Case Analysis

Patients Profile:
Name: A.M
Age: 2 years old
Birth date: January 7, 2012
Birth place: Manila
Address: 106 J.P. Paz cpd., Manila NCR, Firs !isric
Religion: "#lesia ni Criso
Nationality: Filipino
Admitting Diagnosis: acue #asro eneriis $i% &oderae si#ns o' de%ydraion
Date of Admission: May 16, 201(
Chief Complaint: )o&iin# and loose *o$el &o)e&en
Admitting Physician: +eus Paric, M. -)an#elisa, M!
History of Present illness:
.$o days prior o ad&ission, paien %ad sudden onse o' loose *o$el &o)e&en and
)o&iin# o' pre)iously in#esed 'ood. Consul don/ o PM!. A'er consul paien %ad )o&iin#
and loose *o$el &o)e&en o 012 and $as ad&ied.
Laboratory Results:
Result nit Reference! Ranges
"BC 1(.304 105671 #$%&'($%
RBC (.81 1051271 #$)&)$*
Hemoglobin 190.74 #71 '#(&'+) g!L
Haematocrit 0.9364 ($#')&($)(#
,C- 38.00 '1 %.&*%
,CH 23.66 P# .%&//
,CHC 99.33 //&/0g!L
Platelet count 87(4 #71 ')(&#((
RD" 18.704 10561 ''$#&'#$(
Neutrophil (6.30 : #(&+(1
Lymphocyte (0.30 : '*$(&#%$(1
Aosinophil 0.60 : .$(&%$(1
,onocyte 03.20 : ($((&')$(1
Basophil 0.604 : ($((&)$(1

2342 R34L2 R353R3NC3
A$ Physical
Color ;ello$ 6ello7&Bro7n
Consistency <aery 5ormed
B$ ,icroscopic
Leu8ocytes 0=27 2PF 5e7 present
RBC 1=272PF 5e7 Present
6east Cell Fe$
C$ Remar8s Ascaris lu&*riodes o)a : 0=172PF
9nterpretation:
.%e aendin# p%ysician re>uesed %e C?C e@a& o #i)e )alua*le in'or&aion a*ou %e
#eneral sae o' %e %eal%. "n %e e@a&, %e <?C is %i#% $%ic% i is an essenial par o' %e i&&une
syse& and %elps o 'i#% in'ecion, so i indicaes in'ecion. .%e %e&o#lo*in is lo$ $%ic% &ay si#ni'y
ane&ia. 2e&aocri &easures %e a&oun o' space o' R?C a,e up in %e *lood. 2e&aocri and
%e&o#lo*in are %e $o &aAor es %a s%o$s i' ane&ia or polycy%e&ia is presen. Plaele coun in %e
resul is %i#% $%ic% &ay indicae *lood clo 'or&in# in %e *lood )essels. R!< &easures i' %e cells are
all %e sa&e or di''eren sizes or s%apes. ?asop%ils
Fecalysis is o analyze %e condiion o' a personBs di#esi)e rac in #eneral. A 'ecalysis is
per'or&ed o c%ec, 'or %e presence o' any reducin# su*sances suc% as $%ie *lood cells C<?CsD, su#ars,
or *ile and si#ns o' poor a*sorpion.
Name Action 9ndication Contraindication Analysis
:eneric Name:
Paracea&ol
Brand Name:
.e&pra
Reduce 'e)er Fe)er reducion. 2ypersensii)iy .%e p%ysician ordered
paracea&ol o reduced
'e)er since %e paien
%as sli#% 'e)er %a &ay
*e cause *y in'ecion as
e)idenced *y increase
<?C.
;inc 4ulfate syrup 0yn%esis and sa*ilizaion
o' proeins and nucleic
acids in su*cellular and
&e&*rane ranspor
syse&.
Pre)en race ele&en
de'iciencies.
2ypersensii)iy o iodides .%e p%ysician ordered
zinc sul'ae syrup
*ecause %e paien %ad
diarr%ea and nausea.
Assessment Nursing Diagnosis Planning 9nter<entions Rationale 3<aluation
E*Aeci)e:
=!ecrease urine
oupu
=Poor s,in ur#or
=0un,en eyes
=<ea, in
appearance
=decrease pulse rae
=<. 6,#
Fluid )olu&e
de'ici relaed o
&oderae
de%ydraion as
e)idence *y
iner&ien
)o&iin# and loose
sools.
A'er nursin#
iner)enions %e
clien $ill
=&ainain 'luid
)olu&e a a
'uncional le)el as
e)idenced *y
ade>uae urinary
oupu, sa*le )ial
si#ns, &ois
&ucous &e&*rane,
#ood s,in ur#or.
=Fer*alize
1. Monior F70 o'
%e paien.
2. Assess %ydraion
saus Ccapillary
re'ill, saus o'
&ucous &e&*rane
and s,in ur#or.D
=.o pro)ide a
*aseline daa.
=.o deer&ine %e
condiion o' %e
circulaion o' %e
paien and also o
deer&ine i' %ere is
any aleraions %a
&ay s%ould *e #i)en
an i&&ediae
iner)enion.
A'er nursin#
iner)enions %e
clien %ad:
=&ainained 'luid
)olu&e a a
'uncional le)el as
e)idenced *y
ade>uae urinary
oupu, sa*le )ial
si#ns, &ois
&ucous &e&*rane,
#ood s,in ur#or.
=Fer*alized
undersandin# o'
causai)e 'acors
and purpose o'
indi)idual
%erapeuic
iner)enions and
&edicaion.
9. Noe c%an#e in
neurolo#ic saus.
(. Monior a&oun
o' 'luid ina,es and
&easure %e oupu
accuraely.
8. E*ain daily
$ei#%.
6. -ncoura#e
paien o increase
'luid ina,e and
coninue "F
in'usion as
p%ysician/s ordered.
=Neurolo#ic saus
&ay *eco&e e)iden
in se)ere de%ydraion.
= Paien &ay a*sain
'ro& all ina,es
resulin# o
de%ydraion
= .o deer&ine %e
%ydraion saus.
= .o replace %e 'luid
loss.
undersandin# o'
causai)e 'acors
and purpose o'
indi)idual
%erapeuic
iner)enions and
&edicaion.