Liceo de Cagayan University College of Nursing
Individual Care StudyName of Client
Submitted to:
CLINICAL INSTRUCTOR
In Partial Requirement for NCM501___ RLE
Submitted by:
Group B7 – Cluster 2
I. INTRODUCTION
Upper respiratory tract infection (URI) is a nonspecific term used to
describe acute infections involving the nose, paranasal sinuses, pharynx, larynx,
trachea, and bronchi. The prototype is the illness known as the common cold,
which will be discussed here, in addition to pharyngitis, sinusitis, and
tracheobronchitis. Influenza is a systemic illness that involves the upper
respiratory tract and should be differentiated from other URIs.
Viruses cause most URIs, with rhinovirus, parainfluenza virus,
coronavirus, adenovirus, respiratory syncytial virus, coxsackievirus, and influenza
virus accounting for most cases. Human metapneumovirus is a newly discovered
agent causing URIs. Group A beta-hemolytic streptococci (GABHS) cause 5% to
10% of cases of pharyngitis in adults. Other less common causes of bacterial
pharyngitis include group C beta-hemolytic streptococci, Corynebacterium
diphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Chlamydia
pneumoniae, Mycoplasma pneumoniae, and herpes simplex virus. Streptococcus
pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most
common organisms that cause the bacterial superinfection of viral acute sinusitis.
Less than 10% of cases of acute tracheobronchitis are caused by Bordetella
pertussis, B. parapertussis, M. pneumoniae, or C. pneumoniae.
Most URIs occurs more frequently during the cold winter months, because
of overcrowding. Adults develop an average of two to four colds annually.
Antigenic variation of hundreds of respiratory viruses results in repeated
circulation in the community. A coryza syndrome is by far the most common
cause of physician visits in the United States. Acute pharyngitis accounts for 1%
to 2% of all visits to outpatient and emergency departments, resulting in 7 million
annual visits by adults alone. Acute bacterial sinusitis develops in 0.5% to 2% of
cases of viral URIs. Approximately 20 million cases of acute sinusitis occur
annually in the United States. About 12 million individuals are diagnosed with
acute tracheobronchitis annually, accounting for one third of patients presenting
with acute cough. The estimated economic impact of non–influenza-related URIs
is $40 billion annually.
Influenza epidemics occur every year between November and March in
the Northern Hemisphere. Approximately two thirds of those infected with
influenza virus exhibit clinical illness, 25 million seek health care, 100,000 to
200,000 require hospitalization, and 40,000 to 60,000 die each year as a result of
related complications. The average cost of each influenza epidemic is $12
million, including the direct cost of medical care and indirect cost resulting from
lost work days. Pandemics in the 20th century claimed the lives of more than 21
million people. A widespread H5N1 pandemic in birds is ongoing, with threats of
a human pandemic. It is projected that such a pandemic would cost the United
States $70 to $160 billion.
B. OBJECTIVES OF THE STUDY
This individual case study provides goals or objectives which can be used as an
instrument in assessing the patient’s health status and in his present conditions:
1. Use to obtain a complete heath data and can be used in follow up care.
2. Impart knowledge by conducting health teaching about the necessary
information pertaining in the disease condition.
3. Understands the course and essence of the chosen care study.
C. SCOPE AND LIMITATION OF THE STUDY
The study includes all the data gathered during the interview and the
observation claimed by the patient as well as the significant others. It also deals
with the several factors observed and gathered during the interview. That
information gathered was the exact answer and the problems of the people in the
community and not just basing in the opinions of the students conducting the
interview of the students.
The limitation of this study is limited in the place of interaction itself which
is in the hospital. This study was completed in 2 days by the interaction of the
student and the patient.
II. HEALTH HISTORY:
A. Profile of the Patient
NAME:
AGE:
SEX:
RELIGION:
BIRTH DATE:
CIVIL STATUS: Single
NATIONALITY: Filipino
ADDRESS: tagloan
DATE OF ADMISSION: November 18, 2008
TIME OF ADMISSION: 9:05pm
VITAL SIGNS ASSESMENT
TEMPERATURE: 36.6
PULSE RATE: 86 bpm
RESPIRATORY RATE: 100 bpm
HEIGHT: 94 cm
WEIGTH: 12.7 kg
ALLERGY: No allergy
B. FAMILY AND PERSONAL HEALTH HISTORY
Jurey was born on November 18, 2007. He was delivered NSVD in the
Polymedic General Hospital. He was a healthy and a lovable boy. One month
after birth Jurey experienced diarrhea lasting for two days, her mother panic
and admitted him into the Polymedic General hospital. He was then
diagnosed of having a diarrhea having a watery stool, Jurey stayed in the
hospital for almost a day. A week after, Jurey had a fever due to infection. Her
mother gave him paracetamol and she had performed a tepid sponge both on
him. After giving the medications and performing tipid sponge bath the
temperature of Jurey drop from 38° c to 36.8° c.
C. HISTORY OF PRESENT ILLNESS:
The case of 2 years old male, Roman Catholic lived in Taguluan,came in
Sabal Hospital CDOC at 12:50 pm on November 18 , 2008 with a chief
complains of Loss bowel movement (LBM) and vomiting. Jurey had a cough
lasting for 6 days.
On that day, Jurey had LBM three consecutive defecation within an
interval of 30minutes with watery, nonblood seen associated with vomiting at
least two times after such intake of foods/fluids as stated by the mother where
prompt to admission. There was no associated symptom like fever during that
day.
Jurey was diagnosed to have an acute gastroenteritis with mild
dehydration (AGE).
D. CHIEF COMPLAINS
The chief complain of the patient is loss bowel movement and
vomiting last November 18, 2008 at 12:05 pm.
III. DEVELOPMENTAL DATA:
Sigmund Freud’s Psychosocial Development:
According to Freud, the source of bodily pleasure is concentrated in zones
around the musculocutaneous junctions. These erotogenic zones displace one
another in sequence as the child matures. Initially, the infants erotogenic zone is
the mouth, thus gratification of the id is derived through oral satisfaction. During
the first 6 months of life, the infant is in the oral dependent or oral passive stage,
as evidenced by sucking. After the first teeth erupt at about 5 to 7 months of age,
the infant enters the oral aggressive stage with biting and sucking as the means
of gratification.
Infants enjoy sucking and later biting anything that touches the erogenous
zone of the lips and mouth. Some infants enjoy this oral activity more than the
others. While some may be satisfied by sucking at the breast or bottle, others
require pacifiers, toys or other objects that can be orally manipulated.
The young infant operates on the basis of primary narssism or self-love,
wanting what is wanted immediately and unable to tolerate a delay in
gratification. This process, the pleasure principle, later becomes a part of the ego
structure that operates on the reality principle, giving up what is wanted now for
something better in the future. If the mother or her substitute always sees to it
that the infant’s need before there is evidence of these needs, the infant will feel
no control over the environment. On the other hand, if required to wait too long
after expressing a need, the infant will feel unable to control the environment and
thus learns to mistrust the caregiver.
IV. MEDICAL MANAGEMENT
MEDICAL ORDERS/RATIONALE/MEDICINE/LABORATORY:
MEDICINE ORDERED DATE ORDERED RATIONALEo Cotrimoxazole
125mg/5ml suspension 4.0ml BID (8-6)
November 18,2008 Antibacterial – for Shigellosis or UTIs caused by susceptible strains of Escherichia coli, Proteus (in dole positive or negative),Klebsiella, or Enterobacter species.
o Metronidazole 125mg/5ml suspension 4.0ml TID(8-1-6)
November 18, 2008 Amoebicides & Antiprotozoals – intestinal Amebiasis
o Prozinc drops 1.3ml OD (once daily)
Food supplement - contains zinc an essential mineral that stimulates the activities of many enzymes promoting normal biochemical reaction in the body. Strengthen the immune system, support normal growth and drugs and help prevent retardation.
o Fecalysis November 18, 2008 To check for abnormalities.
o Urinalysis November 18, 2008 To check for abnormalities.
o Hemochrome November 18, 2008 To check for abnormalities.
DRUG STUDY
GENERIC NAME OF THE DRUG: CETTRIAXONE
DATE ORDERED: November 18, 2008
CLASSIFICATION: Cephalosporin
DOSE AND FREQUENCY:
MECHANISM OF ACTION:
SFECIFIC INDICATION: Lower respiratory tract infection, skin and skin structure
infection due to s.aureus
SIDE EFFECTS: Increases in the serum creatine presence of cast in the urine,
alternation of PFs.
NURSING PRECAUTION:
1. IM injection should be deep in the body of the large muscle.
2. IV infusion should contain concentrations of 40 mg/mL of sterile water.
3. Do not mix the drug with other antibiotics
V. ANATOMY AND PHYSIOLOGY:
Acute gastroenteritis
Viruses and bacteria from the contaminated food
It produces toxins that react with the small intestine mucosa
Dysentery caused by bacteria which affects the colon
Abdominal cramping, diarrhea and vomiting
Fluid electrolytes imbalance
Parasites invade the circulation and localize in the
Gastrointestinal tract
Inflammation
Watery stools and vomiting occur
THE DIGESTIVE SYSTEM
Consists of (1) an alimentary canal- a long muscular tube beginning at the
lips and ending at the anus, including the mouth, pharynx (oral and laryngeal
portions), esophagus, stomach, and small and large intestine, and (2) accessory
glands that empty secretions into the tube- salivary glands, pancreas, liver, and
gallbladder.
1. Teeth
a. Crown projects above the gum, root below. Dentin (bulk of tooth)
surrounds pulp cavity. Enamel covers dentin of crown; cementum
covers dentin of root and anchors tooth to periodontal ligament.
b. Each quadrant of mouth has eight teeth-two incisors, one canine,
two premolars, and three molars.
2. Esophagus
a. Mucous membrane lined with stratified squamous epithelium rather
than simple columnar epithelium, as in stomach and intestine,
b. Muscular layer of upper third, striated; lower third, smooth; middle,
both striated and smooth.
c. Segment above stomach (indistinguishable anatomically from
remainder of esophagus) functions as sphincter, remaining closed
until reflexively relaxed as peristaltic wave approaches,
3. Stomach
a. Consists of upper fundus, central body, and constricted lower pyloric
portion (antrum).
b. Musculature contains an oblique inner layer of smooth muscle in
addition to external longitudinal and underlying circular smooth muscle
layers found elsewhere in digestive tract.
c. Thick circular muscle in pyloric portion forms pyloric sphincter.
d. Openings: cardia, between esophagus and stomach; pylorus, between
stomach and duodenum.
4. Small Intestine
a. Divided into duodenum, jejunum, and ileum.
b. Surface area, serving absorptive function, increased by:
1. Circular folds (plicae circulares)- permanent, transverse folds.
2. Villi – fingerlike projections
3. Microvilli- processes on free surface of epithelial cells that form the brush
order.
c. Invagination of ileum into cecum – the first part of the large intestine –
forms ileocecal valve, which opens rhymthmically during digestion,
permitting gradual emptying of ileum and preventing regurgitation.
5. Large Intestine
a. Extends from the end of the ileum to the anus and is divisible into the
cecum, colon, rectum, and anal canal. The major part is the colon, which
consists of ascending, transverse, descending, and sigmoid portions.
b. The longitudinal muscle of the cecum and colon forms three
conspicuous bands(taeniae coli).
c. Thickene circular smooth muscle of anal canal forms the internal
anal sphincter. Surrounding skeletal muscle forms the external sphincter.
6.Salivary Glands
a. Three pairs (parotid, submaxillary, and sublingual), with ducts opening into
the mouth.
b. Two types of secretions:
1. Serous containing ptyalin –enzyme initiating digestion of the starch.
2. Mucous – viscous, containing mucus, which facilitates mastication.
7. Pancreas
a. Two types of secretory cells in exocrine pancreas:
1. Enzyme- secreting acinar cells.
2. Bicarbonate-and-water-secreting –intralobular duct cells.
b. Pancreatic duct empties pancreatic juice into duodenum.
8. Liver and Gallbladder
a. Bile secreted by liver is essential for normal absorption of digested lipids.
Bile salts combine with products of lipid digestion to form water-soluble
complexes (micelles) which are absorbed by intestinal cells.
b. Gallbladder concentrates and stores bile.
c. Hepatic duct, formed from the bile duct system of liver, joins cystic duct of
gallbladder to form common bile duct, which empties into duodenum.
Motility of Digestive Tract
1. Swallowing
a. In buccal stage (voluntary) bolus pushed toward pharynx.
b. In pharyngeal and esophageal stages (involuntary) bolus passes
through pharynx into esophagus and through esophagus into
stomach.
c. Reflexes raise soft palate, raise larynx, adduct aryepiglottic folds
and true and false vocal cords, and inhibit respiration. When food
enters the pharynx, reflex contraction of the superior constrictor
muscle initiates peristalsis, propelling the food, and relaxation of the
upper and lower esophageal sphincters allows food to pass first
into the esophagus and then into the stomach.
2. Peristalsis in Stomach
a. Mixes contents and forces chime through pylorus.
b. Three waves each beginning every 20 seconds near midpoint of
stomach, lasting about one minute, and ending with contraction of
pyloric sphincter travel down stomach at one time.
c. Rate of emptying determined largely by strength of contractions.
d. Feedback from duodenum regulates gastric emptying. Two control
mechanisms, one neuronal (enterogastric reflex), the other
hormonal (mediated mainly by enterogastrone), inhibit gastric
motility.
3. Contractions of the Small Intestine
a. Segmenting: rhythmic contractions along a section dividing it into
segments: primarily mixing action.
b. Peristaltic waves superimposed upon segmenting contractions.
c. Ingestion of food increases ileal peristalsis and frequency of
opening of ileocecal valve (gastroileal reflex).
4. Contractions of Large Intestine
a. Simultaneous contraction of circular and longitudinal muscle,
forming haustra,
b. Infrequent usually two or three times daily of most mass
movements transferring contents from proximal to distal colon and
into rectum. Most commonly occur shortly after a meal (gastrocolic
reflex).
5. Defecation reflex
a. Distention of rectum triggers intense peristaltic contractions of colon
and rectum and relaxation of internal anal sphincter.
b. Reflex preceded by voluntary relaxation of external sphincter and
compression of abdominal contents.
Digestion
1. Mouth
a. Enzymatic action: initiation of the digestion of carbohydrate by ptyalin,
which splits starch into the disaccharide maltose. Action in mouth slight,
but continues in stomach until acid medium inactivates ptyalin.
b. Regulation: exclusively nervous- impulses transmitted from center in
medulla activated principally by taste, smell, or sight of food to salivary
glands by parasymphatetic nerve fibers.
2. Stomach
a. Enzymatic action: initiation of protein digestion by pepsin, producing
proteoses, peptones, and polypeptides. Pepsinogen secreted by chief
cells converted to pepsin by autoactivation process in presence of acid
secreted by parietal cells.
b. Regulation
1. Cephalic phase- initiated by taste, sight, or smell of food; secretion
stimulated directly or indirectly by the hormone gastrin. Gastrin, released
from so called G cells in the pyloric region of the stomach, stimulates the
secretion of an acid-rich gastric juice.
2. Gastric phase- initiated by food in stomach; secretion triggered directly or
indirectly, as in cephalic phase.
3. Intestinal phase- initiated by digestive products in upper small intestine;
mediated by hormone released by duodenum acting on stomach.
4. Inhibition- strong acid in antrum inhibits gastrin release. Fat, acid, or
hypertonic salt solutions in duodenum stimulate release of hormones
which inhibit gastric secretion.
3. Intestine
a. Enzymatic action- fat digestion and continuation of carbohydrate and
protein digestion.
1. Pancreatic lipase splits fat into monoglycerides, fatty acids, and glycerol.
2. Pancreatic amylase converts starch and glycogen into maltose. Intestinal
disaccharidases split maltose, sucrose, and lactose into their constituent
monosaccharides,
3. Pancreatic enzymes trypsin and chymotrypsin both endopeptidases split
proteins and the products of pepsin digestion into peptides. Peptidases
split peptides into amino acids.
b.. Regulation of pancreatic secretion: by vagus nerve during cephalic and
gastric phase of gastric secretion and by two duodenal hormones-
cholecystokinin-pancreozymin and sectetin. Vagus stimulation and
cholecystokinin-pancreaozymin stimulate enzyme secretion; secretin
stimulates bicarbonate secretion.
Absorption
1. Occurs almost exclusively in the small intestine.
2. Simple sugars, amino acids, short-chain fatty acids, and glycerol are
absorbed into blood stream via capillary network of villi. Products of lipid
digestion are absorbed as chylomicrons into intestinal lymphatics via
central lacteal of villi.
Digestion process- the digestive system prepares food for consumption by the
cells through five basic activities:
1. Ingestion- is an active, voluntary process of taking in food. Food must be
placed in the mouth before it can be acted on.
2. Propulsion is movement of food along the digestive tract. Swallowing is
one example of food movement that depends largely on the propulsive
process called peristalsis. Peristalsis is involuntary and involves
alternating waves of contraction and relaxation of the muscles in the organ
wall to squeeze food along the tract.
3. Digestion- the breakdown of food by both chemical and mechanical
processes.
4. Absorption- the passage of digested food from the digestive tract into the
cardiovascular and lymphatic systems for distribution to cells. For
absorption to occur, the digested foods must first enter the mucosal cells
by active or passive transport processes. The small intestine is the major
absorptive site.
Defecation- the elimination of indigestible substances from the body
VI. NURSING ASSESMENTEENT:𓀿 Impaired vision 𓀿 blind 𓀿 pain 𓀿 reddened 𓀿 drainage𓀿 gums 𓀿 hard of hearing 𓀿 deaf𓀿 burning 𓀿 edema 𓀿 lesion 𓀿 teethAsses eyes, ears, noseThroat for abnormality 𓀿 no problemRESPIRATION𓀿asymmetric 𓀿 tachypnea𓀿 apnea 𓀿 rales 𓀿 cough 𓀿 barrel chest𓀿 bradypnea 𓀿 shallow 𓀿 rhonchi𓀿 sputum 𓀿 diminished 𓀿 dyspnea𓀿 orthopnea 𓀿 labored 𓀿 wheezing𓀿 pain 𓀿 cyanoticAsses resp. rate, rhythm, depth, patternbreath sounds, comfort 𓀿 no problemCARDIO VASCULAR𓀿 arrhythmia 𓀿 tachycardia 𓀿 numbness𓀿 diminished pulses 𓀿 edema 𓀿 fatigue𓀿 irregular 𓀿 bradycardia 𓀿 murmur𓀿 tingling 𓀿 absent pulses 𓀿 painAssess heart sounds, rate, rhythm, pulse, bloodpressure, etc., fluid retention, comfort𓀿 no problemGASTRO INTESTINAL TRACT𓀿 obese 𓀿 distention 𓀿 mass𓀿 dysphagia 𓀿 rigidity 𓀿 painAsses abdomen, bowel habits, swallowing, bowel sounds, comfort 𓀿 no problemGENITO-URINARY and GYNE𓀿 pain 𓀿 urine color 𓀿 vaginal bleeding𓀿 hematuria 𓀿 discharge 𓀿 nocturiaAssess urine freq., control, color, odor, comfort/Gyn-bleeding, discharge 𓀿 no problemNEURO𓀿 paralysis 𓀿 stuporous 𓀿 unsteady 𓀿 seizures𓀿 lethargic 𓀿 comatose 𓀿 vertigo 𓀿 tremors𓀿 confused 𓀿 vision 𓀿 gripAssess motor function, sensation, LOC, strength, grip, galt, coordination, orientation, speech.𓀿 no problemMUSCULOSKELETAL and SKIN𓀿 appliance 𓀿 stiffness 𓀿 itching 𓀿 petechiae𓀿 hot 𓀿 drainage 𓀿 prosthesis 𓀿 swelling𓀿 lesion 𓀿 poor turgor 𓀿 cool 𓀿 deformity𓀿 wound 𓀿 rash 𓀿 skin color 𓀿 flushed𓀿 atrophy 𓀿 pain 𓀿 ecchymosis 𓀿 diaphoretic 𓀿 moistAsses mobility, motion, galt, alignment, joint function /skin color, texture, turgor, integrity 𓀿 no problem
Sunken eyeballs
P Dry , cracked lips
Abdominal pain
Dry skin
Febrile T: 38˚C
Appeared weak
Dry skin and Afebrile T: 36.6˚C
NameTumacas ,Jurey Date: _November 18, 2008Vital Signs:Pulse: _100 bpm BP: ______Height___94 cm____ Temp: _ 38_ ° c_
NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVECOMMUNICATION:( ) Hearing Loss Comments: “wla may ( ) visual changes problima sa pan-(x)denied dungog ug pan- Lantao” as verba- Lized by the mother.
( ) glasses ( ) languages( ) contact lense ( ) hearing aidePupil size 3-5 mm_ ( ) speech difficultiesReaction _Pupils are equally rounded and reactant to _light accommodation._
OXYGENATION:( ) dyspnea Comments: “ Dili man siya() smoking history galisud ug ginha- ___none____ hawa.” As ( ) cough verbalized by the( ) sputum mother.(x ) denied
Resp. (x ) regular () irregularDescription _R: right lung is clear in secretions and have a equal size to left lung_ L: left lung is clear in secretions and equal size to right lung
CIRCULATION:( ) chest pain Comments: “gasakit lang ( ) leg pain ang iyang tiyan”.as( ) numbness of verbalized by the Extremities mother.(x) denied
Heart Rhythm (x) regular ( ) irregularAnkle edema There was no presence of ankle edema
Pulse Car Rad AP FemR ______ + + L ________ + + Comments: _. Not all pulses is present
NUTRITION:Diet:full diet Comments: ” la na siya ( ) N ( x) V gana mokaon” asCharacter vaerbalized by (x) recent change in the mother. weight, appetite( ) swallowing difficulty( ) denied
( ) dentures (x) none
Complete Partial
Upper ( ) ( ) Lower ( ) ( )
ELIMINATION:Usual bowel pattern ( ) urinary frequency
Loss bowel movement _ 5-7 times a day
( ) urgency Constipation remedy ( ) dysuria ( ) hematuria Date of last LBM ( ) Incontinence November 18, 2008 ( ) polyuria(x ) diarrhea ( ) foly in place character ( ) denied__not present__
_____
Comments: “ sahay nlngMan gasakit akko tiyan.
MGT. OF HEALTH & ILLNESS:( ) alcohol ( ) denied ( amount, frequency)._______not applicable_______________________ ( ) SBE Last Pap Smear _____________LMP : ___not applicable____________
______________
Briefly describe the patient’s ability to follow
treatments ( diet, meds, etc.) for chronic
health problems (if present)
The patient is a 2 years old child, and I am
having a difficulty in administering medication
to him. Her mother is the one who is giving
the medication.
Bowel sounds: hyper active bowel soundPresent ( ) yes (x) no Urine*(color,consistency, Odor)
If foley is in place?
SUBJECTIVE OBJECTIVESKIN INTEGRITY:(x) dry Comments: “Uga kayo iyang( ) itching panit”.as verbalized( ) denied by her mother.
(x) dry () cold () pale(x ) flushed (x ) warm( ) moist ( ) cyanotic* rashes, ulcers, decubitus (describe size, location, drainage) .The patient has a flushed, warm and dry skin.
ACTIVITY/SAFETY:( ) convulsion Comments:” Luya kayo ang () dizziness lawas ni Juey, dili kaa-( ) limited motion yo siya galihok”. As of joints verbalized by the Limitation in mother. ability to() ambulate() bathe self( ) other(x ) denied
( ) LOC and orientation Gait: ( X) steady ( ) unsteady ________________
( ) sensory and motor losses in face or extremities: No sensory and motor loss( ) ROM limitations : patient has the ability to do ROM
COMFORT/SLEEP/AWAKE:() pain Comments: “gasakitaay ako (location, iyang tiyan” as verbalized by frequency her mother. remedies) ( ) nocturia( ) sleep difficulties( ) denied
(x) facial grimaces() guarding() other signs of pain .Pain due to abdominal cramping.
COPING:
3 members of the family___ Members of household
_His father Mr. TumacasMost supportive person
Observed non-verbal behavior : The patient is rubbing his abdomen portion and has a facial grimace due to pain
The person and his phone number that can be
Reached any time _Was not given by the significant others . __________
MEDICAL ORDERS/RATIONALE/MEDICINE/LABORATORY:
MEDICINE ORDERED DATE ORDERED RATIONALEo Cotrimoxazole
125mg/5ml suspension 4.0ml BID (8-6)
November 19,2008 Antibacterial – for Shigellosis or UTIs caused by susceptible strains of Escherichia coli, Proteus (in dole positive or negative),Klebsiella, or Enterobacter species.
o Metronidazole 125mg/5ml suspension 4.0ml TID(8-1-6)
Amoebicides & Antiprotozoals – intestinal Amebiasis
o Prozinc drops 1.3ml OD (once daily)
Food supplement - contains zinc an essential mineral that stimulates the activities of many enzymes promoting normal biochemical reaction in the body. Strengthen the immune system, support normal growth and drugs and help prevent retardation.
o Fecalysis November 19,2008 To check for abnormalities.
o Urinalysis November 19, 2008 To check for abnormalities.
o Hemochrome November 19, 2008 To check for abnormalities.
Diagnostic Examination:
FECALYSIS:
Date: November 19,2008
Macroscopic appearance:
Color: yellow Consistency: Soft
Microscopic appearance:
Pus cells: none seen /hpf
RBC: none seen /hpf
Fat globules: none seen / hpf
Amoeba:
Cyst: 0-2 /hpf
Result: Positive amoeba
URINALYSIS
Date: November 18, 2008
Color: Yellow
Appearance: Clear
Specific gravity: 1.025
Protein (Albumin): Negative
Glucose: Negative
Bacteria: Few
Result: No findings
Hemochrome
Date: November 19,2008
WBC- 13.4 normal range (5-10x103ml3)
VII. IDEAL NURSING MANAGEMENT
Acute pain related to abdominal cramping and irritation.Desired outcomes/evaluation criteria – the patient relievesAbdominal pain
INDEPENDENT Encourage the mother to increase
the oral intake of fluids containing electrolytes, such as juices and etc.
Monitor Intake and Output. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria.
Auscultate the abdomen of the patient.
Restrict the solid intake as indicated by the physician.
Provide prompt diaper change and cleansing gently.
Place the bedpan in the bed of the patient or a commode chair near the bed.
Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill.
Weigh daily
Maintain oral restrictions, bed rest.
To maintain the skin integrity of the patient, because skin breakdown can occur quickly when LBM occur.
Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.
To determine for presence, location and characteristic of the bowel sound.
To allow bowel rest5 or to reduce intestinal workload.
To avoid skin breakdown and diaper rash.
To provide easy access and to reduce the need to wait.
Indicates excessive fluid loss/resultant dehydration.
Indicator of overall fluid and nutritional status.
Colon is placed at rest for healing and to decreased intestinal fluid losses.
Note generalized muscle weakness or cardiac dysrhytmias.
DEPENDENT Administer parenteral fluids, blood
transfusions as indicated.
Monitor laboratory studies, e.g., electrolytes (especially potassium, magnesium) and ABGs (acid-base balance).
Administer medications as indicated:
Antidiarrheal e.g., dipphenoxylate (Lomotil), loperamide (Imodium), anodyne suppositories.
Antiemetics, e.g., trimethobenzamide (Tigan), hydroxyzine (Vistaril), prochlorperazine (Comparazine);
Antipyretics, e.g., acetaminophen (Tylenol);
Electrolytes, e.g., potassium supplement (KCl-IV;K-Lyte, Slow-K);
Vitamin K (Mephyton)
Excessive intestinal loss may lead to electrolyte imbalance, e.g., potassium, which is necessary for proper skeletal and cardiac muscle function. Minor alterations in serum levels can result in profound and/or life-threatening symptoms.
Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. Note: fluids containing sodium may be restricted in presence of regional enteritis.
Determines replacement needs and effectiveness of therapy.
Reduces fluid losses from intestines.
Used to control nausea and vomiting in acute exacerbations.
Controls fever, reducing insensible losses.
Electrolytes are lost in large amounts, especially in bowel with denuded, ulcerated areas, and diarrhea can also lead to metabolic acidosis through loss of bicarbonate (HCO3).
Stimulates hepatic formation of prothrombin, stabilizing coagulation and reducing risk of hemorrhage.
IDEAL NURSING MANAGEMENT
Knowledge deficient regarding condition, prognosis, treatment, self-care, and discharge needs as related to unfamiliarity with resources and information misinterpretation.
Desire outcomes/evaluation criteria- the significant others will:
Verbalize understanding of disease processes, possible complications.
INTERVENTION RATIONALEINDEPENDENT
Determine the mother’s perception of disease process.
Giving of information’s about the factors that causes the disease condition of the client. Encouraging the mother to ask question about it.
Giving of information’s about the medication as well as it’s side effects and action.
Stressing the importance of the following :good skin care, e.g., proper hand washing techniques
Establishing knowledge regarding the disease condition of her child .
Precipitating/aggravating factors are individual; therefore, the mother needs to be aware of what foods, fluids, and lifestyle factors can precipitate symptoms. Accurate knowledge base provides opportunity for the mother to make informed decisions/choices about future and control of chronic disease. Although most others know about their own disease process, they may have outdated information or misconceptions.
Promotes understanding and may enhance cooperation with regimen.
Reduces spread of bacteria and risk of skin irritation/breakdown,
and perineal skin care.
Emphasize need for long-term follow-up and periodic reevaluation.
infection.
Patients with IBD are at risk for colon/rectal cancer, and regular diagnostic evaluations may be required..
IDEAL NURSING MANAGEMENT
Impaired skin integrity related to effects of excretions on delicate tissue.
Desired outcomes/evaluation criteria- patient will:
The patient will be able to maintain his skin integrity as well as to maintain fluid volume.INTERVENTION RATIONALEIndependent
Provide the patient with oral mouth care.
Maintain accurate intake and output and calculate also the 24 urine collection.
Instruct the mother to use less frequently mild cleanser or soaps and to provide optimal skin care.
Dependent:
Administer medication to prevent the skin and mucous membrane from cracking as indicated by the physician.
This is to prevent from injury because of dryness.
To determine the fluids taken by the patient and also to calculate the output of the patient.
This is to maintain skin integrity of the patient and to prevent excessive dryness.
To prevent injury and also to prevent the cracking of the mucous membrane of the patient.
VIII. Actual Nursing Management
S
“Nagsakit man the tiyan ni Jurey tapos cige siya ug kalibang”.
O
>hyper active bowel sound.
>Facial Grimace
>Dry skin
A
Acute pain related to abdominal cramping
P
Long term:
At the end of 2o minutes the patient will be able to reestablish
and maintain the normal pattern of Bowel functioning.
Short Term:
At the end of 15 minutes the patient will be able to maintain the
normal patter of normal bowel functioning.
I
1. Auscultate the abdomen of the patient.
2. Restrict solid foods intake as indicated by the
physician.
3. Encourage the mother to increase the fluid intake
of her son containing electrolytes. such as juices to
prevent dehydration.
4. place the bedpan near the bed top have a easy
access.
E
5. Administer medications that can relieve abdominal
pain as indicated by the physician.
6.
After the nursing intervention given the patient abdominal pain
will be reduce.
Actual Nursing Management
S “Init kayo si Jurey ug ga chill siya”.
O >Temperature:40°c
>Pulse rate: 160 bpm
>Respiratory Rate :72 cpm
>Flushed skin
A Fever related to infection
P
Long term:
At the end of 20 minutes the temperature of Jurey will drop into a
normal range..
Short Term:
At the end of 10 minutes the temperature of Jurey will drop
slowly into the normal range..
I
1. Perform tepid sponge bath.
2. Change the clothing of the patient into a more
comfortable one.
3. Change the clothing of the patient as often as
possible.
4. Apply hot water bag in the lower extremities of the
patient. To lower his temperature.
5. Open the doors and windows in the patient room
so that the fresh air will come in.
6. Administer medications prescribed by the
E
physician. To lower the temperature of the patient.
After the nursing Intervention gentle patients body temperature
will drops slowly into the normal range.
IX. HEALTH TEACHING
MEDICATIONS For the medications, Instruct the
mother of the patient to continue the
medication prescribed by the physician
and to give the medication on the
proper time and route. The
paracetamol which can lower the body
temperature and should be given every
4 hours.
EXERCISE For the exercise, Instruct the mother to
teach her son to do the relaxation
exercise. This is to relieve his
abdominal pain.
TREATMENT Instruct the mother to follow the
treatment given by the physician, which
includes the proper administration of
the medications, the time the
medication be given and the diet that
the patient must have. That treatment
is necessary for the complete recovery
of the patient.
OUT PATIENT Instruct the mother to be back in the
hospital after 1 week after the
discharge of the patient. This to
determine if the condition of the patient
is already stable and if there is another
treatment be given.
DIET Instruct the mother to give her child
foods rich in fibers such as vegetables
and also to increase the fluid intake of
the patient.
X. Evaluation:
In the case of Jurey, Immediate intervention was given because Jurey was
admitted to the Sabal Hospital after experiencing loss bowel movement and
vomiting. History was taken to document the onset and frequency of diarrhea.
Exposure to contaminated food or water is initiated with the patient where
drinking water might be contaminated. Physical examination helps the physician
to identify underlying systemic disease. The doctor ordered for some diagnostic
tests to find the cause of diarrhea which include the fecalysis where positively
amoebiasis was detected. Urinalysis and hemochrome was also ordered to
provide more specific data.
Treatment for acute gastroenteritis includes restoration of fluid and
electrolyte balance, management of signs and symptoms and treatment of
causative factors.
XI. REFERRALS:
No one can escape from having this kind of disease Children are very
susceptible to illness that is why I imparted knowledge to Mrs. Tumacas to
continue giving nutritious foods, and vitamins. As much as possible report to the
physician immediately if there are any unusualities may observe because
diarrhea can be dangerous in newborns and infants. Children, especially those
younger than 6 months of age and those with other health risks, need special
attention when they have diarrhea because they can become dehydrated.
Because a child can die from dehydration within a few days, the main treatment
for diarrhea in children is dehydration. Quickly Careful observation of the child's
appearance and how much fluid he or she is drinking can help prevent problems.
And lastly I told her to follow-up the rural health center for his complete
immunization.
XII. BIBLIOGRAPHY:
>://www.google.com/search?
hl=en&q=case+study+acute+gastroenteritis&btnG=Search
>Smeltzer, S, et al Medical-Surgical Nursing. 10th Edition Lippincott Williams and
Wilkins (2004)
>Kozier, B, et al Fundamentals of Nursing. 7th Edition Pearson Education South
Asia PTE LTD Philippines 2004
