Case Pres Start Polished Chin

8/3/2019 Case Pres Start Polished Chin

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ST. PAUL UNIVERSITY MANILA(St. Paul University System)680 Pedro Gil Malate, Manila

College of Nursing and Allied Medical Sciences

NURSING CASE STUDY(Application of Nursing Process)

Submitted: Date:I. ASSESSMENT

A. General InformationClients Initials: R.P.J Rm/Wd: Bed 1, Pav. 2Date Admitted: 05-12-05 Age: 4y/o Sex: M CS: Single

Nat.: Filipino Religion: Roman CatholicEducational Attainment: Nursery Occupation: N/AAdmission Complaints: fever and rashesAdmission Diagnosis: T/C KawasakiAdmitting VS: T: 38.5 P: 110 beats/min R: 25 breaths/min

BP: 90/60 Wt.: 13.3 kg Ht.:Arrived on Unit By: Ambulatory assisted by motherAllergies: NoneMedications: Ceelin (Vitamin C),Penicillin G, Izoniazid, AM-ambroxol,Pyrazinamide, Diephenhydramine, Rifampicin, Paracetamol

B. Nursing History (Based on the Functional Health Pattern by Gordon)1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN1.1 Clients description of his/her health:

Before Admission:Patients mother verbalized: Pabalik-balik lagnat ng

anak ko tapos bigla siyang nagkaroon ng rashes sa mukhae wala naman siyang allergies.At Present:

Patients mother verbalized: Ok na siya ngayonmedyo masigla na ulit.

1.2 Health Management:Self

Mother stated that the patient had completeimmunizations, observes proper hygiene and eats nutritiousfoods.

FamilyThe mother verbalized that she is a good homemaker

and plans their meals which consists of foods such asvegetables, meat and fish which are healthy and that all ofthem observes proper hygiene.

1.3 History of Present Illness:2 days prior to admission, patient was noted to have

moderate to high grade fever accompanied by appearanceof erythematous rashes which started from the head andprogressed to the trunk down through the peripheral andupper and lower extremities. The patient was highly febrile.And no medications were given except parentheral. Thepatient was also noted to have a strawberry tongue.

1.4 Past Illnesses:The patients past illnesses were usually fever, cough

and colds.


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1.5 History of Hospitalization (when, where, and why)Patient was born in Jose Reyes Medical Center dated

May 12, 2001. Patient has never been hospitalized againuntil now.

1.6 History of Illness In the Family:The father of the patient has Diabetes Mellitus andasthma. But they live in a congested area where space islimited more them to move.

1.7 Expectations of Hospitalization:Patients mother verbalized: Sana gumaling na ng

tuluyan anak ko.

Patient verbalized: Gusto ko na po umuwi. Sanagumaling na ako.

1.8 Anticipation of Problem of caring upon oneself upondischarge:

Patients mother verbalized: Wala naman problemasa pag-aalaga namin sa kanya pero sana di masyadomadami yung gamot para di masyadong mahal.

1.9 Knowledge of Treatment or Practices prescribed:Patients mother verbalized understanding regarding

the treatment and practices prescribed. They were explainedproperly and her questions were answered by the doctor and

nurses.

1.10 Reaction to above prescriptions:Patients mother feels relieved that the prescribed

medications will help him recover.

2. NUTRITION AND METABOLIC PATTERN

2.1 Usual food Intake (before admission) Breakfast:

For breakfast the patient eats hotdog, oatmeal,bread and rice

Lunch:For lunch, his meal includes rice, vegetables or anyviand served.

Supper:For supper, his meal also includes rice, vegetables,fish or any viand served.

Snacks:The patient eats sandwiches and fruit juices.

Preferences:The patient prefers to eat sweets and spaghetti.

2.2 Usual fluid intake (type/ amounts):The patient drinks 6-8 glasses of water a day and fruit

juices during snacks.

Preferences: The patient prefers to drink water and juices.

2.3 Any food restrictions:The patient does not have any food restrictions.

2.4 Any problems with ability to eat:The patient has no problems with the ability to eat.


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2.5 Any supplements (vitamins/feedings)Vitamin C PO 1 tsp. per day everyday.

3. ELIMINATION PATTERN

3.1 BladderUsual Frequency per day:Patient usually urinates 10 times a day approximately

400-600 cc.

Color:Urine is red orange due to medications-rifampicin.

Complaints of usual pattern of urination:Patient has no complaints when urinating.

3.2 BowelUsual pattern/day (time, frequency, color, consistency):

Patient moves his bowel one to two times daily,usually 9 am and with no particular time in the evening. It islight brown in color and appears to be mushy.

Complaints of usual pattern of bowel movement:Patient has no complaints when moving his bowels.

Home Remedies:

Since patient has no complaints on bowel movement,there are no home remedies given for treatment.

3.3 Any assertive Device:There are no assertive devices used by the patient.

3.4 Skin (Condition):The patient has a good skin turgor and eliminates

sweat without foul smell.

4. ACTIVITY EXERCISE PATTERN

4.1 Exercise/Leisure:The patient usually enjoys biking every afternoon for 4

times a week. This is also his hobby.

4.2 Any Limitation of Physical Activity:Patient has no limitation on physical activity.

4.3 History of Dyspnea or fatigue:Patient experienced dyspnea for one week.

5. SLEEP REST PATTERN

5.1 Usual sleep pattern:Bedtime:

Patient has a usual bedtime of 8 pm and wakes up at9 am.

Hours slept:Patient sleeps for around 10-12 hours.

Number of Pillows:Patient is comfortable and contented in sleeping with

one pillow.


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Sleep Routine:The patient plays for a while until he feels sleepy or

watches TV until he falls asleep.

5.2 Any problems regarding sleep:Patient experiences interruption of sleep due to a bad

dream then he tends to cry.

5.3 Usual Remedies:The mother of the patient sleeps beside him at times

when he cries.

6. COGNITIVE - PERCEPTUAL

6.1 Any deficits in sensory perception (hearing, sight andtouch):The client doesnt have any deficit in sensory

perception.

6.2 Ability to read and write. Any difficulty in learning?The client cant read and write but can count from 1-

20 and can state the alphabet. He was also able to identifypictures that were shown to him.

6.3 Any complaints (e.g. pain)

The client feels pain every time CBC is done. On thescale of 1-10, 10 is rated subjectively.

7. SELF PERCEPTION PATTERN7.1 What the client is most concerned?

The client is concerned about getting out of thehospital, for him to be able to go to school and play with hisfriends.

7.2Present health goals:The watcher verbalized Sinasabi niya lagi na gusto

na niyang gumaling at umalis na dito sa ospital.

7.3Effects of present illness to selfHe wasnt able to go to school to learn how to read

and write because of his illness. He was required to stay inthe hospital long enough until he recovers.

7.4How does the client see/feel about self?The client is confident that he will recover and will not

get the disease again.8. ROLE-RELATIONSHIP PATTERN

8.1Language spokenThe client speaks Filipino/Tagalog.

8.2Manner of SpeakingThe client doesnt speak much; he only uses gestures

instead of speaking. The client is soft-spoken and speaks ina respectful tone. He uses po and opo as a sign ofrespect to older people.

8.3Significant person to clientThe mother stands as a significant person right now

because she is the one who takes care of him andaccompanies him. Since his father is not around, he is more

attached to his mother.


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8.4Complaints regarding familyThe client has no complaints about his family.

8.5Living with (members of family)

The client lives with his father, mother and his twosiblings.

9. SEXUALITY SEXUAL FUNCTION PATTERN9.1Anticipated change in sexual relations because of illness:

It is not applicable to the clients age.

9.2Knowledge of sexual functioning:The client is able to distinguish the difference

between a boy and a girl.

10.COPING STRESS MANGAEMENT PATTERN10.1 Decision making abilityThe client is able to decide for himself when it comes

to small things like what he wants to eat or what to wear. Hisparents decide for him when it comes to bigger decisions likegoing to school.

10.2 Any significant stress in the pastThe client experiences stress whenever his parents

scold him. As of now, his hospitalization brings stress to him.

10.3 Management of stressThe client will cry and then will keep quiet after beingscolded by his parents.

10.4 Expectation from nurses to provide comfort and securityduring hospitalization.

The client has no expectations from the nurses.

11.VALUE BELIEF SYSTEM11.1Source of strength and meaning

The clients source of strength or meaning is hisfamily and God.

11.2 Importance of God to clientClient believes there is God but he doesnt pay much

attention to His presence.

11.3 Religious practices (type and frequency)The client goes to mass every Sunday with his family.

11.4 Request for religious person/practiceThe client has no request for any religious person or

practice.

12. DEVELOPMENTAL TASKS(Assess for achievement of developmentaltasks)

The patient is included in the preschool period, age 3-5.

FREUDS STAGE OF CHILDHOOD:

Phallic Stage - Childs pleasure zone shifts from the anal to thegenital area. He learns sexual identity throughawareness of the genital area. Childs sexual interest


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could lead to fondling his own genitals as a normalarea of exploration.

According to the mother, the client was able todistinguish a boy from a girl. He was able todetermine the work of a man from a woman like a

woman cooks food while a man drives a car and doescarpentry. He can also determine the sex of his

playmates if he or she is a boy or a girl.

DEVELOPMENTAL TASK OF ERIKSON:

Initiative vs. Guilt - Learning initiative is learning how to do things.The child initiates motor activities of varioussorts on their own and no longer merelyresponds or imitates the actions of parents orother children. The client was able to do thingson his own as stated by his mother and relative.

As told by the mother, the client was given morefreedom in playing physical activities like runningand bike riding. The mother also allows the childto play with toys that would develop his skills likecoloring books and molding clays. Also, themother noted that the client enjoys playingoutside their house with his playmates.

PIAGETS THEORY OF COGNITIVE DEVELOPMENT:Preoperational Thought (Intuitive Thought) - Thought becomes

symbolic. The child tends tolook at an object and see onlyone of its characteristics.

He knows the differentparts of the body, able tocount from one to twenty, andwas able to differentiateshapes of certain object beingshown to him. Also, whenasked what is the use of akey, the client thinks that it isonly a metal and it doesnthave a purpose.

KOHLBERGS THEORY OF MORAL DEVELOPMENT:

Preconventional - They tend to do good out of self-interest ratherthan out of true intent to do good or because of astrong spiritual motivation. They imitate what theysee and have great difficulty knowing what rulesapply to new situations.

When asked the reason why he has to eat thevegetables, the client answered that it is what hismother and father instructed him to do. He doesntknow that eating vegetables would be for his owngood. He imitates his siblings when they kiss thehands of the elders because he knows if he did that,he would make his parents proud.


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C. PHYSICAL ASSESSEMENT Date performed: July 5, 2005

AREA MODE OF ASSESSMEN

T

NORMALFINDINGS

ABNORMAL

FINDINGS

1. Head to ToeExamination1.1. General Survey

1.2 Vital Signs

1.3 Head & Facea. Cranium

b. Temporalarteries

c. Face

d. Cranial Nerve V& VII

Inspection

InspectionInspection

Inspectioninspectioninspection

inspection

inspection

inspection

inspection

inspection

InspectionPalpationInspection

PalpationPalpation &inspectionPalpation &inspectionInspection

Palpation

Inspection

Inspection

InspectionInspection &

palpationInspection &

palpation

Inspection

> awake, alert &responsive to people& environment>good body posture> walks easily, withcomfort and goodbalance.> skin uniform in color> body symmetrical> (-) body deformities

> personal hygiene &grooming appropriateto age & socio-economic group>hair dark brown incolor, moderate inquantity, equal indistribution andsmooth in texture.> Height appropriatewith age and gender.> (-) body and breathodor.

T= 36.9 CPR= 122 bpmRR= 45 bpm

> (-) tenderness> round, smooth skullcontour> (-) lumps> (-) deformities> size proportional tobody

> temporal arteriesare palpable

> symmetrical facialmovement & features> (-) involuntarymovements> (-) edema> (-) masses

> good contraction ofthe temporal andmasseter muscles onboth sides when client

was asked to clench

> (+ non-productivecough


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e. Nose & CranialNerve I

Inspection


InspectionInspectionPalpationInspection

InspectionInspectionInspection

his teeth> good facialsensation> (+) corneal reflex> (-) facial weakness

> symmetrical> (-) discharge> (-) tenderness> perceives odor oneach side andidentifies it> (-) nasal obstruction> (-) nasal flaring> (-) deformities

1.4 Eyes & Vision

a. External EyeStructure

b. Visual Acuity

c. Extra Ocular

MuscleFunction (cranial nerveIII, IV, VI)

d. Pupillary reflex

e. Internal EyeStructurewith

Opthalmoscope

Inspection

Inspection

Inspection &PalpationInspection &PalpationInspectionInspection


Inspection

Inspection

Inspection


Inspection

Not done (noopthalmoscope)

> dark brown eyessymmetrical & aligned

> eyebrows normal inquantity & distribution> (-) edema

> (-) nodules

> white sclera & pinkconjunctiva> pupils 3mm in size,

round in shape &symmetrical> (-) erythema> (-) swelling oflacrimal gland &lacrimal sac

> can recognizepicture withinreasonable distance

> symmetrical corneal

reflections> normal conjugatemovement of eyes ineach direction> good convergence> (-) ptosis

> PERRLA

1.5 Ears & Hearing

a. External Ear

b. Hearing

InspectionInspectionInspection &PalpationInspectionInspectionInspection

Inspection

> (-) deformities> (-) discharge> (-) lumps

> (-) lesions> (-) ear pain> (+) pinna recoil

> can hear on bothears within


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c. Ear Canal & TympanicMembrane with

Otoscope

Not done (nootoscope)

reasonable distance &volume

1.6 Necka. Musculoskeletalstructure

b. Lymph Nodes

c. Thyroid Gland

d. musculoskeletalfunction &

cranialNerve XI

e. Carotid Arteries

Inspection

Palpation

Palpation

Inspection

Inspection

Palpation

Inspection

Inspection

Inspection

Inspection

Inspection

Inspection

Palpation

> muscle equal insize> head centered> (-) masses> (-) scars

> not palpable

> central placementin midline of neck> spaces are equal

on both sides> ascends duringswallowing but isnot visible

> smoothcoordinatedmovement with nodiscomfort> head flexes 45degrees

> head hyper-extends 60 degrees> head laterallyflexes 40 degrees> with equalstrength> able to shrug hisshoulders againstresistance

> palpable

> full equalpulsation

1.7 Upper Extremitiesa. musculoskeletal

structures, skin, nails

b. Musculoskeletalfunction

Inspection

Inspection

PalpationInspection &

Palpation

Inspection

Inspection

Inspection

Inspection

> arms equal in sizeon both sides of thebody> (-)contractures/tremors> normally firm

> no grossdeformities,tenderness, swelling> no edema onarms> nails are pinkishin color, smooth andconvex in size &hard to touch

>no signs of

cyanosis

>skin is pinkwith slightrashes

present


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c. Brachial and

Radial arteries

Inspection

Palpation

>smoothcoordinatedmovement>able to flex,extend, rotate,

abduct, and adductupper extremities

> palpable withequal pulsations

1.8 Anterior Chesta. Breast and Axillae

b. Thorax

c. Pericardium

Inspection

InspectionPalpation

Inspection

Palpation

AuscultationInspection

InspectionPalpation

Auscultation

>same color withother parts of thebody

>(-) lesions>(-) tenderness,swelling, mass

> symmetrical chestexpansion>(-) mass,tenderness andswelling

>no lesions

> no signs ofinflammation> (-) tenderness andswelling>(-) murmurs

>(+ rales )

1.9 Backa. Musculoskeletal

Structures

b. Fist percussionover spine and kidney

c. Posterior Thorax

Inspection &PalpationInspection

InspectionInspectionInspectionInspection &Palpation

InspectionPalpationInspection

> no lesions,tenderness> no signs ofinflammation

> full & symmetricchest expansion>Chest wall intact>Skin intact> no presence ofany limps & bulges

> (-) lesion>(-) lumps> with full &symmetrical chestExpansion

1.10 Neck Veins Inspection

Palpation

>(-) jugular venousdistention> not palpable

1.11 Abdomena. Four abdominal Inspection > symmetric


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Quadrants

b. Specific OrgansLiver

Spleen

Kidneys

Inspection

PalpationPalpation

Palpation

Palpation

Palpation

>protrudingabdomen>(-) tenderness> (-) mass

> not palpable

> not palpable

> no palpable1.12 Lower Extremities

a. Musculoskeletalstructures, skin and toe nails

b. Musculoskeletalfunction

c. Popliteal, Posterior,Tibial & pedal arteries


PalpationInspection &Palpation

InspectionInspection andPalpation

Inspection

Inspection

Inspection

Palpation

> Legs equal in size> (-) contractures /tremors

> normally firm> no grossdeformities,tenderness orswelling> no edema on legs> toenails re pinkishin color smooth,convex I shape, &hard to touch> no signs of

cyanosis>Smoothcoordinatedmovement> able to flex,extend, abduct &adduct lowerextremities

>Palpable withequal pulsation

Summary of Abnormal Findings

Based from the above physical assessment done, the presence of non-productive cough, (+) rales and presence of rashes on the skin were noted.

C. REVIEW OF RECORDS:

1. Medical Plan of Care:

IV therapy

Medications- Pen G IV 200,000 U q 6 hrs; IZN 200 mg 15 mL4 cc OD; Ambroxole 1 tsp. BID PO; PZN 7.5cc OD PO;Diphenhydramine 15 mg IV q 8 hrs; Rifampicin 4 cc OD PO;Paracetamol 3 mL q 4 hrs. PO


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DATEPERFORME

D

DIAGNOSTICTEST

RESULTS NORMALVALUES

SIGNIFICANCE IMPLICATION OFABNORMAL RESULT

NURSING RESPONSIBILITIES

June 13,2005 UrinalysisF. Physical1.specific

gravity1.005 1.015-

1.030

Urinalysis is a testused to assessthe status of thekidney function,nutri tion, andcertain metabolicand systemicdisease.

The client hasdecreased specificgravity of urineindicating that there isdehydration due to thefever manifested bythe client.

Before:1. Explain that this test requires urine specimen-aids

diagnosis of renal or urinary tract diseases andhelps evaluate over all body function

2. Check patients history for recent use ofmedications that may affect results

3. teach patient that the first voided morningspecimen is the ideal urine specimen for analysis

because of its concentration and characteristicaudityAfter:

1. If culture and sensitivity is needed a clean catchor midstream method is used and the perinealarea or penis should be applied with and Iodinepreparation to reduce contamination.

2. Tell the patient that the specimen are collectedover a time that may range from 2-24 hours

June 15,2005 Hematology testA.WBC 17.2 5.0-10.0

10^g/ulWBC is used todeterminedinfection in thebody system. It isalso used todetermine the

need for WBCdifferential bone

The clients WBC isincreased indicatingthat there is infectionin the body system.

Before:1. Explain the procedure to the patient before the

procedure proper.2. Inform the patient that the test requires blood

sample and he need not fast before the test, butthat he should avoid eating heavy meal before thetest.

3. Advise the patient to avoid strenuous exercise for24 hours before the test.


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marrow biopsy. 4. If patient is being treated for an infection, tell himthat this test will be repeated to monitor hisprogress.

5. Check patients history for drugs that may alterresults.

After1. Monitor Vital Signs closely, if temperature

increases do TSB and refer to POD.2. If a hematoma develops at the venipuncture site,

apply warm soaks to ease discomfort.3. Instruct patient to resume to normal activities

restricted before the test.

B. RBC 3.79 4.0-6.0 10^12/ul

RBC is used tosupport otherhematologic testsin diagnosis ofanemia and polycytopenia.

The clients RBC isdecreased indicatingthere is inflammationand granulation in thelungs.

C. Hemoglobin 96 120-140g/dl

Hemoglobinthrough the redblood cellstransports O2 and

removes CO2from the body. Itis used tomeasure theseverity of anemia or polycythemia.

The hemoglobin of theclient is decreaseddue to inadequate foodintake which leads to

malnutrition.

D. Hematocit 0.28 0.38-0.45%

Hematocrit issignificant as the percentage ofRBC in the totalvolume. Changesin RBC size willmake a differencein the test values.

The hematocrit of theclient is decreased dueto inadequate foodintake which leads tomalnutrition.

E. Neutrophils 0.72 0.63-0.65%

Neurtrophils arethe most numerous of the

circulatingleukocytes.

The clients neutrophilsis increased indicatingthat the bone marrow

is releasing cells thatare not developed and


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Phagocytosis isthe major modeof action. It is thebodys primaryline of defenseagainst infectionbecause they arethe first to arrivein theinflammatory site.

that the stimulation forproduction and releaseof leukocytes is notenough.

June 15, 2005 Chest X- ray

AP/LATRoentological &UTZ findings

Primary

Kocksinfection

none X-ray films of the

chest are used toidentify variousabnormalities ofthe lungs andstructures in thethorax; the size ofthe heart,abnormalities inthe ribs or diaphragm canalso bedetermined.

The client had an

anterior posterior (AP)lateral (LAT) view of x-ray. It was seen thatthe client is (+) primarykochs infection; anextensive pathologicprocess in the lungs inthe absence of symptoms is detected.

Before:

1. Explain the procedure to the patient before theactual test/ examination.2. Remove clothing of patient down to the waist then

drape maintaining and respecting patientsprivacy.

3. Remove all jewelry or any metal objects.4. Position patient noting for its safety (cover testes,

may lead to impotence)5. Instruct patient correctly and clearly. (deep breath

and hold)After:

1. Isolate patient from other patient; same asisolation of the patients articles.

2. Standard safety precautions should be observed.3. Do hand washing and meticulous hygiene.4. Adequate nutrition should be given to the patient.5. Monitor VS with U & B monitoring; refer

accordingly.

6. Note for bleeding/ blood on secretions and stool.7. Monitor patients condition; give meds on time as


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ordered by the doctor.

June 16, 2005 Chemistry ReportformSpecimen:Serum

AlanineAminotrasferase(PE/ALT)

47 5-45 u/L Alanine-Aminotransferase(ALT) is anecessaryenzyme in theKrebs cycle. It isessential for t issue energy production. It is

an indicator ofhepatocellulardamage.

The clients ALT isincreased indicatingthat there isdisseminatedTuberculosis whichoften have associatedliver involvement.Damaged liver cellrelease increased

amount of ALT.

Before:1. Explain to the patient that this test help assess

liver functions, that he need not restrict foods orfluids before the test and that the test requires ablood sample.

2. Falsely elevated ALT levels may follow use ofbarbiturates, chlorpromazines, isoniazid,methyldopa, oprate analgesics, para-aminosalicylic acid, phenothiazines, henytoin,

salicylates, tetracycline and other drugs thataffect liver. If meds must be continued, make anote on the laboratory slip.

3. Ingestion of lead or exposure to othertetrachloride injures hepatic cells and elevatesALT sharply.

After:If a hematoma develops, at the venipuncture site, applywarm soaks to ease discomfort.

June 19,2005 UrinalysisF. Physical1.specific

gravity1.015 1.015-

1.030Urinalysis is atest used toassess the statusof the kidneyfunction, nutrition,and certainmetabolic and

systematicdisease.

The clients specificgravity of urine iswithin normal values.

Just continue nursing care.


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June 19, 2005 Chemistry ReportformSpecimen:Serum

Creatinine

Total Protein

Albumin A

44

56

30

53-133umd/L

60-80 q/L

40 - 60q/L

Creatinine is anon protein end product in thebreakdown ofcreatinine phosphate in the

skeletal muscle.

Decrease inSerum Total Protein reflectsdecrease inAlbumin Globulin

Albumin is thesmallest proteinmolecule andmakes up thelargest portion oftotal serum protein. It issynthesized in

the liver

Although thedecreased increatinine is too little toindicate actual musclewasting, it alsosuggest incoming

problem with regardsto total muscle mass.

The client hasdecreased total proteindue l iver functiondisease, since liver isgreatly involved inTuberculosis.

The client hasdecreased albuminindicating loss ofappetite during thedisease process.

Before1. Explain to the patient that this test evaluates

kidney function.2. Instruct him to resist foods and fluids for about 8

hours before the test.3. Tell the patient that the test requires a blood

sample.4. Check the patients history for any drugs that mayinterfere the test results. For instance, ascorbic,barbiturates, diuretics might increase creatininelevels.

5. Check the patients record diet history for foodsthat may interfere with the test results. Example,a diet high in roasted meat increase creatininelevel.

After1. If a hematoma develops at the venipuncture site,

apply warms soaks to ease discomfort.

Before1. Explain to the patient that this test determines the

protein content of blood. Tell him that he need notrestrict foods or fluids before the test. Mentionthat the test requires a blood sample.

2. Check the patients medication history for drugsthat may influence Serum Protein levels, such as


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A/G Ratio1.115 1.5 - 2.2 Albumin/Globulin

ration (A/G ratio)shows the proport ion ofalbumin toglobulin. Thoughonce considereduseful, it is nowrarely used as theratio may influence many

diseases.

The client hasdecreased A/G ratioindicating that there isdecreasedsedimentation rateoccurring within thelarge cells. Viscosity ofthe blood of decreased plasma protein alsoslows thesedimentation rate.

cytotoxic agents. If they must be continued, noteon the laboratory slip.

3. Avoid pretest administration of a contrast agentwhich falsely elevates test results.

After1. If a hematoma develops at the venipuncture site,

apply warm soaks to ease discomfort.

1. Observe for frothy urine--- it may indicate proteinexcretion.

2. Observe the patient for signs of edema.3. Instruct the patient & the family to save all urine &notify nursing staff of each void.

Before:1. Explain to the patient that this test helps diagnose

liver and other disorders by measuring certainprotein levels in the blood. Answer any questionhe may have.

2. Instruct that a blood sample will be taken and heneed not restrict foods or fluids before the test.

3. Check patient medication history and report anycurrent drug therapy. Certain drugs interfere withtotal protein level.

After:If a hematoma develops at the venipuncture sites, applywarm soaks to ease discomfort.

June 18,2005 HEMATOLOGY

TESTWBC 12.5 5.0-10.0 White blood cells The clients WBC is

Before:

6. Explain the procedure to the patient before theprocedure proper.


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RBC

Hemoglobin

3.83

95

10^g/ul

4.0-6.010^12/ul

120-140g/dl

are used todetermineinfection in thebody system. It isalso used todetermine theheed for WBCDifferential orbone marrowbiopsy.

Red blood cellsare used tosupport otherhematologic testsin diagnosis ofdifferentdiseases.

Hemoglobinthrough the redblood cellstransports O2 andremoves CO2from the body. Itis used tomeasure theseverity of anemia or

polycythemia.

still increased indicating that there isinfection in the bodysystem.

The clients RBC isdecreased indicatingthere is inflammationand granulation in thelungs.

The hemoglobin of theclient is decreaseddue to inadequate foodintake which leads tomalnutrition.

7. Inform the patient that the test requires bloodsample and he need not fast before the test, butthat he should avoid eating heavy meal before thetest.

8. Advise the patient to avoid strenuous exercise for24 hours before the test.

9. If patient is being treated for an infection, tell himthat this test will be repeated to monitor hisprogress.

10.Check patients history for drugs that may alterresults.

After4. Monitor Vital Signs closely, if temperatureincreases do TSB and refer to POD.

5. If a hematoma develops at the venipuncture site,apply warm soaks to ease discomfort.

6. Instruct patient to resume to normal activitiesrestricted before the test.


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Hematocrit

Neutrophils

0.29

0.61

0.38-0.45%

0.63-0.65%

Hematocrit issignificant as the percentage ofRBC in the totalvolume. Changesin RBC size willmake a differencein the test values.

Neutrophils arethe most

numerous of thecirculatingleukocytes.Phagocytosis isthe major modeof action. It is thebodys primaryline of defenseagainst infectionbecause they arethe first to arrivein theinflammatory site.


The clients neutrophilsis now decreased may

be referred to as adegenerative shiftwhen the body cannotrespond sufficiently tomature leukocytes,indicatingoverwhelming bacterialinfections.

June 21, 2005 Echocardiography/ color flow/Doppler

Echocardiogramsare used tomeasure thediameter of thecardiac chambers

and evaluateother structural

Situs solitus; AV:VAconcordance; normalsystemis and pulmovenousconnection; IVS intact;

IAS intact; good LVfunction; normal

Before:1. Explain to the patient everything about the test.2. Warn him of he might feel slight discomfort during

the test.3. Tell patient that he will be instructed to breath in

and out slowly to hold his breath or to inhale agas with slightly sweet odor.


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abnormalities ofthe heart.

cardiac chambers; withmild mitral regurgitation; slightlydilated LMCA of 2.75mm; normal RMCAand (-)pericardialeffusion; with ejectionfraction of 81 %.

4. Instruct patient to remain still during the test.After:

1. Monitor VS closely.2. Check for any abnormalities on heart sounds/

irregular heart sounds; breathing.3. Monitor condition of patient at all times.4. Give meds on time as ordered by the doctor.5. Refer to the POD accordingly for any abnormal

development on the patient.June 24, 2005 Hematology test

WBC

Hemoglobin

15.8

112

5.0-10.010^g/ul

120-140g/dl

White blood cellsare used todetermineinfection in thebody system. It isalso used todetermine theheed for WBCDifferential orbone marrowbiopsy.

Hemoglobinthrough the redblood cellstransports O2 andremoves CO2from the body. It

is used tomeasure the

The clients WBC isstill increased indicating that there isinfection in the bodysystem.


Before:11.Explain the procedure to the patient before the

procedure proper.12.Inform the patient that the test requires bloodsample and he need not fast before the test, butthat he should avoid eating heavy meal before thetest.

13.Advise the patient to avoid strenuous exercise for24 hours before the test.

14.If patient is being treated for an infection, tell himthat this test will be repeated to monitor hisprogress.


After7. Monitor Vital Signs closely, if temperature

increases do TSB and refer to POD.8. If a hematoma develops at the venipuncture site,

apply warm soaks to ease discomfort.9. Instruct patient to resume to normal activities



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Hematocrit

Lymphocytes

Neutrophils

0.33

0.22

0.78

0.38-0.45%

0.25-0.35%

0.63-0.65%

severity of anemia or polycythemia.

Hematocrit issignificant as the percentage ofRBC in the totalvolume. Changesin RBC size willmake a difference

in the test values.

Lymphocyteshave a major act ivi ty in theimmunology andimmune reactivityNeutrophils arethe most numerous of thecirculatingleukocytes.Phagocytosis isthe major modeof action. It is thebodys primaryline of defenseagainst infection

because they arethe first to arrive


The client has slightdecreased lymphocyesthough it is stillconsider to be in thenormal values.The clients neutrophilsis now decreased maybe referred to as adegenerative shiftwhen the body cannotrespond sufficiently tomature leukocytes,indicatingoverwhelming bacterialinfections.


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in theinflammatory site.

June 26, 2005 Hemoglobin

Platelet

93

830

120-140g/dl

140-40010^g/ul

Hemoglobinthrough the RBCtransports O2and removesCO2 from thebody. It is used tomeasure theseverity of

anemia or polycythemia.

Platelets are produced in thebone marrow asfragments of megakaryocytes.It is significant toevaluate plateletproduction.


The client hasincrease platelet dueto myeloproliferation ofmegakryocytes.

Before:16.Explain the procedure to the patient before the

procedure proper.17.Inform the patient that the test requires blood

sample and he need not fast before the test, butthat he should avoid eating heavy meal before thetest.

18.Advise the patient to avoid strenuous exercise for24 hours before the test.

19.If patient is being treated for an infection, tell himthat this test will be repeated to monitor hisprogress.


After10.Monitor Vital Signs closely, if temperature

increases do TSB and refer to POD.11.If a hematoma develops at the venipuncture site,

apply warm soaks to ease discomfort.12.Instruct patient to resume to normal activities



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Give health teachings:> Encourage intake of warmwater.

>Give tea with honey

Warm water loosens secretionstrapped in airways.

To lessen the irritation oflarynx.

Subjective:Pabalik-balik anglagnat niya asverbalized by therelative.

Objective: T=38.5 C Skin warm to

touch Flushed skin WBC=13.2x10

4 g/L Discomfort

Altered bodytemperature r/tpresence ofsystemicinfection.

At the end of theshift, patient willmaintain bodytemperature withinnormal range

(36.5-37.5 C)

Tepid Sponge Bath if feverexists; Sponge Bath iftemperature is withinnormal range.

Monitor temperature qH if

fever exists. Provide a cool environment. Administer antipyretics and

antibiotics as ordered.

Give Health teachings: Increase Oral Fluid Intake.

Teach watcher proper TSB.

Heat loss through evaporation.

To know the effectiveness of

intervention given. Heat loss through convection. Antipyretics lower body

temperature; Antibiotics killsand inhibits growth of bacteria

To replace fluid loss andprevent dehydration.

If the nurse is not available, themother can do it.

Patient was ableto maintain bodytemperature withinnormal range asevidenced by

T=36.9C

Subjective: Relative

verbalized,Wala siyanggana kumain.Hindi siyagaanongmakanguya.

Objective:

ImbalancedNutrition: Lessthan BodyRequirements r/tlow food intakesecondary toloss of appetite.

At the end of the 6-hour shift, thepatient will be ableto consumeadequatenourishment asmanifested by goodappetite.

Know weight, strength,activity/rest level.

Discuss patients eatinghabits including food,preferences and state oforal cavity, drug interaction,side effects and allergy.

Consider six small nutrient

dense meals than 3 largermeals.

To provide baseline for futurecomparison.

To determine if these factorsaffect patient appetite, foodintake, and absorption.

6 feedings reduce feeling of

fullness and satiety anddecreases possibility of

The patient wasable to consumeadequatenourishment asmanifested bygood appetite.


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Loss ofappetite

Dry lips Body

weakness Wt. 13 kg

Provide good oral carebefore and after meals.

Provide a pleasantenvironment and prevent orminimize unpleasant odoror sight.

Health Teaching: Do handwashing before

eating. Encourage more oral fluid

intake but limit fluid intakeat least one hour beforemeals.

vomiting. May enhance appetite.

Unpleasant environment mayhave negative effect onappetite.

To reduce presence ofmicroorganism in the hand.

Water relieves dry mouth and

may enhance appetite. Limitingfluid intake before mealsdecreases possibility of earlysatiety.

Subjective:Relative verbalized,Natatakot siya lagikapag maydumadating naka-puti.

Objectives: Slightly scared Restlessness Irritability Poor eye

contact Teary eyes

upon the

Mild anxiety r/thospitalprocedures.

Within the shift,patient will appearrelax and anxietywill be reduced asmanifested by:

Activeinteractionwith thenurse/doctor.

Absence ofirritability.

Establish a therapeuticrelationship and conveyingempathy.

Provide accurateinformation about thesituation.

Be truthful with patient,avoid bribing.

Provide comfort measures.

Modify procedures aspossible.

For patient to be at ease onhospital staff.

Helps patient to identify what isreality based.

To sooth fears and provideassurance.

To acquire resting period orrelaxing moments.

To avoid overwhelming ofpatient.

The patientappeared relaxand anxietyreduced asmanifested byactive interactionwith the nurse/doctor andabsence ofirritability.


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arrival ofnurse/doctors

Subjective:Grandmotherverbalized, Naiinipna siya dito sahospital kasi walasiyang makalaro.

Objective: Shy Untalkative Withdrawn

attitude Irritability Looks bored Seeking for

someone toplay with

Appears lonely

Impaired socialinteraction r/tprolongedhospitalization.

Within the shift,patient will beinvolved inachieving positivechanges in socialbehaviors andinterpersonalrelationshipsmanifested by

being responsiveand elicitingpositive interactionwith staff.

Note changes in socialbehavior or patterns relatingwith others.

Establish therapeuticrelationship with patient.

Encourage patientverbalization of problem.

Provide positivereinforcement by involvingfamily members withpatients care.

Provide positive feedbackwhen interacting withpatient.

Plan activity for the patient(e.g. playing with others).

Instruct watcher to interactwith patient always.

To determine underlyingproblem regarding behavior.

Establishes rapport andfacilitates interaction withpatient.

To determine feeling ofdiscomfort and problems aboutsocial situation.

For the improvement in socialbehaviors and interactions.

To develop positive socialskills.

To establish harmoniousrelationship with patient.

Facilitate interaction betweenfamily members.

Patient elicitedpositive socialbehavior asmanifested by hisresponsivenessand goodinteraction withstaff.


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E. Data from the Textbook:Definition of diagnosis:Kawasaki Disease- is an acute febrile illness with inflammation of small andmedium size blood vessels throughout the body in particular, the coronaryarteries (blood vessels around the heart). It is also known as Mucocutaneous

Lymph Node Syndrome. It is most likely caused by a very common infectiousmicroorganism that only causes problems in a small number of in predisposedindividuals.

- infectious disease caused by bacteria or bacterial superantigens (particularly Streptococcus pyogenes) and/or virus: because Kawasakidisease is rarely seen in adults, this suggests that adults may have developedimmunity with the causative agent. The disease is usually self-limiting andresolves spontaneously without treatment within 4-8 weeks.

S/S FROM THE BOOK S/SMANIFESTE

D BY CLIENT

RATIONALE

1. FEVER (ABOVE 39DEGREES CELSIUS)

When infectious bugs stimulatewhite blood cells in a specific way,they release a substance calledendogenous pyrogenes whichsignals the brains hypothalamus toraise the bodys thermostat setting.In turn, the body heats up byincreasing its metabolic rate,shivering or seeking warmenvironment.

2. CONJUNCTIVITIS Kawasaki Disease is also known asthe Mucocutaneous Lymph NodeSyndrome. The microorganismresponsible for the occurrence ofthis disease will attack and invadesome of the mucous membranes inthe body including conjunctiva. Asmicroorganism attacks, theinflammatory response of the bodywill be activated particularly causingthe conjunctiva to be inflamed.

3.CHANGES INEXTREMITIES SUCHAS PERIPHERALEDEMA, PERIPHERALERYTHEMA ANDDESQUMATION OFPALMS ANS SOLES-PARTICULARLYPERIUNGUAL PEELING

Because microorganism attacks thebody, immune response will beactivated. Basophils will dilate the

passageway including the capillariesto have more amount of blood to be

perfused so as rashes may bevisible. Dilation of passageway isnecessary to attract moremonocytes / macrophages againstmicroorganisms.

4. DRY, RED, CRACK

LIPS WITH BLEEDING

Kawasaki Disease is also known as

the Mucocutaneous Lymph NodeSyndrome. The microorganismresponsible for the occurrence ofthis disease will attack and invadesome of the mucous membranes inthe body including oral mucousmembrane. As microorganismattacks, the inflammatory responseof the body will be activated

particularly causing the oral mucousmembrane to be red and be dried.

5.OROPHARYNGEALREDDENING

Caused by tissue erythema andprominent papillae.


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6. ANEURYSMS Kawasaki Disease involvesinflammation of the blood vessels.

And because of the inflammation, itmake the blood vessel weak andmight break. Then the calcium from

the bones will fill up that break as aprocess of calcification. As a resultthere will be a smaller passage ofthe blood and much pressure willcause the aneurysm.

8.VOMITING Due to the entry of themicroorganisms responsible for theoccurrence of this disease in thehuman body, making the individualimmunosuppressed thus there willbe loss of appetite. Loss of appetite

may result to accumulation of gastricacids in the stomach makingindividual to vomit.

PTB (Primary Complex) -is chronic recurrent infections. Disease that usuallyaffects the lungs, although any organ can be affected. It is transmitted by dropletnuclei airborne droplets produced when an infected person sneeze, coughs,speaks or sings. Infection may occur when a susceptible host breathes in aircontaining droplet nuclei and the contaminated particle to reach the alveoli.

S/S FROM THETEXTBOOK S/S MANIFESTED BYPATIENT RATIONALE1. FATIGUE Because of fever, an

individual wouldexperience discomfort.The body woulddecrease the glycogenreserve that leads tohypoxia or musclewasting. Therefore, therewould be not enough

oxygen that wouldcirculate in the body.2. ANOREXIA ANDWEIGHT LOSS

Due to discomfort,anorexia and weight lossmay occur. The bacteriacauses infiltration andgranuloma whichreleases chemicals thatresults to loss of appetite.

3. COUGH: initially dry,later productive of

purulent and /or blood-tinged sputum

Cough may indicateserious pulmonary

disease. It result fromirritation of the mucusmembranes anywhere inthe respiratory tract. Dueto presence ofsecretions, the clientwould stimulate torelease these secretions.Purulent discharge is dueto infection while blood-tinged sputum appears

because of the irritationof the mucous


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membranes.

5. LOW GRADEAFTERNOON FEVERAND NIGHT SWEATS

Inhalation ofmycobacterium invadesthe alveoli that activates

the t-cells. Aninflammatory responsewould occur thatstimulates WBC torelease pyrogens thatsignals the hypothalamusto increase heat andraise the metabolic rate.

F. PROBLEM LISTDate Identification F. PROBLEM LIST

Nursing DiagnosisPrioritization

Day1

Day2

Day3

Ineffective airway clearance r/tpresence of secretion in thelung fields

High Risk for Altered BodyTemperature r/t presence ofsystemic infection

Imbalanced Nutrition: Lessthan Body Requirements r/tlow food intake secondary toloss of appetite.

Mild Anxiety r/t hospitalprocedures

Impaired Socialization r/tprolonged hospitalization


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DRUG STUDY

Name of Drug Dose, Frequency and Route Classification/Action/Indication

Contraindication/adverseReactions

Nursing Responsibilities

Penicillin (Penicillin GPotassium Penicillin GSodium Penicillin V)

200,000 U q 6 ID > anti-infectives

> binds to bacterial cell wallresulting in cell death

Pharmacokinetics:

Absorption:

- Variably absorbed fromthe GI tract. Procaineand henzathine penicillin IM absorptish isdelayed and prolongedand results in sustainedtherapeutic blood levels.

Distribution:

- Widely distributed,although CNSpenetration is poor in thepresence of uninflammedmeninges. Cross the placenta and enterbreast milk.

CHON binding: 60%

Metabolism and Excretion:

- Minimally metabolized by

> Previous hypersensitivity topenicillins (cross sensitivitymay exist withcephalosphorins)

- Hypersensitivi ty toprocaine/benzathine

(only)- Some products that

contain tartrazine andshould be avoided in patients with knownhypersensitivity.

AR:> CNS: seizures

GI: N/V, diarrhea, gastricdistress, pseudomembranouscolitis

GU: interstitial nephritis

Derm: rashes, urticaria

Hemat: eosinophilia,hemolytic anemia, leukopenia

Local: phlebitis at IV site,

pain at IM site

> Assess patient for infectionat beginning and throughoutcourse of therapy.

> Observe patient for signsand symptoms of draphylaxis(rash, pruritus, laryngeal

edema, wheezing).> Instruct patient to take med.RTC and to finish drugcompletely even if feelingbetter. Advise patient thatsharing med. May bedangerous.

> Advise patient to reportsigns of superinfection (block,furry overgrowth on tongue,loose/foul-smelling stools andallergy).


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the liver, excreted mainlyunchanged by thekidneys.

life: 30-60 mins.

Misc: superinfection, allergicreaction including Anophylaxisand serum sickness

Isoniazid (INH, Isotamine) 200/5ml 4 cc OD > anti-tubercular

> Inhibits mycobacterial cellwall synthesis and interfereswith metabolism.

Pharmacokinetics:Absorption:

- Well absorbed followingoral and IM admin.

Distribution:

- Widely distributed tomany body tissues andfluids. Readily crossesthe blood-brain barrier.Crosses the placentaand enters breast milk inconcentrations equal toplasma.

> Used as first-lineantitubercular in combinationwith other agents in the tx ofactive disease. Prevention of

tuberculosis in patient

> Hypersensitivity

- Acute liver disease- Previous hepatitis from

IsoniazidAR:>CNS: peripheral neuropathy,

seizures, psychosisEENT: visual disturbances

GI: N/V, hepatitis

Derm: rashes

Endo: gynecomastia

Hemat: blood dyscracias

Misc: fever

> Advise patient to notifyphysician/other health careprovider promptly if signs andsymptoms of hepatitis/yelloweyes and skin, N/V, anorexia,dark urine, unusualtiredness/weakness orperipheral neuritis (numbness,tingling paresthesia) occurs.

> Advise patient to take med.exactly as directed.

> Caution patient to avoid theuse of alcohol during thistherapy, as this may increasethe risk of hepatotoxicity.

> Emphasize the importanceof regular follow-up physicaland ophthalmogic exam. tomonitor progress and to checkfor side effects.


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exposed to active disease.

AM-Ambroxol (Ambroxol HCl) Children 6-12 y/o: 1 tsp bid-tidorally

.Cough and cold remedy,treatment of respiratorydisorders associated withviscous mucus.

Special precautions topregnancy and lactation

> Advise client to increase oralfluid intake to loosen up thephlegm.

> Explain to the patient thedrugs mechanism of action.

> Give the medication to theright patient, at the right time.

> Document administration ofmedication.

> Teach patient the properbreathing and coughingexercises.

Pyrazinamide 250/5 ml 7.5 cc OD oral Action: decreased bonemarrow reserve

Indication: used incombination with other agentsin the treatment of activetuberculosis

Hypersensitivity.

AR:

Frequent arthralgia, mayalgia(usually mild and self limiting),urticaria, pruritus,photosensitivity

Baseline Assessment

Question with hypersensitivityto pyrazynamide, isoniazid,ethionamide, niacin. Ensurecollection of specimen withculture, sensitivity. Evaluateresults of initial CBC, hepaticfunction test, uric acid levels.

Intervention

monitor hepatic results-be alert with hepatic

reactions: jaundice


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malaise, fever, livertenderness,anorexial/N&V, (stopdrug and notifyphysician promptly

check serum uric acidlevels

assess with hot painfuljoints esp. big toe,ankle, knee (gout)

evaluate blood sugarlevels, diabetic statuscarefully (pryrazinamidemakes managementdifficult)

assess with rash, skineruptions

Monitor CBG forthrombocytopenia,anemia.

Diphenhydramine 15 mg, IV, q8h > Antihistamine

> Blocks histamine, therebydecreasing allergic response,affects respiratory system,blood vessels, GI system.

> Acute asthmatic attack,severe liver disease, lowerrespiratory disease, neonate

> Side Effects: fatigue,drowsiness, dizziness,nausea, vomiting, urinaryretention, blurred vision, dry

> Advise patient to take withfood/fluid stomach.

> Use with caution to patientwith asthma.

> To relieve dry mouth, give

ice chip, hard candy or


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mouth, constipation sugarless gum.

> Do not give without doctorsorder.

> Report any adverse effect oruntoward effect.

Rifampicin 200/5 ml 4 cc OD oral Action: Inhibits RNA synthesisby blocking RNA transcriptionin susceptible organism.

Indication: Active tuberculosis

(with other agents).Elimination of meningococcalcarriers.

> hypersensitivity toconcurrent indenairs,nesfinavir, pyrazinamide, orsquinavir.

AR:CNS: headache, fatigue,drowsiness, dizziness, mentalconfussion, generalizednumbness

CV: shock

EENT: visual disturbance,exudative conjunctivitis

GI: epigastric distress,anorexia, nausea andvomiting, abdominal pain,diarrhea, flatulence, soremouth and tongue

GU: hemoglobinuria,hematuria

HEMATOLOGIC: eosiniphilia,

thrombocytopenia, hemagtic

> Perform mycobacterialstudies and susceptibility testprior to and periodically duringtherapy to detect possibleresistance.

> Assess lung sounds andcharacter and amount ofsputum periodically duringtherapy.

> Evaluate renal function,CBC, and urinalysisperiodically and duringtherapy.

> Monitor hepatic function atleast monthly. May increaseBUN, AST, HLT, and serumalkaline phosphatose, bilirubinand uric acid considerations.


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anemia

MUSCULOSKELETAL:osteomalacia

RESPI: shortness of breath,wheezing

SKIN: pruritus, urticuria, rash

Paracetamol 250/5 ml 3 ml q4h oral Action: Inhibits the synthesisof prostaglandins that mayserve as mediators of painand fever, primarily in theCNS. Has no significant anti-inflammatory properties or GItoxicity.

Indications: mild pain, fever.

> previous hypersensitivity> products containing

AR:

HEMATOLOGIC: hemolyticanemia, neutropenia,leucopenia, pancytopenia

HEPATIC: liver damage,jaundice

METABOLIC: hypoglycemia

SKIN: rash, urticaria

> use liquid form for childrenand patients who havedifficulty in swallowing

> in children, dont exceed 5doses in 24 hours

> advise patient that drug isonly for short term use and toconsult prescriber if giving tochildren for longer than 5 days

> warn patient that


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II IMPLEMENTATION (for charting)

NURSING DIAGNOSIS IMPLEMENTEDNURSING

INTERVENTION

EVALUATION

Ineffective airwayclearance r/t presence ofsecretion in the lungfields.

Auscultated lungfields. Elevated head of

bed 45-90. Backclapping

done. Chest

physiotherapy andpostural drainagedone.

Administered

medications asordered.

Increased oralfluid intake.

Providedadequate rest andlimited activities.

The patient was able toexpectorate secretionand maintained airway

patency.

High risk for altered bodytemperature r/t presenceof systemic infection.

Monitoredtemperature.

Sponge bath donedaily.

Increased oralfluid intake.

Administeredantipyretics andantibiotics asordered.

Provided a coolenvironment.

Patient was able tomaintain bodytemperature withinnormal range as

evidenced by T=36.9C

Imbalanced Nutrition:Less than Body

Requirements r/t lowfood intake secondary toloss of appetite.

Considered sixsmall nutrient

dense meals than3 larger meals. Provided good

oral care beforeand after meals.

Provided apleasantenvironment and

prevent orminimizeunpleasant odor

or sight. Did handwashing

before eating. Encouraged more

oral fluid intakebut limit fluidintake at least onehour beforemeals.

The patient was able toconsume adequate

nourishment asmanifested by goodappetite.

Mild anxiety r/t hospital

procedures.

Established a

therapeutic

The patient appeared

relax and anxietyreduced as manifested


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relationship andconveyingempathy.

Provided accurateinformation about

the situation. Avoid bribing. Provided comfort

measures. Modified

procedures aspossible.

by active interaction withthe nurse/ doctor andabsence of irritability.

Impaired socialinteraction r/t prolongedhospitalization.

Noted changes insocial behavior or

patterns relatingwith others.

Establishedtherapeuticrelationship with

patient. Encouraged

patientverbalization of

problem. Provided positive

reinforcement byinvolving family

members withpatients care.

Provided positivefeedback wheninteracting with

patient. Planned activity

for the patient(e.g. playing withothers).

Instructed watcherto interact with

patient always.

Patient elicited positivesocial behavior asmanifested by hisresponsiveness and

good interaction withstaff.

DISCHARGE PLANS

Date of possible discharge: A weekafter treatment

1. Medication to be taken athome:Rifampicin,Isoniazid,Pyrazinamide and Ferrous

Sulfate2. Diet: Eat foods that are nutritiousand healthy.3. Activities restricted: Avoidextraneous activities. Advise not to skipmeals.4.Special Health TeachingsProper Diet5. Check-up Schedule:

FOLLOW-UP EVALUATION(Home Visit)


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HEALTH TEACHING GUIDE

Topics: PROPER DIET

Time Allotment: 15 minutes

OBJECTIVES CONTENT TEACHINGSTRATEGY

EVALUATION

Nutrition&ActivityTo promote thenutritionalstatus andactivity of thepatient.

BreathingExercisePatternTo achievemore efficientand controlledventilation andto decrease the

work of breathing of thepatient.

HandwashingTo eliminatethe presence ofmicroorganismsand thusprevent thecause of infection.Prevents thepatient fromtransferringinfection toother people.

Advise the patient to drink thetake home medications. Also tellthe patient to increase his intakeof nutritious foods and drinks.Instruct mother of the patient to

increase fluid intake preferablyclean distilled/sterilized water.

Reference:

Promotes musclerelaxation

Relieves anxiety

Eliminates ineffective,

uncoordinated pattern ofrespiratory muscle activity

Slows the respiratory rate

Decreases the effort forbreathing

Demonstration or instruction topatient to patient:

Inhale through the noselike youre smelling thescent of a certain flower

Exhale through the mouthlike youre blowing candles

Effective handwashing requires atleast 15 seconds of vigorousscrubbing with special attention tothe area around the nail beds andin between fingers, where there isa high burden. Hands should be

thoroughly rinsed after thiswashing then dry their hands withclean towel. Do this especiallybefore and after meals.

Oralexplanation andcite someexamples offood that the

patient can eat.

Discussion withactualdemonstrationfrom nurse thena return

demonstrationfrom thepatients.

Discussion withactualdemonstrationof the nurse tothe patient.;then ask thepatient to do itwith the nursedaily sameprocedure.Lastly, askpatient todemonstrate italone to thenurse.Samedemonstrationsand return

The mother ofthe patient willbe able toverbalizeunderstanding

on the properdiet.

Patient hasprolongedexhalation.Patientdemonstratedgood breathing

exercisethroughperformingprocedureclosely as hownurse did theexercise.

Patientdemonstratedthe procedurevery well just ashow the nursehad done it.


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demonstrationswill be done bythe relatives ofpatient presentin the

discussion.

Case Pres Start Polished Chin

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