Case Study on Scarlet Fever12
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Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
College of Nursing
Case Study
On
PERFURATEDRECTUM
Presented to:
Mr. Rex Tomas, RN
Clinical Instructor
In partial fulfillment
Of the requirements in
NURSING CARE MANAGEMENT - RLE
St. James Hospital- ICU
Presented by:
GOLDWYN A. ADVERSALO
BSN IV BROMELIADS
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Republic of the Philippines
University of Northern Philippines
Vigan City
COLLEGE OF NURSING
CASE STUDY GRADING SHEET
PARAMETERS GRADE
Introduction & Objectives 5
Personal Data
Nursing History of Past & Present Illness5
PEARSON Assessment 15
Diagnostic Procedure
a. Ideal
b. Actual
5
Anatomy and Physiology 5
Pathophysiology
a. Algorithm
b. Explanation
15
Management
a. Medical & Surgical
b. NCP with Evaluation
c. Promotive & Preventive Mgt.
5
20
5
Drug Study 5
Discharge Plan 5
Updates 5Bibliography 2.5
Organization 2.5
TOTAL 100
REMARKS:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Mr. Rex Tomas, RN
CLINICAL INSTRUCTOR
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INTRODUCTION
Scarlet fever is caused by certain strains of the group A streptococci
bacteria (which also causes strep throat) and it is common to think of scarlet
fever as strep throat with a rash. Symptoms usually develop about 1 to 7 days
(incubation period) after being exposed to someone with strep throat or scarlet
fever. This is most common in children under 10 years old and begins with a fever
and sore throat. Other symptoms can include vomiting, headache, chills and
abdominal pain. Many children with this infection have a high fever initially,
which may reach 103 to 104 degrees F. Without treatment, the fever may last 5
to 7 days, but usually quickly goes down within a day after starting antibiotic
therapy. After 12 to 48 hours of developing symptoms, the infected person will
then develop a red rash, which consists of very small red bumps that begin on
the neck and groin and then spreads to the rest of the body. The rash has the
characteristic feel of sandpaper and typically lasts 5 to 6 days. The rash is
sometimes worse on the neck, elbow creases, arm pits (axilla) and groin and
once the rash fades, the skin may peel. This peeling may last up to 6 weeks.
Although the sandpapery rash does not usually occur on the face, the patients
forehead and cheeks may appear red and flushed. In addition to this flushed
appearance, there is usually a pale area around his mouth (circumoral
pallor).Another common finding is dark, hyperpigmented areas on the skin,
especially in skin creases. These areas are called Pastia's lines.The fever and rash
is usually also accompanied by a red, swollen throat and tonsils that can have a
white coating of pus, swollen glands, decreased appetite and energy
level.Another common finding is a red and swollen tongue. At first, the tongue
usually also has a white coating on it, and with the red swollen papillae of the
tongue protruding through this white coating, it gives the appearance of a
strawberry tongue.
http://pediatrics.about.com/od/symptoms/a/1006_strep_symp.htmhttp://pediatrics.about.com/od/symptoms/a/1006_strep_symp.htm -
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If scarlet fever is suspected in the patient, the doctor will probably do a
throat swab to confirm that there is infection with strep bacteria. This infection
requires treatment with antibiotics, usually penicillin. If the patient is no longer be
contagious after being on an antibiotic for 24 hours. It is important to take a
complete course of antibiotics to prevent patient from getting rheumatic fever.
This case study is focused on a patient named Clendon Ramos, 11 years
old, from Amparo Village, Caloocan City, Clendon is an incoming grade six
pupil. He was diagnosed first with atypical Kawasaki disease but later on
diagnosed with Scarlet Fever. He was confined at National Childrens Hospital in
Quezon City.
http://pediatrics.about.com/od/childhoodinfections/ig/Strep-Throat-Tests/index.htmhttp://pediatrics.about.com/od/childhoodinfections/ig/Strep-Throat-Tests/index.htm -
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OBJECTIVES
General Objectives:
After making this case study, the student nurse will be able to acquire
knowledge, skills and attitude in caring for the patient with scarlet fever.
Specific Objectives:
To learn and study the case of the patient in detailed to have enoughknowledge of the condition, and regarding on its disease process and
treatment or cure.
To obtain a comprehensive past, present and family history of patientsillness.
To assess the condition of the patient using systemic way by assessing ina cephalocaudal way to get cues for the plan of care.
To make a detailed assessment of the patient being studied followingthe PEARSON (psychosocial, elimination, activity and rest, safety,
oxygenation and nutrition) format.
To be familiar with the diagnostic procedure done to the patient andeven the actual diagnostics to be done, and to make an appropriate
nursing responsibilities for each diagnostic exams and also to study the
result and outcome of the procedure to be able to relate it on patients
condition.
To be able to trace the etiology, by establishing an appropriatePathophysiology of the disease, this includes the algorithm and its
explanation.
To familiarized the ideal and actual medical and surgical interventionsdone to the patient.
To be able to provide and implement a nursing care plan for an easyrecovery of the patient and to attain goal and objective set using
SMART (specific, measurable, attainable, realistic and time frame).
To make list of the different drugs taken and is presently taking by thepatient with their corresponding dosages, mechanism of action, side
effects/ adverse effects and together with the nursing responsibilities.
To formulate a discharge plan covering the following areas: METHOD(medications, Exercises, Treatments, Health Teachings, Out-patient
department and diet).
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PATIENTS PROFILE
PERSONAL PROFILE
Name: Precentation TorreAge: 73 years old
Sex: Female
Civil Status: Single
Religion: Roman Catholic
Date of Birth: February 2, 1939
Address: Binalangayan Sto. Domingo, Ilocos SurNationality: Filipino
MEDICAL PROFILE:
Date Admitted: June 16, 2012: Saturday
Time Admitted: 4:45 P.M
Medical Institution: St. James Hospital
Ward: Intensive Care Unit, B2
Chief Complaint: (-) Bowel movement for 2 days, abdominal
pain and tenderness
Initial Diagnosis: Acute abdomen secondary to perforated
rectum
Admitting physician: Dr. Paz
Final diagnosis: Perfurated Ischemic Rectum with Santol
Seeds
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HISTORY OF PAST AND PRESENT ILLNESS
A. PAST HISTORY
According to the patients mother, she gave birth to Clendon via Normal
spontaneous delivery attended by a midwife, Clendon had experienced minor
illnesses like common colds, fever and coughs. And whenever he had this signs
and symptoms, it was relieved by OTC drugs that are being bought by his
mother. His mother added that Clendon has no known allergy to food and drugs,
and never been hospitalized, this is his first hospital confinement. There is no
history of such hereditary diseases in his mothers side but in hisfathers side, the
grandfather has a history of hypertension.
B. PRESENT HISTORY
According to the patients mother, a week before the admission the patient is
experiencing fever, and there is a macular rash appeared on the patient
associated with itching. The mother misdiagnosed it as measles. The fever was
treated with paracetamol. The rash started on the abdomen and gradually
spread on the face and other parts of the body, there was a spontaneous
resolution of fever. After 2 days fever is still present and the mother noticed that
there is a desquamation on patients palms, fingers and toes. Two days after they
noticed the desquamation on palms, fingers and toes, the mother noted that
there is an abdominal distension but with no complaints of pain. After 1 day, the
patient complained epigastric pain that is colicky in nature. So, they decided to
bring the patient to the hospital. They brought him first at Tala Hospital located at
South Caloocan. But they referred it to National Childrens Hospital.
They admitted the patient and put it miscellaneous 3, non- infectious ward
bed number 3. He was hooked with D5 IMB 500ml to consume for 24 hours
inserted @ Right Metacarpal vein. Series of diagnostic exam was done like: CBC,
Blood typing, urinalysis and ASO titer.
According to the mother, the patient has decreased hemoglobin so they doseries of blood transfusion. Following medications are given:
Paracetamol 250mg/5ml; 5ml every 4 hours- for fever Ranitidine 25mg every 8 hours- H2 receptor antagonist
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Penicillin Na 940,000 every 6 hours ANST(-)- for bacterial infection Nifedipine 5mg PRN for BP >130/100- Calcium channel blocker: for
hypertension
Enalapril 2.5mg 1tab BID- Angiotensin Coverting enzyme inhibitor; forhypertension
Recently they requested for 2D echo and Anti DSDNA but the patient is not
yet subjected for this kind of diagnostic procedure due to financial problem.
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PEARSON ASSESSMENT
APRIL 26,2011 (10:00am-2:00pm) APRIL 27, 2011 (10:00am-2:00pm)
The patient is 74 years old female, presently living at Sto.
Domingo Ilocos Sur
She is restless and disoriented.
According to Erik Ericksons theory of Psychosocial
Development, patient is under industry versus inferiority
stage. He is under industry because; he is able to do
simple house works and knows what to do when his mother
left them together with his sister specially when going to
school.
Upon arrival to the ICU, the patient is
still restless and disoriented
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The oral mucosa of the patient is dry.
With NGT opened to drained connected to a bedside botlle
with greenish output and minimal discharge.
She has an Indwelling Fulley Catheter connected to Hbag
draining yellowish output with adequate amount during the
entire shift
Her urine is being measured hourly.
(-) Bowel movement in the entire shift.
Patient has a penrose drain
The oral mucosa of the patient is dry.
With NGT opened to drained connected
to a bedside botlle with greenish output
and minimal discharge.
She has an Indwelling Fulley Catheter
connected to Hbag draining yellowish
output with adequate amount during
the entire shift
Her urine is being measured hourly.
(-) Bowel movement in the entire shift.
Patient has a penrose drain
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ACTIVITY
Patient is on bed restless.
The patient cannot able to perform ADL because of
restlessness, and restraints.
She attempts to get out from bed.
REST
The patient is restless
She gets a period of sleeps when given sedatives .
Has no other disturbances during her sleeps except when
nurse take hers vital signs.
ACTIVITY
Patient is on bed restless.
The patient cannot able to perform ADL
because of restlessness, and restraints.
She attempts to get out from bed.
REST
The patient is restless
She gets a period of sleeps when given
sedatives .
Has no other disturbances during her sleeps
except when nurse take hers vital signs.
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Patient has a restraints on both upper and lower extremities
due to restlessness and she wants to get up from bed.
He has no allergy to foods and drugs.
With body temperature of 37.8 C/ axilla, febrile, skin is warm
to touch.
With dry dressing on the operative site
With dry and crackly lips.
The room of the patient is clean, with fluorescent lights and
ventilated with air condition.
WBC is 7.7, on its normal range
Patient has a restraints on both upper
and lower extremities due to restlessness
and she wants to get up from bed.
He has no allergy to foods and drugs.
With body temperature of 38.7 C/ axilla,
febrile, skin is warm to touch.
With dry dressing on the operative site
With dry and crackly lips.
The room of the patient is clean, with
fluorescent lights and ventilated with air
condition.
No CBC done for this day
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RR is 32 cpm initially before the intubation
With Oxygen support via face mask regulated to 4-6LPM
PR is 140 bpm
Difficulty in breathing was observed manifested by grunting.
Use of accessory muscles notified.
Oxygen saturation is 100% initially before desaturation occurs
Capillary refill time is 2 seconds.
No cyanosis in the nail beds and lips was observed.
The hemoglobin is 116, in normal range
With ETT connected to Mechanical Ventilator with the
following set-up:
AC mode, TV- 450ml, BUR- 18, and FIO2- 40%
PR is 120 bpm
O2 saturation: 98%
Capillary refill time is 2 seconds.
No cyanosis in the nail beds and lips was
observed.
Still with ETT connected to Mechanical
Ventilator with the following set-up:
AC mode, TV-450ml, BUR- 14, FIO2- 40%,
and peak rate of 60.
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Diet is NPO
With NGT
With an IVF of D5 LRS 1L @ 41 drops per minute infusing well @
Left arm.
Diet is NPO
With NGT
With an IVF of D5 LRS 1L @ 41 drops per
minute infusing well @ Left arm.
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ACTUAL DIAGNOSTIC EXAMS
CBCPARAMETERS NORMAL 1ST INDICATION
Hemoglobin
Mass
140-180g/L 80 the hemoglobin is decrease which may
indicate various anemias.
Hematocrit 0.40-0.54 0.26 Decreased, may indicate severe anemias
Leukocyte
Count
5-10x10^9/L 8.8 Normal
Defferential Count
Segmenters 0.40-0.75 0.66 Normal
Lymphocytes 0.20-0.40 0.30 Normal
Monocytes 0.00-0.07 Normal
Eosinophils 0.00-0.05 0.04
Normal
Reticulocytes 0.5-2% -- --
Platelet Count 150-
400x10^9/L
455 Increased may indicate malignancy,
myeloproliferative disease.
Coaglation
Studies
-- --
Prothrombin
Time
11-15secs -- --
% 70-120 -- --
Activity -- --
Active PTT -- --
RH typing -- --
CRP
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NURSING RESPONSIBILITIES:
Tell the patient that when the needle is inserted to draw blood,
he may feel moderate pain, or only a prick or stinging
sensation. Afterward, there may be some throbbing.
URINALYSISURINALYSIS- is a used as a screening and/or diagnostic tool because it can help
detect substances or cellular material in the urine associated with different
metabolic and kidney disorders. It is ordered widely and routinely to detect any
abnormalities that require follow up. Often, substances such as protein or
glucose will begin to appear in the urine before patients are aware that they
may have a problem. It is used to detect urinary tract infections and other
disorders of the urinary tract. In patients with acute or chronic conditions, such
as kidney disease, the urinalysis may be ordered at intervals as a rapid method
to help monitor organ function, status, and response to treatment.
PHYSICAL
APPEARANCE
NORMAL RESULT IMPLICATION
COLOR AMBER YELLOW REDDISH YELLOW Medications. Anumber of drugs
can darken urine,
including the
antimalarial drugs
chloroquine and
primaquine; the
antibiotic
metronidazole;
nitrofurantoin,
which treatsurinary tract
infections;
laxatives
containing
cascara or senna;
and
methocarbamol,
a muscle relaxant.
Medical
conditions. Some
liver disorders,
especially
hepatitis and
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cirrhosis, and the
rare hereditary
disease
tyrosinemia canturn urine dark
brown. So can
acute
glomerulonephritis,
a kidney disease
that interferes with
the kidney's abilityto remove excess
fluid and waste.
TRANSPARENCY CLEAR HAZY Turbidity or
cloudiness may be
caused by
excessive cellular
material ( such as
the presence of
RBC's and pus
cells) or protein in
the urine or may
develop from
crystallization or
precipitation of
salts upon
standing at room
temperature or in
the refrigerator.
REACTIVITY ACIDIC ACIDIC NORMAL
SPECIFIC GRAVITY 1.000-1.038 1.010 NORMAL
CHEMICALS
PROTEIN NEGATIVE +3 Indicates
proteinuria
Protein in the urine
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can be a
symptom of
kidney stones,
inflammation ofthe kidneys,
degenerative
kidney disease
SUGAR NEGATIVE NEGATIVE NORMAL
MICROSCOPIC
RBC NEGATIVE OVER 100/HPF Hematuria is the
presence ofabnormal
numbers of red
cells in urine due
to: glomerular
damage, tumors
which erode the
urinary tract
anywhere along
its length, kidney
trauma, urinary
tract stones, renal
infarcts, acute
tubular necrosis,
upper and lower
uri urinary tract
infections,
nephrotoxins, and
physical stress.
PUS NEGATIVE 30-35/HPF severe urinary
tract infection
which may
ascend upwards
into ureter and
kidneys
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EPITHELIAL NEGATIVE OCCASIONAL represent possible
contamination of
the specimen with
skin flora.AMORPHOUS
URATE
FEW May be due to the
process of
refrigeration
NURSING RESPONSIBILITIES:
Instruct patient to drink plenty of water
Teach patient how to catch urine
Instruct patient to bring specimen immediately to the laboratory
When results are in refer it to the doctor.
ASO TITERPROCEDURE REFERENCE VALUE RESULT IMPLICATION
ANTI STREPTOLYSIN
O TITER
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IDEAL DIAGNOSTIC PROCEDURES
COMPLETE BLOOD COUNT
A complete blood count is a non-specific test. It is done to
determine the severity of the infection. If the white blood count is very
high, this is suspicious for a worse infection, such as bacteremia orsepsis. If
there is suspicion of this, a blood culture is needed. A complete blood
count also indicates the level of platelets in the blood. A very high level of
platelets (above 1,000,000), may indicate Kawasaki disease instead of
scarlet fever.
Definition
A complete blood count (CBC) test measures the following:
The number of red blood cells (RBCs)
The number of white blood cells (WBCs)
The total amount of hemoglobin in the blood
The fraction of the blood composed of red blood cells (hematocrit)
The size of the red blood cells (mean corpuscular volume, or MCV)
The CBC test also provides specific information the size and hemoglobin content
of individual red blood cells. This is determined from the additional following
measurements:
Mean corpuscular hemoglobin (MCH)
Mean corpuscular hemoglobin concentration (MCHC)
The platelet count is also usually included in the CBC.
Alternative Names
Complete blood count
How the test is performed
Blood is typically drawn from a vein, usually from the inside of the elbow or the
back of the hand. The site is cleaned with germ-killing medicine (antiseptic). The
health care provider wraps an elastic band around the upper arm to apply
pressure to the area and make the vein swell with blood.
Next, the health care provider gently inserts a needle into the vein. The blood
collects into an airtight vial or tube attached to the needle. The elastic band is
removed from your arm.
Once the blood has been collected, the needle is removed, and the puncture
site is covered to stop any bleeding.
In infants or young children, a sharp tool called a lancet may be used to
puncture the skin and make it bleed. The blood collects into a small glass tube
http://wiki.medpedia.com/Bloodhttp://wiki.medpedia.com/Sensitivity_and_Specificityhttp://wiki.medpedia.com/Sepsishttp://wiki.medpedia.com/Kawasaki_Diseasehttp://www.healthline.com/galecontent/blood-counthttp://www.healthline.com/adamcontent/hemoglobinhttp://www.healthline.com/adamcontent/hematocrithttp://www.healthline.com/adamcontent/rbc-indiceshttp://www.healthline.com/adamcontent/platelet-counthttp://www.healthline.com/adamcontent/platelet-counthttp://www.healthline.com/adamcontent/rbc-indiceshttp://www.healthline.com/adamcontent/hematocrithttp://www.healthline.com/adamcontent/hemoglobinhttp://www.healthline.com/galecontent/blood-counthttp://www.healthline.com/galecontent/blood-counthttp://wiki.medpedia.com/Kawasaki_Diseasehttp://wiki.medpedia.com/Sepsishttp://wiki.medpedia.com/Sensitivity_and_Specificityhttp://wiki.medpedia.com/Blood -
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called a pipette, or onto a slide or test strip. A bandage may be placed over
the area if there is any bleeding.
How to prepare for the test
There is no special preparation needed.
How the test will feel
When the needle is inserted to draw blood, you may feel moderate pain,
though most people feel only a prick or a stinging sensation. Afterward there
may be some throbbing orbruising.
,NORMAL VALUES
PARAMETERS NORMAL
Hemoglobin Mass 127-183g/L
Hematocrit 0.37-0.54
Leukocyte Count 4.5-10x10^9/L
Defferential Count
Segmenters 0.50-0.70
Lymphocytes 0.20-0.40
Monocytes 0.00-0.07
Eosinophils 0.00-0.05
Reticulocytes 0.5-2%
Platelet Count 150-400x10^9/L
Coaglation Studies
Prothrombin Time 11-15secs
% 70-120
Activity
Active PTT
RH typing
CRP
Semi-quantitative CRP
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ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
ALOGORITHM
EXPLANATION
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MANAGEMENT
MEDICAL AND SURGICAL MANAGEMENTS
MEDICAL MANAGEMENT
IDEAL
ACTUAL MEDICAL MANAGEMENT
IV FLUIDS:
D5 IMB 500ml to run for 24 hours PNSS 500ml to run for 24 hours
MEDICATIONS:
Paracetamol 250mg/5ml; 5ml every 4 hours- for fever Ranitidine 25mg every 8 hours- H2 receptor antagonist Penicillin Na 940,000 every 6 hours ANST(-)- for bacterial infection Nifedipine 5mg PRN for BP >130/100- Calcium channel blocker: for
hypertension
Enalapril 2.5mg 1tab BID- Angiotensin Coverting enzyme inhibitor; forhypertension
OTHERS:
Blood transfusion due to decrease hemoglobin count
SURGICAL MANAGEMENT
IDEAL SURGICAL MANAGEMENT
ACTUAL SURGICAL MANAGEMENT
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PROMOTIVE AND PREVENTIVE MANAGEMENT
A.PROMOTIVE MANAGEMENT
o Provide a soft or liquid diet for a few days until their throat soreness has
diminished to prevent dryness of the skin which increases discomfort. Soft
liquid diet is less irritating to patients sore throat.
o Give analgesic or antipyretic such as acetaminophen or childs ibufropen
for pain or fever.
o Provide comfort measures because the rash tends to be pruritic.
o Complete 10 day coarse of penicillin
o Apply calamine lotions or use colloidal baths in lukewarm water as
indicated because it help soothe the skin and decreases itching
o
Instruct patient to press on the itchy area rather than scratch becausepressing the area may help to diminished the itching sensation.
o Apply cool compress to the area to decrease inflammation, and help
soothe the itching sensation.
o Encourage the patient to participate in wound dressings, participation of
the patient provides purposeful activity and helps to promote a feeling of
control.
o Provide divertional activities to divert attention from the itch.
o Dress the patient in cool, lightweight, cotton clothing because
perspiration and overheating worsen itching, further irritating the skin.
B. PREVENTIVE MANAGEMENT
IN AVOIDING COMPLICATION:
Although most cases are mild, some children and adults can become very
sick with scarlet fever. If left untreated for long enough:
o The infection can spread to the blood and cause bacteremia,
pneumonia, or sepsis. Meningitis is rare.
o If left untreated, even if the illness resolves, the individual can be at risk of
developing rheumatic fever or rheumatic heart disease. These are
autoimmune diseases where the body starts attacking cells of the body
that resemble portions of the Streptococcus bacteria.
o Streptococcal glomerulonephritis can occur after a case of strep throat,
impetigo, or scarlet fever, usually about 7-14 days afterwards. This disease
cannot be prevented with treatment with antibiotics. Fortunately, this
disease is usually self-limiting and resolves in about two weeks.
IN PREVENTING OCCURENCE OF THE DISEASE:
o Avoiding exposure to children who have the disease will help prevent thespread of scarlet fever.
o Handwashing is key to the prevention of strep throat. Children with strep
throat or scarlet fever should be kept at home, as they are contagious.
They remain contagious for about 3-4 hours after antibiotics have
reached a steady, effective concentration in their body.
http://wiki.medpedia.com/Bacteremia?action=edit&redlink=1http://wiki.medpedia.com/Pneumoniahttp://wiki.medpedia.com/Meningitishttp://wiki.medpedia.com/Autoimmune_Diseaseshttp://wiki.medpedia.com/Cellshttp://wiki.medpedia.com/Glomerular_Diseaseshttp://wiki.medpedia.com/Impetigohttp://wiki.medpedia.com/Clinical:Hand_Washing:Why,_When,_and_Howhttp://wiki.medpedia.com/Clinical:Hand_Washing:Why,_When,_and_Howhttp://wiki.medpedia.com/Impetigohttp://wiki.medpedia.com/Glomerular_Diseaseshttp://wiki.medpedia.com/Cellshttp://wiki.medpedia.com/Autoimmune_Diseaseshttp://wiki.medpedia.com/Meningitishttp://wiki.medpedia.com/Pneumoniahttp://wiki.medpedia.com/Bacteremia?action=edit&redlink=1 -
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o This can vary by individual. To ensure the health of other children, children
should stay home until at least 24 hours after their first dose of antibiotics.
o Adequate and quick treatment of strep throat can prevent most cases of
scarlet fever. However, some cases may present with both scarlet fever
and strep throat. In some rare cases, scarlet fever may arise without anyrecognized symptoms of strep throat. Sometimes, scarlet fever occurs as
early as one day after the onset of strep throat.
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NURSING CARE PLANASSESSMENT
(S&O)
DIAGNOSIS ANALYSIS PLANNING NURSING
INTERVENTION
RATIONALE EVALUATION
SUBJECTIVE:
Nahihilo siya,
mataas kasi ang
BP niya as
verbalized by the
patients mother
OBJECTIVE:
-fairly active
-decrease
muscle strength
V/S taken as
follows:
BP- 110/80mmHg
P> Injury risk for
E> r/t dizziness
S> as evidenced
by mothers
verbalization of
Nahihilo siya,mataas kasi ang
BP niya .
BP- 110/80mmHg
Causes
Presence of
health threats
(dizziness)
Body weakness
Risk for falling
Possible
consequences
like injury
(med surge
Nsg.6th ed)
04-26-11
10 AM-2:00PM
After 4 hours of
nursing
interventions,
Within the shift,
the mother willbe able to
acquire
knowledge
regarding the
consequences of
falling and injury
with proper
health teachings.
Independent:
-provide
environmental
safety
-assist patient in
walking or goingto CR
-raise side rails if
patient is alone
-instruct patients
significant others
not to leave the
patient alone
-provide pillows if
side rails notavailable
-instruct patient to
have a rest
-to prevent injury
-patient is
experiencingdizzeness so
most likely he is
prone to be
injured
-raising side rails
prevents the
patient from
falling
-so that the
patient have an
assistance in
doing activities
of daily living
-to prevent
patient fromfalling on bed.
-rest may relieve
the dizziness
04-26-11
LEVEL OF
ATTAINMENT:
GOAL met as
evidenced by:The mother
understands the
health teachings
regarding the risk
of injury to the
patient.
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-Have a proper
ventilation
Collaborative:
- Administer
medications as
indicated (
calcibloc 5mg for
BP greater than
130/100).
INDEPENDENT:
Review disease
process,
patient or
parents
expectation.
Explain all
-it may aid
dizziness
-this drugs may
relieve increase
in BP thus
decreasing
dizziness.
.
Provides
knowledge
base fromwhich patient
can make
informed
therapy
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SUBJECTIVE
hindi ko alam
kung ano yan
ang
pagkakaalam ko
eh tigdas siya as
verbalized by the
patients mother
P> Knowledge
deficit regarding
condition,
treatment, self-
care and
discharge needs.
E> R/T unfamiliarity
with the
disease/condition.
S> As evidenced
by inaccurate
follow through of
instructions orasking questions
regarding the
disease.
Knowledge
deficit is a
condition in
which the client
or the nearest kin
dont have
enough
knowledge
about the
disease. This is
evidenced by
lack of skill in
performing
proper hygiene
and or takinginappropriate
medications or
not participating
in
04-26-11
10 AM-2:00PM
Within the shift,
the nearest kin
will be able to
understand the
disease process
and will
participate in the
treatment
regimen.
procedures
done to the
patient.
Explain the
importance of
treatment
regimen.
COLLABORATIVE:
Refer to the
physician so
that the
physician will
explain the
disease
choices.
In order for
them to be
informed and
have
knowledge
with the
procedure.
For the faster
recovery ofthe patient.
The physician
has a wider
knowledge
about the
disease in
terms of
management
and the
disease itself.
04-26-11
Level of
attainment: Goal
met
AEB: the mother
acquired
sufficient
knowledge on
the disease
process and
participates on
the care of the
patient.
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Mothers
verbalization of
hindi ko alam
kung ano yan
ang
pagkakaalam ko
eh tigdas siya
.
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DRUG STUDY
NAME AND
DOSAGE
INDICATION MECHANISM OF
ACTION
CONTRAINDICATION ADVERSE EFFECTS NURSING RESPONSIBILITIES
Nifedipine
5 mg PRN for
BP> 130/100 S.L
Hypertension Inhibits the influx of
calcium ions into
cardiac and
smooth-muscle
cells; reducesstrength of heart-
muscle
contraction,
reduces
conduction of
impulses in the
heart and causes
vasodilation.
Reduces blood
pressure and
prevents angina.
Contraindicated in
patients
hypersensitive to
drug or any of its
components. Use cautiously in
patients in those
with heart failure or
hypotension.
Use extended-
release tablets
cautiously in
patients with severe
GI narrowing
because obstructive
symptoms may
occur.
CNS: headache,
dizziness
CV: flushing, heart
failure, hypotension
GI: abdominaldiscomfort, diarrhea,
nausea
Observe the 10 rights in
administering the drug.
Assess patients condition before
during and after therapy Monitor blood pressure regularly
thereafter
Monitor patients potassium level.
Avoid taking drug with grape juice.
Do not crush or chew extended
release tablet.
Do not give the drug if the blood
pressure is below 100 or 60
Penicillin
Sodium
940,000 units IV
Q6
Bacteria(Strept
ococcal)infection such
as scarlet fever
Inhibits cell wall
synthesis duringmicroorganism
multiplication.
Kills susceptible
Contraindicated in
patientshypersensitive to the
drug or other
penicillins.
CV: thrombophlebitis,
Hematologic:hemolytic anemia,
leucopenia,thromboc
ytopenia
Observe the 10 rights in
administering the drug. Assess patients condition before
during and after therapy.
Obtain history of allergy to penicillin
and cephalosporin before giving
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bacteria. Use cautiously in
patients with other
drug allergies,
especially to
cephalosporins and
cephamycins.
Other: hypersensitivity
reactions.
first dose.
Obtain culture and sensitivity
before giving the first dose.
When given intravenously, inject
slowly.
Monitor renal and hematopoietic
function.
Increase fluid intake.
Continue the medication even
after the disease is gone for 1 week.
Enalapril
2.5 mg tab BID
P.O
Hypertension
Inhibits the actionof angiotensin,
which results in
decreased
vasopressor
activity and
decreased
aldosterone
secretion.
Lowers blood
pressure.
Contraindicated inpatients
hypersensitive to
drug or any of its
components.
In patients with
history of
angioedema from
ACE inhibitor.
In patients with
renal impairment,
especially those
with bilateral renal
artery stenosis in a
single or unilateral
renal artery stenosis
in a singlefunctioning kidney.
CNS: dizziness,headache, fatigue
CV: hypotension
GI: abdominal pain,
diarrhea
Observe the 10 rights inadministering the drug.
Obtain patients blood pressure
before giving first dose.
If angioedema occur, notify the
physician and stop the drug
immediately.
Monitor patients vital signs
specially BP.
Instruct patient to avoid sodium
substitutes.
Monitor potassium level.
Monitor CBC before, during and
after therapy.
Rise slowly to avoid orthostatic
hypotension.
Report signs of angioedema suchas difficulty of breathing and
swelling of face, eyes, lips or
tongue.
Light-headedness can occur
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especially during first few days of
therapy.
Paracetamol
250 tab Q4 PRN
For mild pain or
fever
Relieves pain and
reduces fever
Hypersensitivity to drug.
In patients with history
of liver diseases and
chronic alcoholism.
Hematologic: hemolytic
anemia, leukopenia,
neutropenia,
pancytopenia,
thrombocytopenia
Hepatic: liver damage,
jaundice
Metabolic: hypoglycaemia
Observe the 10 rights in administering the
drug
Assess pts pain or temp. before and
during therapy
Be alert for adverse reactions and drug
interactions.
Monitor liver function.
Do not take with alcohol.
Maybe taken without food.
Ranitidine
25 mg IV Q8
Self medication
for occasional
heartburn, acid
indigestion and
sour stomach
Inhibits the action of
H2-receptor sites of
parietal cells,
decreasing gastric acid
secretion.
Relieves GI
discomforts.
Hypersensitivity to drug
or any of its
components.
Use cautiously in
patients with hepatic
dysfunction.
CNS: vertigo.
GI: abdominal discomfort,
constipation,diarrhea,
nausea and vomiting
Hematologic: reversible
leukopenia, pancytopenia,
thrombocytopenia
Skin: rash
Other: anaphylaxis,
angioedema, burning
sensation at injection site.
Observe the 10 rights in administering the
drug.
Assess GI condition before starting the
therapy.
Take drug with or without food.
Take drug once daily at bed time.
Should not be taken with antacid, it may
interfere the absorption.
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DISCHARGE PLANNING
o Penicillin sodium x 7 days, 8am- for prophylaxis
o Enalapril 2.5mg per orem 8am and 6pm- for
hypertension
o Nifedipine 5mg as needed
o Follow strict medication compliance
o Avoid not following schedules of medication
to prevent drug-resistance
o Follow proper order dose of drugs to achieve
drug reactions
o Avoid OTC drugs that is not prescribed by the
physician
o moderate exercises: active ROM exercise
like:
Walking biking
o Allow child to play in moderation
o Avoid lifting heavy objects
o Avoid extraneous activities
o Strict medication compliance
o Treat signs and symptoms like fever, rash,
headache, dizziness
o Intake of vitamin c and d to strengthenimmune system.
o Assistance of the family for physical therapy
or activities of the patient
o Continuous moderate active ROM exercises
o Strict medication compliance
o Promote proper skin care
o Promote hand washing to prevent infectiono Promote proper nutrition
o Intake of vitamin c to strengthen immune
system
o Monitor signs and symptoms of infection
o Monitor complications like:
Acute rheumatic fever Bone or joint
problems(osteomyelitis,arthritis)
Ear infection (otitis media) Inflammation of a gland (adenitis) or
abscess
Kidney damage (glomerulonephritis) Liver damage (hepatitis) Meningitis
http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003940/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000437/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001243/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000638/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001353/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000484/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001154/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000680/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000680/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001154/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000484/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001353/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000638/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001243/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000437/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003940/ -
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Pneumonia Sinusitis
Go for follow-up check up and update
health by going to regular check-up
Continue medications as prescribed by the
doctor
Go for check up if patients experience
dizziness
Consult doctor if signs and symptoms of
scarlet fever occur
Diet for age with SAP
Increase protein intake
Eating foods like: egg, meat, beans and
legumes
High carbohydrate diet
Foods like: bread, rice and pastries
Low salt low fat diet
Foods like: fish, meat
http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000145/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000647/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000647/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000647/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000145/ -
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UPDATES
Bibliography
BOOKS
Bare, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical
Nursing. 10th Edition Philadelphia: I.B Lippincott Company. 2004.
Nettina, Sandra M., Manual of nursing Practice. 7th Edtion. I.B. Lippincott
Company. 2001.
Rozler, Barbara et al. Fundamentals of Nursing. 5th Edition. Newyork:
Addison-Weatleylongman, Incorporated. 1998.
Marleb, Elaine N. Essential of Human Anatomy and Physiology. 7th Edition.
Singapore. Pearson Education South Asia Pte. Ltd. 2004.
Potter, Patricia and Perry, Anne. Fundamentals of Nursing. 6th Edition
Baltimore: C.V. Mosby and Company. 2005.
Doenges, M., Moorhouse, M.F. , GeisslerMurr, A. Nurses Pocket Guide,
Diagnosis, interventions and rationales, 9th Edition (2004).
Doenges, M., Moorhouse, M.F. , GeisslerMurr, A., Nursing Care Plans.
Guidelines for Individualizing Patient Care. 6th
Edition. F.A. DavisCompany, 2002.
INTERNET
http://en.wikipedia.org/wiki/Scarlet_fever
http://en.wikipedia.org/wiki/Scarlet_feverhttp://en.wikipedia.org/wiki/Scarlet_feverhttp://en.wikipedia.org/wiki/Scarlet_fever -
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http://pediatrics.about.com/cs/commoninfections/a/scarlet_fever.htm
http://wiki.medpedia.com/Scarlet_Fever
http://medical-dictionary.thefreedictionary.com/scarlet+fever
http://kids.emedtv.com/scarlet-fever/scarlet-fever-in-children-p2.html
http://www.healthline.com/adamcontent/throat-swab-culture#ixzz1KdJRA7Qb
http://www.healthline.com/adamcontent/physical-examination#ixzz1KdKP7WuU
http://www.wrongdiagnosis.com/s/scarletina_scarlet_fever/book-diseases-
http://pediatrics.about.com/cs/commoninfections/a/scarlet_fever.htmhttp://pediatrics.about.com/cs/commoninfections/a/scarlet_fever.htmhttp://wiki.medpedia.com/Scarlet_Feverhttp://wiki.medpedia.com/Scarlet_Feverhttp://medical-dictionary.thefreedictionary.com/scarlet+feverhttp://medical-dictionary.thefreedictionary.com/scarlet+feverhttp://kids.emedtv.com/scarlet-fever/scarlet-fever-in-children-p2.htmlhttp://kids.emedtv.com/scarlet-fever/scarlet-fever-in-children-p2.htmlhttp://www.healthline.com/adamcontent/throat-swab-culture#ixzz1KdJRA7Qbhttp://www.healthline.com/adamcontent/throat-swab-culture#ixzz1KdJRA7Qbhttp://www.healthline.com/adamcontent/physical-examination#ixzz1KdKP7WuUhttp://www.healthline.com/adamcontent/physical-examination#ixzz1KdKP7WuUhttp://www.healthline.com/adamcontent/physical-examination#ixzz1KdKP7WuUhttp://www.healthline.com/adamcontent/throat-swab-culture#ixzz1KdJRA7Qbhttp://kids.emedtv.com/scarlet-fever/scarlet-fever-in-children-p2.htmlhttp://medical-dictionary.thefreedictionary.com/scarlet+feverhttp://wiki.medpedia.com/Scarlet_Feverhttp://pediatrics.about.com/cs/commoninfections/a/scarlet_fever.htm