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DANDY WALKER SYNDROME
Presented by:Group 4 BSN S31
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I. INTRODUCTION
This case of Patient D who was diagnosed with DandyWalker Syndrome secondary to Hydrocephalus on 2006. Thepatient was initially diagnosed with hydrocephalus but afterperforming several laboratory and diagnostics test, the resultsshows that patient was suffering from dandy walker syndrome.Dandy-Walker Syndrome is a rare malformation of the brain thatis present at birth (congenital). It is characterized by anabnormally enlarged space at the back of the brain (cystic 4thventricle) that interferes with the normal flow of cerebrospinalfluid through the openings between the ventricle and other parts
of the brain (foramina of Magendia and Luschka). Excessiveamounts of fluid accumulate around the brain and causeabnormally high pressure within the skull, swelling of the head(congenital hydrocephalus), and neurological impairment. Motordelays and learning problems may also occur.
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II. OBJECTIVES OF THE STUDY
We chose this case for us to extend and improve our
knowledge and understanding with regards to the causes,effects, complications, signs and symptoms and nursingimplications for Dandy Walker Syndrome for us to be able toattain a comprehensive and thorough learning experience withregards to our study that would benefit not only us but also thereaders and for the patients that we will be catering in the futurewith such kind of disease.
This case study is important because it imparts knowledgeregarding the complication in having dandy walker syndrome.We, as students will benefit from this study as we reviewed theanatomy and physiology and studied nursing interventions forthis case.
The scopes of this study are patients who are suffering anddiagnosed from dandy walker syndrome. This case presentationwill attempt to cover and discuss the disease process and presentcondition of the patient. This case presentation will be limitedonly to the patient’s verbalizations, laboratory reports, signs andsymptoms as evidenced by and observed from the patient.
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III. BIOGRAPHICAL DATA
Name: Miss D
Age: 7 years old
Date of Birth: March 16, 2004
Place of Birth: Malolos, Bulacan
Gender: Female
Religion: Roman Catholic
Civil Status: Single
Address: Purok 2, Kaybanban, San Jose del Monte, Bulacan
Educational Attainment: Grade 1
Occupation: Student
Ethnic Group: Tagalog
Primary Language Spoken: Tagalog
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Theoretical framework
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Ida Jean Orlando, a first-generation American of
Italian descent was born in 1926. She received hernursing diploma from New York Medical College, LowerFifth Avenue Hospital, School of Nursing, her BS inpublic health nursing from St. John's University,Brooklyn, NY, and her MA in mental health nursing from
Teachers College, Columbia University, New York.
The focus of Orlando’s paradigm hubs the context of a dynamic nurse-patient phenomenon constructivelyrealized through highlighting the key concepts such as :Patient Behavior, Nurse Reaction , Nurse Action.
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The nursing process is set in motion by the PatientBehavior. All patient behavior, verbal ( a patient’s use of language ) or non-verbal ( includes physiological
symptoms, motor activity, and nonverbalcommunication) , no matter how insignificant, must beconsidered an expression of a need for help and needsto be validated .
The Patient behavior stimulates a Nurse Reaction .In this part, the beginning of the nurse-patientrelationship takes place. It is important to correctlyevaluate the behavior of the patient using the nursereactions steps to achieve positive feedback responsefrom the patient.
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Critically considering one or two ways in
implementing Nurse Action. When providingcare, nursing action can be done eitherautomatic or deliberative. Automatic reactionsstem from nursing behaviors that are performed
to satisfy a directive other than the patient’sneed for help. Deliberative reaction is a“disciplined professional response” It can be
argued that all nursing actions are meant to helpthe client and should be considered deliberative.
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We used Orlando’s Dynamic Nurse-Patient Relationship in ourpatient with Dandy-Walker Syndrome. It is ordered to give PRNParacetamol to the patient if experiencing fever. It was Monday when our
patient had fever. Automatic response of the nurse is to give the client aTepid Sponge Bath and administer Paracetamol as ordered.. Beingdeliberate in your actions include knowing the pharmacokinetics of thedrug in relation to the client’s physiologic standing.
The patient’s motor activity is a non-verbal cues that must be
considered to be an expression of a need for help. Since our patient isunsteady, we used precautionary measures by offering or giving helpwhen the patient wants to stand or walk. Also, side rails are always up toprevent client from fall.
The rapport built between us nurse and our patient also plays an
important role to achieve patient’s cooperation in achieving health. Ourpatient was able to verbalized her needs and what she feels, like forexample is pain. As a nurse, it is important for her case to identify andattend all her needs in order to promote a satisfaction in both parties andprevent the patient from feeling of helplessness.
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FUNCTIONAL HEALTH PATTERNS
HEALTH PERCEPTION AND HEALTH MANAGEMENTPATTERN
BEFORE
Before the patient rate herself 6 from 1 to 10 which is fairand she consider herself as near to healthy child and she
usually eat fruits and vegetables to remain healthy as herhealth goal. Before she always washes her hands beforeand after she eats to prevent the microorganism entersher body as her traditional beliefs and practices.
Our patient sees her health care provider five times for this
past year because of her high fever, cough, pains anddrowsiness. Before, it’s not been easy for her to find waysto follow the suggestions of her Nurse and Doctor. Shepractices healthy eating habits as her safety practices.
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She thinks healthy lifestyle is the mostimportant to keep health because she thinkthat it can lower the risk of getting an illness.For her personal hygiene she took a bath
regularly, hand washed regularly, trimmedher fingernails regularly, wear slippersregularly and brushed her tooth two times aday. On our patient’s environment they
practice complete sanitation asenvironmental sanitation practice.
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DURING
Now that she was confined she rates herself 8 from 1
to 10 which is average. She usually eats fruits andvegetables to remain healthy as her health goal. Untilnow she always washes her hands before and after sheeats to prevent the microorganism that will enters herbody as her traditional beliefs and practices.
Our patient sees her health care provider every other daybecause she was confined for the reason that the V/P shuntwas infected. For her, now it’s been easy to find ways tofollow things nurses or doctors suggestions because thereis some instances that she needs to do what the doctor is
preventing her to do. She still practices healthy eatinghabits as her safety practices.
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Until now she thinks that healthy lifestyle is the most important to keephealth still because it can lower the risk of getting an illness. Now that shewas confined, she usually take a bath three times a week, hand washed
regularly, trimmed her fingernails regularly, wear slippers regularly andbrushed her tooth two times a day. Our patient’s environments practicescomplete sanitation as environmental sanitation practice.
Analysis
The parent rate their daughter’s general health 8/10. Before, she can’t easilyfollow the doctor’s suggestion. Now, that she was confined she is willing tofollow the doctor’s suggestion. Before she usually take a bath everyday.Now she only do it three times a week.
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E. NUTRITIONAL AND METABOLIC PATTEN
BEFORE Patient D’s typical daily food intake is biscuits and she has her medicines
supplements. She prefers to drink more juice than soft drinks or even water.proper nutritional food suitable for her condition proper nutritional foodsuitable for her condition Proper nutritional food suitable for her conditionproper nutritional food suitable for her condition proper nutritional foodsuitable for her condition
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DURING
Patient D’s typical daily food intake is still biscuits and she has her medicinessupplements. She prefers to drink more juice than soft drinks or even water.proper nutritional food suitable for her condition proper nutritional foodsuitable for her condition Proper nutritional food suitable for her conditionproper nutritional food suitable for her condition proper nutritional foodsuitable for her condition nutritional food is suitable for health condition. He
still loves to eat chocolate foods and she hates vegetables even her parentspractice her to eat vegetables. Even now that she was confined, therepreparations of food want to be neat. She eats on her bed with her parents.Her grandmother is still the one who budgeting for her food. She lost herweight for 1kg. Patient D still has her fair appetite and she has discomfortsin eating. She has lots of restriction in food esp. on junk foods and street
foods. She had dryness on her skin and had dental problems. Analysis
There is no changes in her nutritional and metabolic pattern.
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F. ELIMINATION PATTERN
BEFORE
She always does bowel elimination once a day andshe only feel pain if she is constipated because of eatingbanana. On urinary elimination she does it always, eighttimes a day and she doesn’t have any problem on
controlling her urine and she doesn’t feel any pain duringurinary elimination. She does it whenever it is necessaryand she do it frequent as needed to achieve normalelimination. She doesn’t have any odor problem on it.
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DURING
Even now that she was confined, she always does bowel
elimination every other day and she only feels pain if she isconstipated. On urinary elimination she does it many times. And yet,she doesn’t have any problem on controlling her urine and shedoesn’t feel any pain during urinary elimination. She does itwhenever it is necessary and she do it frequent as needed to achieve
normal elimination. She doesn’t have any odor problem on it.
Analysis
Before, she used to void 8 times a day and now she is voidingapproximately 16 times a day.
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G. ACTIVITY-EXERCISE PATTERN
BEFORE
Our patient always wakes up early to go toschool. Sometimes they do some exercises. Afterher school, she plays on their house with the PSP
and watch television. Patient D is satisfied withthe amount of exercise she gets from school andshe really needs to do it every day for her health.She spares her time playing her PSP and eats
outside with her family and was satisfy of it.
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DURING
Our patient wakes up early in the hospital because sheneeds to take her medications. Then after that she is playing
with the PSP and talking with her parents. Patient D cannotperform exercises because of her confinement. Shespares her time playing PSP and eating. Her activitieswere limited because of her condition.
AnalysisBefore, she used to exercised at her school. Now that she
was confined she doesn’t have enough chance to haveher regular exercise pattern. Her activities was now
limited because of her situation.
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H. SLEEP-REST PATTERN
BEFORE She sleeps mostly 11 hours a day and she is satisfied with that. She
usually sleeps at 9:00 P.M. and she usually wake-up at 8:00 A.Mcontinuously. She feels refreshed when she wake-up. She have pillow on herlap. She doesn’t have any problem in falling sleep and a simple massage can
help her sleep. She takes nap during afternoon. She prefers sleeping as aform of relaxation.
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DURING
Since that Patient D is in hospital, she sleeps mostly 12 hours a
day and she is satisfied with that. She usually sleeps at 7:00 P.M andshe usually wake-up at 7:00 A.M not continuously because every nowand then she is taking her medications. She doesn’t feel refresheswhen she wake-up. She have pillow on her lap. Now, she hasproblem in falling sleep but a simple massage and drinking milk canhelp her sleep. She takes nap during afternoon. She prefers sleeping
as a form of relaxation.
Analysis
Before, she slept calmly and feel refreshed when she woke up. Butnow, she need to wake up at around midnight to take her
medication.
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COGNITIVE-PERCEPTUAL PATTERN
Before:
The client can’t read, right and she also have difficulty on concentrating on reading and writing.About the client’s sense of hearing and sight, it seems to be good at all. There are no changes at allon her memories and she finds difficulty in learning. The client doesn’t have any problem inspeaking but she has a problem when it comes into reading and writing. The client’s sense of smelland taste seems to be good and she always plays and exercises when she’s at school.
Present:
The client still can’t read, right and still have difficulty on concentrating on her reading andwriting. About the client’s sense of hearing, it doesn’t change at all but when it comes to her senseof sight, there a change like her sight become blur and still she doesn’t use and eye glasses. Abouther memory, there’s no change at all and still she find difficulty in learning. About her speaking,reading and writing, still the same as before. There’s no also a change on her sense of smell and
taste. And right now the client can’t plays and exercises anymore in the school unlike before.
Analysis:
It seems that there’s a changes in the client like her vision became blurred and she does plays orexercise anymore in the school unlike before because on her condition.
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SELF-PERCEPTION AND SELF-
CONCEPT PATTERN Before:
Before, most of the time , the client described herself that she feels sogood and said that there’s no changes on her body at all and she doesn’t feel anychanges on her body. The client expresses herself by telling what she feels insideto her parents. The client seems to be a moody type of person and she get angrywhen she don’t get her will, and when she doesn’t get her will, she frown andgrumble.
Present:
The client described herself that she feels so good but she said that herhead started to change after her operation. The client doesn’t feel any changeson her body except on her head. Still the client expresses herself by telling what
she feels inside to her parents. The client still seems to be a moody type of person and she still get angry when she don’t get her will, and when she doesn’tget her will, she frown and grumble.
Analysis:
The client finds that something is changing on her after she goes throughthe operation. She noticed that her head circumference is changing.
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ROLE-RELATIONSHIP PATTERN
Before:
The client lives with her parents and her grandparents, and the client seems to be aprincess on her family because she’s the only child of her parents. It’s also seems that the familydoesn’t find any difficult on handling a family problems. When it comes in organizing someactivities, the client’s mother and grandmother we’re the one who organizes their activities. Theclient tells to her parents when she feels something unusual to her. Things are seem good whenshe’s at school and the client feels part of the neighborhood.
Present: The client still lives with her parents and her grandparents, and still the client seems to be a
princess on her family because she’s the only child of her parents. It’s also seems that the stillfamily doesn’t find any difficult on handling a family problems. When it comes in organizing someactivities, the client’s mother and grandmother we’re still the one who organizes their activities.The client tells to her parents when she feels something unusual to her. Things are seem not goodwhen the client stopped going to her school because she seems to be shy with her condition andthe client feels apart of the neighborhood because of her condition.
Analysis: Thing get change after her operation, she stopped on her studies and she feels that she’s
not a part of the neighborhood because she seems to be shy on her condition.
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COPING-STRESS TOLERANCE
PATTERN Before:
The client find herself on handling her stress by playing andmost of the time she finds that her mother is the most helpfulwhen it comes in talking things over. And there are no changes atall on her life.
After:
The client still find herself on handling her stress by playingand most of the time she still finds that her mother is the mosthelpful when it comes in talking things over. And now there’s achanges on her life after the operation in her life.
Analysis: After the operation, there’s a change on the client’s life, she
seems to be shy to people because of her condition.
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VALUE-BELIEF PATTERN
Before: The clients finds that eating healthy foods such as vegetables can make a
person healthy and when it comes in prioritization, the client prioritize health to be #1. She always prays every time before she goes to sleep. The client seems to get
whatever she wants when her parents can afford the things that she wants. Religion
were seems to be important to the client because it seems that she get her strength
through prayers and the support of her family.
After:
The clients still finds that eating healthy foods such as vegetables can make a personhealthy and when it comes in prioritization and still the client prioritize health to be #
1. She still prays every time before she goes to sleep. The client still seems to get
whatever she wants when her parents can afford the things that she wants because
she’s the only child in their family. Religions were still to be important to the client
because it seems that she get her strength through prayers and the support of her
family.
Analysis:
There’s no change at all when it comes to the client’s values and beliefs.
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Area to assess Normal Findings Abnormal Findings
ANTHROPOMETRIC
MEASUREMENT
WEIGHT: 45 LBS.
HEIGHT: 3’11 ft.
The patient’s weight is below the
normal range.
VITAL SIGNS TEMPPERATURE: 37.4 DEGREES
CELSIUS
PULSE RATE: 78 bpm
RESPIRATORY RATE: 23 cpm
BLOOD PRESSURE: 90/60 mmHg
SKIN Skin is smooth Pale in skin color.
When skin is released it rapidly
returns to its original contour.
HAIR Hair varies from dark black to pale
blonde.
The distribution of hair is partially
scalp baldness.
The texture of hair was thin and
easily breaks off.
NAILS Nails are normally having a pink
cast and have a capillary refill
within 2-3 seconds.
The shape and configuration of
nails are smooth and slightlyrounded to flat.
The textures of the nails base are
firm upon palpation.
HEAD The scalp is normally shiny, intact
and without any lesions.
There is an enlargement of the
head without any enlargement of
the facial structures.
Hard masses in the cranial bones
upon palpation.
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FACE The facial structure is
partially deformed.
EYES Has normal visual acuity of
20/20.
EYELIDS The eyelids appear
symmetrically.
CORNEA The corneal surface was
moist and shiny withoutdischarges.
IRIS The iris is smooth and
without apparent
vascularity.
PUPIL The pupil is deep black,
round and of equal
diameter ranging from 2-
6mm.
LENS The lenses are transparent.
VOICE WHISPER TEST Hard to correctly repeat the
words when whispered.
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EXTERNAL EAR The color is matching the
color of the rest of the
patient’s skin and is
positioned centrally andis proportion to the head.
The patient doesn’t
complain pain or
tenderness during
palpation.
NOSE Located at the midline of
the face and is without
swelling, bleeding, lesions
and masses.
Each nostril is patent.
No evidence of swelling
around the nose and
eyes.LIPS The lips and membranes
are pinkish and have no
lesions or inflammation.
The lips are dry.
TONGUE The tongue is in the
midline of the tongue.
The tongue doesn’t move
freely.
TEETH Th t th t i
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TEETH The teeth are not in
proper alignment, has
dental caries.
NECK The muscle is
symmetrical.
Has palpable mass.
VP shunt is seen and
palpable
BREAST The breasts and axillae are
flesh colored, and the
areolar areas and nipples
are darker in
pigmentation.
No tenderness upon
palpation and has no
lesions.ABDOMEN The right lower quadrant
of the abdomen is
protruded because of
thew swelling
abdomen has tenderness
upon palpation
VP shunt is seen and
palpable BOWEL SOUNDS Hypoactive bowel sounds
GENITALIA N/E N/E
KNEES Knees are in alignment
with each other
The skin is fair in color
without any lesions and
scars.
ANKLE AND FOOT The foot is alignment with
the lower leg.
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Components Normal Values SI units
WBC count 5.0 Adult: 5-10
Newborn: 9-10
x10^9/L
Hemoglobin 111 Male: 140-170
Female: 120-140 Newborn: 187-201
gm/L
Hematocrit 0.351 Male: 0.40-0.050
Female: 0.38-0.48
Newborn: 0.49-0.55
%
LABORATORY EXAMINATION Ms. D 6y/o/Female Room: OPD
Sample no: 083 HEMATOLOGY
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Differential count Normal Values SI units
Neutrophil 0.49 Adult: 0.45-0.65
Newborn: 0.40-0.58
%
Lymphocyte 0.42 Adult: 0.25-0.50
Newborn: 0.31-0.60
%
Monocyte 0.05 0.02-0.06 %
Eosinophils 0.04 0.02-0.04 %
Basophils 0.00-0.01 %
Bands 0.02-0.04 %
Platelet count 331 150-450 x10^9/L
MCV 82.5 80-100 fL
MCH 26.1 27-31 pg
MCHC 316 320-336 g/L
RDW 14.3 11.6-14.6 %
Toxic Granules
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Drug study
DRUG ACTION INDICATION SIDE EFFECT NURSING INTERVENTION
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Generic Name
Oxacilin sodium
Dosage/ Route/
Frequency 475 mg IV q12
hrs.
Bactericidal: Inhibits
synthesis of bacterial
cell wall, causing cell
death
Infections due to
penicillinase-producing
staphylococci; may be use to
initiate treatment when a
staphylococci infection issuspected.
Lethargy, hallucinations,
seizures, stomatitis, sore
mouth, anemia.
Report difficulty of
breathing, rashes, severe
diarrhea, severe pain at
injection site, mouth sores.
DRUG ACTION INDICATION SIDE EFFECT NURSING INTERVENTION
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Generic Name
Paracetamol
Brand Name
Biogesic
Dosage/ Route/
Frequency
250 mg/ oral/
PRN
Antipyretic: Reduces
fever by acting directly
on the hypothalamic
heat-regulating center
causes vasodilation
and sweating, which
helps dissipate heat.
Bacterial or viral infections
with pain and fever.
Headache, chest pain,
dyspnea, hepatic toxicity and
failure.
Advice the patient not to
exceed recommended
dosage and not to take for
longer than 10 days
Take the drug only for
complaints indicated; it is
not an inflammatory agent
Give drug with food if GI
upset occurs
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DRUG ACTION INDICATION SIDE EFFECT NURSING
INTERVENTION
Generic Name
Ceftriaxo
ne
Sodium Brand Name
Rocephin
Dosage/
Route/
Frequency
475 mgIV q12
hrs.
Bactericidal:
Inhibits
synthesis of
bacterial cell
wall, causingcell death
> Infections caused
by Staphylococcus
aureus
Headache, nausea,
vomiting,
abdominal pain,
pseudomembranous
colitis,nephtotoxicity
Protect drug from
light
Have Vitamin K
available in case
hypoprothrombinemia occurs
Discontinue if
hypersensitivity
occurs
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List of Prioritized Problems
Acute pain
Hyperthermia
Risk for situational low-esteem
ASSESSMENT NURSING PLANNING INTERVENTION EVALUATION
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DIAGNOSIS
Subjective
“Mainit ang
pakiramdam
ko”, asverbalized by
the patient
Objective
Flushed skin
Warm to
touch
T= 37.9 0C
Increased body
temperature
related to
infection
After 8 0 of nursing
intervention, the
patient will be able
to maintain normalbody temperature
1. Monitored
temperature.
2. Promoted surface
cooling by means of tepid sponge bath
3. Monitored intake and
output
4. Discussed importance
of adequate fluid
intake to prevent
dehydration
5. Administered
paracetamol as
ordered.
After of nursing
intervention, patient’s
temperature was
reduced 36 0C from 37.90C
ASSESSMENT NURSINGDIAGNOSIS
PLANNING INTERVENTIONS EVALUATION
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DIAGNOSIS
Subjective:
“ Masakit yung itto ko
pag hinahawakan” as
verbalized by the
patient.
Pain scale of 7/10according to the
patient.
Objective:
Positioning to avoid
pain
Irritable
Reduced interaction
with people and
environment.
Acute Pain
related to
infective VP
shunt.
After 8hours of nursing
intervention, the patient
will:
Report pain as
tolerated.
Demonstrated use of relaxation skills and
diversional activities.
Verbalized non
pharmacologic
methods that provide
relief.
Monitored pain
Provided comfort
measures (e.g.
repositioning)
Encouraged use of
relaxation techniqueto distract attention
and reduce tension
Encouraged
diversional activities
(playing psp)
After 8 hours of nursing
intervention the patient:
Reported pain as tolerated
Demonstrated use of
relaxation skills and
diversional activities Verbalized non
pharmacologic methods that
provide relief
Pain scale is also reduced
from 7/10 to 4/10
ASSESSMENT NURSING
DIAGNOSISPLANNING INTERVENTIONS EVALUATION
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DIAGNOSIS
Subjective:
“nahihiya akomakipaglaro sa
ibang bata eh.” As
verbalized by the
patient.
Objective: Shyness
Self-isolation
Risk for
situationallow self-
esteem
due to
physical
illness
After 5 days of
nursingintervention, the
patient will:
Partially
improve her
self confidence.
Communicate
and interact
well with
other people
Listened to
client’s
comments and
stories
Encouraged
significant
others to treatclient normally
as possible
After 5 days of nursing
intervention thepatient:
Partially improved
her self
confidence.
Interacted wellwith other people
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DISCHARGE PLANNING
Medication •Continue taking medicines as prescribed at the right dose, time, frequency, and routeExercise
•Encouraged patient to exercise regularly•Encouraged to get enough rest and sleep•Advised patient to stay in clean, safe and comfortable place
Treatment •Instructed the patient to seek medical aid in the nearest hospital for continuing health care•Encouraged to follow treatment regimen
Health Teaching •The patient is instructed about the importance of an adequate oral intake and of maintaining bowel and urinary tract function•The patient should resume activities gradually
•Encouraged patient to limit doing strenuous activities
Out-patient follow up •The patient is reminded about following appointment after 2 weeks
Diet •Encourage to follow recommended diet
Spiritual Counseling
•Advise the patient to go to the church every weekends to uplift of spiritual health•Encourage patient to participate in desired religious activities