A

CASE STUDY OF

Hyperthermia related to Infection as evidenced by 38.9 C and foul smelling post-operative

wound

Cabral, Sean Philippe P.

Calderon, Kristin Lea Y.

Cristal, Cleo Joyce C.

Dayrit, Rey Christopher U.

Clinical Instructor

Ms. Mary Ann Bayani, RN, MAN

November 16, 2020

IV. GORDON’S HEALTH ASSESSMENT

HEALTH PERCEPTION AND MANAGEMENT PATTERN

According to the client, describing his current state with a scale of 1 to 10, with 10 being
the healthiest and 1 the poorest in health, as he suffers from continuous pain in his right upper
quadrant abdomen with a pain scale of 8 and his foul smelling post-op wound, he scored his
health as 6. Whenever he is sick, he doesn’t take any medicine and just sleeps it off. He also
considers water therapy or hydrotherapy as an alternative. But ever since he was diagnosed with
biliary dyskinesia that resulted in his open cholecystectomy, he started taking his medication.
The client also stated that he smokes about 2-3 sticks per day. He doesn’t have any allergies and
doesn’t take any maintenance but he makes sure to drink his vitamin C, 500 mg everyday.

Interpretation: DEVIATION FROM NORMAL

Analysis: When people become ill, they behave in certain ways that sociologists refer to as
illness behavior. Illness behavior, a coping mechanism, involves ways individuals describe,
monitor, and interpret their symptoms, take remedial actions, and use the health care system.
Often people continue with self treatment and delay contact with health care professionals as
long as possible.

Reference: Kozier’s Fundamentals of Nursing 10th edition, p 244

NUTRITION AND METABOLIC PATTERN

SEPT. 13 SEPT. 14 SEPT. 15

Breakfast Breakfast Breakfast

1 pc Hard-Boiled Egg 2 Glasses of Water 2 glasses of water

1 Slice of White Bread 1 pc pandesal

2 glasses of water

Lunch Lunch Lunch

1 cup Crab and Corn Soup 1 Slice of Watermelon 1 pc Hard-Boiled Egg

3 glasses of Water 3 1/2 glasses of water 2 glasses of water

Dinner Dinner Dinner

1 Slice of White Bread 2 pc Spanish Bread 1 glass of water

3 glasses of water 3 glasses of water

This is the client’s food intake for 3 days before admitting to the hospital. The client
usually eats a light meal every breakfast or sometimes none. He has been on a special diet,
usually low-fat dairy products, fish and cooked beans since last year because he had biliary
dyskinesia, however, after the operation he could not eat properly because of the pain he is
experiencing.

According to the patient, on September 13, he is taking less food that he is accustomed
with and the reason is that he does not feel well on that day. On September 14, he did not eat for
breakfast as the stomach ache was worsening. The next day, he was able to eat something for
breakfast but not for dinner. He has no food allergies and his usual fluid intake is 8 glasses of
water. His favorite food to eat is soup, especially crab and corn soup.

Interpretation: DEVIATION FROM NORMAL

Analysis: The inflammatory response is often confined to the site, causing local signs and
symptoms. Fever is the most common sign of a systemic response to injury. During this process,
general, nonspecific symptoms develop, including malaise, loss of appetite, aching, and
weakness.

Reference: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 14th edition, pg. 407
& 408

ELIMINATION PATTERN

During the interview, the client stated that he defecates 5-6 times a day since his
gallbladder has been removed. It is in the form of brown loose stools. The client is not using any
laxatives. The client stated that he has difficulty in controlling his bowel movement but does not
have difficulty in urinating and usually urinates at least 8 times a day because he likes to drink
water. He stated that, “minsan po kulay dilaw yung ihi ko, at minsan naman kulay puti”.

Interpretation: DEVIATION FROM NORMAL

Analysis: According to Kozier, the frequency of defecation is highly individual, varying from several
times per day to two or three times per week. The amount defecated also varies from person to person.
The consistency should be formed, soft, semisolid, and moist and defecated without difficulty. Personal
habits regarding urination are affected by the social politeness of leaving to urinate, the availability of a
private clean facility, and initial bladder training. Urinary elimination is essential to health, and voiding
can be postponed for only so long before the urge normally becomes too great to control.

Reference: Kozier, Erb, Blais, & Wilkinson’s Fundamental of Nursing, 5th edition, pg. 1182 & 1183.
ACTIVITY-EXERCISE

Before Operation Cholecystectomy During Hopitalization

. Bed Rest
MORNING
. Sit
· Morning walks in the park with his dog
. Walks to use the comfort room
. Check email and surf the internet

· Drives to work

. Takes a bath

AFTERNOON

· Supervising café staff.

· Preparing weekly work schedules for staff

· Eats lunch and surf the internet

NIGHT

· Prepare for closing and cleaning the

coffee shop

· Gets home from work

· Shower

· Eats take out food

. Reads light novel

· Sleep
 Before his operation, he is active and he usually does morning walk with his dog in the
morning as part of his exercise and checks email before going to work despite the pain. “Minsan
maglalakad ako sa park namin kasama yung aso ko at minsan morning jogging pero madalas
walking lang.”After morning routine, he would supervise the staff and do the the rest of the work
for the day and clean the coffee shop before going home. “Ang usual na ginagawa ko ay mag
supervise ng mga staff namin tas gawin ang mga task na kailangan tapusin.” His breaks usually
consist of relaxing and internet surfing. In the evening, he reads novels and eats a take out
dinner.

3 weeks after his cholecystectomy, he filed a week vacation due to the pain he was
experiencing in RUQ abdomen.

During hospitalization, he would just lay in bed and sometimes sit beside it. “Masakit
yung incision kaya naka higa lang ako most of the time.” The time that he would stand up is
when he has to go to the bathroom.

Interpretation: NORMAL

Analysis: According to Brunner and Suddarth, problems commonly associated with immobility
include weakened muscles, joint contracture, and deformity. Each joint of the body has a normal
range of motion; if the range is limited, the functions of the joint and the muscles that move the
joint are impaired. Mobility may be restricted owing to pain, paralysis, loss of muscle strength.
Bed rest is prescribed until the infection shows signs of clearing. If hospitalized, the patient is
observed carefully until the clinical condition improves

Reference: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 14th edition, p 608 &
1163

COGNITIVE AND PERCEPTUAL PATTERN

During the interview, the client stated that he doesn’t have any difficulty hearing and has
a normal vision of 20/25. He doesn’t use any equipment to support his visual and auditory
senses. He sometimes forgot to turn off the stove causing the rice to be burnt. “Minsan kapag
weekend, kumakain ako sa bahay tapos naglilinis, nakakalimutan kong may sinaing ako.” as
verbalized by the client. He doesn’t feel any pain in his senses. His replies are well-oriented, her
ideas are well ordered, and words are coordinated for his responses.

Interpretation: NORMAL
Analysis: According to Brunner and Suddarth, cognition can be affected by many variables,
including sensory impairment, physiologic health, environment, sleep, and psychosocial
influences. Forgetting something is part of the aging process. Older adults may experience
temporary changes in cognitive function
Reference: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 14th edition, p 697

SLEEP AND REST PATTERN

The patient stated that he can’t sleep at all because the pain he feels doesn’t let him sleep.
He verbalized “Masakit na nga, nilalagnat pa. ‘Di ako makatulog ng maayos sa nararamdaman
ko.” Before hospitalization, he mentioned that he doesn’t experience any sleeping difficulties and
interruptions at all. He approximately gets 6-7 hours of sleep per day since he needs to wake up
early for his work. His rest for the day is usually from his 1-hour lunch break. Then during
weekends, he tends to sleep all day.

Interpretation: DEVIATION FROM NORMAL

Analysis: According to Kozier, most healthy adults get 7 to 8 hours of sleep per night (National
Sleep Foundation, n.d.d). However, individual needs do vary—some adults may be able to
function well (e.g., without sleepiness or drowsiness) with 6 hours of sleep, and others may need
10 hours to function optimally. Adults working long hours or multiple jobs may find their sleep
less refreshing. Medical conditions and pain are factors that interrupt sleep. When pain lasts only
through the expected recovery period, it is described as acute pain, whether it has a sudden or
slow onset, regardless of its intensity. Chronic pain, also known as persistent pain, is prolonged,
usually recurring or lasting 3 months or longer, and interferes with functioning.
Reference: Kozier Fundamental’s of Nursing 10th edition, p. 1068

SELF PERCEPTION AND SELF CONCEPT PATTERN

During the interview, the client stated that scars are what makes him who he is. “Okay
lang naman na may peklat ako, ibig-sabihin no’n nalagpasan ko yung gano’ng hirap sa buhay.”
as verbalized by the client. He stated that he is confident with his looks and body image. “Pag
may problema ako, tinutulog ko nalang muna kasi paano ka mag-iisip kung pagod isip mo ‘di
ba?” as verbalized by the client.

Interpretation: NORMAL
Analysis: According to Brunner and Suddarth, self-perception and self-concept are both related
to the cognitive and emotional processes that people use to formulate their beliefs and feelings
about themselves. Patients who do not understand the health consequences of their disease
process and its management are at risk for noncompliance.
Reference: Medical Surgical-Nursing 12th Edition, Brunner and Suddarth, p. 696

ROLES AND RELATIONSHIP PATTERN

The client stated that he lives alone with his dog and has a good relationship with his
parents and relatives. Every holiday, they go out of town or country. When he has a problem, he
usually runs to his sister or mother because mothers know best, he stated.
Interpretation: NORMAL
Analysis: According to Brunner and Suddarth, support from family members helps to lessen the
patient’s burden of managing self-care for cardiac illnesses. A recent Scientific Statement from
the AHA highlights the importance of social support.
Reference: Medical Surgical-Nursing 12th Edition, Brunner and Suddarth, p. 1881

SEXUALITY AND REPRODUCTIVE PATTERN

The client stated that he was circumcised at the age of 12. He has a current partner,
although, they are practicing abstaining because of the situation of the client.

Interpretation: NORMAL
Analysis: According to Brunner and Suddarth, the common reason for decreasing sexual activity
is due to concerns that people have about the effects of physical exertion especially after
operation. Often, patients and their partners do not have adequate information about the physical
demands related to sexual activity and ways in which these demands can be modified.

Reference: Medical Surgical-Nursing 12th Edition, Brunner and Suddarth, p. 1881

COPING AND STRESS PATTERN

During the interview, the client stressed about the said RSB or Retained Surgical Foreign
Body, which was revealed that there’s gauze left behind inside his abdomen. “Kaya pala di
nawawala yung sakit, akala ko dahil lang sa opera pero hindi pala.” the client verbalized. He’s
also conscious regarding his post-op wound because it has a foul smell.

The client mentioned that whenever he has a problem, he usually talks it out with his sister or his
mother and he also prays when he is alone. He handles things very well, he said.

Interpretation: DEVIATION FROM NORMAL

Analysis: According to Kozier, stress is a universal phenomenon. Stress can result from both
positive and negative experiences. The concept of stress is important because it provides a way
of understanding the person as a being who responds in totality (mind, body, and spirit) to a
variety of changes that take place in daily life. Coping strategies are also viewed as long term or
short term. Long-term coping strategies can be constructive and practical. In certain situations,
talking with others and trying to find out more about the situation are long-term strategies. There
is never only one way to cope. Some people choose avoidance; others confront a situation to
cope. Still others seek information or rely on religious beliefs.
Reference: Kozier Fundamental’s of Nursing 10th edition, p.178

VALUES AND BELIEF PATTERN

During the interview, the client stated that his religion is Roman Catholic. He always prays to
God whenever he wakes up in the morning, before going to bed and especially when he has a
problem. The client stated that he goes to church every Sunday. The client has no superstitious
belief in regards to health but believes in ghosts and believes that when the sun is shining and
raining at the same time, there is a wedding of “tikbalang” going on.
Interpretation: NORMAL
Analysis: According to Potter & Perry, spirituality is a complex concept and it depends on a
person’s culture, development, life experiences, beliefs and ideas about life. Spirituality gives
patients the energy needed to help them discover themselves, cope with difficult situations and
maintain their health. Spirituality also enables a person to love, hope, seek guidance in life and
nurture relationships with others.
Reference: Fundamentals of Nursing 9th Edition, Potter and Perry, p. 734