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IndirectInguinal Hernia Indirect Inguinal
HerniaIN
3D
Demographic Data
Patient Name : H.M.Age : 10 years oldSex : FemaleBirthday : December 2,2000Civil Status : childAddress : Indang CaviteReligion : Roman CatholicNationality : FilipinoEducational Background : Elementary LevelDate of Admission : September 9,2010Chief Complaint : Fever and abdominal painFinal Diagnose : Dengue Fever SyndromeAttending Physician : Dr. ReyesHospital : Korean Philippines Friendship Hospital
SOURCES AND RELIABILITY OF THE INFORMATION
• The data presented in the case was taken from the hospital chart as well as from the patient mother through nursing patient interaction.
III. Chief Complaint
According to the mother she brought her son the hospital because of high fever with abdominal pain.
• IV. History of Present Illness
• Two days prior to admission the patient experience cough, colds and fever
• V. Past Medical History
• According to the mother all vaccination of his son is completed since at birth and this is the first time she brought her son to the hospital.
Family History
Health Perception and Health Maintenance
According to the patient’s mother she always consulted with the health center whenever her children got sick or not feeling well.
• Self-esteem, Self Concept and Self Perception Pattern
• • According to the mother her child always
telling her everything that happen to her especially what is happening in the school.
• Sleep / Rest Pattern
• According to the mother her child always sleep early during weekdays and even though during weekends.
• • Activity and Exercise• As verbalize by the mother, her child is not
really interested in any kind of activities at home but participated activities at school.
• Nutrition and Elimination Pattern• According to the mother her child eat any
kind of food she prepared and consume junk food also.
• Sexuality• According to segmund freud (psychosocial
theory). He belong in the school age child in the latent phase (children libido appears to be diverted into concrete thingking.)
• • • EnterPersonal Relationship• As verbalize by the mother, her child is a
loving daughter and always has fun with their neighbor.
• • Stress Management / Tolerance Pattern• According to the patient’s mother her child way of
handling pressure especially at school is talking to her and to his father.
• • • Personal Habit• As verbalize by the mother she always reminds her
child on good hygiene and she always follow her instruction.• • Environmental Hazard• The patient live besides the highway, and their place is
prone to accident.
Review of systemsSept. 12, 2010 Sept. 13, 2010
Pale looking, with Abdominal pain scale of 4, Limited movementFebrile- 38.7*C(+) petichae.
Pale looking, with Abdominal pain scale of 4, Limited movementAfebrile- 36.9*C(+) petichae.
(+) petichae, warm skin to touch, flush skin
(+) petichae, warm skin to touch, flush skin
RR= 29cpm, with productive cough
RR= 26cpm, with productive cough
CR= 66bpm,Bp=80/60mmHgNo abnormal sound
CR= 72bpm Bp=90/60mmHg Normal heart sound
Normal bowel and urine output.
Normal bowel and urine movement.
Limited range of movement
Limited range of movement
Scalp intact, no lesions, pale conjunctiva
Teary eyes, pale conjunctiva, normal vision
Blood
Whole blood has two components:(1) blood plasma, a watery liquid matrixthat contains dissolved substances, and
(2) formed elements, which are cells andcell fragments.Blood is about 45% formed elements and 55% plasma. Normallymore than 99% of the formed elements are red-colored red blood cells. Pale colorless white blood cells and platelets occupy less than 1% of total blood volume.
Anatomy and Physiology
Bite from Infected Aedes Aegypti
Dengue Virus Type I(Chikungunya Virus)
IgG adheres to the platelet(initiates destruction of the platelet)
inflammatory response
petechial rash, high fever, headacheabdominal pain)
Normal Results Significance Nursing implimentation
WBC 4.1- 10.9 5.0 Normal Within the normal range
Lympocytes 0.6-4.1 .71 Normal Within the normal range
Segmenters 0.45-.65 .29 Decrease Infection
RBC 4.20-6.30 4.2 Normal Within the normal range
HGB 12.0-18.0 12.9 Normal Within the normal range
Hct 37-51 38 Normal Within the normal range
Platelet count
140-440 139 Decreased Risk for bleeding
Normal Results Significance Nursing implimentation
WBC 4.1- 10.9 6.4 Normal Within the normal range
Lympocytes 0.6-4.1 1.5 Normal Within the normal range
Segmenters 0.45-0.65 .31 Decrease Infection
RBC 4.20-6.30 4.4 Normal Within the normal range
HGB 12.0-18.0 13.2 Normal Within the normal range
Hct 37-51 39 Normal Within the normal range
Platelet count
140-440 135 Decreased Risk for bleeding
Dosage, Frequency and Route
Indication & Contraindication
275mg IV q 4 >I- Treatment of mild to moderate pain and fever does not have antirheumatic effects (analgesics)>C- hypersensitivity to acetaminophen or any component of the formulation: patients with known G6PD deficiency.
Side Effects Mechanism & Action
Anemia, hepatitis, analgesic nephropathy, nephrotoxicity with chronic overdose, sterile pyuria. (limited to important of life threatening symptoms.
Reduce fever by acting on the hypothalamus to cause vasodilatation and sweating.
Nursing Responsibilities
- assess patient for history of liver disease or alcohol abuse (acetaminophen and excessive alcohol may have adverse liver effects)-monitor vital signs and signs of adverse reaction at beginning of therapy and at regular intervals with long term use.-take with food or milk.
Drug Name Classification
Generic Name:ParacetamolBrand Name:Tempra
Honohoid analgesics and antipyretics
Drug Name Classification
Generic Name:Ambrozol HDIBrand Name:Ambrolex
Mucolytic agents
Dosage, Frequency and Route
Indication & Contraindication
7.5 ml TID >I- Acute and chronic disorders of the respiratory tract associated with pathologically thickened mucus and impaired mucus transport.>C- Hypersensitivity to ambroxol or any ingredient of ambrolex.
Side Effects Mechanism & Action
>Headache, nausea, vomiting , anoresia, gastric discomfort, diarrhea, GI bleeding and disturbances, skin rash. Bronchospasm, stomatitis, and rhinorrhea. Chills, fever. Hemoptysis. Other isolated reports including dizziness, insomia,palpitation and mild hypoglycemia.
>Reduces the viscosity of bronchial secretions and facilitates expectoration.
Nursing Responsibilities
>Obtain patients history of cough before therapy and reassess after giving the drugs.> Instruct patient to follow exactly the direction on medication. Stress the importance of not taking more drug than directed.> Advice medical consultation for persistent cought of than more than 7 days.> Adise patient to avoid smoking, smoke filled rooms, perfumes, dust and environmental pollutants, these can increase cough.> Suggest sugarless loznges to decrease throat irritation and cough. Hard candy orgum can be used to prevent dry mouth.
Dosage, Frequency and Route
Indication & Contraindication
750mg IV q 8 >I- serious respiratory tract in fection, UTI, skin structure infection, bone or joint infection, septicaemia, meningitis, gonorrhoea
preoperative prevention.
>C
- contraindicated in pts hypersensitive to drug or other
cephalosporins.
Side Effects Mechanism & Action
CV: phlebitis, thrombophlebitis
GI: diarrhea, nausea and vomiting, anorexia.
Second generation cephalosporin that inhibits cell wall synthesis promoting osmotic instability; usually bactericidal.
Nursing Responsibilities
- before giving drug ask if he is allergic to penicillins or cephalosporins.
-obtain specimens for culture and sensitivity test before giving first dose. Therapy may begin while awaiting results.
Drug Name Classification
Generic Name:Cefuroxime
sodiumBrand Name:zinacef
2nd generation cephalosporin
Dosage, Frequency and Route
Indication & Contraindication
1 ampule q 8 >I- active duodenal gastric ulcer. -maitenance therapy for duodenal or gastric ulcer -gastro-esophageal reflux -erosive esopahagitis>C- in patients hypersensitivity to drugs and those with acute porphyria
Side Effects Mechanism & Action
CNS: headache malaise, vertigoEENT: blurred visionHepatic: JaundiceOthers: Anaphylaxis, angioedema, burning and itching at the injection site.
Competitively inhibits action of histamine on the H2 and the receptors site of parietal cells, decreasing gastric acid secretion.
Nursing Responsibilities
-Assess patient for abdominal pain.-Note presence of blood in emesis, stool, or gastric aspirate.- drug may be added to total parenteral nutrition solutions.-instruct patient to which or without regard to meals because absorption isn’t affected by food
Drug Name Classification
Generic Name:Ranitidine Hydro-chlorideBrand Name:Zantac
H2 receptor antagonist
ACTUAL PROBLEM
PROBLEM DATE IDENTIFIED DATE RESOLVED
1 Fever September 12, 2010 Resolved
2 Ineffective airway clearance September 12, 2010 Resolved
3 Abdominal pain September 12, 2010 Resolved
4 Ineffective tissue perfusion September 12, 2010 Ongoing
PROBLEM NO PROBLEM
1 Risk for bleeding
POTENTIAL PROBLEM
PLANNING
Short TermAt the end of the shift the patient temperature will decrease from 38.7 to 37.
Long TermPrior to dismissal the patient will identify underlying factors & importance of treatment as well as s/sx requiring further evaluation or intervention
EXPECTED OUTCOME
The pt shall have a decreased body temperature from 39.8 to 37The pt shall have identified underlying factors and importance of treatment as well as s/sx requiring further evaluation or intervention
ASSESSMENT DIAGNOSIS
S> “Mainit ang pakiramdam nya” as verbalized by the motherO>
> Temp of 38.7
> Flushed skin
> Skin warm to touch
Hyperthermia related to increase metabolic rate in the body as evidence by temperature of 38.7
Actual Problem “Fever “
Planning
Short TermAt the end of the shift the patient will be able to maintain airway patency
Long TermAt the end of hospitalization the patient will be able demonstrate behaviors to improve or maintain clear airway.
Intervention Rationale
>Establish Rapport>Monitor Vital Signs
>Encourage deep breathing and coughing exercises.>Elevate the head of the bed or change position. >Increase fluid intake to at least 2000ml/ day.>Auscultate breath sounds and assess air movement.>Encourage opportunities for rest and limit activities to level of respiratory tolerance.
>To gain patient trust>To obtain baseline data
>To incision to maximize effort.>To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of ventilation to different lung segment.>To help liquefy secretion.> To acertain status and note progress.>To promote wellness.
Expected outcomes
The patient will be able to maintain airway patency.
Assessment Diagnosis
S>”Nahihirapan siyang huminga” as verbalized by the mother.O>reproductive cough>with wheezes>with crackles upon auscultation on both lung fields.>RR=29
Ineffective Airway Clearance related to increased mucous production in the bronchial tree as evidence by productive cough
ineffective airway clearance
Planning
Short Term*At the end of the shift the pain will be able to decrease the pain from 6 to 4, which is mild pain.
Long term*At the end of the hospitalization the patient will be able to free from pain
Expected outcome
The patient will able to decrease the pain from 6 to 4.
Assessment Diagnosis
S> “Nasakit ang tiyan niya” as verbalized by the mother.O>facial grimace>Pain scale of 6 with is moderate pain>Irritable
Acute pain alteration in comfort related to asmanifested by facial grimace and verbal report of pain.
Knowledge Deficient
Planning
Short Term At the end of the shift the patient will demonstrate behaviors to improve circulation.
Long Term At the end of hospitalization the pt will demonstrate increased perfusion as appropriate
INTERVENTION RATIONALE
IndependentEstablish RapportMonitor Vital Signs
Assess patient’s condition
Note customary baseline data
Determine presence of dysrhythmias
Perform blanch test
Check for Homan’s sign
Note presence of bleeding
Elevate HOB
Encourage quiet & restful atmosphere
Instruct to avoid tiring activities
Encourage light ambulation
Encourage use of relaxation techniques
DependentAdminister medications
To gain patient trustTo obtain baseline data
To assess contributing factors
For comparison with current findings
To identify alterations from normal
To identify / determine adequate perfusion
To determine presence of thrombus formation
To determine risk of anemia
To promote circulation
To promote comfort & decrease tissue O2 demand
To decrease cardiac workload
To enhance venous return
To decrease tension and anxiety level
To treat underlying cause
EXPECTED OUTCOME
The pt shall have demonstrated behaviours to improve circulationThe pt shall have demonstrated increased perfusion as appropriate
ASSESSMENT DIAGNOSIS
Subjective:“nanghihina sya” as verbalized by the motherObjective:
-decreased WBC
-decreased platelet
-decreased HgB
-decreased capillary refill time
Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to DHF 1
ineffective tissue perfusion
Planning
Short Term
At the end of the shift the patient mother will able to demonstrate safety precaution to avoid potential injury
Long TermPrior to dismissal the patient will able to decrease potential injury
INTERVENTION RATIONALE
IndependentTo monitor vital sign.Apply pressure on the injection site.Instruct to avoid injury from sharp objectsProvide safe environment (pad side rails to prevent fall)Observe stool and emesis for occult blood.DependentAdminister meds care fully, monitor for side effect.
To have baseline data and evaluate efficiency of intervention.Prevent bleeding on the site Provide precautionary measureMinimizes fall and injury if falls occurs.Detect early evidence of bleedingReduces the side effect secondary to damage liver in ability to detoxify.
EXPECTED OUTCOME
Patient will demonstrate safety precaution to avoid potential injury.
At the end of the shift the patient mother will able to demonstrate safety precaution to avoid potential injury
At the end of the shift the patient mother will able to demonstrate safety precaution to avoid potential injury
Risk for Skin Integrity