Medical Case Study

7/29/2019 Medical Case Study

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Pneumonia is the inflammation of the lung

caused by bacteria in which the air sacs

become filled with inflammatory cells and thelung becomes solid. The symptoms include

those of any infection (fever, malaise,

headache, etc.,) together with cough andchest pain.

It is estimated that, worldwide, some 4 million

children under five years of age, die each

year from acute respiratory infection (ARI)

with the most of these deaths caused

by pneumonia in developing countries.
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In 1989, when the program for ControlAcute Respiratory Infections (CARI) of

the Philippines was launched, the death tollfrom pneumonia among children under the ageof five years was 25,000. The latest statistics(2006) disclosed that almost 60 out of 1000

children under five children sufferfrom pneumonia and five in every 11,000 diefrom the disease. The Department ofHealth believes that if health workers used a

standard method of detecting and managingARIs specially pneumonia, infant deaths couldbe cut by half, saving 50,000 lives a year.Pneumonia can be categorized by type of

infiltrate: lobar pneumonia and
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Acute gastroenteritis is usually caused bybacteria and protozoan. In the Philippines, one

of the most common causes of acutegastroenteritis is E. histolytica. The pathologicprocess starts with ingestion of focallycontaminated food and water. The organism

affects the body through direct invasion and byendotoxin beingreleased by the organism. Through these twoprocesses the bowel mucosal lining is

stimulated and destroyed the eventually lead toattempted defecation or tenesmus as the bodytries to get rid of the foreign organism in thestomach.


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The client with acute gastroenteritis may

also report excessive gas formation that

may leads to abdominal distention andpassing of flatus due to digestive and

absorptive malfunction in the system.

Feeling offullness and the increase motility of the

gastrointestinal tract may progress to

nausea and vomiting and increasing

frequency of defecation. Abdominal pain

and feeling of fullness maybe relieved only

when the

patient is able to pass a flatus.


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These are the two illnesses diagnosed

by the client in this Case Study; the client

is experiencing Acute Gastroenteritis withMild Dehydration accompanied by

Pneumonia. Based on Statistics

conducted Las 2010 of January involvingall countries all over the world, these two

disease are seldom seen together at a

time, but is possible. Furthermore, allthese diseases are can be easily cured but

if not treated accordingly, about 58-65%

may lead to Death.


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General Objective:

Upon presentation of the case

Acute Gastroenteritis with mild

dehydration and Bronchopneumonia,Group 2 of BSN 3A will be able to

facilitate learning in the delivery of

quality nursing care to a patient withAcute Gastroenteritis with mild

Dehydration and Bronchopneumonia.


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Specific ObjectivesKNOWLEDGE:

1. Define Acute Gastroenteritis with mild Dehydration

and Bronchopneumonia.

2. List the clinical manifestations present in a client with

Acute Gastroenteritis with mild Dehydration and

Bronchopneumonia.

3. Enumerate predisposing and precipitating factors of

Acute Gastroenteritis with mild Dehydration and

Bronchopneumonia.

4. Discuss the disease process of Acute Gastroenteritiswith mild

5. Dehydration and Bronchopneumonia.

6. Evaluate the effectiveness of the nursing interventions

rendered to the client.


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SKILLS:

1. Present a clear and precise case study

about Acute Gastroenteritis.

2. Provide an environment conducive for

learning and discussion.

3. Expound a thorough and completeassessment data obtained from the client.

4. Maximize the time allocated for the case

presentation.5. Employ critical thinking in answering

questions thrown during the case

presentation.


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ATTITUDE:1. Maintain privacy and confidentiality of the

client at all times.2. Observe proper behaviour although out the

case presentation.3. Observe punctuality in initiating the case

presentation.4. Accept corrections, suggestions and

comments as means of improvement.5. Ask for spiritual guidance before and after

the case presentation.6. Establish collaborative and harmonious

relationship within the group.


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Date of admission: September 19, 2011

Time of admission: 10:45 am

Chief complaint: LBM and VomitingAdmitting diagnosis: Acute Gastroenteritis

with mild Dehydration

Principal diagnosis: Acute Gastroenteritiswith mild Dehydration and

Bronchopneumonia

Attending physician: Dr. B Weight: 11 kgs

Height: 0.73 m

BMI: 20.75 kgs/m2


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VITAL SIGNS UPON ADMISSION:

Cardiac Rate- 92 bpm

TEMP- 38.7 OC

RR- 43 cycles per minute

DIET: (24 Hour DIET Recall)

BREAKFAST: Rice and hotdog with milk

(Breastfeed)

LUNCH : Rice, fried fish, smashed squash

DINNER: Rice, milk and one pc. Banana

and water


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GENERAL APPEARANCE

The patient was lying on bed, she is weakand flushing of skin especially on the face

noted. The childs height and weight is normal

for her age. Curly and short hair with twoupper incisor of the tooth lacking, sunken and

sleepy eyes, her skin are drying especially on

her oral mucousa. The child doesnt want to

eat and with frequent episodes of cough, thechild is continuously raising her both

shoulders up and down, an indication that she

has Difficulty in Breathing.


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The patient was first admitted at

VGDH when she was 7 months old

and was diagnosed of having acute

gastroenteritis. During her first

admission, she was confined at the

hospital for 3 days. Several days after

discharged from the hospital, mother

verbalized that her daughter was

experiencing frequent coughs and

fever. The child is not allergic to any

drug administered during her

confinement nor to an food re ared.


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The night before the patient was

admitted at VGDH last September 19, 2011,

the mother verbalized Gabi-I kay

nakulbaan na jud ko, sunod-sunod na iyang

pagkalibang tubig, gahilanat pa pagka

dasun galibug akong ulo kung nganong

nabudlayan na siyag gulpig hangup ughangin.

Before the illness developed, the child

was experiencing continuous productive

cough that leads to difficulty of breathing.

The mother stated that the childs illness

was due to the water she drinks from the

deep well. The child was not able to eat her


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Th hild b tf d b h th til


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The child was breastfed by her mother up until

the age of 10 months. The child was fed with

vegetables like squash and eggplants at the age of

11 months. She prefers to eat fruits like bananas andmangoes. For her 24 hour diet recall, her breakfast

consists of bread, one banana and a bottle of milk.

She does not have any solid food for lunch, she just

consumes another bottle of formula milk. For dinner,meat or vegetables cut into small pieces are usually

offered to the child in small amounts. Another

banana is also eaten by the child. Her sleeping

pattern varies, especially during nights when thereare episodes of coughing. The child sleeps for 10

hours if there are no episodes of coughing. In the

afternoon, she takes a nap for 2 hours. She usually

la s with their nei hbors children but tires easil .


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DISEASE MATERNAL PATERNAL

HYPERTENSION - +

DIABETESMELLITUS - -

ASTHMA

+ -


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HEENT:

Head: Head has no lesions, scaling and

tenderness, face is symmetric. Ears: External ears are symmetrical, ear

canals are patent with no lesions and

deformities. Eyes: Sunken eyeballs, white sclera, pupils

constrict to light, eyelids are intact with no

lesions. Nose: Presence of mucous secretions

Throat: There is absence of soreness and

tenderness of throat. No lesions are


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RESPIRATORY:

With increased respiratory rate of 43cpm which is already above normal for a 1

yr and 6 month old child of 20-40cpm only.

This means that the child is a fast breather.

Use of accessory muscles when

coughing noted such as rising of both

shoulders simultaneously. Upon

auscultation there were faint cracklesheard, with wheeze and rales can also be

heard upon getting the childs cardiac rate.


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CARDIOVASCULAR:

The pulse rate is normal ( 92bpm). Upon

auscultation of the childs cardiac heart rate,sounds like rales and wheeze can still be

heard. Regular Cardiac Rhythm,

Hemoglobin- 11.2 gms% and Hematocrit-30.0 %, Peripheral Circulation: nail beds and

conjunctivas are pale, Capillary refill: 3

seconds


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MUSCULOSKELETAL:

Patient has limited range of motion and

cannot fully extend arms and legs.Decreased muscle strength was also noted.

The muscles of the mouth and TMJ can

open 1-2 times as the time weve asked thechild to open her mouth


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INTEGUMENTARY:

Face was pale. Skin was dry and soft

and warm touch with no lesions. Small red

spots noted on the left side of the childs

face.Poor skin turgor. Arms, Hands, and

Fingers skin color is fair as with the otherbody parts.


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GASTROINTESTINAL:

No abdominal tenderness

palpated and with normoactive, a

little fading like-borborygmi bowelsound upon auscultation.

Abdominal Circumference: 25.5cm


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GENITOURINARY:

Has no bladder distention.

Amount of urine notedapproximately 40cc per hour.

NEUROLOGIC


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NEUROLOGIC

The child still withdrawing a smile to other people coming

near him, but becomes restless when the mother is not around,

she usually cries. For the cranial nerve functions, her sense ofsmell was normal and active (olfactory nerve). His vision was

normal (optic nerve) since he can still recognize people around

like her mother and father. Both of his eyeballs were moving

bilaterally (occulomotor, trochlear, and abducens nerve). Pupils

also react to light (occulomotor). Patient was able to move his

facial muscles. He can smile, frown, puffed out cheecks and

raise and lower eye brows (facial nerve). She was able to open

mouth and move jaw from side to side (trigeminal). Hearing was

active and can respond to sounds (vestibulocochlear). The childdoesnt want to eat because she cant seem to taste the food she

eate due to fever as stated by the mother (glossopharyngeal

nerve). The child produces sound like crying whenever her

mothers not around (vagus nerve). The chid is using her

shoulders and abdomen when breathing(spinal accessory


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NORMAL VALUE RESULTS NURSINGIMPLICATIONS

NURSING CONSIDERATIONSRBC 4.5-5.0x

109

/dL

4.0 X

10X109

/L

Decreased in

amount mayindicate

Anemia

Encourage the

mother to let her childtake Iron

supplementations

WBC 5-10 x 109/L 12.5x109/L An increase inamount may

indicate

Infection

*Stress to the mother

the importance of

taking antibiotics as

prescribed for the

child.

*Encourage the

mother to increasechilds Vit.C intake

like calamansi and

oranges.


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NORMAL

VALUERESULTS NURSING

IMPLICATIONSNURSING CONSIDERATIONS

NEUTROPHIL

S60-70% 41% A decrease in

amount is due to

infection.

Pathogens

invade the body

that alters

neutrophil count

*Encourage the S.O to

provide a well-balanced

diet.*encourage SO childs

Oral Fluid Intake and Vit.

C Supplementations.LYMPHOCYT

ES 25-33% 53% An Increase inamount mayindicate

infection.

*Emphasize to the S.Othe importance of

hygiene and sanitation

to the child and home.

*Instruct the mother to

provide the child withfruits rich in vit. C like

calamansi and

Oranges.


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NORMAL

VALUERESULTS NURSING

IMPLICATIONSNURSING

CONSIDERATIONSEOSINOPHIL

S1-3% 6% May indicate

allergic reaction

and developing

infection

*Administer anti-

allergy as indicated.*Instruct mother to

observe personal

hygiene.

BASOPHILS 0.25-50% 1.5% May indicateallergic

reaction and

indicative of

infection

*Administer anti-

histamine as

indicated.

*Increasing Oral

Fluid intake andprovide food that

is properly

prepared.

NORMAL

VALUE

RESULTS NURSINGIMPLICATIONS

NURSING CONSIDERATIONS


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VALUE IMPLICATIONSHEMOGLOBIN 14-

16gms%

11.2

gms%

A decrease in

amount may

indicate

Anemia and

dietary

deficiency

*Encourage the mother

to provide a

comfortable place for

the childs adequate

rest and sleep.

*Increase intake of Iron

supplementations as

prescribed.

HEMATOCRIT 42+- 5% 36.0% A decrease in

amount may

indicate blood

loss andanemia

*Instruct mother to

maintain the childs

taking of Iron

supplementations.

*Provide dairy

products like milk and

eggs for childs nucleic

acid production


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The digestive system consists of two linked parts:the alimentary canal and the accessory digestiveorgans. The alimentary canal is essentially a tube,

some 9 meters (30 feet) long, that extends from themouth to anus, with its longest section- the intestines-packed into the abdominal cavity. The lining of thealimentary canal is continuous with the skin, so

technicallyits cavity lies outside the body. Thealimentary tube consist of linked organs that each playtheir own part in digestion: mouth, pharynx,esophagus, stomach, small intestine, and largeintestine. The accessory digestive organs consist ofthe teeth and tongue in the mouth; and thesalivaryglands, liver, gallbladder, and pancreas, which are alllinked by ducts to the alimentary canal.

STOMACH is a J- shaped enlargement of the


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STOMACH is a J shaped enlargement of the

GI tract directly under the diaphragm in the

epigastric, umbilical and left hypochondriac regions

of the abdomen. When empty, it is about the size ofa large sausage; the mucosa lies in large folds,

called RUGAE. Approximately 10 inches long but

the diameter depends on how much food it

contains. When full, it can hold about 4 L (1galloon) of food. Parts of the stomach includes

cardiac region which is defined as a position near

the heart surrounds the cardioesophageal sphincter

through which food enters the stomach from theesophagus; fundus which is the expanded part of

the stomach lateral to the cardia region; body is the

mid portion; and the pylorus(a funnel shaped which

is the terminal part of the stomach.)

sphincter or valve With the gastric


48/98

sphincter, or valve. With the gastric

glands lined with several secreting cells

the zymogenic (peptic) cells secrete theprincipal gastric enzyme

precursor, pepsinogen. The parietal

(oxyntic) cells produce hydrochloricacid, involved in conversion

of pepsinogen to the active enzyme

pepsin, and intrinsic factor, involved inthe absorption of Vitamin B12 for the

red blood cell production. Mucous cells

secrete mucus.


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Secretions of the zymogenic, parietal andmucus cells are collectively called the gastric

juice. Enteroendocrine cells secrete stomachgastrin, a hormone that stimulates secretionof hydrochloric acid and pepsinogen,contracts the lower esophageal sphincter,

mildly increases motility of the GI tract,andrelaxes the pyloricsphincter. Most digestiveactivity occurs in the pyloric region of thestomach. After food has been processed in

the stomach, it resembles heavy cream andis called CHYME. The chyme enters thesmall intestine through the pyloric sphincter.


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Difficulty Of Breathing

Loose Bowel Movement Fever

Body Weakness Cough

PROBLEMS RANKCUES PHYSIOLOGIC BEHAVIORAL


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ACTUAL POTENTIAL ACTUAL POTENTIAL

Ineffectiv

e

Breathing

Pattern r/t

retained

secretion

s

Risk for

Ineffective

tissue

perfusion r/t

impaired

transport of

oxygen

Disturbed

Sleep

Pattern r/t

shortness

of breath

Risk for

powerlessnes

s r/t lack of

adequate

sleep

Deficient

fluid

volume r/t

passage

of watery

stools

Risk for

Imbalanced

Nutrition:

Less than

body

requirementsr/t frequent

passage of

watery stools

Powerles

sness r/t

inadequat

e

Nutritional

status

Risk for

Social

Isolation r/t

frequent

passing out

of waterystools

PROBLEMS RANK

Difficulty

ofBreathing

1

Frequent

passage

of Watery

Stools

2

CUES

Murag tubig

na katin-awonang iya

ginkalibang.

Pag-admit

namon sa

buntag,

gasuka-sukana siya katulo

jud

Objectives:

Poor Skin

Turgor

Pallor

Sunken

Eyeballs

Dry Buccal

Mucosae

PHYSIOLOGIC BEHAVIORAL

PROBLEM RANK PHYSIOLOGIC BEHAVIORAL


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OS

Fever 3

Adequat

e Sleep

4

ACTUAL POTENTIAL ACTUAL POTENTIAL

Ineffective

Thermo

regulation r/tinflammation

of Bowel

mucosal lining

Risk for

disorganized

infantbehaviour r/t

discomfort of

elevated body

temperature

Impaired

Comfort r/t

fluctuations inBody

Temperature

Risk for

Activity

Intolerance r/tweakness

Sleep

Deprivation r/t

breathing

difficulty and

frequent

passage of

watery stools

Risk for

delayed

development

r/t lack of

adequate

sleep.

Impaired

Social

Interactions r/t

weakness due

to lack of

sleep

Risk for

impaired

attachment r/t

inability to

initiate

parental

contact due to

altered

behavioural

organization

S O OG C O


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General Objective:

-To facilitate the maintenance of supply ofoxygen to all body cell.

CUES NURSINGDIAGNOSIS EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION


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SUBJECTIV

E:

Murag tubig

na katin-aw

iyaginakalibang,

Pag-admit

namu sa

buntag, ga

suka-suka na

siyag mga ika

tilo jod

Tapos ambot

naunsa pod ky

di namn sya

kaginhawagmaayu nuon

Ineffective

BreathingPattern r/t

INFLAME

D

BRONCHI

AL TISSUE

Within 2 days

of Nursing

Interventions

the patient

will be ableto:

*Maintain

Effective

breathing

pattern

*Maintain

Patent airway

with absence

of mucous

secretions

INDEPENDE

NT:

>Auscultate

breath sounds.

Noteadventitious

breath sounds,

e.g. wheezes,

crackles and

rhonchi.

>Some degree

ofbronchospasm

is present with

obstructions

in airway and

may not bemanifested in

adventitious

breath sounds,

e.g. scattered,

moist crackles(bronchitis) or

faint, with

expiratory

wheezes

(emphysema)

After 2 days

of Nursing

Interventions,

goals are

Partially Metas Evidenced

by:

*Accessory

muscles like

shoulders are

seldom used.

*Coughing

with

secretions isminimal



60/98

OBJECTIVE

:

*Presence of

adventitiousbreath sounds

such as rales

and wheezes

upon

auscultation

*Poor Skin

turgor

*S.O verbalize

understanding

of cause and

therapeutic

managementregimen to the

patient

*S.O verbalize

sense of

comfort andcontentment of

the patients

Health

Improvement

*S.O may

report

improvement

in sleep and

rest pattern of

the patient

>Assess/

Monitor

respiratory

Rate. Noteinspiratory/exp

iratory ratio.

>Tachypnea is

usually present

in some degree

and may be

pronounced onadmission or

during stress

on current

acute process.

Respirations

may beshallow and

rapid. Chronic

emphysema

patients

usually have

prolonged

expiration in

comparison to

inspiration.

*Slight

improvement

of the S.O

towardsunderstanding

therapeutic

management

regimen to the

patient.

*Slight

improvement

about sense of

comfort

according to

the S.O



61/98

* Pallor

*Sunken

eyeballs

*Dry buccalmuscles

*Accessory

muscles like

shoulder and

abdomen are

used in

breathing

*Passing out

of watery

stool 5x a

day.

>Monitor

Vital Signs

>Monitorrespirations

and breath

sounds

noting rate

and sounds.

>Determine

Presence of

factors/physi

calconditions as

noted in

related

factors.

>to establish

baseline data.

>Indicativeof distress or

accumulation

of secretions

>To

determine

causes of

breathingimpairments

*The child is

able to sleep

at night with

10-12 hours

and at least 2

hours rest in

the

afternoon.



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*Cardiac

Rate- 92

bpm

*TEMP-38.7 OC

*RR- 43

cpm

*WBC-

12.5x10

9

/L*RBC-4.0 X

10X1012/L

*Hemoglobi

n: 11.2

gms%

*Hematocrit

: 36.0%

>Position

head

appropriate

for age andcondition.

>Observe for

signs/sympto

ms and

infections

(increase

dyspnea with

onset of

fever)

>To

maintain

patent

airway in atrest or

compromise

d individuals

>To identify

secretions

process and

promote

timely

interventions



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DEPENDENT

>Administer

Salbutamol

and

ALBUTEROLE SULFATE

via inhalation

as prescribed

every 4 hours

and as needed.

>Administer

O2 Inhalation

at 2L via face

mask asprescribed.

>Inhaled

adrehergic

against. And a

first linetherapies for

rapid

symptomatic

improvement

in severe

bronchiconstipation.

>Relaxes

smooth muscle

and reduce

localcongestion

reducing

airway spasm

and mucous

production.



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COLLABOR

ATIVE:

>Monitor

laboratory

results asindicated

>Administer

replacement of

fluids and

electrolytes asordered.

REFERENCE:

-NANDA (12TH )

-Edition. Pp 80-

84, 151- 155

>To determine

altered lab.

Results

>To support

circulating

volume and

tissue

perfusion.

REFERENCE:

-NANDA (12TH )

-Edition. Pp 80-

84, 151- 155


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General Objective:

-To facilitate the maintenance of fluid

and electrolyte balance.

CUES NURSINGDIAGNOSIS PATHOPHY

SIOL

EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION


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SIOL

OGYSUBJECTIV

E:

Murag tubig

na katin-awiya

ginakalibang,

Pag-admit

namu sa

buntag, ga

suka-suka nasiyag mga ika

tilo jod

Tapos

ambot naunsa

pod ky di

namn syakaginhawag

maayu nuon

Deficient

fluid

volume r/t

passage

of watery

stools

Within 2days

of Nursing

Interventions

the patient will

be able to:

*Maintain

fluid Volume

level at

functional

level

*Minimize

episodes of

passing out of

water stools

from more than

5 times to 2

times a day.

INDEPENDE

NT:

>Assess Vital

Signs.

>NoteComplains and

physical signs

associated with

fluid loss (poor

skin turgor)

>For baseline

data, fevertachycardia

may indicate

severe fluid

loss.

>To assess ordetermine if

there is

alterations on

patients

condition and

provideimmediate

action.

After 2days of

Nursing

Interventions

goals areMET, as

Evidenced by:

*Maintenanceof Volume at a

functional

level, urine

output of

approx.40 cc

and frequentintake of at

least 8 glasses

of water a day.

CUES NURSINGDIAGNOSIS PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION


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OBJECTIVE:

*Presence of

adventitious

breath soundssuch as rales

and wheezes

upon

auscultation

*Poor Skin

turgor

*Maintain

Good Skin

Turgor

*Mother willverbalize

understanding

of causative

factor and

purpose ofintervention

done.

>Instruct the

mother to

increase oral

fluid intake ofthe child at

least 6-8

glasses a day

as tolerated.

>To restore

fluid

balance.

*The childs

Stool output

was reduced

to two times aday not so

watery,

smooth-well

formed stool.

*Moist Oral

mucosa andgood skin

turgor, with

skin goes back

a little bit

slowly when

pinchvertically on

the abdomen.

CUES NURSINGDIAGNOSI

S

PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION


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S* Pallor

*Sunken

eyeballs

*Dry buccal

muscles*Accessory

muscles

like

shoulder

and

abdomenare used in

breathing

*Passing

out of

watery stool

5x a day.

DEPENDENT:

>Administer

IOPERAMIDE-

MAALOX, 1mg.P.O. tid on the

first day. As

ordered by the

physician.

>Administer and

Regulate IVF asordered by the

physician.

>Proper dosage

of the medicine

ensures recoveryand prevents

diarrhea causing

dehydration.

>To ensure

adequate fluidreplacement.

*S.O

verbalizes

understanding

of causativefactors and

purpose of

interventions

and

medications

with propercompliance on

the dosage

and timing.


*Cardiac COLLABORA


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Cardiac

Rate- 92

bpm

*TEMP-

38.7 OC

*RR- 43cpm

*WBC-

12.5x109/L

*RBC-4.0

X

10X1012/L

*Hemoglob

in: 11.2

gms%

*Hematocri

t: 36.0%

COLLABORA

TIVE:

>Monitor

clients intake

and output asendorsed.

>Monitor every

Laboratory

Results

conducted tothe patient.

REFERENCE:

NANDA 12th

edition pp. 372-

375, 756- 763

>Provide

information about

over-all fluidbalance.

> To know

clients progress

and alteration in

condition.

REFERENCE:

NANDA 12th

edition pp. 372-

375, 756- 763


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General Objective:

-To promote safety through prevention

of accident, injury or other traumaand through the prevention of thespread of infection.

CUES NURSINGDIAGNOSIS PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTIO

NRATIONALE EVALUATION


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SUBJECTI

VE:

Murag

tubig na

katin-aw

iya

ginakaliba

ng, Pag-

admit

namu sa

buntag, ga

suka-suka

na siyag

mga ika

tilo jod

Tapos

ambot

naunsa pod

ky di namn

sya

kaginhawa

g maayu

nuon

Ineffective

Thermoregulation r/t

inflammatio

n of

Gastrointesti

nal Tractsecondary to

Acute

Gastroenteri

tis

Within 2

days of

nursing

intervention,the patient

will be able

to:

*Restore

temperature

to a normal

level of 36.5-

37.5 C

INDEPEN

DENT:

>Assess

neurological response,

noting

level of

consciousn

ess and

orientation

and

reaction to

stimuli,

reaction of

pupils, and

presence of

posturing or

seizures.

>For proper

assessmentof the

severity of

the problem.

CUES NURSINGDIAGNOSI

SPATHOPHYSIO

LOGY EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION


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OBJECTI

VE:

*Presence

of

adventitiou

s breath

sounds

such as

rales and

wheezes

upon

auscultatio

n

*Poor Skin

turgor

*Diminish

flushing of skin

which is an

indication of

hyperthermia

*Reduce heat of

the skin to

normal warmth

*Reduce

excessive

sweating.

>Assess

environment

for possible

sources ofheat gain

through

evaporation,

conduction,

convection,or radiation.

>To

minimize

risk of heat

gain.


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*Cardiac

Rate- 92

bpm

*TEMP-

38.7 OC

*RR- 43

cpm

*WBC-

12.5x109/L

*RBC-4.0

X

10X1012/L

*Hemoglo

bin: 11.2

gms%

*Hematocr

it: 36.0%

>Monitor

heart rate and

rhythm

>Provide

tepid spongebath but avoid

using alcohol

as a solution.

>Dysrrhythmia

s and ECG

changes are

common due toelectrolyte

imbalance.

>May help

reduce fever.Ice water and

alcohol may

cause chills

actually

elevating

temperature

CUES NURSINGDIAGNOSIS PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTION

RATIONALE EVALUATION


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>Promote

surface

cooling by

undressingor not

double

wrapping

the infant.

DEPENDE

NT:

>Administe

r

PARACET

AMOL

120 mg P.O

q4 to 6

PRN

>To promote

heat loss in

the body

> Proper

dosage of

the medicine

ensuresrecovery.

CUES NURSINGDIAGNOSIS

PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION


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>Administer and

Regulate IVF as

ordered by the

physician.

COLLABORATIVE

:

>Monitor

laboratory studies

such asABCs,

electrolytes,

cardiac and liver

enzymes, glucose

urinalysis, and

coagulationprofile.

REFERENCE:

NANDA 12th

edition pp. 372-

375, 756- 763

>To ensure

adequate fluid

replacement.

>May reveal

tissue

degeneration,myoglobinuria,

proteinuria, and

hemoglobinuria

.


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CLASSIFICATION IMPLICATION MECHANISM OFACTION


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*DEXOMETHOR

PAN

HYDROBROMID

E

Robitussin

Pediatric

Timing: Q8 (8

am, 4pm and

12am)

120mg a day

Expectorants

and antitussives

Productive

cough

individualized

dozes

Antitussive that

suppresses the

cough reflex by

direct action on

the cough center

in the medulla

SIDE/ADVERSEEFFECTS NURSINGCONSIDERATIONS PATIENTS TEACHING REFERENCE

S G


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CN: drowsiness,

dizziness

G.I nausea,

stomach pain

*Dont use when

cough is a

valuable

diagnostic signor is beneficial

(as after thoracic

surgery)

*Monitor Vital

signs especiallyRespirator and

Cardiac Rate.

*Use drug with

chest percussion

and vibration.

*Monitor cough

type and

frequency

*Instruct themother to give

drug to the

patient exactlyas prescribed.

*Instruct the

mother to report

adverse

reactions.*Tell the S.O to

report nausea,

abdominal pain

or discomfort

NURSING 2007DRUG

HANDBOOK

LippincottWilliams andWilkins



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*IOPERAMIDE

MAALOX

>1mg. P.O. tid

on the first day.

Anti -diarrheals Loose Bowel

Movement

Inhibits

peristaltic

activity,

prolonging

transit and

intestinal

contents


CNS d i *Ski T t t b *I t t th t NURSING 2007


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CNS: drowsiness,

fatigue and

dizziness

G.I: dry mouth,abdominal pain,

distention or

discomfort,

constipation,

nausea and

vomiting.

Skin: Rash,

hypersensitivity

reactions.

*Skin Test must be

done to monitor

clients possible

allergic reaction tothe drug.

*Contraindicated

in patients with

bloody diarrhea

with fever greater

than 39C.

*Drug is likely to

be effective if no

response occurs

within 48 hours.

*Monitor childclosely for CNS

effects, children

are more sensitive

to these effects

than adults

*Instruct mother to

report alterations

noted from the

child.*Encourage the

mother to follow

frequent timing of

taking

medications

prescribed.

*Tell the mother

the necessity of

drug compliance.

*Note if the patient

is experiencingbloody stool and

immediately ask

the mother to

report if this

happen.

NURSING 2007DRUG

HANDBOOK

LippincottWilliams andWilkins


*ALBUTEROL


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*ALBUTEROL

E SULFATE

2.5 mg t.i.d. bynebulizer for 10

mins as needed

not exceeding

2.5 mg

Bronchodilators For patientswith obstructive

airway and

Difficulty of

breathing

Relaxes

bronchial andvascular smooth

muscles for

patent airway


D d i it t d *C t i di t d t I t t th t NURSING 2007


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Dry and irritated

nose, cough ,

hypersensitivity

reactions.CNS:Headache

CV:palpitations

G.I: heartburn,

increased appetite

*Contraindicated to

patients with

hypersensitivity to

drug or itsingredients.

*Monitor Vital

Signs Especially

Respiratory rate

Instruct mother to

shake the inhaler

and clear nasal

secretions.*Tell the mother to

remove canister and

wash inhaler with

warm water every

after use.

*Report alterations

in the administration

of drug

*Teach the S.O the

proper position for

the patient in takingthe drugs and follow

promptly doctors

order of dosages.

NURSING 2007

DRUG

HANDBOOK

Lippincott

Williams and

Wilkins


*PARACETA


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*PARACETA

MOL

120 mg 1 tsp.

P.O q4 to 6

PRN

AntipyreticsFever

Relieve fever

through central

action in the

hypothalamic

heat-regulating

center


H t l i I hild d t *T ll t t NURSING 2007


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Hematologics:

hemolytic

anemia,

neutropeniaandleucopenia

Hepatic: Jaundice

Skin: Rash

In children, dont

exceed five doses

in 24 hrs.

*Monitor Vital

Signs especially

checking of

temperature every

15 mins.

*Perform TSB

and provide warm

and comfortable

environment to

the patient

*Tell parents to

consult prescriber

for children

younger than 2.

*Advice parents

that drug are only

for short term use.

*Advice mother

to report

immediately

alterations and if

the fever still

persists

NURSING 2007

DRUG

HANDBOOK

Lippincott

Williams and

Wilkins


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PROBLEM HEALTHTEACHING

RATIONALE


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Hygiene:

1. Daily bath

2. Nail care

3. Oral care

4. Hand washing

Activity

Walking exercises astolerated.

Adequate rest and

sleep.

Active range ofmotion exercises like

flexion and

extension.

Recurrence of LBM

PROMOTIVE:Encourage the

mother for the daily

bath if the patient.

Encourage the

client to have

adequate rest and

sleep for at least 8

hours per day.

Encourage to

perform active range

of motion exercises

like flexion and

extension of thearms and legs for at

least 15-30 min/day.

To promote well

being and for the

client to feel

comfortable.

To regain

strength and

energy.

These exercises

maintain or

increase muscle

strength andendurance and

help to maintain

cardio-respiratory

function.

.

Diet CURATIVE:


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Maintain oral fluid

intake.

Low fiber dietVit. C

(calamansi,guava)

High Iron Intake

Instructions:

Take medications

as prescribed.

Follow upchecked up 1

week after

discharged.

Instruct client to

takemedications as

prescribed by

the physician. Instruct client to

have a follow up

checked up 1

week after

discharged

For fast

recovery.

To preventrecurrence of

the condition

and to note

further

complication.


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One day is never more challenging than the


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One day is never more challenging than the

next

As we ascend to higher levels oflearning, we have learned that to gain

progress is never a petty thing to take for

granted. Great and insurmountable amountof effort must be infused with determination.

Now that we have reached our 2nd year of

learning and loving this course, we, theGroup 1, is yet to be initiated to enter the

world of a student nurse.

This Medical Case Study is our stepping


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This Medical Case Study is our stepping

stone towards attaining a sense of fulfilment

and growth. Fulfilment, for we have nowapplied what knowledge we have gained for

these past semesters and we have known

that working as a team would really result toa greater achievement. Growth, in a sense

that as great and complicated tasks litter our

everyday lives, our own understanding and

open- mindedness also grows and matures.

In the making of this Case Study, we


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In the making of this Case Study, we

have come to an agreement that each

member of the Group should take part andfuse all knowledge and the lessons they

have learned to come up with a great

presentation. The preparation is really never

easy. The sleepless nights, headaches,

stress and struggles we have experienced

bonded as even more closely. A great deal

of suffering was also incorporated, for thiscase study demands our utmost time,

dedication, finances and most of all effort.

But this did not hinder us to finish this task.


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Despite all these hindrances, we are still able

to smile and share jokes to lessen the stress

we have experienced. As we finished this

case study, a great wave of fulfilment and pride

washed over us. We believe that we have

presented our case study clearly andeffectively. Yes, more great and overwhelming

tasks are still up ahead for us to face, but with

our determination, teamwork, our instilled

knowledge and the amount of effort we are

ready to give, we can conquer all of this and

reach the higher echelons of the nursing

course.


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Prepared by:


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Prepared by:

Prepared by:


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Prepared by:

Medical Case Study

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Transcript of Medical Case Study