Elimination

The client urinates 3-4 times per day and defecates every two days. There is no pair upon
urinating and defecating nor verbalization that he experienced constipation.

Analysis and Interpretation

Elimination of the waste products of digestion from the body is essential to health. Defecation is
the expulsion of feces from the anus and rectum also termed as bowel movement. The frequency
of defecation is highly individual, varying from several times per day or 2-3 times per week.

Exercise
The client has no definite mode of exercise. Going to the gym and playing any sports was
verbalized. Like any in any individual, walking in the most common form of exercise. At home
he uses dumbbell but it is done when feels like using the equipment.

Analysis and Interpretation

People often define their health and physical fitness by their activity because mental well being
and the effectiveness of the body functioning depend largely on their mobility status. The ability
to move also influences self-esteem and body image. Activity-exercise pattern-common known
as exercise refers to a person’s routine of exercise, activity, leisure and recreation.

Exercise as part of one’s activities of daily living play’s a very vital role. Exercise, not merely
regular is essential for healthy functioning of major body systems. In this case, the patient has no
definite mode of exercise that can predispose him to poor functioning which may be the cause
why he has a decrease output. Blood flow to his kidneys might be insufficient. In this reason, the
patient’s body was unable to excrete waste effectively.

Hygiene
The patient verbalized that he maintains good personal hygiene. He did not emphasize his
hygienic practice nor verbalized additional information regarding his personal hygiene.

Analysis and Interpretation

Hygiene is the Science of health and so is maintenance. Personal hygiene in the self-care by
which people attend such functions as bathing. Toileting, general body hygiene and grooming.
Hygiene is a highly personal matter determined by individual values and practices. It involves
care of the skin, hair, nails, teeth, oral and nasal activities.

The patient satisfactorily exhibits good personal hygiene. Being an alcoholic, he must maintain
good hygiene especially on his oral hygiene. Hence, the patient has a higher risk for having
stomatitis and halitosis for continuous session of alcoholic consumptions.

Substance abuse
The patient does not engage in any drug abuse nor take drug that are over the counter. He is a
known alcoholic for 5 years. He drinks 2-3 times per week and for every session 2-3 bottles of
500ml of redhorse. The usual alcoholic he did not verbalize any alcoholic drink.
Being an alcoholic drinker predispose a person to many disease to many disease (liver and
kidney disease). In so far, in the case of the patient, systemically, his body is not yet
experiencing severe/negative effects of alcohol intoxication. The patient’s condition is still
reversible at this present time.

Rest and sleep

the client usually sleeps at least 8 hours a day and with a nap of at least 1-2 hours. She never
experiences any sleep disturbances.

The client experiences insomia due to side effects of medications, breathing problems
disruptions of bedtime ritual or routine when a person is hospitalized.

Medication: Senokot 2tabs for constipation

CoAmoxiclav 625mg 1 tab bid 6doses

Exercise: advised not to overstress self and not to perform exhausting tasks. Instructed to do
passive assisted exercise such as dangling, ankle pumps and hamstring stretch

Therapy: advised a family therapy. Encourage client to open feelings or problems together with
family.

Health teachings: client is instructed to avoid alcoholic drinks and to seek a healthier lifestyle

Observation:

Diet: high fiber diet, green leafy vegetables and avoid fatty foods

Medical History
Five hours prior to admission the patient was seen lying on the floor with loss of consciousness
and no signs of vomiting. The patient arrived at home intoxicated with alcohol. Relatives
suspected that the he might have fallen from his bed. Few hours before, the client regained
consciousness but lethargic which prompted the relatives to consult medical help.

A. Past Medical History

The client stated that he had been diagnosed with Pneumonia of the year 2004
B. History of Present Illness
The client denied any presence of illness such as hypertension, asthma and non-diabetic.
C. Family History
The Client denied any hereditary disease such as Cancer, Malignancy of the heart, liver
or kidney disease, asthma, Pulmonary Tuberculosis not allergy to food or drugs.
D. Personal and Social History
The client is a non-smoker but drinks alcoholic beverages. He has no food preference.

Course in the Ward

The patient stayed in the hospital for total of 6 days. On the 1st day, the client was admitted to
E.R. due to loss of consciousness. Upon admission, vital signs were taken as for baseline data,
client was placed on NPO, inserted with NGT, hooked to an oxygen, cardiac monitor and pulse
oximeter. The client was venoclyzed with D5LR 500, PNSS 1L. Few Laboratory test was done
where: CBC which revealed leukocytosis and lyphopenia, Urinalysis which revealed hematuria,
liver profile which revealed an increase of SGPT was then transferred to Intensive Care Unit.

On the 2nd day of hospitalization, the patient had low verbal response, lethargic and asphasic with
a Glasgow coma scale score of 9. He was venoclyzed with PNSS 1L with 1ampule of Neurobion.
He demonstrated projectile vomiting. His feeding was put on hold together with other
medication. He was also transferred to the ward 3c. Vital signs were done. Intake and output was
recorded. Referred and endorsed.

On the 3rd day of hospitalization, the client was the referred to neurosurgery and was then found
that there was no intracerebral hematoma with no pressure signs. However, the patient cannot
appreciate the subdural hematoma.

On the 4th day of hospitalization, the client’s NGT was removed a started to orally feed but with
strict aspiration precaution. The indwelling foley catheter was then removed. He was also
maintained on a moderate high back rest.

On the 5th day of hospitalization, client was ready for discharge

On the 6thy day of hospitalization, the client was home at 1pm.

Head to Toe Physical Assessment

Level of consciousness:
GLASCOW COMA SCALE: GC9 E4M4V1
Eye opening response: Spontaneous
Best motor response: withdraws
Best verbal response: None
 the client’s score is 9, lethargic and asphasic

Body Part Method Of Actual Findings Interpretation and

Assessment analysis
Skin/ color