CASE ANALYSIS

Instruction: Consider the case presented for Activity 1 and Activity 2. Plot the activity 1 in the
TPR sheet and Activity 2 in the I and O sheet. For each RLE group, divide yourself into 2 and
assigned task to each member. An oral presentation will be conducted during the
Synchronous session.
ACTIVITY 1
A 14-yr-old male patient presents to your clinic complaining of sore throat and cough. He has been
feeling ill for about 1 week, and has had no fever, nasal congestion, or runny nose. He says he feels tired
and his mom states that he hasn't been getting out of bed to go to school for the past few days.

He is a previously healthy young man without any significant medical history. Physical examination is
remarkable only for a mildly erythematous throat without petechiae.

Lungs are clear, and the rest of his exam is normal. Vital signs are monitored.

A rapid strep screen is negative, and you diagnose him with a viral syndrome and recommend
symptomatic relief.

Consider the following vital signs provided.

Aug 12 Temp Pulse Respiration

10 am 36.8 86 12
2pm 37 90 18
6pm 37.8 98 18
10pm 37.5 88 16
Aug 13
2am 36.8 78 25
6am 37 75 22
10am 37.8 78 20
2pm 37.5 80 18
6pm 36.8 80 16
10pm 37.2 84 24
Aug 14
2am 37.8 84 28
6am 37 75 22
10am 37.6 90 26
2pm 38 88 24
6pm 38.6 102 28
10pm 38.4 110 24

ACTIVITY 2
Intake and Output Monitoring

Aug. 12, 2021 – Aug 14, 2021

GDV2021
Consider 1 shift is equal to 8 hours

Standing order -Plain LR 1 Liter @30cc/hr for the next 3 days. Compute the total amount infused every 8
hours.

Transfuse FWB 500 cc 2 packs for the next 12hours after proper crossmatching. Start at
8pm.

Encourage to consume oral fluids at least 16 glasses for the next 24 hours. Divide the
number of glasses within the 3-shift period.

Continues Heparin infusion at 10ml/hr for the next 2 2shift. To start at 11pm

Nurse on duty assessment:

• Consumes 1 8 oz of soda – drinks 2 oz of coffee lunch time and drinks 2 oz of

coffee – Aug 12 and Aug 13 8 breakfast
• 4pm – urinates – 30cc
• 6pm – Urine – 500 cc
• 12 midnoc – urine – 1200
• 4 am - chest tube drainage 800cc
• 8 am – chest tube drainage - 400 cc
• 12 nn – urinates – 500 cc
• 4pm – urinates – 300 cc
• 6pm – urinates – 700 cc

GDV2021