SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

S.Y. 2018-2019

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NCM 102

Submitted to:

Mrs. Rochel Ignacio, RN, MAN

Submitted by:

Jam Mikka G. Rodriguez

Date Submitted:

March 27, 2018

TABLE OF CONTENTS
 SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

S.Y. 2018-2019
Acknowledgements

Abstract

Chapter I (Case Overview) 1

Introduction 1

Objectives 2

Scope 4

Limitation 5

Chapter II (Case Data and Information) 6

Patient’s Biographical Data 6

Health History 7

Functional Health Patterns 9

Physical Assessment 14

Laboratory Examinations 19

Chapter III (Literature Review) 22

Normal Anatomy and Physiology 22

Theoretical Background 29

Chapter IV (Case Analysis and Intervention 35

Pathophysiology 35

Medical Management 37

Pharmacologic Management 39

Nursing Care Management 45

Progress Notes 52

Discharge Plan 53

Chapter V (Conclusions and Recommendations) 55

Conclusion 55

Recommendation 56

References 57

ACKOWLEDGEMENT
 SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

S.Y. 2018-2019
First of all, I would like to thank God, for giving me enough
strength, wisdom, perseverance & skills to come up this study
possible.

To my beloved Dean Malou Dinopol, for motivating & giving me

words of wisdom for this case study.

To Mrs. Rochel Ignacio for giving me encouragement, support,

patience & courage during my case study.

To the nurses on duty of Negros Oriental Provincial Hospital

Pediatric Ward Station 2 for giving me all the information, data &
laboratory test that I need in this study.

To my Family, for giving their financial & moral support, for

their understanding & serves as inspiration while we doing this study.

To my friends & classmates who supported & help me in editing &

revising this case study.

To the School library, for other references that we used to make

our research detailed.

And mostly, to my Patient for her utmost cooperation from the

beginning up to the end of this case study.

ABSTRACT

This is a case study about a 4-year old girl namely patient S.M.G
with a chief complaint of “Naa cyay mga bunol sa bukton og tiil mao ng
amo gpacheck up”, as verbalized by the patient’s father. Her
 SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

S.Y. 2018-2019
laboratory results revealed that she had very low platelet count that
led to her diagnosis of Idiopathic Thrombocytopenia Purpura (ITP). She
was given medications such as intravenous fluids, prednisone, folic
acid, zinc zulfate, ceftriaxone and paracetamol for temperatures that
would reach 38 degrees celcius and above. Platelet concentrate
transfusion was also done. Different nursing managements were
implemented towards patient S.M.G such as monitoring her intake and
output as well as her vital signs and the like. Laboratory
examinations are also still being done to monitor her condition.