final case study with help f my lyf

8/8/2019 Final Case Study With Help f My Lyf

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oleObject0

Liceo de Cagayan UniversityRNP Blvd. Carmen, Cagayan de Oro City

College of Nursing

In partial fulfillment of NCM501204Related Learning Experience

Individual Case Study

Submitted by:

MEDEL, Roin Carl B.

Submitted to:

Gemma Reambonanza RN

Date:

Monday, July 26, 2010


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TABLE OF CONTENTS

Introduction

Overview of the case

Objective of the study

Scope and Limitation of the study

Health History

Profile of patient

Family and Personal Health history History of Present Illness

Chief Complaint

Developmental Data

Medical Management

Laboratory Results

Drug Study

Pathophysiology with Anatomy and Physiology

Nursing Assessment (System Review & Nursing Assessment II)

Nursing Management

Ideal Nursing Management (NCP)

Actual Nursing Management (SOAPIE)

Referrals and Follow-up

Evaluation and Implications

Bibliography


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I. INTRODUCTION

In every duty it is important for us nursing students to have a knowledge on the health problem

of our patients and know its nursing intervention that can help the patient to recover from their disease.

Before going to duty, the primary goal of a student nurse is to have a further assessment to be able to

come up to right nursing interventions. During our duty at Sabal Hospital we are able to encounter

certain health problems that lead us to choose for our own individual case study. Through this case

study, we are able to enhance our nursing knowledge and skills for us to be able to be competent

enough as we go on to our future duties. One of the health problems that made me interested is about

the case of my patient which is Dengue Fever.

A. Overview of the Case

Dengue Fever is caused by one of the four closely related, but antigenically distinct, virus

serotypes Dengue type 1, Dengue type 2, Dengue type 3, and Dengue type 4 of the genus Flavivirus

and Chikungunya virus. Infection with one of these serotype provides immunity to only that serotype of

life, to a person living in a Dengue-endemic area can have more than one Dengue infection during their

lifetime. Dengue fever through the four different Dengue serotypes are maintained in the cycle which

involves humans and Aedes aegypti or Aedes albopictus mosquito through the transmission of the

viruses to humans by the bite of an infected mosquito. The mosquito becomes infected with the Dengue

virus when it bites a person who has Dengue and after a week it can transmit the virus while biting a

healthy person. Dengue cannot be transmitted or directly spread from person to person. Aedes aegypti

is the most common aedes specie which is a domestic, day-biting mosquito that prefers to feed on

humans.

Dengue viruses are transmitted to humans through the infective bites of female Aedes

mosquito. Mosquitoes generally acquire virus while feeding on the blood of an infected person. After

virus incubation of 8-10 days, an infected mosquito is capable, during probing and blood feeding of

transmitting the virus to susceptible individuals for the rest of its life. Infected female mosquitoes mayalso transmit the virus to their offspring by transovarial (via the eggs) transmission.

Humans are the main amplifying host of the virus. The virus circulates in the blood of

infected humans for two to seven days, at approximately the same time as they have fever. Aedes

mosquito may have acquired the virus when they fed on an individual during this period. Dengue

cannot be transmitted through person to person mode.


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B. Objective of the Study

Individual care study provides goals or objectives which is necessary to serve as an

instrument in comprehensively assessing the patients health status and present condition. It also

focuses on the following aims:

To conduct a thorough assessment of the patient in order to formulate appropriate nursing care

plan based on accurate and complete data;

To formulate nursing diagnosis, develop outcomes and plan nursing care with specific goals for

a patient with Dengue Fever.

To implement nursing care and evaluate outcomes for effectiveness and achievement of care;

and Integrate knowledge about Dengue Fever to achieve quality of care to the patient and

understand the course and essence of the chosen care study.

Utilizing the nursing process in the management of patients health condition and in giving

quality nursing care.

Obtain a complete health data that can be used in the follow-up care.

Impart health teachings about necessary information pertaining to the disease condition.

Add up additional knowledge and understanding in the Nursing profession.

C. Scope and Limitation of the Study

The extent of study includes the overall data gathered during the interview and observation as

manifested by the patient and his complaints. It also deals with the several factors observed during the

assessment within the span of time given. The information gathered was based on the manifestations

and complaints of the patient observed and the exact answers of the patients support person since the

patient is only 5 years old .Interventions were rendered gradually depending on the objective


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assessment of the student. The following information only involves the exact words and answers

supported by the mother.

The limitation of the study includes the place of interaction itself which was in Sabal Hospital,

Station 3. The study was completed altogether by both research and actual hands-on exposure and

interaction with the patient's mother during the three (3) days clinical duty.

II. HEALTH HISTORY

A. Profile of the Patient

Name: Rafael M. Tuto

Age: 5 years old

Sex: Male

Birth date: September 20, 2005

Religion: Roman Catholic

Civil Status: Child

Nationality: Filipino

Occupation: None

Address : Brgy. 25 Cagayan de Oro City

Name of Father : Alfredo B. Tuto

Occupation : Security Guard

Name of Mother : Ephy M. Tuto

Occupation : Housewife

Date of Admission : July 7, 2010

Time of Admission : 10:20 am

Admitting Physician : Dr. J. Neri

Vital Signs Assessment


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Temperature : 38.6 oC

Pulse Rate : 132bpm

Respiratory Rate : 28 cpm

Height : not obtained

Weight : Not obtained

Allergy : No known allergy

B. Family History and Personal Health History

Rafaels father is a security guard while her mother is a plain housewife. They live in Brgy

25 Cagayan de Oro City. His fathers salary is enough for their living which has a net income of P10,

000.00/month. As I have interviewed her mother, the family has no known food and drug allergy. They

do not also have a family history of Diabetes and asthma.

C. History of Present Illness

A case of 5 years old patient (male) from Brgy 25; with chief complaint of fever with epigastric

pain. Condition noted 2 days PTA on moderate grade fever (+) vomiting once. PTA (+)

epigastric pain. Prompted for admission.

D. Chief Complaint

Rafael M. Tuto , 5 years old, male, from Brgy 25 C.D.O was admitted to Sabal Hospital

due to fever with epigastric pain.


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Diagnostic Examination

Urinalysis

45rffff Name: Reuben Gabriel Dagoldoldhhd Ward: Pediatric ward Date: 12/8/09Trtgg Result Nursing interpretation

Color: yellowTransparency:Glucose -Pus: 1-3 hpf

RBC: 1-3 hpf Epithelial cells: fewMucus thread: -Bacteria: fewPh: 6.0SpGr: 1.080

Normal color of urine

presence of bacteria

abnormal result of urine gravity Complete Blood Count

Result Expected Values: Nursing Interpretation

WBC: 3,500 5,000 - 10,000/ mm3 Overwhelming infectionRBC: 4.28 4.35 - 5.90 mil/mm3 anemiaHemoglobin: 11.6 g/dl 13.7 - 16.7 g/dl Risk anemia

Hematocrit: 34.9 vols % 40.5 - 49.7 vols % Anemia, malnutritionPlatelet Count: 190,000 144,000 372,000 low platelet count

Differential CountGranulocyte: 40 43.4 76.2%


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Lymphocytes: 10.6 17.4% - 48.2% Viral infection

Monocytes: 7.8 0 -10%

Eosonophil: 08 0 6%

B. DRUG STUDY

Generic Name of ordered

drug

Maalox Syrup

Brand Name Maalox Syrup

Date Ordered July 7, 2010Classification AntacidDose/Frequency/Route 5 ml 3x daily POMechanism of Action Slows intestinal motility by acting on the nerve endings on and or intramural ganglia

embedded in the intestinal wallSpecific Indication For treatment of stomach painContraindication Discontinue if abdominal distention develops in ulcerative colitis in clients with

constipationSide Effects/Toxic Effects Abnormal pain , distention, discomfort, dry mouth.Nursing Precaution Hypersensitivity to drug. Discontinue after 48 hours and report if ineffective.

Generic Name of ordered drug ParacetamolBrand Name None

Date Ordered July 7, 2010Classification Non-opioid analgesic;antipyreticDose/Frequency/Route 5 ml q 4 hours PO PRN for signs of fever Mechanism of Action Produces analgesic effect by blocking pain impulses, by inhibiting prostaglandins or

pain receptors sensitizers; may relieve fever by acting in hypothalamic heat

regulating center

Specific Indication For mild pain and fever Contraindication To patients going long-term therapy for chronic noncongestive angle-closure

glaucoma; hyponatremia; hypokalemia; hepatic impairment; adrenal gland failure

hypechloremic acidosisSide Effects/Toxic Effects Confusion; anorexia; aplastic anemia; rash; renal calculiNursing Precaution Report signs of F/E imbalance


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V. PATHOPHYSIOLOGY with ANATOMY AND PHYSIOLOGY

BLOOD

Blood is considered the essence of life because the uncontrolled loss of it can result to

death. Blood is a type of connective tissue, consisting of cells and cell fragments surrounded by a liquidmatrix which circulates through the heart and blood vessels. The cells and cell fragments are formed

elements and the liquid is plasma. Blood makes about 8% of total weight of the body.

Functions of Blood:

>transports gases, nutrients, waste products, and hormones

>involve in regulation of homeostasis and the maintenance of PH, body temperature, fluid balance, and

electrolyte levels

>protects against diseases and blood loss

PLASMA

Plasma is a pale yellow fluid that accounts for over half of the total blood volume. It

consists of 92% water and 8% suspended or dissolved substances such as proteins, ions, nutrients,

gases, waste products, and regulatory substances.

Plasma volume remains relatively constant. Normally, water intake through the GIT closely

matches water loss through the kidneys, lungs, GIT and skin. The suspended and dissolved substances

come from the liver, kidneys, intestines, endocrine glands, and immune tissues as spleen.

FORMED ELEMENTS

Cell Type Description Function

Erythrocytes (RBC) Biconcave disk, no nucleus, 7-8micrometers in diameter Transport oxygen and carbondioxideLeukocytes (WBC):

Neutrophil Spherical cell, nucleus with twoor more lobes connected by thinfilaments, cytoplasmic granulesstain a light pink or reddish

purple, 12-15 micrometers indiameter

Phagocytizes microorganism


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Basophil

Eosinophil

Lymphocyte

Monocyte

Spherical cell, nucleus, withtwo indistinct lobes,cytoplasmic granules stain blue-

purple, 10-12 micrometers indiameter

Spherical cell, nucleus often bilobed, cytoplasmic granulessatin orange-red or bright red,10-12 micrometers in diameter

Spherical cell with roundnucleus, cytoplasm forms a thinring around the nucleus, 6-8micrometers in diameter

Spherical or irregular cell,nucleus round or kidney or horse-shoe shaped, containmore cytoplasm thanlymphocyte, 10-15 micrometersin diameter

Releases histamine, which promotes inflammation, andheparin which prevents clotformation

Releases chemical that reduceinflammation, attacks certainworm parasites

Produces antibodies and other chemicals responsible for destroying microorganisms,responsible for allergicreactions, graft rejection, tumor control, and regulation of the

immune system

Phagocytic cell in the bloodleaves the circulatory systemand becomes a macrophagewhich phagocytises bacteria,dead cells, cell fragments, anddebris within tissues

Platelet Cell fragments surrounded by acell membrane and containinggranules, 2-5 micrometers indiameter

Forms platelet plugs, releasechemicals necessary for bloodclotting

PREVENTING BLOOD LOSS

When a blood vessel is damaged, blood can leak into other tissues and interfere with the

normal tissue function or blood can be lost from the body. Small amounts of blood from the body can

be tolerated but new blood must be produced to replace the loss blood. If large amounts of blood are

lost, death can occur.

BLOOD CLOTTING

Platelet plugs alone are not sufficient to close large tears or cults in blood vessels. When a

blood vessel is severely damaged, blood clotting or coagulation results in the formation of a clot. A clot

is a network of threadlike protein fibers called fibrin, which traps blood cells, platelets and fluids.


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The formation of a blood clot depends on a number of proteins found within plasma called

clotting factors. Normally the clotting factors are inactive and do not cause clotting. Following injury

however, the clotting factors are activated to produce a clot. This is a complex process involving

chemical reactions, but it can be summarized in 3 main stages; the chemical reactions can be stated in

two ways: just as with platelets, the contact of inactive clotting factors with exposed connective tissue

can result in their activation. Chemicals released from injured tissues can also cause activation of

clotting factors. After the initial clotting factors are activated, they in turn activate other clotting

factors. A series of reactions results in which each clotting factor activates the next clotting factor in the

series until the clotting factor prothrombin activator is formed. Prothrombin activator acts on an

inactive clotting factor called prothrombin. Prothrombin is converted to its active form called thrombin.

Thrombin converts the inactive clotting factor fibrinogen into its active form, fibrin. The fibrin threads

form a network which traps blood cells and platelets and forms the clots.

CONTROL OF CLOT FORMATION

Without control, clotting would spread from the point of its initiation throughout the entire

circulatory system. To prevent unwanted clotting, the blood contains several anticoagulants which

prevent clotting factors from forming clots. Normally there are enough anticoagulants in the blood to

prevent clot formation. At the injury site, however, the stimulation for activating clotting factors is very

strong. So many clotting factors are activated that the anticoagulants no longer can prevent a clot from

forming.

CLOT RETRACTION AND DISSOLUTION

After a clot has formed, it begins to condense into a denser compact structure by a process

known as clot retraction. Serum, which is plasma without its clotting factors, is squeezed out of the clot

during clot retraction. Consolidation of the clot pulls the edges of the damaged vessels together,

helping the stop of the flow of blood, reducing the probability of infection and enhancing healing. The

damaged vessel is repaired by the movement of fibroblasts into damaged area and the formation of the

new connective tissue. In addition, epithelial cells around the wound divide and fill in the torn area.

The clot is dissolved by a process called fibrinolysis. An inactive plasma protein called

plasminogen is converted to its active form, which is called plasmin. Thrombin and other clotting

factors activated during clot formation, or tissue plasminogen activator released from surrounding


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tissues, stimulate the conversion of plasminogen to plasmin. Over a period of a few days the plasmin

slowly breaks down the fibrin.

PATHOPHYSIOLOGY

Precipitating Factors: AgeMale

Predisposing Factors: Immuno compromizedEnvironment

Bite of a aedes aegypti mosquito carrying a virus

Virus goes into circulation

Dengue Virus Type II

IgG adheres to the platelet

thrombocytopenia

increased potential for hemorrhage

stimulates intense inflammatory response

petechial rash, high fever, headache,vomiting, abdominal pain, (+) torniquet test

VI. Nursing Assessment Name: Reuben Gabriel Dagoldol Date: July 8,2010Vital Signs: Pulse: 132bpm R R: 28cpm T emp: 38.6C Height: Not obtained Weight: 13kgsEENT:


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oleObject1 [ ] impaired vision [ ] blind

Flushed skin

Fever (38C)

Warmrestlesness

Fatigue

[ ] pain [ ] reddened [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teethAssess eyes, ears, nose, throatFor abnormality [x] no problemRESPIRATORY[ ] asymmetric [ ] tachypnea[ ] apnea [ ] rales [ ]cough[ ] barrel chest[ ] bradypnea [ ] shallow [ ] rhonchi[ ] sputum [ ] diminished [ ]dyspnea[ ] orthopenea [ ] labored [ ]wheezing[ ] pain [ ] cyanoticAssess resp.rate, rhythm, depth, patternBreath sounds, comfort [ x] no problemCARDIOVASCULAR [ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [x ] fatigue

[ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate, rhythm, pulse,circulation, fluid retention, comfort [ ] noGASTRO INTESTINAL TRACT[ ] obese [ ] distention [ ] mass


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oleObject2 [ ] dysphagia [ ] rigidity [ ] painAssess abdomen, bowel habits, swallowing,

Bowel sound, comfort [ } no problemGyn-bleeding, discharge [x] no problem NEURO[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] gripAssess motor function, sensation, LOC, strength,Grip, gait, coordination, orientation, speech [x] no problemMUSCULOSKELETAL and SKIN[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[x ] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] deformity[] wound [ ] rash [ ] skin color [ x] flushed[ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moist

Assess mobility, motion, galt, alignment, joint function/Skin color, texture, turgor, integrity [ ] no problem

Nursing Assessment II

SUBJECTIVE OBJECTIVECommunication:[ ] hearing loss [ ] visual changes[ ]deniedComments: wala may problema sa pandungog ug

panan aw sa akong anak as verbalized by themother.

[ ] glasses [ ] language[ ] contact lens [ ] hearing aide

R LPupil size : 3mmReaction: Pupil equally round reactive to light andaccommodation.[ ] speech difficulties


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Oxygenation:[ ] dyspnea [ ] smoking history [ ] cough [ ]sputum [ ] deniedComments: dli man galisod ug ginhawa akong anak as verbalized by the mother.

Respiratory [ x] regular [ ] irregular Describe: Respirations are regular 25cpm within thenormal range.R: Normal symmetrical breathingL: Normal symmetrical breathing

Circulation:[ ] chest pain [ ] leg pain[ ] numbness of extremities[ ] deniedComments: di man gasakit ang dughan sa akonganakas verbalized by the mother.

Heart Rhythm [x] regular [ ]irregular Ankle Edema: nonePulse Car. Rad. DP. Fem.*R :+ 132 + + _+L :+ 132 + + +Comments: Normal and palpable pulses

Nutrition:Diet: as toleratedCharacter: [ ] recent change in weight,

appetite[ ] swallowing difficulty [ ] denied

Comments: gasuka siya pero dili kaayoasverbalized by the mother.

[ ] dentures [x] noneFull Partial With Patient

Upper [ ] [ ] [ ]Lower [ ] [ ] [ ]

Elimination:Usual bowel pattern Urinary frequency

Once a day 3 times a dayconstipation remedy [ ] urgency

n/a [ ] dysuriaDate of last BM [ ] hematuria

Dec. 8, 2009 [ ] incontinenceDiarrhea character: [ ] polyuria

None [ ] foley in place[ ] denied

Bowel sounds: Audible bowel soundAbdominal Distention

Present [ ] yes [ x] noUrine* (color, consistency, odor)*if they are in place

Comments: The urine is normal and yellow color.

Management of Health and Illness:[ ] alcohol [ ] denied(amount, frequency)Comments: N/A

[ ] SBE Last Pap Smear: N/ALMP: N/A

Briefly describe the patients ability to followtreatments (diet, meds, etc.) for chronic health

problems (if present).

The client follow strictly the medication and diet as prescribed by the physician.

SUBJECTIVE OBJECTIVE

Skin Integrity:[ ] dry [ ] itching [ ] deniedComments: wala man siya gapangatol As verbalized

by the mother.

[ ] dry [ ] cold [x] pale [ ] flushed[ x ] warm [ ] cyanotic

*rashes,ulcers, decubitus (describe size, location,drainage) The patient has no rashes in upper and


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lower extremities.Activity/ Safety:[ ] convulsion [ x] dizziness[ ] limited motion of jointsLimitation inability to:[ ] ambulate [ ] bathe self

[ ] other [ ] deniedComments: Ga kapoy ang iyang lawas as verbalized

by the mother.

LOC and orientation:Patient is conscious.Gait: [ ] walker [ ] cane [ ] other [x ] steady [ ] unsteady[ ]sensory and motor losses in face or extremities:

none[ ]ROM limitations: no range of motion is limited

Comfort/ Sleep/ Awake[ ] pain (location, frequency, remedies)[] nocturia [ ] sleep difficulties [ ] deniedComments: Dili man siya galisud pag matulog, as

verbalized by mother.

[ ] facial grimaces[ ] guarding[ ] other signs of pain: none[ ] siderail release form signed ( 60 + years ) N/A

Coping:Occupation (mother): none

Members of household: 3Most supportive person: Mr. Ephy Tuto

Observed non- verbal behavior:none

The person and his phone number that can bereached any time: Not obtained.

VII. Nursing Management

A. Ideal Nursing Management

1. Hyperthermia r/t infection

Interventions Rationale


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Independent:

Limit physical activity

Increase fluid intake as tolerated

Perform TSB

Provide fresh air if necessary by opening the windows

if ever there's a window

Let patient wear light clothings

This will help lower down temperature

Help lower down the temperature and prevent

hypovulemia

This will help lower down the body temperatureThis will help relxed the patient

To prevent from sweating.

Dependent:

1. Administer prescribed medications as ordered

(Paracetamol) such as Calpol 5ml PRN for fever

To help reduce the temperature

2. Acute pain related to inflammatory response

Interventions Rationale


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Independent:

Monitor vital signs

Instruct deep breathing exercise

Encourage to have diversional activites likewatching t.v.

Place patient on comfortable position

Encourage to have adequate bed rest

Provide therapeutic touch

To determine alteration

Helps in relieving pain

To divert attention of patient from pain

Helps reduce pain felt

For relaxation and to prevent stress

To provide comfort

Helps in relieving pain

Dependent:

Administer Maalox as ordered 3x a day 5ml PO

3. Fluid Volume Deficit related to frequent loss of fluid in the gastrointestinal tract as evidenced by frequent

vomiting.

Interventions RationaleIndependent:

Independent:

Monitor Intake and Output

Withhold foods and fluids for about 3 hours.

Ensure accurate picture of fluid status

To prevent irritation in stomach.

To determine if the stomach can already toleratefluids


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Instruct to sip small amounts of fluids after threehours fasting.

Instruct to give crackers and toasted bread.

To relieve hunger due to the fasting done.

Prevents fluctuation in fluid levels

B. ACTUAL NURSING MANAGEMENT

S Gihilantan mana siya" as verbalized by patients mother..O pale skin

T-38.6

Warm skin to touchA Hyperthermia r/t infectionP Long term: At the end of 3 days of care, client's mother will know how to prevent fever

Shot term: At the end of 30 minutes nursing intervention, the patients body temperature will decrease

into normal rangeI Independent:

1. Use preventive measures:

a. Remove hard toys from the bed

b. Pad the sides of the crib or side rails of the bed

c. Have a suction machine available to remove secretions during seizure

d. Have an emergency oxygen source in the room in case of sudden respiratory difficulty

2. Make sure that the child can be readily observed

3. During a seizure, monitor vital signs and assess neurologic status frequently

4. Following a seizure, check the child frequently and report the ff:

a. Behavior changes


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b. Irritability

c. Restlessness

d. Listlessness

Dependent:

Given bronchodilators (Salbutamol) as ordered, to relax bronchial smooth muscles thus facilitating airflow.

E After 30 minutes, the clients body temperature will be lower down to prevent seizure.

S Galisod siya kaginhawa kung muatake na iyang convulsion as verbalized by the mother.

O Dyspnea

A Ineffective breathing pattern RT spasms of respiratory musculature

P Long term: At the end of 2 days of care, patient will be able to resume daily activities by not having a

fever to prevent seizure

Short term: At the end of 30 minutes nursing intervention, client will have a effective breathing patternI Independent:

1. During a seizure take the following emergency actions:

a. Clear the area around the child

b. Do not restrain the child

c. Loosen the clothing around the neck

d. Turn the child on side so that saliva can flow out of the mouth

e. Place a small, folded blanket under the head to prevent trauma if the seizure occurs when the

child is on the floor.

2. Suction the child, and administer oxygen as necessary

3. Do not give anything by mouth or attempt to place anything in the mouth.

4. After the seizure, place the child in a side lying position.

Dependent

1. Maintained supplemental oxygen therapy as ordered


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E After 30 minutes, client will have a effective breathing pattern

S Maulaw siya sa kapag mu atake ang convulsion. as varbalized by the mother.

O

crying

restlessnessA Social Isolation related to the childs feelings about seizures or public fears and misconceptions

P Long term: At the end of 2 days nursing care, the patient will have develop to socialize with people

Short term: At the end of 8 hours of nursing intervention, the patient will develop and learn that he mustsocialize to other people

I Independent:

Advise the parents that the child should be in an environment that is as normal as possible

Encourage regular attendance at school after the school nurse and teachers have been notified, and

emergency treatment of seizures is understood.

Encourage the child to participate in organizations and outside activities with limited restrictions.

a. Each child must be treated individualy; the kind of activity depends on the degree of control.

b. Generally, the children with seizure disorders should not be allowed to climb in high places or

to swim alone.

c. Responsible adults should be made aware of the childs disorder.

E After 8 hours of nursing interventions, the goal was achieved by seeing the patient socializing toother people


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S Gihilantan man ni siya as verbalized by the mother of the patient.O Flushed skin

Warm to touch

Temp. (38 C)A Hyperthermia related to infection as evidenced of temp. above normal rangeP Long term: At the end of 2 days of care, client temperature will maintain in normal range.

Shot term: At the end of 30 minutes of nursing intervention, the patient temperature will lower down from38 C to 37 C.

I Independent:

1. Apply Tepid Sponge Bath

2. Increase fluid intake

3. Monitor body temperature

4 Let wear light clothings

5. Provide well ventilated room

6. Limit physical activities

Dependent:

5. Given Paracetamol as ordered, to help lower the temperature therapeuticcaly.

E After 30 minutes of nursing intervention, the patient temperature was lower down from 38 C to 37 C.

VIII. REFERRALS & FOLLOW-UP

HEALTH TEACHINGS


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MEDICATIONS Encourage the patient's mother the need for religious adherence to medication

regimen

Explain to the patient each medication prescribed.

Explain proper administration of medication according to its route (e.g. oral, topical)

together with the knowledge about potential side effects

EXERCISE Encourage patient's mother to avoid excessive stress and have adequate rest and

sleep.

Encourage the patient to perform self-hygiene activities

TREATMENT The patient instructed to religiously facilitate in taking the prescribed home

medication on time as ordered.Instruct to observe proper food preparation or proper sanitation.

OUT-PATIENT(Check-Up)

Emphasize importance of keeping schedule appointments with health care providers

1 week after discharge especially when there are noticeable changes in the condition

and refer to Dr. Neri

DIET Encourage the patient's mother eat nutritious food such as vegetable and fruits

Instruct the patient's mother to maintain proper diet that he can tolerate, such as

fruits, to help promote wellness.

Advice patient's mothert to monitor fluid intake or adequate hydration, to help her

body re-hydrate to prevent fluid imbalance.

Advice patient's mother to have proper nutrition to enhance immune.

IX. EVALUATION AND IMPLICATIONS

Being exposed to the hospital specifically at pediatric ward as nursing students to care for

pediatric ill patients, we have encountered many interesting cases that would surely enriched our

nursing knowledge and skills, and Dengue is one of those problems.


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In a sense that I am a future health care provider, it is crucial in my part that I see to it and

identified the health problem of my patient, which is significant in my nursing field and study,

somehow I was able to identify nursing diagnosis and implemented possible effective nursing care,

which gave sense of accomplishment in my part as student nurse. Eventually, I should be cautious at all

times in giving care to my patient and should always bear in mind that I am dealing with life. And must

always be compassionate and provide holistic approach.

This study will serve as a reference material in rendering competent care to my client

especially those with similar situation. Through this, I will be able to develop my knowledge as well as

my skills and attitudes in applying the prescribed procedure to improve the health status of the patient.

This study will act as a baseline as well as a guide for coming up with a good, reliable,

accurate and comprehensive research paper dealing with issues commonly experienced by patient in

the hospital setting. This may aid the researchers to widen the scope of the study in relation to more or

less similar cases. The case study paved way for researcher to identify and determine issues related to benign febrile seizure.

X. BIBLIOGRAPHY

A. BOOKS

Barbara Kozier; Fundamentals of Nursing 7 th edition

Smeltzer, Suzanne. Medical-Surgical Nursing, 11 th edition

The Lippincott Manual of Nursing Practice 6 th Edition

Springhouse corporation Disease and Disorders Handbook

WEBLIOGRAPHY

http://emedicine.medscape.com/article/927340-overview

www.nursingcrib.com

www.yahoo.com

www.wikipidia.com.dengue Fever
http://emedicine.medscape.com/article/927340-overviewhttp://www.nursingcrib.com/http://www.yahoo.com/http://www.wikipidia.com.dengue/http://www.nursingcrib.com/http://www.yahoo.com/http://www.wikipidia.com.dengue/http://emedicine.medscape.com/article/927340-overview


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Rating Scale

A. WRITTEN WEIGHT RATINGI. Introduction

a. Overview of the Case

b. Objective of the Study

c. Scope and Limitation of the Study

II. Health History

Profile of the Patient

Family and Personal Health History

Chief Complaint

III. Developmental Data

5

5

5


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IV. Medical Management

Medical Orders with Rationale

Drug Study

V. Pathophysiology with anatomy and physiology

VI. Nursing Assessment

Nursing System Review Chart

Nursing Assessment II

VII. Nursing Management

Ideal Nursing Management

Actual Nursing Management

VIII. Referrals and Follow-up

IX. Evaluation and Implication

X. Documentationa. Documentation of Evidence of Care for 1 Week Rotation

b. Organization/Grammar/Bibliography

20

(10)

(10)

10

10

30

(10)

(20)

5

5

5

Total ScoreEquivalent Grade

final case study with help f my lyf

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