Republic of the Philippines

Isabela State University

Echague Campus

San Fabian, Echaue, Isabela

A Case Study of Septicemia: To a Newly Diagnosed Cerebral palsy

Presented to the Faculty and staff of the College of Nursing

February 26,2020

Presented by:

Agustine, Honie Gie

Ancheta, Xyla Faith

Cauilan, Angelica

Clemente, Kate

Delafuente, Mary joy

Duran, Angel

Esteban, Aira Crizzel

Manalo, Princess Meljane

Miguel, Jomarie May

Ortiz, Karl Bryan

Rivera, Trixie
Table of Content

I. Patient profile
II. Patient History
a. History of present Illness
b. Past Medical History
c. Social History
d. Family History
III. Overview of the Disease
IV. Anatomy and Physiology
V. Physical Assessment
VI. 11 Areas of assessment
VII. Pathophysiology
VIII. Course in the Ward
IX. Laboratory Results
X. Drug study
XI. NCP
XII. Discharge Planning
 I. Patient Profile

Patient name: Patient Y

Age: 1year old

Birthdate: 11/24/2018

Birthplace: Santiago city

Civil Status: New born

Gender: Male

Nationality: Filipino

Religion: Catholic

Address: Balintocatoc, Santiago city Isabela

Fathers name: M

Mothers name:

Date of administration: 2/22/2020

Time of administration: 5:51pm

Chief complaint: fever

Admitting diagnosis: Sepsis cerebral palsy

Attending physician: Dr. G. Cristobal

Room: Private 6
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for fall After 3hours -Demonstrate -Identifying After 3hours
“Hindi ko sya r/t impaired of nursing to patient SO factors helps of nursing
pwedeng iwan na physical intervention, to identify to know the intervention
mag isa kasi baka mobility patient SO will factors that interventions patient SO
mahulog sya” secondary verbalize may affect that will be verbalized
to cerebral Understandin needs stabilized. understanding
Objective: palsy g about the -Instruct SO -It is helpful about the
- Decreased ways on how to assess the to determine ways to
strength in to decrease patient ability the client decrease risk
extremities risk of falling to ambulate functional
- Weak in safety with or abilities to
appearanc without plan for ways
e assistive of improving
- Absence devices. the problem
of side rails -Thoroughly areas.
- Presence of orient the SO -For the client
scattered to SO to
lesions environment familiarize
the
-Advice the surroundings.
SO to always -in order to
stay with the ensure client
patient. safety
-Instruct the
SO to always -Putting up
put side rails side rails can
when reduce risk of
learning falling
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Sleep After 3hours -Advice SO to Arranging care After 3 hours
“May mga deprivation r/t of nursing arrange care will promote of nursing
oras Na sustained intervention, to provide for good sleep intervention,
inaabot sya Ng environmental SO will agree uninterrupted pattern. SO agreed to
madaling stimulation; to the periods for the different
araw, Hindi unfamiliar of different ways rest, especially ways and
sya uncomfortable and means to allowing for means to
makatulog” as sleep improve good longer period improved
verbalized by environment sleep pattern of sleep at good sleep
the patient SO of the patient night when patient of the
Objective: possible. Do as patient
-Irritability much care as
-restlessness possible
without
walking client
-Instruct SO to -Providing a
provide a quiet
quiet environment
environment and comfort
and comfort measures
measures (eg. promote good
Backrub, sleep of the
washing patient
hands/face,
cleaning and
straightening
sheets) in
preparation
for sleep
-Discuss to SO -Bed rituals
the effective enhance
age clients ability
appropriate to fall asleep
bedtime
rituals (eg.
Going to bed
as same time
each night,
drinking warm
milk, rocking
; story
reading,
cuddling,
favorite
blanket/toy
-Encourage SO
to provide for
 Childs -Providing
(impaired Childs sleep
individuals) time safety
sleep time will promote
safety (eg. sense of
Infant placed security for
on the back, child.
bedrails/bed
in low
position, none
plastic sheets)

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective After 4 hours -Monitor -To indicative After 4 hours
“nahihirapan airway of nursing respiration of respiratory of nursing
huminga ang clearance intervention and breath distress or intervention
anak ko”as related to The patient sound accumulation The patient
verbalized by retained will able to of secretion would able to
the Mother of mucus demonstrate -instruct SO to demonstrate
the patient secretion as behavior to increase water -to loosen behavior to
Objective: evidence by improve intake secretion improved
-Irritability unproductive airway airway
-adventitious cough clearance clearance
sound -position head
(crackles) appropriate -to open or
-Inability to for condition maintain open
expectorate such as fowler airway in at
phlegm position rest or
-RR of 27bpm compromised
individual

-Encourage SO
to take the -to limit
patient fatigue
adequate rest
period of time