily with arms in lapSternum is positioned at midline & straightRetractions not observed, reported of joint pain & epigastric pain.Skin color even. Scapulae are symmetric and non protruding. No use of accessory muscles and nasal flaring are observed. Client reports of no tenderness, pain or unusual sensations.Skin and sucuatneous tissue are free of lesions and masses. Three types of normal breath sounds may be auscultated-bronchial, bronchovesicular and vesicular.Noadventious sounds are ausculatated.

7. BreastBreast small in size, round , and symmetrically bilaterally. Skin is dark brown with darker brown areola, no dimpling. Free movement in all positions. Nipples are everted, no discharged expressed. No thickening or tenderness noted. Lymph nodes nonpalpable.Breast can be a variety of sizes and somewhat round and pendulous. One breast may be normally be larger than the other. Color varies depending on the clients skin tone. Texture is smooth without edema. Areolas vary from dark pink to dark brown. Small Montgomery tubercles are present.Nipples are nearly equal bilaterally in size and are the same location on each breast.Nipples are usually everted with no signs of dimpling or retraction. Breast should be smooth, firm and elastic. No masses should be palapated.

8. Heart No pulsations visible. Clear, brief heart sounds throughtout. No gallops, murmurs, or rubs.The jugular venous pulse is not normally visible with the client sitting upright. No blowing or swishing or other sounds are heard.Nopulsations or vibartions are palpated in the areas of the apex, left sternal border or base.Normally no murmurs are heard

9. AbdomenAbdomen is symmetric, rounded, does not bulge when client raises head. Skin color is dark brown, dry, thickened and shiny.Abdomen free of hair, bruising and increased vasculature. Umbilicus is midline, recessed and round.Bowel sounds low pitched and gurgling at 14/min x4 quads.Abdominal skin may be paler than the general skin, smooth, free of lesions or rashes, umbilical is midline at lateral line,recessed or protruding no more than .5cm. and is round or conical. Abdomen is flat, rounded or scaphoid, symmetric, does not bulge when raises head.A series of intermittent, soft clicks and gurgles are heard at a rate of 5-30 per minute. Borborygmi may be normally heard.

10. Musculoskeletal Gait

Temporomandibular joint

Cervical, thoracic and lumbar

Shoulders, arms and elbows

ROM

Wrist

Hands and fingers

Knees

Ankles and feetUneven weight bearing is evident. Client propels forward. Posture slightly stooped.Decreased muscle strength.

Cervical and lumbar are concave. Flexion of the cervical spine is 45 degrees. Extension of the cervical spine is 45 degrees.Shoulders symmetrically round, dry, thickenedand clients reported of joint pain as she moves, elbows are rough and hard

Decreased muscle strength, painful and limited abduction, adduction, flexion and hyperextension

Symmetric,thickened and waxy, no nodules noted, have increased pain with extension and flexion of the wrist, decreased muscle strength

Hand and finger are symmetric, without nodules but thickened and schlerotic or stiff, tender, deformed and distorted, limited in motion, decreased muscle strength

Knees symmetric,tendered and warmth with a boggy consistency, skin is thickened and dry, inability to extend knee fully, decreased muscle strength against resistance , reports of pain on examinationThickened, tendered, skin is dry,with calluses, decreased strength against resistance and clients reports of painEvenly distributed. Equal on both sides. Posture erect, arms swing in opposition.Jaw protrudes and retracts easily. The clients mouth opens and closes smoothly.

Cervical and lumbar are concaveFlexion of the cervical spine is 45 degrees. Extension of the cervical spine is 45 degrees.

Shoulders are symmetrically round, no redness, swelling or deformity or heat. Muscles are fully developed.Client reports no tenderness nor pain.

Extent of forward flexion should be 180 degrees; hyperextension 50 degrees; adduction 50 degrees and ;abduction 180 degrees. Client should have full ROM against resistance. Wrist are symmetric, without redness or swelling, nontender and free of nodules Normal range of motion are 90 degrees flexion; 70 degrees hyperextension; 55 degrees ulnar devialtion; and 20 degrees radial deviation. Client should have full ROM against resistance.Hands and fingers are symmetric, nontender and without nodules. Fingers lie in a straight line. No swelling or deformities. Normal range are 20 degrees of abduction, full adduction fofingers(touching), 90 degrees of flexion, and 30 degrees of hyperextension. The thumb should easily move away from other fingers and 50 dgrees of thumb flexion is normal. The client has full ROM against resistance.Knees symmetric, hollows present on both sides of the patella, no swelling or deformities, nontender and cool, muscles firm, no nodules.Normal ROM rmages 120 degrees to 130 degrees of flexion; 0 degress of extension to 15 degress of hyperextension; Clients should have full ROM against resistance.No pin, healt, sweeling or nodules are present, Skin is smooth and free of corns and calluses. Clients should have a full ROM against resistance.

GORDONS FUNCTIONAL HEALTH PATTERNBEFORE HOSPITALIZATIONDURING HOSPITALIZATION

1. 1. Health Perception Health Management Pattern

Subjective: Sumasakitnayungsikmuramgaisangbuwanpero once kolangpinacheck up, niresathanako ng gamotininomkoyunperohindirinnamantumatalab kaya tinigilkonalang bale sapagsususkanamanmedyonawawalawalarinyungsakit as verbalized by patient H.E.Diagnosis: Ineffective self-health maintenance related to current illness as evidenced by not having further checkupSubjective: Nang parangsatinginko ay lumalalayatayungsakitko, lumuwasna kami samaynilasinamakoyunghipagko para matingnanditosa hospital, kasinararamdamankonarinnaparangtumitigasyungkatawankomagsimulasapaahanggangpaakyatnasya Objective: Hypopigmentation was noted to spread to face, neck trunks and extremities, skin is hardened and dry.Diagnosis: Effective health seeking behavior related to current illness as evidenced by prompting consult.

2. Nutritional-Metabolic PatternS: Datimatabaakomatakawkasiakokumain as verbalized by the patient O: weigh of 70kg., height 55D: Risk for Imbalanced nutrition as evidenced by BMI of 27.34S- ngayonditoakosa hospital bumabanayungtimbangko at nawawalannakasiako ng ganasapagkainkasingapalagiakongnagsusuka as verbalized by the patientO- weigh of 51kg., height 55A- Patient H.As nutritional status has been changed due to her confinement and medical health condition. D: Imbalanced nutrition, less than body requirement related to current illness as manifested by BMI of 19.92

3. Elimination Pattern

S: "Dumudumiakodalawangbesesarawaraw, at madalasnamanakongumihi as verbalized by the patient

O: defecates 2 times daily without experiencing discomforts, usually morning and afternoon. Stool is brown in color and is well formed, voids 6-8 times a day, urine is yellow in color. No pain when voiding

S Hindi akomadalasdumumiditosa hospital tsakayungpagihikorin ay nabawasan, tsakaarawarawakosumusukatalagatuwinghaponas verbalized by the patientO defecates once a day but not everyday, stool is soft, is minimal in amount and yellow to brown in color, void 3-4 times without pain and discomfortA- Bowel -There was a change in the frequency, consistency and amountBladder: there was a change in the frequency and amount

D: Risk for electrolyte imbalance related to less fluid intake and frequent vomiting

4. Sleep-Rest Pattern

S: "Sa bahayhindiakomakatulogmaayosdahilngasanararamdamankomasakityungmga joints ko, halos buongkatawantalagamakirottalaga, kaya sagabipalgiakonagigising as verbalized by the patientO: dark circles around the eyes, feel not rested and comfortable PS: 8/10D: Disturbed sleep pattern secondary to joint pain as manifested by pain scale of 8/10

D: Insomnia secondary to pain as manifested by restlessnessS: "ngayonditoakosaospitalwalanatalagaakongmagandangtulog,pakontinalang ng pakontiyungtulogko dittoO: Presence of dark circles around the eyes , frequent yawning, patient has increased restlessness and irritability. A- Illness that causes pain or physical distress can result in sleep problems. People who are ill require more sleep than normal and the normal rhythm & wakefulness is often disturbed (Fundamentals of nursing 7th edition by Barbara kozier, et al.p 1117). There is a total disruption of the sleep-wake cycle because of the patients diseaseD: Sleep deprivation related to prolonged discomfort as manifested by malaise, fatigue and decreased ability to function

5. Activity-Exercise Pattern

Briskwalkingang exercise kotuwingumaga, mgaisangoraslangnamansaprobinsya, kasonungnagsimula ng tumigasyungmga muscle kosapaataposnagsimulanarinsumakit, palaginalangakonakahiga at di konanagagawayungmgapangarawarawna Gawain ko as verbalized by the patientO- decreased muscle strength, inability to do daily activity living, D: Impaired physical mobility related to limited movement of the body or of one or more extremities as manifested by muscle aching and joint painS: ngayon, mabuti at me nagtuturoritosa hospital ng kung anoangmakakabuti para maibsanangnararamadamanko kaya kahitmedyomasakit pa ring gumalaw ay naglalakadakopapuntangbanyo para maligomagisa, nageexercisenarinakokahitpakontikontikatulad ng pagikot ng mgakamay, tapos mag deep breathing exercise, simple langperomakakatulongtalaga para bumalikyung dating sigla ng katawanko." as verbalized by the patientO: taken a short walk, and practiced deep breathing exercise 10 cycles per hourA- client is willing to adapt or to learn the health teaching in able to perform activities of daily livingD: Readiness for enhanced activity exercise

6. Cognitive Perception Pattern

S: mga 1 month ago ay grabetalagayungsakitnanararamdamankobuongkatawan, magsimulasakatawanpaakyat, kaya umiiyaktalagaako as verbalized by the patient

O: hardened skin, Pain scale of 9/10

D:Chronic Pain secondary to schleroderma as manifested by Pain scale of 9/10

S: "ditosa hospital nababawasanyung pain kosagamotnabinibigaysa akin, perohindikoparinkayangbumagonmagisanagpapaassist pa rinakokasi ng masakitgumalawdahilditosa joint pain ko" verbalized by the patientO: hardened, thickened skin with straight line white patches scattered in areas of the thebody,fingers distorted, pain scale 7/10 A- patient cannot do those things that she usually do, she really needs an assistance.D: Alteration in comfort related to current illness as manifested by facial grimace whenever she moves

7. Self-Perception Self-Concept Pattern

S- Im a friendly person madalasakongnakikihalubilosamgataokasinganegosyanteako ng isda, perosimulanungdumaposa akin itongsakitnaito ay nagkukulongakosakwarto ng isambuwanhindiakonagpapakitasamga friends kokasinakitakosasalaminna para biglatumandaangakinghitsura as verbalized by the patientO: skin is hardened and thickened with straight white patches all over, shiny, fingers distorted, brittle nails, sudden weight lossD: Disturbed body image related to present illness as manifested by thickened, shiny skin, fingers distorted , and sudden weight lossSituational low self-esteem related to present illness as manifested by self isolation

S: "sinabihankongayung doctor kona kung pwedebaako I mercy killing nalangako" as verbalized by the patient.O: passivity, decreased appetite, sleep pattern disturbanceA- Events or situations may change the level of self concept over time, illness and trauma can also affect the self- concept (Fundamental of Nursing 7th edition by Barbara Kozier p. 959 & 962) Due to her present condition, there is a change to the level of patient self-perception and self-concept knowing that her disease is rare and incurable, the symptoms can prevented but it might be present all the time.D: Hopelessness related to prolonged activity restriction and deteriorating physiological condition as evidenced by fatigue, malaise and change in physical appearance

8. Role-Relationship

S: malakasangkitakosa business pagbebenta ng isda, at me sarilikamingmgabangkataposdinadalakosyasa manila kung saan mas malakiat bultuhanangbentahan, mabokaako kaya maramiakong costumer, kaya langnungnagkaroonnaako ng sakitnaito, nagkukulongnaakosakwarto , ayawkonamunamakipagusapsamgakaibigan at mga costumer naming kasibakanakahawaito or pandirihanako as verbalized by the patientO: shy and minimal talkingD : Social isolation related to negative self-perceptions and unknowledgeable about her own diseaseS Naawangaakosadalawakonganakkasisimulanungnagakasakitako ng ganito ay hindikonasilanagagabayan, lao pa ngayonmalayoakoditoakosa manila nagpaconfine as verbalized by the SOO:D : Impaired parenting related to inability to provide needs as primary care taker of children

9.Sexual Pattern

S: me asawaako at dalawaanganak naming, malalkinarinsilayungisa ay college na at yungisa ay highschool as verbalized by the patientO: married, 2 children D: Active family ProcessS Dahilditosasakitko,atpalaginalangakonasa hospital, hindikonamagagampanan pa siguroyung role kobilangasawa as verbalized by the patientO: refrain from sexual activityD:Sexual dysfunction related to present illness as manifested by verbalization

10. Coping-Stress Tolerance

S: walaakomakausapsabahay, kasipalagirinwalayungasawakonaghahanapbuhayiniiwanannalangnyaako ng pagkainsaloob ng kwarto, hindirinnilaakokinakausapsabahay at inaasikaso, yunghipagko pa angtinatawag para magalaga as verbalized by the patientO: on bed most of the time aloneD: Compromised family coping related to insufficient, ineffective, or compromised support from the family membersS: nakakastress din talagayunglagikanakahiga, walakamagawataposganito pa yungkalagayanko lifetime komararamdamanito kaya ngakinausapkodatiyungdoktorkoimercy killing nalangako, walanarinnamanakongsilbirin, di namakapaghanapbuhay, tapos di konarinmaaalagaanmgaanakko as verbalized by the patientO: lying on bed, impulsive, lonely, fatigue, decreased use of social supportA: According to Folkman and Lazaruz, coping is the cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person ( Fundamentals of Nursing by Kozier page 1020) Due to his condition, patient H.A. does not have an outlet to divert his feelings.

D: ineffective coping related to inadequate level of confidence in ability to cope as manifested by verbalizationRisk for suicide related to situational crises and inability to conserve adaptive energies

11. value-Belief PatternS: "Matagalnaakohindinakakapagsimbasimulanungdumaposa akin itongsakitnaito" as verbalized by the patientO: refrain from attending mass every SundayD: Risk for impaired religiosity related to illness as barriers to practicing religionS- Ngayonditosa hospital me nagbigaysa akin ng book tungkolsaatingPanginoo, basahinko raw ito raw ay food for the soul nungsinimulana koi to basahin ay nagibanarinyungpananawko bale dapat faith langpalatalagakay God me Awa angDiyosgagalingrinako at hindikonarindapatisipin pa angmganakakapa stress sa akin, sisimulankonarinmagattend ng misasaQuiapo at sasimbahan dun sa Eastwood at lumapitke Padre Pio as verbalized by the patientO- Presence of Rosary and religious booklet on bedsideD: Readiness for enhanced religiosity related to ability to experience and integrate meaning and purpose in life through connectedness with a power greater than oneself.

DIAGNOSTIC EVALUATION:ECG: done July 23, 2014 @ 1:23 p.m.Findings: Vent rate : 116 bpm QRS duration : 80ms QT/QTc : 316 / 439 ms PR interval : 116 ms P duration: 88 ms RR interval : 517 ms P-R-T axes: 58 55 13

Interpretation: Sinus tachycardia, Poor R-wave Progression V1-V3, Non Specific ST-T-Wave Changes, Low voltage tracingInterpreted by Cardiologist Dr.Ranulfo B. Javelosa Jr.

URINALYSIS: done July 24, 2014 @ 12:28 p.m. by Med. Tech ALeth Sales and read by Pathologist Dr.Araceli JacobaCOLORRESULTSNORMAL VALUES

TurbidityYellowVarying degree of yellow

ReactionClearClear

Specific gravityAcidicVariable, usually acidic

Protein1.015Variable

SugarNegativeNegative

RBC0-1 hpfNegative

WBC(female)0-5 hpf0-2/hpf

CastsNone

BacteriaNone

Epithelial cellsFew

INTERPRETATION: WBC may indicate infections due to increase in disease fighting cells.

CBC

TestResultunitNormal Values

Hemoglobin110g/L140-160

Hct36%40-54

RBC5.5X1012/L4.5 5.0

MCHC30%32-37

MCH20.0Pg27.5-33.2

MCV65fL80-94

RDW18.9%11-15

WBC14.1X109/L5-10

Diff. Count

neutrophils89%40-75

Stabs%

Lymphocytes11%20-45

Monocytes%

Eosophils%0-1

PlateletNormalX109L150-440

MPV8.6fL7.5 11.5

INTERPRETATION:Low amount of hemoglobin in blood lowers the synthesis of erythropoietin, a hormone secreted by the kidneys that increases the rate of production of red blood cells in response to falling levels of oxygen in the tissues. The erythrocyte volume is lower than the normal value, it may be due to less oxygen that binds with the iron portion to form oxyhemoglobin. Other components of the blood are within the normal range.

BLOOD CHEMISTRY:Done on July 24, 2014 @ 11:56 a.m. by Med. Techs Christine Cipriano& Maria Esperanza Cagurangan, Pathologist Dr.JacobaAracelli

TESTRESULT NORMAL Range

UREA NITROGEN SUBSTC2.29 mmol/L3.2 6.8 mmol/L

CREATININE SUBSTC57 unmol/L44 106 umol/L

SODIUM140 mmol/L135 155 mmol/L

POTASSIUM3.2 mmol/L3.5 5.3 mmol /L

CPK - total173 Iu/L36 188 Iu/L

INTERPRETATION: The main cause of decrease in BUN are severe liver disease, anabolic state and syndrome of inappropriate ADH.

UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER# 64 Aurora blvd, Quezon CityCollege of Nursing

CASE: GASTRITIS SECONDARY TO SCLERODERMA

Submitted By: SUZETTE M. PIPOGroup A2Surgical Ward

Submitted To:Ms. ZandralineOng, MSN RNClinical Instructor Level III

July 30, 2014