Liceo de Cagayan University
RNP Blvd. Carmen, Cagayan de Oro City
College of Nursing
In partial fulfillment of
Related Learning Experience
Individual Case Study
MEDEL, Roin Carl B.
Gemma Reambonanza RN
Monday, July 26, 2010
TABLE OF CONTENTS
• 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
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 may also 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.
B. Objective of the Study
Individual care study provides goals or objectives which is necessary to serve as an instrument in comprehensively assessing the patient’s 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 patient’s 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 patient’s support person since the patient is only 5 years old .Interventions were rendered gradually depending on the objective 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
Birth date: September 20, 2005
Religion: Roman Catholic
Civil Status: Child
Address: Brgy. 25 Cagayan de Oro City
Name of Father: Alfredo B. Tuto
Occupation: Security Guard
Name of Mother: Ephy M. Tuto
Date of Admission: July 7, 2010
Time of Admission: 10:20 am
Admitting Physician: Dr. J. Neri
Vital Signs Assessment
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
Rafael’s father is a security guard while her mother is a plain housewife. They live in Brgy 25 Cagayan de Oro City. His father’s 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.
45rffff Name: Reuben Gabriel Dagoldol
dhhd Ward: Pediatric ward Date: 12/8/09 Trtgg Result Nursing interpretation Color: yellow
Pus: 1-3 hpf
RBC: 1-3 hpf
Epithelial cells: few
Mucus thread: –
SpGr: 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 infection RBC: 4.28 4.35 – 5.90 mil/mm3 anemia Hemoglobin: 11.6 g/dl 13.7 – 16.7 g/dl Risk anemia Hematocrit: 34.9 vols % 40.5 – 49.7 vols % Anemia, malnutrition Platelet Count: 190,000 144,000 – 372,000 low platelet count Differential Count Granulocyte: 40 43.4 – 76.2% 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, 2010 Classification Antacid Dose/Frequency/Route 5 ml 3x daily PO Mechanism of Action Slows intestinal motility by acting on the nerve endings on and or intramural ganglia embedded in the intestinal wall Specific Indication For treatment of stomach pain Contraindication Discontinue if abdominal distention develops in ulcerative colitis in clients with constipation Side 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 Paracetamol Brand Name None Date Ordered July 7, 2010 Classification Non-opioid analgesic;antipyretic Dose/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 patient’s going long-term therapy for chronic noncongestive angle-closure glaucoma; hyponatremia; hypokalemia; hepatic impairment; adrenal gland failure’ hypechloremic acidosis Side Effects/Toxic Effects Confusion; anorexia; aplastic anemia; rash; renal calculi Nursing Precaution Report signs of F/E imbalance V. PATHOPHYSIOLOGY with ANATOMY AND PHYSIOLOGY
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 liquid matrix 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 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.
Cell Type Description Function Erythrocytes (RBC) Biconcave disk, no nucleus, 7-8 micrometers in diameter Transport oxygen and carbon dioxide Leukocytes (WBC):
Spherical cell, nucleus with two or more lobes connected by thin filaments, cytoplasmic granules stain a light pink or reddish purple, 12-15 micrometers in diameter
Spherical cell, nucleus, with two indistinct lobes, cytoplasmic granules stain blue-purple, 10-12 micrometers in diameter
Spherical cell, nucleus often bilobed, cytoplasmic granules satin orange-red or bright red, 10-12 micrometers in diameter
Spherical cell with round nucleus, cytoplasm forms a thin ring around the nucleus, 6-8 micrometers in diameter
Spherical or irregular cell, nucleus round or kidney or horse-shoe shaped, contain more cytoplasm than lymphocyte, 10-15 micrometers in diameter
Releases histamine, which promotes inflammation, and heparin which prevents clot formation
Releases chemical that reduce inflammation, attacks certain worm parasites
Produces antibodies and other chemicals responsible for destroying microorganisms, responsible for allergic reactions, graft rejection, tumor control, and regulation of the immune system
Phagocytic cell in the blood leaves the circulatory system and becomes a macrophage which phagocytises bacteria, dead cells, cell fragments, and debris within tissues Platelet Cell fragments surrounded by a cell membrane and containing granules, 2-5 micrometers in diameter Forms platelet plugs, release chemicals necessary for blood clotting
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.
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.
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 tissues, stimulate the conversion of plasminogen to plasmin. Over a period of a few days the plasmin slowly breaks down the fibrin.
Precipitating Factors: Age
Male Predisposing Factors: Immuno compromized
Bite of a aedes aegypti mosquito carrying a virus
Virus goes into circulation
Dengue Virus Type II
IgG adheres to the platelet
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 8,2010
Vital Signs: Pulse: 132bpm RR: 28cpm Temp: 38.6°C Height: Not obtained Weight: 13kgs
[ ] impaired vision [ ] blind
[ ] pain [ ] reddened [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion [ ] teeth
Assess eyes, ears, nose, throat
For abnormality [x] no problem
[ ] asymmetric [ ] tachypnea
[ ] apnea [ ] rales [ ]cough[ ] barrel chest
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ]dyspnea
[ ] orthopenea [ ] labored [ ]wheezing
[ ] pain [ ] cyanotic
Assess resp.rate, rhythm, depth, pattern
Breath sounds, comfort [ x] no problem
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [x ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate, rhythm, pulse,
circulation, fluid retention, comfort [ ] no
GASTRO INTESTINAL TRACT
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain
Assess abdomen, bowel habits, swallowing,
Bowel sound, comfort [ } no problem
Gyn-bleeding, discharge [x] no problem
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures
[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors
[ ] confused [ ] vision [ ] grip
Assess motor function, sensation, LOC, strength,
Grip, gait, coordination, orientation, speech [x] no problem
MUSCULOSKELETAL 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 OBJECTIVE Communication:
[ ] hearing loss [ ] visual changes
Comments: “wala may problema sa pandungog ug panan aw sa akong anak “as verbalized by the mother.
[ ] glasses [ ] language
[ ] contact lens [ ] hearing aide
Pupil size : 3mm
Reaction: Pupil equally round reactive to light and accommodation.
[ ] speech difficulties Oxygenation:
[ ] dyspnea [ ] smoking history [ ] cough [ ] sputum [ ] denied
Comments: “dli man galisod ug ginhawa akong anak “as verbalized by the mother.
Respiratory [ x] regular [ ] irregular
Describe: Respirations are regular 25cpm within the normal range.
R: Normal symmetrical breathing
L: Normal symmetrical breathing Circulation:
[ ] chest pain [ ] leg pain
[ ] numbness of extremities
[ ] denied
Comments: “di man gasakit ang dughan sa akong anak”as verbalized by the mother. Heart Rhythm [x] regular [ ]irregular
Ankle Edema: none
Pulse Car. Rad. DP. Fem.*
R :+ 132 + + _+
L :+ 132 + + +
Comments: Normal and palpable pulses Nutrition:
Diet: as tolerated
Character: [ ] recent change in weight,
[ ] swallowing difficulty [ ] denied
Comments: ” gasuka siya pero dili kaayo”as verbalized by the mother.
[ ] dentures [x] none
Full Partial With Patient
Upper [ ] [ ] [ ]
Lower [ ] [ ] [ ] Elimination:
Usual bowel pattern Urinary frequency
Once a day 3 times a day
constipation remedy [ ] urgency
n/a [ ] dysuria
Date of last BM [ ] hematuria
Dec. 8, 2009 [ ] incontinence
Diarrhea character: [ ] polyuria
None [ ] foley in place
[ ] denied
Bowel sounds: Audible bowel sound
Present [ ] yes [ x] no
Urine* (color, consistency, odor)
*if they are in place
Comments: The urine is normal and yellow color.
Management of Health and Illness:
[ ] alcohol [ ] denied
[ ] SBE Last Pap Smear: N/A
Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).
The client follow strictly the medication and diet as prescribed by the physician.
[ ] dry [ ] itching [ ] denied
Comments: “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 lower extremities. Activity/ Safety:
[ ] convulsion [ x] dizziness
[ ] limited motion of joints
Limitation inability to:
[ ] ambulate [ ] bathe self
[ ] other [ ] denied
Comments: “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 [ ] denied
Comments: “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: 3
Most supportive person: Mr. Ephy Tuto Observed non- verbal behavior:
The person and his phone number that can be reached any time: Not obtained.
VII. Nursing Management
A. Ideal Nursing Management
1. Hyperthermia r/t infection
Interventions Rationale 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 temperature
• This will help relxed the patient
To prevent from sweating.
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 Independent:
Monitor vital signs
Instruct deep breathing exercise
Encourage to have diversional activites like watching 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 Rationale Independent:
Monitor Intake and Output
Withhold foods and fluids for about 3 hours.
Instruct to sip small amounts of fluids after three hours fasting.
Instruct to give crackers and toasted bread.
Ensure accurate picture of fluid status
To prevent irritation in stomach.
To determine if the stomach can already tolerate fluids
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
• Warm skin to touch A Hyperthermia r/t infection P 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 patient’s body temperature will decrease into normal range I 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
• Given bronchodilators (Salbutamol) as ordered, to relax bronchial smooth muscles thus facilitating airflow.
E After 30 minutes, the client’s 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 pattern I 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.
1. Maintained supplemental oxygen therapy as ordered 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.
• restlessness A Social Isolation related to the child’s 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 must socialize to other people
• 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 child’s disorder.
E After 8 hours?of nursing?interventions, the goal was achieved by seeing the patient socializing to other people
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 range P 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 from 38° 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
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
• 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.
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.
• Barbara Kozier; “Fundamentals of Nursing” 7th edition
• Smeltzer, Suzanne. Medical-Surgical Nursing, 11th edition
• The Lippincott Manual of Nursing Practice 6th Edition
• Springhouse corporation Disease and Disorders Handbook
A. WRITTEN WEIGHT RATING I. 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
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
a. Documentation of Evidence of Care for 1 Week Rotation
b. Organization/Grammar/Bibliography 5
5 Total Score Equivalent Grade