Course Code RLE 116/117

Course Title ENT SURGERY

Level Offering 3rd Year 2nd Semester AY 2021
Clinical area of assignment ENT WARD
Date of Exposure MARCH 8 - 10, 2021
No. of hours 24 hours
RELATED LEARNING EXPERIENCE
ENT WARD CASE STUDY

CONGRATULATIONS! For you are a few steps away of pursuing your dream of becoming a “nurse”.
Remember: ‘The Way to Get Started Is to Quit Talking and Begin Doing.” – Walt Disney
INSTRUCTIONS:
Read the case of a patient whom you are to provide nursing care. Take time to analyze and process the information provided, before
answering the activities following each section of your module.
You may take a break, as necessary. You can ask your friends, classmates, parents, or any person whom you think can help you
understand but remember a greater amount of output should come from you, as you are the LEARNER here.
Of course, you can ask me, your clinical instructor, for clarification on areas you do not seem to understand and do not know what to
do. Would be thankful and gladly help you on your learning needs. You can contact me through my number Messenger/ Mobile
number/ Email address at ______________________________________________

Modular: Remember that you are given 3 days to finish this task

IDENTIFICATION OF THE CASE:

The case of a 9 year old female student who has a recurrent tonsillitis for 3 years. Patient seeks medical consultation
and admitted for management.
History of past illness:
In 2018, patient had sore throat, fever and CLAD C (cervical lymph adenopathies) medication was prescribed and
treated. The following year, sign and symptoms were recurred 2times.patient seeks medical advise and was treated.
History of present illness:
Patient consulted medical help accompanied by mother due to recurrent fever, sore throat, and CLAD 3 times in 2020
and was advise for surgical intervention.
Medications prescribed: Amoxicillin 80mg/kg/day in 3 divided doses
Co-amoxiclav 50 mg/kg/day in 2 divided doses
Cefixime 8mg/kg/day in divided 2 divided doses
Clindamycin 30 mg/kg/day in 3 divided doses
Paracetamol 250mg q4h for fever/pain
Family history:
No history of heredofamilial diseases, asthma, HPN, DM, CA.
Social and environmental history:
Patient lives with her parents in a bungalow house, grade 3 student attending her online class, no pets at home.

NURSING ASSESSMENT:
Personal Data:
Name: KT
Nationality: Filipino
Religion: Jehova’s witness
Address: 110 camp allen Baguio City
Age: 9 years old
Civil Status: child
PRE OPERATIVE ASSESSMENT:
Reveals that patient had no abnormal findings of 13 areas of assessment except the affected part.
Vital signs prior to operation: Temp:38.0 C RR: 22bpm Spo2: 98%
CR: 89 bpm Bp: 100/70mmhg

Chief Complaint: recurrent sore throat.

Clinical diagnosis: recurrent tonsillitis
Proposed operation: Tonsillectomy.

Activity # 1 (day 1): problem - fever -( ncp and charting preoperative. )

A

I .NURSING CARE PLAN

CUES EXPLANATION OBJECTIVES NURSING RATIONALE EVALUATION

OF THE PROBLEM INTERVENTION
Subj: STG: STG:

Obj:

LTG: LTG:

Nsg.dx
II. CHARTING:

F>

D>

A>

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Prepared by: Froilan T. Adaci

Clinical Instructor