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Liceo de Cagayan University

College of Nursing

Individual Care Study

Submitted to:
Mrs. Azenith Jabagat RN

In Partial Requirement for NCM501204


Submitted by:

Karen Monette Jane G. Agno

Group A17

Overview of the Study . . . .
Objectives of the Study . . . .
Scope and Limitations . . . .
II. Health History
A. Profile of patient . . .
B. Family and Personal .
Health History
C. History of Present Illness
D. Chief Complaint . . . .
Laboratory Results. . . . . .
Drug Study . . . . . .
Ideal Nursing Management
Actual Nursing Management
XI. EVALUATION . . . . . .

Upper respiratory tract infection (URI) is a nonspecific term used to

describe acute infections involving the nose, paranasal sinuses, pharynx, larynx,
trachea, and bronchi. The prototype is the illness known as the common cold,
which will be discussed here, in addition to pharyngitis, sinusitis, and
tracheobronchitis. Influenza is a systemic illness that involves the upper
respiratory tract and should be differentiated from other URIs.

Viruses cause most URIs, with rhinovirus, parainfluenza virus,

coronavirus, adenovirus, respiratory syncytial virus, coxsackievirus, and influenza
virus accounting for most cases. Human metapneumovirus is a newly discovered
agent causing URIs. Group A beta-hemolytic streptococci (GABHS) cause 5% to
10% of cases of pharyngitis in adults. Other less common causes of bacterial
pharyngitis include group C beta-hemolytic streptococci, Corynebacterium
diphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Chlamydia
pneumoniae, Mycoplasma pneumoniae, and herpes simplex virus.
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
are the most common organisms that cause the bacterial superinfection of viral
acute sinusitis. Less than 10% of cases of acute tracheobronchitis are caused by
Bordetella pertussis, B. parapertussis, M. pneumoniae, or C. pneumoniae.

Most URIs occurs more frequently during the cold winter months, because
of overcrowding. Adults develop an average of two to four colds annually.
Antigenic variation of hundreds of respiratory viruses results in repeated
circulation in the community. A coryza syndrome is by far the most common
cause of physician visits in the United States. Acute pharyngitis accounts for 1%
to 2% of all visits to outpatient and emergency departments, resulting in 7 million
annual visits by adults alone. Acute bacterial sinusitis develops in 0.5% to 2% of
cases of viral URIs. Approximately 20 million cases of acute sinusitis occur
annually in the United States. About 12 million individuals are diagnosed with
acute tracheobronchitis annually, accounting for one third of patients presenting
with acute cough. The estimated economic impact of non–influenza-related URIs
is $40 billion annually.

Influenza epidemics occur every year between November and March in

the Northern Hemisphere. Approximately two thirds of those infected with
influenza virus exhibit clinical illness, 25 million seek health care, 100,000 to
200,000 require hospitalization, and 40,000 to 60,000 die each year as a result of
related complications. The average cost of each influenza epidemic is $12
million, including the direct cost of medical care and indirect cost resulting from
lost work days. Pandemics in the 20th century claimed the lives of more than 21
million people. A widespread H5N1 pandemic in birds is ongoing, with threats of
a human pandemic. It is projected that such a pandemic would cost the United
States $70 to $160 billion.

Upper Respiratory Tract Infections

The upper respiratory tract consists of our nasal cavities, pharynx, and larynx. Upper
respiratory infections (URI) can spread from our nasal cavities to our sinuses, ears, and
larynx. Sometimes a viral infection can lead to what is called a secondary bacterial
infection. "Strep throat" is a primary bacterial infection and can lead to an upper
respiratory infection that can be generalized or even systemic (affects the body as a
whole). Antibiotics aren't used to treat viral infections, but are successful in treating most
bacterial infections, including strep throat. The symptoms of strep throat can be a high
fever, severe sore throat, white patches on a dark red throat, and stomach ache.

An infection of the cranial sinuses is called sinusitis. Only about 1-3% of URI's
are accompanied by sinusitis. This "sinus infection" develops when nasal
congestion blocks off the tiny openings that lead to the sinuses. Some symptoms
include: post nasal discharge, facial pain that worsens when bending forward, and
sometimes even tooth pain can be a symptom. Successful treatment depends on
restoring the proper drainage of the sinuses. Taking a hot shower or sleeping
upright can be very helpful. Otherwise, using a spray decongestant or sometimes a
prescribed antibiotic will be necessary.
Otitis Media
Otitis media in an infection of the middle ear. Even though the middle ear is not
part of the respiratory tract, it is discussed here because it is often a complication
seen in children who has a nasal infection. The infection can be spread by way of
the 'auditory (Eustachian) tube that leads form the nasopharynx to the middle ear.
The main symptom is usually pain. Sometimes though, vertigo, hearing loss, and
dizziness may be present. Antibiotics can be prescribed and tubes are placed in
the eardrum to prevent the buildup of pressure in the middle ear and the
possibility of hearing loss.

Tonsillitis occurs when the tonsils become swollen and inflamed. The tonsils
located in the posterior wall of the nasopharynx are often referred to as adenoids.
If you suffer from tonsillitis frequently and breathing becomes difficult, they can
be removed surgically in a procedure called a tonsillectomy.
An infection of the larynx is called laryngitis. It is accompanied by hoarseness
and being unable to speak in an audible voice. Usually, laryngitis disappears with
treatment of the URI. Persistent hoarseness without a URI is a warning sign of
cancer, and should be checked into by your physician.


This individual case study provides goals or objectives which can be used as an
instrument in assessing the patient’s health status and in his present conditions:

1. Use to obtain a complete heath data and can be used in follow up care.

2. Impart knowledge by conducting health teaching about the necessary

information pertaining in the disease condition.

3. Understands the course and essence of the chosen care study.


The study includes all the data gathered during the interview and the
observation claimed by the patient as well as the significant others. It also deals
with the several factors observed and gathered during the interview. That
information gathered was the exact answer and the problems of the patient in the
Hospital and not just basing in the opinions of other people.

The limitation of this study is limited in the place of interaction itself which
is in the hospital. This study was completed in 2 days by the interaction of the
student and the patient.
A. Profile of the Patient

NAME: Bordado, Edeveil Albar

AGE: 8 years old

SEX: Male

RELIGION: Roman Catholic

BIRTH DATE: March 2, 2002



ADDRESS: Elsalvador Cagayan de oro city

DATE OF ADMISSION: January 22, 2011




PULSE RATE: 77 bpm


HEIGHT: 45cm

WEIGTH: 22.5 kg

ALLERGY: No allergy
B. Family and Personal Health History
The patient mother’s name is Mrs. Bordado a business women and
father’s name is Mr. Bordado, a Private employee. They have 3 members of
the family including the said patient. The family have the common problem on
their health like fever, common colds, headache and cough and they just
taking medication like paracetamol, robitossin, and neosep,


6 Days Prior to Admission fever was noted occasional cough and a throat
pain. Few days patient was seen by physician and given antibiotic for
tonsillitis and resistance for fever with vomiting.


The chief complain of the patient was Fever for 6 days and vomiting
last January 22, 2011.

∗ Erik Erikson's stages of psychosocial development

Erikson's stages of psychosocial development as articulated by Erik
Erikson explain eight stages through which a healthily developing human should
pass from infancy to late adulthood. In each stage the person confronts, and
hopefully masters, new challenges. Each stage builds on the successful completion
of earlier stages. The challenges of stages not successfully completed may be
expected to reappear as problems in the future. The stages: Infancy: Trust vs.
Mistrust (0 to 12-18 months) Toddler: Autonomy vs. Shame, Doubt (18 months to 3
years) Preschool: Initiative vs. Guilt (3 to 6 years) Childhood: Industry vs.
Inferiority (6 years to 12) Teenage: Identity vs. Role Confusion (12 to 20 years)
Young Adulthood Intimacy vs. Isolation (20 to 35 years) Middle Adulthood:
Generativity vs. Stagnation (35 to 65 years) Senior: Integrity vs. Despair (65 years
Base of the Psychosocial Theory by Erik Erikson, my patient is under
Childhood: Industry vs. Inferiority (6 years to 12) because when I ask him.

∗ Robert Havighurst of Developmental Task Theory

Developmental psychology', also known as human development, is
the scientific study of systematic psychological changes that occur in human beings
over the course of the life span. Originally concerned with infants and children, the
field has expanded to include adolescence and adult development, aging, and the
entire life span. This field examines change across a broad range of topics including
motor skills and other psycho-physiological processes; cognitive development
involving areas such as problem solving, moral understanding, and conceptual
understanding; language acquisition; social, personality, and emotional
development; and self-concept and identity formation.
Havighurst identified Six Major Stages in human life covering birth to old age:
• Infancy & early childhood (Birth till 6 years old)
• Middle childhood (6-12 years old)
• Adolescence (12-18years old)
• Early Adulthood (18-30 years old)
• Middle Age (30-60years old)
• Later maturity (60 years old and over)
Base of the theory of developmental task by Robert Havighurst, my
patient is under Middle childhood (6-12 years old) but as I observe to my patient his
dependent to his parents and have a little bit of knowledge to the things that I had

∗ Psychosexual Theory of Sigmund Freud

Psychosexual development, as envisioned by Sigmund Freud at the
end of the nineteenth and the beginning of the twentieth century, is a central
element in his sexual drive theory, which posits that, from birth, humans have
instinctual sexual appetites (libido) which unfold in a series of stages. Each stage is
characterized by the erogenous zone that is the source of the libidinal drive during
that stage. These stages are, in order: oral, anal, phallic, latency, and genital. Freud
believed that if, during any stage, the child experienced anxiety in relation to that
drive, that themes related to this stage would persist into adulthood as neurosis.
Freud's model of psychosexual development
Stage Age Range Erogenous zone(s)
Oral 0-18 months Mouth
Anal 18-36 months Bowel and bladder elimination
Phallic 3-5 yrs. Genitals
Latency 6-12yrs. Dormant sexual feelings
Genital 13 – Up Sexual interests mature

Base of the psychosexual theory by Sigmund Freud my patient is under Latency

6-12yrs. Dormant sexual feelings. Because my patient shares the things happened
to him in school telling me that he have friends both girl and boy.

∗ Cognitive Theory of Jean Piaget

The Theory of Cognitive Development, first developed by Jean

Piaget, proposes that there are four distinct, increasingly sophisticated stages of
mental representation that children pass through on their way to an adult level of
Piaget's four stages
Sensorimotor stage (birth -2yrs. old)
Preoperational stage (2 – 7 old years)
Concrete operational stage (7-12 yrs. old)
Formal operational stage (12–15 years of age (puberty) and continues into

Base of the Cognitive Theory of Jean Piaget my patient is under

Stage of Concrete operational Stage because he knew what happening to him,
why he is in the hospital and what is wrong with him.


Respiratory system

The Respiratory System is crucial to every human being. Without it, we would
cease to live outside of the womb. Let us begin by taking a look at the structure
of the respiratory system and how vital it is to life. During inhalation or exhalation
air is pulled towards or away from the lungs, by several cavities, tubes, and

The organs of the respiratory system make sure that oxygen enters our bodies
and carbon dioxide leaves our bodies.

The respiratory tract is the path of air from the nose to the lungs. It is divided into
two sections: Upper Respiratory Tract and the Lower Respiratory Tract.
Included in the upper respiratory tract are the Nostrils, Nasal Cavities,
Pharynx, Epiglottis, and the Larynx. The lower respiratory tract consists of the
Trachea, Bronchi, Bronchioles, and the Lungs.

As air moves along the respiratory tract it is warmed, moistened and filtered.

Breathing and Lung Mechanics

Ventilation is the exchange of air between the external environment and the
alveoli. Air moves by bulk flow from an area of high pressure to low pressure. All
pressures in the respiratory system are relative to atmospheric pressure
(760mmHg at sea level). Air will move in or out of the lungs depending on the
pressure in the alveoli. The body changes the pressure in the alveoli by changing
the volume of the lungs. As volume increases pressure decreases and as volume
decreases pressure increases. There are two phases of ventilation; inspiration
and expiration. During each phase the body changes the lung dimensions to
produce a flow of air either in or out of the lungs.

The body is able to stay at the dimensions of the lungs because of the
relationship of the lungs to the thoracic wall. Each lung is completely enclosed in
a sac called the pleural sac. Two structures contribute to the formation of this
sac. The parietal pleura is attached to the thoracic wall where as the visceral
pleura is attached to the lung itself. In-between these two membranes is a thin
layer of intrapleural fluid. The intrapleural fluid completely surrounds the lungs
and lubricates the two surfaces so that they can slide across each other.
Changing the pressure of this fluid also allows the lungs and the thoracic wall to
move together during normal breathing. Much the way two glass slides with
water in-between them are difficult to pull apart, such is the relationship of the
lungs to the thoracic wall.
The rhythm of ventilation is also controlled by the "Respiratory Center" which is
located largely in the medulla oblongata of the brain stem. This is part of the
autonomic system and as such is not controlled voluntarily (one can increase or
decrease breathing rate voluntarily, but that involves a different part of the brain).
While resting, the respiratory center sends out action potentials that travel along
the phrenic nerves into the diaphragm and the external intercostal muscles of the
rib cage, causing inhalation. Relaxed exhalation occurs between impulses when
the muscles relax. Normal adults have a breathing rate of 12-20 respirations per

The Pathway of Air

When one breathes air in at sea level, the inhalation is composed of different
gases. These gases and their quantities are Oxygen which makes up 21%,
Nitrogen which is 78%, Carbon Dioxide with 0.04% and others with significantly
smaller portions.

In the process of breathing, air enters into the nasal cavity through the nostrils
and is filtered by coarse hairs (vibrissae) and mucous that are found there. The
vibrissae filter macroparticles, which are particles of large size. Dust, pollen,
smoke, and fine particles are trapped in the mucous that lines the nasal cavities
(hollow spaces within the bones of the skull that warm, moisten, and filter the air).
There are three bony projections inside the nasal cavity. The superior, middle,
and inferior nasal conchae. Air passes between these conchae via the nasal

Air then travels past the nasopharynx, oropharynx, and laryngopharynx, which
are the three portions that make up the pharynx. The pharynx is a funnel-shaped
tube that connects our nasal and oral cavities to the larynx. The tonsils which
are part of the lymphatic system, form a ring at the connection of the oral cavity
and the pharynx. Here, they protect against foreign invasion of antigens.
Therefore the respiratory tract aids the immune system through this protection.
Then the air travels through the larynx. The larynx closes at the epiglottis to
prevent the passage of food or drink as a protection to our trachea and lungs.
The larynx is also our voicebox; it contains vocal cords, in which it produces
sound. Sound is produced from the vibration of the vocal cords when air passes
through them.

The trachea, which is also known as our windpipe, has ciliated cells and mucous
secreting cells lining it, and is held open by C-shaped cartilage rings. One of its
functions is similar to the larynx and nasal cavity, by way of protection from dust
and other particles. The dust will adhere to the sticky mucous and the cilia helps
propel it back up the trachea, to where it is either swallowed or coughed up. The
mucociliary escalator extends from the top of the trachea all the way down to
the bronchioles, which we will discuss later. Through the trachea, the air is now
able to pass into the bronchi.

Inspiration is initiated by contraction of the diaphragm and in some cases

the intercostals muscles when they receive nervous impulses. During normal
quiet breathing, the phrenic nerves stimulate the diaphragm to contract and
move downward into the abdomen. This downward movement of the
diaphragm enlarges the thorax. When necessary, the intercostal muscles also
increase the thorax by contacting and drawing the ribs upward and outward.

As the diaphragm contracts inferiorly and thoracic muscles pull the chest wall
outwardly, the volume of the thoracic cavity increases. The lungs are held to the
thoracic wall by negative pressure in the pleural cavity, a very thin space filled
with a few milliliters of lubricating pleural fluid. The negative pressure in the
pleural cavity is enough to hold the lungs open in spite of the inherent elasticity of
the tissue. Hence, as the thoracic cavity increases in volume the lungs are pulled
from all sides to expand, causing a drop in the pressure (a partial vacuum) within
the lung itself (but note that this negative pressure is still not as great as the
negative pressure within the pleural cavity--otherwise the lungs would pull away
from the chest wall). Assuming the airway is open, air from the external
environment then follows its pressure gradient down and expands the alveoli of
the lungs, where gas exchange with the blood takes place. As long as pressure
within the alveoli is lower than atmospheric pressure air will continue to move
inwardly, but as soon as the pressure is stabilized air movement stops.


During quiet breathing, expiration is normally a passive process and does not
require muscles to work (rather it is the result of the muscles relaxing). When the
lungs are stretched and expanded, stretch receptors within the alveoli send
inhibitory nerve impulses to the medulla oblongata, causing it to stop sending
signals to the rib cage and diaphragm to contract. The muscles of respiration and
the lungs themselves are elastic, so when the diaphragm and intercostal muscles
relax there is an elastic recoil, which creates a positive pressure (pressure in the
lungs becomes greater than atmospheric pressure), and air moves out of the
lungs by flowing down its pressure gradient.

Although the respiratory system is primarily under involuntary control, and

regulated by the medulla oblongata, we have some voluntary control over it also.
This is due to the higher brain function of the cerebral cortex.

When under physical or emotional stress, more frequent and deep breathing is
needed, and both inspiration and expiration will work as active processes.
Additional muscles in the rib cage forcefully contract and push air quickly out of
the lungs. In addition to deeper breathing, when coughing or sneezing we exhale
forcibly. Our abdominal muscles will contract suddenly (when there is an urge to
cough or sneeze), raising the abdominal pressure. The rapid increase in
pressure pushes the relaxed diaphragm up against the pleural cavity. This
causes air to be forced out of the lungs.

Another function of the respiratory system is to sing and to speak. By exerting

conscious control over our breathing and regulating flow of air across the vocal
cords we are able to create and modify sounds.

Lung Compliance

Lung Compliance is the magnitude of the change in lung volume produced by a

change in pulmonary pressure. Compliance can be considered the opposite of
stiffness. A low lung compliance would mean that the lungs would need a greater
than average change in intrapleural pressure to change the volume of the lungs.
A high lung compliance would indicate that little pressure difference in
intrapleural pressure is needed to change the volume of the lungs. More energy
is required to breathe normally in a person with low lung compliance. Persons
with low lung compliance due to disease therefore tend to take shallow breaths
and breathe more frequently.

Determination of Lung Compliance Two major things determine lung

compliance. The first is the elasticity of the lung tissue. Any thickening of lung
tissues due to disease will decrease lung compliance. The second is surface
tensions at air water interfaces in the alveoli. The surface of the alveoli cells is
moist. The attractive force, between the water cells on the alveoli, is called
surface tension. Thus, energy is required not only to expand the tissues of the
lung but also to overcome the surface tension of the water that lines the alveoli.

To overcome the forces of surface tension, certain alveoli cells (Type II

pneumocytes) secrete a protein and lipid complex called ""Surfactant””, which
acts like a detergent by disrupting the hydrogen bonding of water that lines the
alveoli, hence decreasing surface tension.

Upper Respiratory Tract

The upper respiratory tract consists of the nose and the pharynx. Its primary
function is to receive the air from the external environment and filter, warm, and
humidify it before it reaches the delicate lungs where gas exchange will occur.

Air enters through the nostrils of the nose and is partially filtered by the nose
hairs, then flows into the nasal cavity. The nasal cavity is lined with epithelial
tissue, containing blood vessels, which help warm the air; and secrete mucous,
which further filters the air. The endothelial lining of the nasal cavity also contains
tiny hairlike projections, called cilia. The cilia serve to transport dust and other
foreign particles, trapped in mucous, to the back of the nasal cavity and to the
pharynx. There the mucus is either coughed out, or swallowed and digested by
powerful stomach acids. After passing through the nasal cavity, the air flows
down the pharynx to the larynx.

Lower Respiratory Tract

The lower respiratory tract starts with the larynx, and includes the trachea, the
two bronchi that branch from the trachea, and the lungs themselves. This is
where gas exchange actually takes place.

1. Larynx

The larynx (plural larynges), colloquially known as the voice box, is an organ in
our neck involved in protection of the trachea and sound production. The larynx
houses the vocal cords, and is situated just below where the tract of the pharynx
splits into the trachea and the esophagus. The larynx contains two important
structures: the epiglottis and the vocal cords.

The epiglottis is a flap of cartilage located at the opening to the larynx. During
swallowing, the larynx (at the epiglottis and at the glottis) closes to prevent
swallowed material from entering the lungs; the larynx is also pulled upwards to
assist this process. Stimulation of the larynx by ingested matter produces a
strong cough reflex to protect the lungs. Note: choking occurs when the epiglottis
fails to cover the trachea, and food becomes lodged in our windpipe.

The vocal cords consist of two folds of connective tissue that stretch and vibrate
when air passes through them, causing vocalization. The length the vocal cords
are stretched determines what pitch the sound will have. The strength of
expiration from the lungs also contributes to the loudness of the sound. Our
ability to have some voluntary control over the respiratory system enables us to
sing and to speak. In order for the larynx to function and produce sound, we need
air. That is why we can't talk when we're swallowing.

1. Trachea
2. Bronchi
3. Lungs

The Right Primary Bronchus is the first portion we come to, it then
branches off into the Lobar (secondary) Bronchi, Segmental (tertiary)
Bronchi, then to the Bronchioles which have little cartilage and are lined by
simple cuboidal epithelium (See fig. 1). The bronchi are lined by
pseudostratified columnar epithelium. Objects will likely lodge here at the
junction of the Carina and the Right Primary Bronchus because of the
vertical structure. Items have a tendency to fall in it, where as the Left
Primary Bronchus has more of a curve to it which would make it hard to
have things lodge there.
The Left Primary Bronchus has the same setup as the right with the lobar,
segmental bronchi and the bronchioles.

The lungs are attached to the heart and trachea through structures that
are called the roots of the lungs. The roots of the lungs are the bronchi,
pulmonary vessels, bronchial vessels, lymphatic vessels, and nerves.
These structures enter and leave at the hilus of the lung which is "the
depression in the medial surface of a lung that forms the opening through
which the bronchus, blood vessels, and nerves pass" (

There are a number of terminal bronchioles connected to respiratory

bronchioles which then advance into the alveolar ducts that then become
alveolar sacs. Each bronchiole terminates in an elongated space enclosed
by many air sacs called alveoli which are surrounded by blood capillaries.
Present there as well, are Alveolar Macrophages, they ingest any
microbes that reach the alveoli. The Pulmonary Alveoli are microscopic,
which means they can only be seen through a microscope, membranous
air sacs within the lungs. They are units of respiration and the site of gas
exchange between the respiratory and circulatory systems.



Medical Orders and Rationale


1-22-11 - Vital sign for every 4 - monitor client’s status
hours - facilitate easy
- Diet soft diet swallowing/digestion,aid
s in the optimal nutrition
- IVF: PNSS 1L @ 20 of the patient.
gtts/min - For hydration and fluid
- Labs: needs
CBC with PH and - Identify lab exam
differential count alterations
Na, K
BUN, Crea
12 lead ECG

- Cilostazol 100 mg 1 tab,
½ tab BID
- Clopedogrel 75 mg 1 tab - prevention of thrombin
OD formation

- prevention of thrombin
- Citicoline 500 mg 1 tab formation or aggregation
BID that may cause more
- Imidapril + HCTZ 1 cerebral infarction.
tablet OD -
- Amlodipine 5mg 1 tab, -
OD - Decrease cardiac action.
- Colcichine 500 mg 1 tab - prevent rise of uric acid
2* a day in the blood
- Alluporinol 3oo mg 1 tab
OD - antigout drug
- Zucon 20 mg 1 tab, ½ -
1/04/2011 tablet OD - May indicate distress
9 AM - Watch out for decrease
sensorium - To provide appropriate
- Will inform AP interventions
- Refer as needed - To provide appropriate
- Add PU hook to 02 @ 21 interventions
pm in nasal cannula. -

- Increase present IVF to - Hydration and fluid

30 gtts/min needs
- TF PNSS L2 + KCL @
30 gtts/min x 3 bottles - Hydration and promote
- NPO until future order cardiac efficiency
- Request for: - For possible NGT placement
Serum : - Assess for
BUA unusualities/deviation from
1/05/2011 SGPT
8:10 AM normal
Chest x-ray PA
CT scan of the brain –
- Aseptic precaution
8:40 AM - Repeat serum Na +, K + - Ensure client’s safety
tomorrow @ AM - Assess changes of status and/or
effectiveness of meds

- Insert NGT 16
- Give paracetamol 500 mg - Aid in providing food and
every 4 hours or IVT or fluids
PRN for fever - For fever
- Give dulcolax 1 tab per
NGT now - Soften stool, avoid
- Give vastarel MR 35g 1 constipation
tab BID/NGT 1 dose now
2:35 PM - Paracetamol 300mg - Anti-anginal drug
IVTT now
5:20 PM - Give NaCl 1tab TID - Faster fever relief
6:00 PM - Sodium supplementation,
- Start cerebrolysin 00000 correct Na deficiency
- Improves the efficiency of
1/06/2011 aerobic energy
2:55 PM metabolism in the brain,
improves the
7 PM - 50 cc plain NSS to intracellular protein
consume for 1 hour synthesis in the developing
please use soluset and aging brain.
- IVT TF with PNSS 1L @
30 gtts/min - Ensure accuracy of infusion
1/07/2011 - Give Lantus 5 “units”
- Hydration and fluid needs
5:25 PM - Give monrapid 6 “units”
- Long-acting insulin to control
- 4 units actuapid SQ - Rapid-acting insulin to control
before feeding hyperglycemia
- Give lantus 20 “units” SQ
before feeding - Rapid-acting insulin to control
- Control hyperglycemia

- Diazepam 5g IVTT now

- Intubated patient with GT
7.5 @ level 21 via direct
visualization - anxiolytic
- Continuous ambubagging - open airway and facilitates in
- Suction secretions providing oxygenation.
- Transfer to ICU
- Hook to MV - Facilitate manual artificial
TV = 500 ml, Fi02 = breathing
100%, BUR 18, PEEP 5 - Clear airway
- Salbutamol + combivent - For intensive care
every 4 hours - Facilitate artificial breathing
9:30 PM - Instill PNSS to ET
suction every 2 hours
- Insert FBC catheter F16 - Facilitate drainage of
and indwell secretions
- AP updated
- Refer to pulmonologist - Ensure airway clearance
Dr. Tancongco
- Facilitate urine drainage

- Give D50 water via IV - keep physician informed

bolus - For collaboration of care and
- Repeat HGT further assessment of client
- Increase NaCl 2 tabs TID
per NGT
- Decrease present IVF rate -
to 20 gtts/min - Assess blood sugar level
- ABG after 30-45 minutes - Provide Na needs
and refer
- Hold co-amoxiclav - Prevent fluid overload
1/08/2011 - Tazocin 2.25g IV every 8
10 AM hours ANST - Assess acid-base balance of
- Nebulize with combivent blood
1 nebule every 6 hours
- Continue fluimucil -
- antibiotic

- HGT now = 128 - Allow easier drainage of

2 PM - Resume HGT monitoring secretions and promote better
5:55 PM QID breathing
- Reduces the viscosity of
purulent and non-
- Decrease present IVF rate purulent pulmonary
1/09/2011 to 15 gtts/min secretions, and
- TF PNSS 1L + 10 meq facilitates removal
KCL @ 15 gtts/min - Assess blood sugar level
1/10/2011 - Na+, K +, tom @ AM - Monitor blood sugar level
3:52 PM - Give actuapid 5 units pre
4:00 PM feeding
- Hold cerebrolysin - Prevent fluid overload
- Give Lantus 10 units SQ - Promote cardiac efficiency
6:15 PM HGT 21 meq/ dL - Assess electrolyte status
- Control hyperglycemia
1/11/2011 - Continuous I and O
monitoring -
- Control hyperglycemia

- Give Lasix 20 mg now

- Pls. refer to Dr. Dela - Monitor intake and output;
Serna for assess affectivity of
Cardio co-management medications

- Give Lantus 8 units now - Provide Potassium needs

SQ - Further assess client in terms
of cardiac function
- Give 3 units actuapid SQ
before breakast
- Control hyperglycemia

- Control hyperglycemia



DATE ORDERED: January 22, 2011

CLASSIFICATION: Penicillin, Antibacterial


MECHANISM OF ACTION: inhibits cell wall synthesis during bacterial


SFECIFIC INDICATION: mild to moderate infections of the lower respiratory

tract and mild to severe infections of the ear, nose and throat; skin or genitalia
SIDE EFFECTS: CNS: lethargy, hallucinations, seizures, anxiety, and confusion
agitation. G.I: nausea, vomiting, diarrhea, gastritis


1. Before giving the medication ask the client about allergic reactions
to penicillin, allergy is no guarantee.
2. If large dose are given, if therapy is prolonged bacteria or fungal
super infection may occur especially in elderly, debilitated or
immune suppressed patient.


DATE ORDERED: January 22, 2011

CLASSIFICATION: non opioid analgesia and antipyretics

DOSE AND FREQUENCY: 5 ml every 4 hours

MECHANISM OF ACTION: unknown, thought to produce analgesia by blocking

pain impulses by inhibiting synthesis of prostaglandin in the CNS or other
substances that sensitize pain receptors to stimulation. Drug may relieve fever
through central action in the hypothalamic heat regulating center.

SFECIFIC INDICATION: mild pain fever

SIDE EFFECTS: hemolytic anemia, neutropenia, leukopenia, jaundice,

hypoglycemia, uticaria

1. Use liquid form for children a patient’s who have difficulty





IVF infuse at the left


Impaired vision blind
Pain reddened drainage
Gums hard of hearing deaf
Burning edema lesion teeth
Assess eyes, ears, nose
Throat for abnormality no problem
Asymmetric tachypnea
Apnea rales cough barrel chest
Bradypnea shallow rhoneht
Sputum diminished dyspnea
Orthopnea labored wheezing
Pain cyanotic
Assess resp. rate, rhythm, depth, pattern
Breath sound, comfort no problem
Arrhythmia tachycardia numbness
Diminished pulse edema fatigue
Irregular bradycardia murmur
Tingling absent pulses pain
Assess heart sounds rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
No problem
Obese distention mass
Dysphagia rigidity pain
Assess abdomen, bowel habits, swallowing
Bowel sounds, comfort no problem
pain urine color vaginal bleeding
Hematuria discharge noctoria
Assess urine freq., control, odor color, comfort/
Gyn-bleeding, discharge no problem
Paralysis Stuporous unsteady seizures
Lethargic comatose vertigo tremors
Confused vision grip
Assess motor function, sensation, LOC, strength,
Grip,galt, coordination, orientation, speech
No Problem
Appliance stiffness itching petechiae
Hot drainage prosthesis swelling
Lesion poor turgor cool deformity
Wound rash skin color flushed
Atrophy pain ecchymosis
Diaphoretic moist
Assess mobility, motion, gait, alignment, joint function

/skin color, texture, turgor, integrity


Glasses Loss Comments __”wala man, clear
Visual changes man ako panan-aw, ok ra pud
Contact lens
Denied akongHearing
pang dongod” as
xR x L verbalized by the
Pupil Size ____3mm_____ pt.________________
Speech difficulties
Reaction _PERRLA_ __________________________
Dyspnea Comments _”nag ubo
Resp. Regular Irregular
Smoking history raman na siya tong nag
Describe: chills siya–”24
__Normal, regular respiration ascpm_______
by the pt.’s mother_____
Cough ______________________
Sputum ________________________
R _R lung symmetrical to left _____________
Denied ________________________
L _L lung symmetrical to right____________

Comments _”wala man pud ok
pain Regular Irregular
Leg pain raman ko” _ as verbalized by
Ankle the pt.__________________
Edema _N-O-N-E___________________________
Numbness of
Pulse Car.
extremities Rad. DP __________________________
Denied __________________________
R _84 bpm +____84 bpm___+______+_______________
L _84 bpm +____84 bpm___+______+_______________
Comments:_pt. have a normal heart__________________________
rhthm @ regular with nor-
mal and regulation pulsation site__________________________
(pulse & radical 84bpm)_____
*If applicable
DietDentures None
__soft diet__________________________
N V Comments _”ganahan man
Character Full Partial ko ug
eat Patient
” as _ verbalized
Recent change in by the pt.______________
Upper _______________________
weight, appetite
Swallowing difficulty _______________________
Lower _______________________
Usual bowel_Patient
Comments pattern had a_ Urinary
Bowel frequency
sounds _Fair normal
normal a day_____
bowel movement ___5-6 times
hypoactive / day
bowel _______
pattern 1-2 day__________ Urgency
Constipation Abdominal
________________________ Dysuria Distention
_________________________ Present yes no
_________________________ Urine* (color, consistency,
_________________________ odor)
Date of last BM
_________________________ _Urinate 4-5 times per
_______________ day;
Folywith yellow aromatic
in place
_________________________ urine__________________
_________________________ _______________________
_________________________ _______________________
_________________________ *If they are in place?


Alcohol Denied Briefly describe the patient’s ability to follow treatments (diet,
(amount, frequency) meds. etc.) for chronic health problem. (if present).

_patient does not drink alcohol____________________

_Patient follow a medication given to him as well as his diet, he drink
_____________________________________________ ensure of what the Doctor prescribed to his conditions having a fever
_____________________________________________ and an episode of
SBE Last Pap Smear__not applicable_____________ vomiting___________________________________________
LMP:____ not applicable___________________________________________________________________________

Dry Cold Comments _”walaPale man ko nag
Flushed Warm katul katul” as ___ _______ _
Moist Cyanotic
verbalized by the pt._________
*rashes, ulcers, decubitus (describe size,
location, drainage) _Patient has a dry and pale skin
Other (scars)
and warm to touch__________________________________
LOC and orientation _Patient is conscious and coherent,
Convulsion and _”wala
oriented to time, day, and present man siya
past happening____
Gait: walker canenakaother
experience ana” as
Steady motion of
Unsteady _________
verbalized by the__ patient’s
joints and motor losses inmother
Sensory face or______________________
extremities _N-O-N-E
no Limitation
sensory and in motor losses____________________________
in faces and extremities___
ability to
self _Patient has ____________________________
limited movement especially
@ the right arm in her IVF_________________________
Facial grimaces Comments _”strsight straight
(location man akong sleep” as verbalize
Other signs
frequency of pain __Patient is felt in pain @ the ® arm
by the patient______________
remedies the IVF ___________________
Side rail
Sleep release form signed (60+ years)
Observed non-verbal behavior _Pt. giggles whenever I asked
him something____________________________________
Member of household ___3 Family Member___
The person
and his
number thatFecanAlbar__________
be reached any
time _elsalvador, CDOC
________________________________________ _______
__________ Daily Weight __________ PT/OT _______________
___________ BP q Shift __________ Irradiation
__________ Neuro vs __________ Urine Test _____________
__________ CVP/SG. Reading _____ __________ 24 hour Urine Collection

Date Diagnostic/ Date Date I.V. Date

ordered laboratory Exams done ordered Fluids/Blood Disc.

1-22-11 x-ray 1-22-11 1-22-11 D5 IMB @ 15-17


1-22-11 CBC 1-22-11

1-22-11 urinalysis 1-22-11

1-22-11 Ct scan


Risk for fluid volume deficient related to vomiting

 Encouraged patient to increase oral  To maximize intake and replace fluid
intake. lost.
 Monitor intake and output  To be insensible to fluid loses to
 Weigh client with the same clothe ensure accurate picture of fluid
and weighing scale. status.
 To compare the recent and past
weight if client is losing to much
 Monitor client’s vital sign. weigh.
 To monitor client’s condition to check
 if further complication occur.

 Note generalized muscle weakness

 ), hydroxyzine (Vistaril),
prochlorperazine (Comparazine);  in acute exacerbations.
 Antipyretics, e.g., acetaminophen
(Tylenol);  Controls fever, reducing insensible
 Electrolytes, e.g., potassium
supplement (KCl-IV;K-Lyte, Slow-K);  Electrolytes are lost in large
amounts, especially in bowel with
denuded, ulcerated areas, and
diarrhea can also lead to metabolic
 Vitamin K (Mephyton) acidosis through loss of bicarbonate

 Stimulates hepatic formation of

prothrombin, stabilizing coagulation
and reducing risk of hemorrhage.
Knowledge deficient regarding condition, prognosis, treatment, self-care, and
discharge needs as related to unfamiliarity with resources and information

Desire outcomes/evaluation criteria- the significant others will:

Verbalize understanding of disease processes, possible complications.

 Determine the mother’s perception  Establishing knowledge regarding
of disease process. the disease condition of her child .

 Giving of information’s about the  Precipitating/aggravating factors are

factors that causes the disease individual; therefore, the mother
condition of the client. needs to be aware of what foods,
Encouraging the mother to ask fluids, and lifestyle factors can
question about it. precipitate symptoms. Accurate
knowledge base provides
opportunity for the mother to make
informed decisions/choices about
future and control of chronic
disease. Although most others know
about their own disease process,
they may have outdated information
or misconceptions.

 Giving of information’s about the  Promotes understanding and may

medication as well as it’s side enhance cooperation with regimen.
effects and action.

 Stressing the importance of the  Reduces spread of bacteria and risk

following :good skin care, e.g., of skin irritation/breakdown,
proper hand washing techniques infection.
and perineal skin care.

 Emphasize need for long-term  Patients with IBD are at risk for
follow-up and periodic colon/rectal cancer, and regular
reevaluation. diagnostic evaluations may be


Impaired skin integrity related to effects of excretions on delicate tissue.

Desired outcomes/evaluation criteria- patient will:

The patient will be able to maintain his skin integrity as well as to

maintain fluid volume.
 Provide the patient with  This is to prevent from injury because
oral mouth care. of dryness.

 Maintain accurate intake  To determine the fluids taken by the

and output and calculate patient and also to calculate the output
also the 24 urine collection. of the patient.

 Instruct the mother to use  This is to maintain skin integrity of the

less frequently mild patient and to prevent excessive
cleanser or soaps and to dryness.
provide optimal skin care.


 Administer medication to  To prevent injury and also to prevent

prevent the skin and the cracking of the mucous membrane
mucous membrane from of the patient.
cracking as indicated by the
VIII. Actual Nursing Management

“Nagsakit man the tiyan ni Jurey tapos cige siya ug kalibang”.

>hyper active bowel sound.
O >Facial Grimace
>Dry skin
Acute pain related to abdominal cramping
Long term:
At the end of 2o minutes the patient will be able to reestablish
and maintain the normal pattern of Bowel functioning.
P Short Term:
At the end of 15 minutes the patient will be able to maintain the
normal patter of normal bowel functioning.
2. Auscultate the abdomen of the patient.
3. Restrict solid foods intake as indicated by the
4. Encourage the mother to increase the fluid intake
I of her son containing electrolytes. such as juices to
prevent dehydration.
5. place the bedpan near the bed top have a easy
6. Administer medications that can relieve abdominal
E pain as indicated by the physician.
After the nursing intervention given the patient abdominal pain
will be reduce.

Actual Nursing Management

S “Init kayo si Jurey ug ga chill siya”.

O >Temperature:40°c
>Pulse rate: 160 bpm
>Respiratory Rate :72 cpm
>Flushed skin
A Fever related to infection
Long term:
At the end of 20 minutes the temperature of Jurey will drop into a
normal range..
P Short Term:
At the end of 10 minutes the temperature of Jurey will drop
slowly into the normal range..
1. Perform tepid sponge bath.
2. Change the clothing of the patient into a more
comfortable one.
3. Change the clothing of the patient as often as
I 4. Apply hot water bag in the lower extremities of the
patient. To lower his temperature.
5. Open the doors and windows in the patient room
so that the fresh air will come in.
6. Administer medications prescribed by the
physician. To lower the temperature of the patient.

After the nursing Intervention gentle patients body temperature

E will drops slowly into the normal range.


MEDICATIONS For the medications, Instruct the
mother of the patient to continue the
medication prescribed by the physician
and to give the medication on the
proper time and route. The
paracetamol which can lower the body
temperature and should be given every
4 hours.
EXERCISE For the exercise, Instruct the mother to
teach her son to do the relaxation
exercise. This is to relieve his
abdominal pain.
TREATMENT Instruct the mother to follow the
treatment given by the physician, which
includes the proper administration of
the medications, the time the
medication be given and the diet that
the patient must have. That treatment
is necessary for the complete recovery
of the patient.
OUT PATIENT Instruct the mother to be back in the
hospital after 1 week after the
discharge of the patient. This to
determine if the condition of the patient
is already stable and if there is another
treatment be given.
DIET Instruct the mother to give her child
foods rich in fibers such as vegetables
and also to increase the fluid intake of
the patient.
X. Evaluation:

In the case of Jurey, Immediate intervention was given because Jurey was
admitted to the Sabal Hospital after experiencing loss bowel movement and
vomiting. History was taken to document the onset and frequency of diarrhea.
Exposure to contaminated food or water is initiated with the patient where
drinking water might be contaminated. Physical examination helps the physician
to identify underlying systemic disease. The doctor ordered for some diagnostic
tests to find the cause of diarrhea which include the fecalysis where positively
amoebiasis was detected. Urinalysis and hemochrome was also ordered to
provide more specific data.

Treatment for acute gastroenteritis includes restoration of fluid and

electrolyte balance, management of signs and symptoms and treatment of
causative factors.


No one can escape from having this kind of disease Children are very
susceptible to illness that is why I imparted knowledge to Mrs. Tumacas to
continue giving nutritious foods, and vitamins. As much as possible report to the
physician immediately if there are any unusualities may observe because
diarrhea can be dangerous in newborns and infants. Children, especially those
younger than 6 months of age and those with other health risks, need special
attention when they have diarrhea because they can become dehydrated.
Because a child can die from dehydration within a few days, the main treatment
for diarrhea in children is dehydration. Quickly Careful observation of the child's
appearance and how much fluid he or she is drinking can help prevent problems.
And lastly I told her to follow-up the rural health center for his complete


>Smeltzer, S, et al Medical-Surgical Nursing. 10th Edition Lippincott Williams and
Wilkins (2004)

>Kozier, B, et al Fundamentals of Nursing. 7th Edition Pearson Education South

Asia PTE LTD Philippines 2004