GROUP 1 BSN II-A

Pneumonia is the inflammation of the lung caused by bacteria in which the air sacs become filled with inflammatory cells and the lung becomes solid. The symptoms include those of any infection (fever, malaise, headache, etc.,) together with cough and chest 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.

In 1989, when the program for Control Acute Respiratory Infections (CARI) of the Philippines was launched, the death toll from pneumonia among children under the age of five years was 25,000. The latest statistics (2006) disclosed that almost 60 out of 1000 children under five children suffer from pneumonia and five in every 11,000 die from the disease. The Department of Health believes that if health workers used a standard method of detecting and managing ARIs specially pneumonia, infant deaths could be cut by half, saving 50,000 lives a year. Pneumonia can be categorized by type of infiltrate: lobar pneumonia and

Acute gastroenteritis is usually caused by bacteria and protozoan. In the Philippines, one of the most common causes of acute gastroenteritis is E. histolytica. The pathologic process starts with ingestion of focally contaminated food and water. The organism affects the body through direct invasion and by endotoxin being released by the organism. Through these two processes the bowel mucosal lining is stimulated and destroyed the eventually lead to attempted defecation or tenesmus as the body tries to get rid of the foreign organism in the stomach.

The client with acute gastroenteritis may also report excessive gas formation that may leads to abdominal distention and passing of flatus due to digestive and absorptive malfunction in the system. Feeling of fullness 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.

These are the two illnesses diagnosed by the client in this Case Study; the client is experiencing Acute Gastroenteritis with Mild Dehydration accompanied by Pneumonia. Based on Statistics conducted Las 2010 of January involving all countries all over the world, these two disease are seldom seen together at a time, but is possible. Furthermore, all these diseases are can be easily cured but if not treated accordingly, about 58-65% may lead to Death.

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 with Acute Gastroenteritis with mild Dehydration and Bronchopneumonia.

Specific Objectives
KNOWLEDGE:
1.

2.

3.

4. 5. 6.

Define Acute Gastroenteritis with mild Dehydration and Bronchopneumonia. List the clinical manifestations present in a client with Acute Gastroenteritis with mild Dehydration and Bronchopneumonia. Enumerate predisposing and precipitating factors of Acute Gastroenteritis with mild Dehydration and Bronchopneumonia. Discuss the disease process of Acute Gastroenteritis with mild Dehydration and Bronchopneumonia. Evaluate the effectiveness of the nursing interventions rendered to the client.

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 complete assessment 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.

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.

NAME: J.L. ADDRESS: Brgy. Mabini, Escalante City GENDER: Female Age: 1 year and 6 months BIRTH DATE: March 12, 2010 NATIONALITY: Filipino RELIGION: Roman Catholic OCCUPATION: N/A (Child) EDUCATIONAL ATTAINMENT: none

Date of admission: September 19, 2011 Time of admission: 10:45 am Chief complaint: LBM and Vomiting Admitting diagnosis: Acute Gastroenteritis with mild Dehydration Principal diagnosis: Acute Gastroenteritis with mild Dehydration and Bronchopneumonia Attending physician: Dr. B Weight: 11 kgs Height: 0.73 m BMI: 20.75 kgs/m2

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

GENERAL APPEARANCE
The patient was lying on bed, she is weak and flushing of skin especially on the face noted. The childs height and weight is normal for her age. Curly and short hair with two upper 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, the child is continuously raising her both shoulders up and down, an indication that she has Difficulty in Breathing.

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 any food prepared.

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 ug hangin. 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

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 and mangoes. 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 there are 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 plays with their neighbors children but tires easily.

DISEASE
HYPERTENSION

MATERNAL

PATERNAL

+
-

DIABETES MELLITUS

ASTHMA

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

RESPIRATORY:
With increased respiratory rate of 43 cpm 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 crackles heard, with wheeze and rales can also be heard upon getting the childs cardiac rate.

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 Hematocrit30.0 %, Peripheral Circulation: nail beds and conjunctivas are pale, Capillary refill: 3 seconds

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 the child to open her mouth

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 other body parts.

GASTROINTESTINAL:

No abdominal tenderness palpated and with normoactive, a little fading like-borborygmi bowel sound upon auscultation. Abdominal Circumference: 25.5cm

GENITOURINARY:

Has no bladder distention. Amount of urine noted approximately 40cc per hour.

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 of smell 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 child doesnt 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

NORMAL VALUE

RESULTS

NURSING IMPLICATIONS

NURSING CONSIDERATIONS

RBC

4.5-5.0x 109/dL

4.0 X 10X109/L

WBC 5-10 x 109/L

12.5x109/L

Decreased in Encourage the amount may mother to let her child take Iron indicate supplementations Anemia An increase in *Stress to the mother the importance of amount may taking antibiotics as indicate prescribed for the Infection child. *Encourage the mother to increase childs Vit.C intake like calamansi and oranges.

NORMAL VALUE

RESULTS

NURSING IMPLICATIONS

NURSING CONSIDERATIONS

NEUTROPHIL S

60-70%

41%

LYMPHOCYT ES

25-33%

53%

A decrease in *Encourage the S.O to amount is due to provide a well-balanced infection. diet. Pathogens *encourage SO childs invade the body Oral Fluid Intake and Vit. that alters C Supplementations. neutrophil count An Increase in *Emphasize to the S.O amount may the importance of indicate hygiene and sanitation infection. to the child and home.

*Instruct the mother to provide the child with fruits rich in vit. C like calamansi and Oranges.

NORMAL VALUE

RESULTS

NURSING IMPLICATIONS

NURSING CONSIDERATIONS

EOSINOPHIL S

1-3%

6%

May indicate *Administer antiallergic reaction allergy as indicated. and developing *Instruct mother to infection observe personal hygiene.

BASOPHILS

0.25-50%

1.5%

May indicate allergic reaction and indicative of infection

*Administer antihistamine as indicated. *Increasing Oral Fluid intake and provide food that is properly prepared.

NORMAL VALUE

RESULTS

NURSING IMPLICATIONS

NURSING CONSIDERATIONS

HEMOGLOBIN

1416gms%

11.2 gms%

HEMATOCRIT

42+- 5%

36.0%

A decrease in *Encourage the mother amount may to provide a indicate comfortable place for Anemia and the childs adequate dietary rest and sleep. deficiency *Increase intake of Iron supplementations as prescribed. *Instruct mother to A decrease in amount may maintain the childs indicate blood taking of Iron loss and supplementations. anemia *Provide dairy products like milk and eggs for childs nucleic acid production

The digestive system consists of two linked parts: the alimentary canal and the accessory digestive organs. The alimentary canal is essentially a tube, some 9 meters (30 feet) long, that extends from the mouth to anus, with its longest section- the intestinespacked into the abdominal cavity. The lining of the alimentary canal is continuous with the skin, so technicallyits cavity lies outside the body. The alimentary tube consist of linked organs that each play their own part in digestion: mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The accessory digestive organs consist of the teeth and tongue in the mouth; and thesalivary glands, liver, gallbladder, and pancreas, which are all linked by ducts to the alimentary canal.

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 of a 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 the esophagus; 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.)

small intestine through the pyloric sphincter, or valve. With the gastric glands lined with several secreting cells the zymogenic (peptic) cells secrete the principal gastric enzyme precursor, pepsinogen. The parietal (oxyntic) cells produce hydrochloric acid, involved in conversion of pepsinogen to the active enzyme pepsin, and intrinsic factor, involved in the absorption of Vitamin B12 for the red blood cell production. Mucous cells secrete mucus.

Secretions of the zymogenic, parietal and mucus cells are collectively called the gastric juice. Enteroendocrine cells secrete stomach gastrin, a hormone that stimulates secretion of hydrochloric acid and pepsinogen, contracts the lower esophageal sphincter, mildly increases motility of the GI tract,and relaxes the pyloricsphincter. Most digestive activity occurs in the pyloric region of the stomach. After food has been processed in the stomach, it resembles heavy cream and is called CHYME. The chyme enters the small intestine through the pyloric sphincter.

Difficulty Of Breathing Loose Bowel Movement Fever Body Weakness Cough

CUES

PROBLEMS

RANK

PHYSIOLOGIC ACTUAL POTENTIAL

BEHAVIORAL ACTUAL POTENTIAL

Murag tubig na katin-awon ang iya ginkalibang. Pag-admit namon sa buntag, gasuka-suka na siya katulo jud Objectives: Poor Skin Turgor Pallor Sunken Eyeballs Dry Buccal Mucosae

Difficulty of Breathing

Ineffectiv e Breathing Pattern r/t retained secretion s

Risk for Ineffective tissue perfusion r/t impaired transport of oxygen

Disturbed Risk for Sleep powerlessnes Pattern r/t s r/t lack of shortness adequate of breath sleep

Frequent passage of Watery Stools

Deficient Risk for Powerles fluid Imbalanced sness r/t volume r/t Nutrition: inadequat passage Less than e of watery body Nutritional stools requirements status r/t frequent passage of watery stools

Risk for Social Isolation r/t frequent passing out of watery stools

PROBLEM S

RANK ACTUAL

PHYSIOLOGIC POTENTIAL ACTUAL

BEHAVIORAL POTENTIAL

Fever

Ineffective Risk for Thermo disorganized regulation r/t infant inflammation behaviour r/t of Bowel discomfort of mucosal lining elevated body temperature

Impaired Comfort r/t fluctuations in Body Temperature

Risk for Activity Intolerance r/t weakness

Adequat e Sleep

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

General Objective:

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

CUES

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

SUBJECTIV E: Murag tubig na katin-aw iya ginakalibang, Pag-admit namu sa buntag, ga suka-suka na siyag mga ika tilo jod Tapos ambot naunsa pod ky di namn sya kaginhawag maayu nuon

Ineffective Breathing Pattern r/t INFLAME D BRONCHI AL TISSUE

Within 2 days of Nursing Interventions the patient will be able to: *Maintain Effective breathing pattern *Maintain Patent airway with absence of mucous secretions

INDEPENDE NT: >Auscultate breath sounds. Note adventitious breath sounds, e.g. wheezes, crackles and rhonchi.

After 2 days of Nursing >Some degree Interventions, goals are of Partially Met bronchospasm as Evidenced is present with by: obstructions in airway and *Accessory may not be manifested in muscles like shoulders are adventitious seldom used. breath sounds, *Coughing e.g. scattered, with moist crackles secretions is (bronchitis) or minimal faint, with expiratory wheezes (emphysema)

CUES

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

OBJECTIVE : *Presence of adventitious breath sounds such as rales and wheezes upon auscultation *Poor Skin turgor

*S.O verbalize understanding of cause and therapeutic management regimen to the patient
*S.O verbalize sense of comfort and contentment of the patients Health Improvement

>Assess/ Monitor respiratory Rate. Note inspiratory/exp iratory ratio.

*S.O may report improvement in sleep and rest pattern of the patient

>Tachypnea is usually present in some degree and may be pronounced on admission or during stress on current acute process. Respirations may be shallow and rapid. Chronic emphysema patients usually have prolonged expiration in comparison to inspiration.

*Slight improvement of the S.O towards understanding therapeutic management regimen to the patient.

*Slight improvement about sense of comfort according to the S.O

CUES

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

* Pallor *Sunken eyeballs *Dry buccal muscles *Accessory muscles like shoulder and abdomen are used in breathing *Passing out of watery stool 5x a day.

>Monitor Vital Signs

>Monitor respirations and breath sounds noting rate and sounds. >Determine Presence of factors/physi cal conditions as noted in related factors.

>to establish *The child is baseline data. able to sleep at night with 10-12 hours >Indicative and at least 2 of distress or hours rest in accumulation the of secretions afternoon.

>To determine causes of breathing impairments

CUES

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

*Cardiac Rate- 92 bpm *TEMP38.7 OC *RR- 43 cpm *WBC12.5x109/L *RBC-4.0 X 10X1012/L *Hemoglobi n: 11.2 gms% *Hematocrit : 36.0%

>Position head appropriate for age and condition.

>To maintain patent airway in at rest or compromise d individuals >To identify secretions process and promote timely interventions

>Observe for signs/sympto ms and infections (increase dyspnea with onset of fever)

CUES

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

DEPENDENT >Administer Salbutamol and ALBUTEROL E SULFATE via inhalation as prescribed every 4 hours and as needed.

>Inhaled adrehergic against. And a first line therapies for rapid symptomatic improvement in severe bronchi constipation. >Relaxes smooth muscle and reduce local congestion reducing airway spasm and mucous production.

>Administer O2 Inhalation at 2L via face mask as prescribed.

CUES

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

COLLABOR ATIVE: >Monitor laboratory results as indicated

>To determine altered lab. Results

>To support >Administer circulating replacement of volume and fluids and tissue electrolytes as perfusion. ordered.

REFERENCE: -NANDA (12TH ) -Edition. Pp 8084, 151- 155

REFERENCE: -NANDA (12TH ) -Edition. Pp 8084, 151- 155

General Objective: -To facilitate the maintenance of fluid and electrolyte balance.

CUES

NURSING DIAGNOSIS

PATH OPHY SIOL OGY

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

SUBJECTIV E: Murag tubig na katin-aw iya ginakalibang, Pag-admit namu sa buntag, ga suka-suka na siyag mga ika tilo jod Tapos ambot naunsa pod ky di namn sya kaginhawag 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.

>For baseline data, fever tachycardia may indicate severe fluid loss. >To assess or determine if there is alterations on patients condition and provide immediate action.

After 2days of Nursing Interventions goals are MET, as Evidenced by:

>Note Complains and physical signs associated with fluid loss (poor skin turgor)

*Maintenance of Volume at a functional level, urine output of approx.40 cc and frequent intake of at least 8 glasses of water a day.

CUES

NURSING PATHOPHY DIAGNOSIS SIOLOGY

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

OBJECTIVE:
*Presence of adventitious breath sounds such as rales and wheezes upon auscultation *Poor Skin turgor

*Maintain Good Skin Turgor *Mother will verbalize understanding of causative factor and purpose of intervention done.

>Instruct the >To restore fluid mother to increase oral balance. fluid intake of the child at least 6-8 glasses a day as tolerated.

*The childs Stool output was reduced to two times a day not so watery, smooth-well formed stool. *Moist Oral mucosa and good skin turgor, with skin goes back a little bit slowly when pinch vertically on the abdomen.

CUES

NURSING PATHOPHY DIAGNOSI SIOLOGY S

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

* Pallor *Sunken eyeballs *Dry buccal muscles *Accessory muscles like shoulder and abdomen are used in breathing *Passing out of watery stool 5x a day.

DEPENDENT: >Administer IOPERAMIDEMAALOX, 1mg. P.O. tid on the first day. As ordered by the physician. >Administer and Regulate IVF as ordered by the physician.

*S.O >Proper dosage verbalizes of the medicine understanding ensures recovery of causative and prevents factors and diarrhea causing purpose of dehydration. interventions and >To ensure medications adequate fluid with proper replacement. compliance on the dosage and timing.

CUES

NURSING DIAGNOSIS

PATHOPHYSI OLOGY

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

*Cardiac Rate- 92 bpm *TEMP38.7 OC *RR- 43 cpm *WBC12.5x109/L *RBC-4.0 X 10X1012/L *Hemoglob in: 11.2 gms% *Hematocri t: 36.0%

COLLABORA TIVE: >Monitor clients intake and output as endorsed. >Monitor every Laboratory Results conducted to the patient.

>Provide information about over-all fluid balance. > To know clients progress and alteration in condition.

REFERENCE:

REFERENCE:

NANDA 12th edition pp. 372375, 756- 763

NANDA 12th edition pp. 372375, 756- 763

General Objective: -To promote safety through prevention of accident, injury or other trauma and through the prevention of the spread of infection.

CUES

NURSING DIAGNOSIS

PATHOPHYSIOL OGY

EXPECTED OUTCOME

NURSING INTERVENTIO N

RATIONALE

EVALUATION

SUBJECTI VE:

Murag tubig na katin-aw iya ginakaliba ng, Pagadmit 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 Thermo regulation r/t inflammatio n of Gastrointesti nal Tract secondary to Acute Gastroenteri tis

Within 2 days of nursing intervention, the patient will be able to:

INDEPEN DENT: >Assess neurologica l response, noting level of consciousn *Restore ess and temperature orientation to a normal and level of 36.5- reaction to 37.5 C stimuli, reaction of pupils, and presence of posturing or seizures.

>For proper assessment of the severity of the problem.

CUES

NURSING DIAGNOSI S

PATHOPHYSIO LOGY

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

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

>Assess environment for possible sources of heat gain *Reduce heat of through evaporation, the skin to normal warmth conduction, convection, *Reduce or radiation. excessive sweating.

>To minimize risk of heat gain.

CUES

NURSING DIAGNOSIS

PATHOPHYSI OLOGY

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

* Pallor *Sunken eyeballs *Dry buccal muscles *Accessor y muscles like shoulder and abdomen are used in breathing *Passing out of watery stool 5x a day.

>Monitor temperature frequently (at least 3 hours), blood pressure, heart and breathing rates, and oxygen levels.

>To know possible and significant changes or to identify deviations that could suddenly occur.

CUES

NURSING DIAGNOSIS

PATHOPHYSIOL OGY

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

*Cardiac Rate- 92 bpm *TEMP38.7 OC *RR- 43 cpm *WBC12.5x109/L *RBC-4.0 X 10X1012/L *Hemoglo bin: 11.2 gms% *Hematocr it: 36.0%

>Monitor heart rate and rhythm

>Dysrrhythmia s and ECG changes are common due to electrolyte imbalance.

>May help reduce fever. Ice water and alcohol may cause chills actually elevating temperature

>Provide tepid sponge bath but avoid using alcohol as a solution.

CUES

NURSING DIAGNOSIS

PATHOPHYSIOL OGY

EXPECTED OUTCOME

NURSING INTERVENTIO N

RATIONALE

EVALUATION

>Promote surface cooling by undressing or 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 ensures recovery.

CUES

NURSING DIAGNOSI S

PATHOPHYSIO LOGY

EXPECTED OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

>Administer and Regulate IVF as ordered by the physician.

COLLABORATIVE :

>To ensure adequate fluid replacement.

>Monitor laboratory studies such as ABCs, electrolytes, cardiac and liver enzymes, glucose urinalysis, and coagulation profile.
REFERENCE:

>May reveal tissue degeneration, myoglobinuria, proteinuria, and hemoglobinuria .

NANDA 12th edition pp. 372375, 756- 763

CLASSIFICATION

IMPLICATION

MECHANISM OF ACTION

*DEXOMETHOR PAN HYDROBROMID E

Robitussin Pediatric Timing: Q8 (8 am, 4pm and 12am) 120mg a day

Expectorants Productive and antitussives cough individualized dozes

Antitussive that suppresses the cough reflex by direct action on the cough center in the medulla

SIDE/ADVERSE EFFECTS

NURSING CONSIDERATIONS

PATIENTS TEACHING

REFERENCE

CN: drowsiness, dizziness G.I nausea, stomach pain

*Dont use when cough is a valuable diagnostic sign or is beneficial (as after thoracic surgery) *Monitor Vital signs especially Respirator and Cardiac Rate. *Use drug with chest percussion and vibration. *Monitor cough type and frequency

*Instruct the mother to give drug to the patient exactly as prescribed. *Instruct the mother to report adverse reactions. *Tell the S.O to report nausea, abdominal pain or discomfort

NURSING 2007 DRUG HANDBOOK Lippincott Williams and Wilkins

CLASSIFICATION

IMPLICATION

MECHANISM OF ACTION

*IOPERAMIDE

MAALOX Anti -diarrheals Loose Bowel >1mg. P.O. tid Movement on the first day.

Inhibits peristaltic activity, prolonging transit and intestinal contents

SIDE/ADVERSE EFFECTS

NURSING CONSIDERATIONS

PATIENTS TEACHING

REFERENCE

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 to the 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 child closely 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 experiencing bloody stool and immediately ask the mother to report if this happen.

NURSING 2007 DRUG HANDBOOK Lippincott Williams and Wilkins

CLASSIFICATION

IMPLICATION

MECHANISM OF ACTION

*ALBUTEROL E SULFATE 2.5 mg t.i.d. by Bronchodilators For patients nebulizer for 10 with obstructive mins as needed airway and not exceeding Difficulty of 2.5 mg breathing

Relaxes bronchial and vascular smooth muscles for patent airway

SIDE/ADVERSE EFFECTS

NURSING CONSIDERATIONS

PATIENTS TEACHING

REFERENCE

Dry and irritated nose, cough , hypersensitivity reactions. CNS:Headache CV:palpitations G.I: heartburn, increased appetite

*Contraindicated to patients with hypersensitivity to drug or its ingredients. *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 taking the drugs and follow promptly doctors order of dosages.

NURSING 2007 DRUG HANDBOOK Lippincott Williams and Wilkins

CLASSIFICATION

IMPLICATION

MECHANISM OF ACTION

*PARACETA MOL 120 mg 1 tsp. P.O q4 to 6 PRN Antipyretics Fever Relieve fever through central action in the hypothalamic heat-regulating center

SIDE/ADVERSE EFFECTS

NURSING CONSIDERATIONS

PATIENTS TEACHING

REFERENCE

Hematologics: hemolytic anemia, neutropeniaand leucopenia 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

PROBLEM Hygiene: Daily bath Nail care Oral care Hand washing

HEALTH TEACHING PROMOTIVE: Encourage the mother for the daily bath if the patient.

RATIONALE

1. 2. 3. 4.

Recurrence of LBM Encourage the client to have adequate rest and sleep for at least 8 hours per day.

Activity
Walking exercises as tolerated.

To promote well being and for the client to feel comfortable. To regain strength and energy.

Adequate rest and sleep.

Active range of motion exercises like flexion and extension.

Encourage to perform active range of motion exercises like flexion and extension of the arms and legs for at least 15-30 min/day.

These exercises maintain or increase muscle strength and endurance and help to maintain cardio-respiratory function.

Diet Maintain oral fluid intake. Low fiber diet Vit. C (calamansi,guava) High Iron Intake

CURATIVE: Instruct client to For fast take recovery. medications as prescribed by the physician. Instruct client to To prevent have a follow up recurrence of checked up 1 the condition week after and to note discharged further complication.

Instructions: Take medications as prescribed. Follow up checked up 1 week after discharged.

One day is never more challenging than the next As we ascend to higher levels of learning, we have learned that to gain progress is never a petty thing to take for granted. Great and insurmountable amount of effort must be infused with determination. Now that we have reached our 2nd year of learning and loving this course, we, the Group 1, is yet to be initiated to enter the world of a student nurse.

This Medical Case Study is our stepping stone towards attaining a sense of fulfilment and growth. Fulfilment, for we have now applied what knowledge we have gained for these past semesters and we have known that working as a team would really result to a 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 have come to an agreement that each member of the Group should take part and fuse 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 this case study demands our utmost time, dedication, finances and most of all effort.

But this did not hinder us to finish this task. 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 and effectively. 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.

Prepared by:

Prepared by:
Alvarez, Billy Abihay, Maria Idhonna Gay Belleza, Marianne Diamante, Keans Quennie Gelogo, Fhemarie Joy Pasilan, Jonalyn Torrecarion, Clarmaine