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CARE STUDY TOPIC
SANRIA O> LUGTU
RLE GROUP CLUSTER I-A11 TERM FINAL
SUBMITTED TO MS. MAYLINDA B. ORO, RN September 29, 2008
This is a case study of an 11month old client admitted at Polymedic
General Hospital with a chief complaint fever for of 2 cough weeks with and and Acute
Bronchitis. Bronchitis means that the tubes that carry air to the lungs (the bronchial tubes) are inflamed and
irritated. When this happens, the tubes swell and produce mucus. This makes you
cough. Acute bronchitis is usually caused by viruses or bacteria and may last
several days or weeks. Acute bronchitis is characterized by cough and sputum (phlegm) production and symptoms related to the obstruction of the airways by the inflamed airways and the phlegm, such as shortness of breath and wheezing. Acute bronchitis symptoms usually start 3 or 4 days after an upper respiratory tract infection. Most people get better in 2 to 3 weeks. But some people continue to have a cough for more than 4 weeks. Infants with bronchitis may have many of the symptoms above, but in many cases they are simply sleepy or have a decreased appetite.
diet and its course of medical and nursing intervention. application of plan activities and evaluate its effect to the patient. plan care. treatment.B. identify health problems. To assess patient thoroughly. . Interventions were rendered gradually depending on the objective assessment of the student. SCOPE AND LIMITATIONS This study in general with limited background and skills of students to care of the patient and problem identified carry through the process of referral to the clinical instructor. and doctor’s during the 2 days duty in the Pedia Ward. staff nurses. C. The following information only involves the exact words and answers supported by the client. To understand the course and essence of the chosen care study and add up additional knowledge and understanding in the Nursing profession. To present the case study to the group members and clinical instructor and evaluate and learn the outcome of the study to the patient and to the student. OBJECTIVE OF THE STUDY This study aims to convey the patient and significant others with information about the disease process. medication.
N. fever. 2008 12:10 PM Dr. Pabre a.D.k. HEALTH HISTORY A. Lim. acute bronchitis Diet: Diet as tolerated for age Vital Signs upon admission: T: 39. Patient’s Profile Name: Age: Sex: Birth date: Birth place: Name of Father: Name of Mother: Civil status: Nationality: Informant: Religion: Address: Allergy: Rossel E. Cough.a REP 11 months old female October 24.II. Bukidnun No known allergy to food and drugs CLINICAL PROFILE Date of admission: Time of admission: Attending physician: Chief Complaint: Admitting diagnosis: September 15. 2007 Cagayan de Oro City Rey Pabre Roseville Pabre Child Filipino Roseville (mother) Roman Catholic Talakag. M.5 0 C RR: 58 cpm .
REP and family had no history of asthma. Pabre. 4 years old experienced cough and fever. Two weeks prior to admission onset of having fever and cough. C. She was brought to the emergency room last September 15. and Mrs.PR: 145 bpm B. AP. History of Present Illness A case of Seanford Luke Montecillo. She is the only child of Mr.5 0 C. Patient’s Health History Rossel E. Consulted to a physician and was given salbutamol and paracetamol. an 11 months old child was born on Cotober 24. Vital signs taken Temp. Bukidnun. Pabre.145 bpm.39. 2008 at 12:10 pm. The family is now currently residing at Talakag. male.. . 1 day prior to admission noted with poor appetite due to poor appetite and vomiting. She was then transferred at Pedia Ward 7th floor PGH. RR58 cpm. 2007. pneumonia or any respiratory problem.
toys or other objects that can be orally manipulated. He believed that the mind of an infant consists only of primitive drives and instincts. Some infants enjoy this oral activity more than others. as many modern views of human development still have their roots in Freudian theory. . Freud developed a general theory of psychological development from infancy to adulthood.II. Freud theorised that an infant's oral focus brought not only nourishment. which he called the "id. A baby's first nourishment is received through suckling. other require pacifiers. and the sucking instinct is usually strong. even in newborns. More modern theories of development have now replaced those of Freud." The Oral Stage: Birth to 18 Months Anyone familiar with very young babies and children knows that they are focused on their mouths. but pleasure. REP belongs to this stage in which she enjoys sucking and later biting anything that touches the erogenous zone of the lips and mouth. such as the need for food and physical comfort. Yet it is still important to be familiar with the basics of Freud's work. while some maybe satisfied by sucking at the breast or bottle. DEVELOPMENTAL HISTORY Sigmund Freud: Psychosexual Theory Psychoanalytic theories of human development began in the 1900's with the work of Sigmund Freud.
REP belongs to Trust vs. Infancy: Birth to 18 Months Ego Development Outcome: Trust vs. and difficulty with later tasks. Robert Havighurst: Developmental Task Theory Robert Havighurst believed that learning is basic to life and that people continue learn throughout life.Erik Erikson: Psychosocial Theory Erikson's greatest innovation was to postulate not five stages of development. Mistrust Basic strength: Drive and Hope Erikson also referred to infancy as the Oral Sensory Stage (as anyone might who watches a baby put everything in her mouth) where the major emphasis is on the mother's positive and loving care for the child. Successful achievement of these tasks leads to success and happiness with later tasks. . that a human being goes through from birth to death. He described growth and development as occurring during six stages. Erik Erikson believed that every human being goes through a certain number of stages to reach his or her full development. Mistrust stage. we will learn to trust that life is basically okay and have basic confidence in the future. each associated with six to ten tasks to be learned. theorizing eight stages. while failure leads to unhappiness in the individual. REP belongs to this stage. If we fail to experience trust and are constantly frustrated because our needs are not met. with a big emphasis on visual contact and touch. but eight. we may end up with a deep-seated feeling of worthlessness and a mistrust of the world in general. If we pass successfully through this period of life. as Sigmund Freud had done with his psychosexual stages.
. Piaget further attested that a child's cognitive structure increases in sophistication with development." schemes. This is the stage where a child does not know that physical objects remain in existence even when out of sight (object permanence). through physical interaction with his or her environment.Developmental Tasks of Infancy and Early Childhood: • • • • • • • Learning to walk.2 years old)—REP belongs to this stage-. Sensorimotor stage (birth . Getting ready to read Jean Piaget: Cognitive Theory Swiss biologist and psychologist Jean Piaget (1896-1980) is renowned for constructing a highly influential model of child development and learning. Learning to take solid foods Learning to talk Learning to control the elimination of body wastes Learning sex differences and sexual modesty Forming concepts and learning language to describe social and physical reality. mental "maps. Piaget's theory is based on the idea that the developing child builds cognitive structures--in other words.for the child. or networked concepts for understanding and responding to physical experiences within his or her environment. moving from a few innate reflexes such as crying and sucking to highly complex mental activities. builds a set of concepts about reality and how it works.
• To meet nutritional needs. • Bactericidal inhibits synthesis causing cell death. To reduce fever and infection. • • • • For laboratory analysis Saline lock. 2008 • DOCTOR’S Order Order Please admit under the service of Dr. Paracetamol drops 1. 2008 • DAT for age Refer accordingly Paracetamol 125mg suppository • .70C 2. • • September 16. >37. for emergency IVTT drugs used MEDS: 1. MEDICAL MANAGEMENT Date September 15.1ml q 4hrs. PRN for Temp. • To monitor unusualities.IV. of bacterial cell wall. • Labs: CBC Urinalysis • IVF D5 0.3% NaCl 500 @ 40 cc/hr. Lim TPR q 4 hours • Rationale To render proper medical management. Cefuroxime (zinacef) 200mg IVT q 8 (ANST -) 0 • To lower fever. To monitor vital signs and note any discrepancies.
000/cc. 2008) Color Yellow . recent hemorrhage.5 10.3% NaCl 500 @ 40 cc/hr.2 NORMAL 30-40 % 11. hemodilution or massive blood loss ---An elevated WBC count commonly signals infection ---Increase monocytes count suggest infection URINALYSIS (Sept.mm 32-36 % 2-8 % 0. 15.12:oo midnight • #2 D5 0.2 1.5. 2008) Hematocrit Hemoglobin WBC MCHC Monocytes Basophils RESULT 32.1 % Clinical Implication: ---Low Hb concentration may indicate anemia. % 11.6 vol.34 35.000-10.7-14 g/dl 5. HEMATOLOGY (Sept.3 11. • Salbutamol (ventolin) neb i q 6° • Chest X-Ray today • • • To prevent dehydration Treatment for cough as bronchodilator For assessment of the lungs or affected part(s) DIAGNOSTIC EXAM The following are the laboratory exams as ordered by the patient’s attending physician. which can cause hemodilution. 15. ---Low HCT suggests anemia. or fluid retention.
PHYSIOLOGY AND PATHOPHYSIOLOGY Every time a breath is taken in.Transparency Odor Protein Glucose Cast Bacteria clear Aromatic Negative Negative None Not seen V. ANATOMY. the air (20% oxygen) passes through the nose or mouth and then past the larynx or voice box into the windpipe (trachea) .
they press the abdominal contents up against the diaphragm and help in expelling air from the lungs. they assist the diaphragm in drawing down the lungs as breathing in takes place.which is about 12. pass from blood into the air sacs and are expelled on breathing out. mainly carbon-dioxide. The diaphragm is a large dome-shaped muscle which separates the chest from the abdominal cavity. The normal rate of breathing at rest is 16–18 times a minute. This rate increases considerably with exertion and also with certain diseases. The main air passage in each lung (the bronchus) divides into successively smaller branches which carry inhaled air to all parts of the lung. The muscles of the abdomen also help in breathing. When the diaphragm muscle contracts. When they tighten up. Each small branch terminates by forming a cluster of very tiny air sacs (the alveoli). Each lung is covered by a lubricated lining called the pleura. PATHOPHYSIOLOGY . A fine network of blood vessels covers the surface of every air sac thereby permitting gas exchange by diffusion. Oxygen from the inspired air passes through the thin tissues to combine with the haemoglobin of the red blood cells. its dome becomes flattened and draws down the lungs. especially those affecting the heart and lungs. causing air to enter them. The act of breathing is mainly due to the diaphragm moving up and down. At its lower end the windpipe divides into two main tubes called bronchi. when they relax. The inner side of the chest wall is also covered by a similar lining. Waste gases.5 cm long. when it relaxes the lungs become smaller and the air in them is expelled. These two layers of pleura are in contact and slide smoothly over one another during breathing.
especially during expiration Airways collapse Air is trapped in the distal alveolar ventilation Abnormal ventilation Fall in PaO2 Increase levels of PaCO2 Body compensates for hypoxemia Polycythemia occurs VI.Impaired muscilliary defenses of the lung Increase susceptibility to infection Mucus production is greater Bronchial walls become thickened and inflamed Obstruct airways. NURSING ASSESSMENT (System Review Chart) EENT: [ ] Impaired vision [ ] blind [ ] pain redden [ ] drainage .
comfort [ x ] no problem GENITO – URINARY AND GYNE [ ] pain [ ] oliguria [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [x ] assess urine frequency. circ. speech [ x ] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechie [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] [x] no problem Body malaise Productive Skin warm to With ongoing D5 . pattern.3NaCl 500cc @ 40 cc/hr .. swallowing [ ] bowel sounds. control. sensation. breath sounds. rate. rate rhythm. blood pressure. bowel habits.[ ] gums [ ] hard of hearing [ ] deaf burning [ ] edema [ ] lesion teeth [ ] assess eyes ears nose [ ] throat for abnormality [x] no problem RESP: [ ] Asymmetric [ x ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ x ] wheezing [ ] pain [ ] cyanotic [ ] assess resp. gait. comfort [ ] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ]numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain [ ] Assess heart sounds. pulse. odor. coordination. rhythm. color. depth. function. LOC. strength [ ] grip. fluid retention. comfort [ x ] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain [ ] assess abdomen. comfort [ ] gyne bleeding [ ] discharge [ x ] no problem NEURO: [ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] treamors [ ] confused [ ] vision [ ] grip [ x ] assess motor.
Of health & illness: __alcohol _x_denied (amount. 2008 __ dentures Upper Lower Full ___ ___ partial ___ ___ _x_none with patient ___ ___ urinary frequency 7 times per day___ __urgency __dysuria __hematuria __ incontinence __ foley in place _ denied Comments: Bowel sounds: Bowel sounds are audible normoactive Abdominal distention present__yes_x_no Urine (color. 16. etc. . frequency) N/A_____________________________________ __ SBE last pap smear N/A__________________ LMP: N/A________________________________ Briefly describe the patient's ability to follow treatments (diet. Consistency) yellow in Color Mgt.SUBJECTIVE Communication: __ hearing loss __visual changes _x_denied Comments: “Wala man problema sa iya pandungog panlantaw”as verba lized by pt’s mother OBJECTIVE __glasses __languages __contact lens __hearing aide Pupil size: 3mm __speech difficulties Reaction Pupil equally round reactive to light and accomodation Resp. meds. odor.) for chronic health problems The patient has difficulty in taking the medications. RR: 58cpm Describe: expansion __regular abnormal and x irregular assymmetrical chest Oxygenation: Comments: “ga ubo2x man japon __dyspnea siya pero usahay na__smoking history lang” as verba None lized by pt’s mother _x cough __sputum __denied Circulation: __chest pain __leg pain __numbness of extremities _x denied Comments: “Wala man problema sa iya paa og dughan” as verbalized by the pt’s mother Heart rhythm __regular x_irregular Ankle edema: No edema seen Pulse Car + rad + DP + fem + R: Pulse are palpable L: Pulse are palpable Nutrition: Diet: Diet as tolerated for age _x_recent change Comments: “dili siya gakaon _x_swallowing difficulty og inom pud sa tambal”as __denied verbalized by pt’s mother Elimination: Usual bowel pattern __once daily __ __constipation remedy watery Date of last BM Sept.
Comments: “ dali raman siya __nocturia makatulog.6 kg daily weight __________ PT/OT_______________ __________BP q shift __________ Irradiation __________Neuro vs _normal___ Urine test ____________ __________CVP/SG reading_______ __________ 24 hour urine collection Date ordered 9/15/08 9/15/08 Diagnostic/lab exams date done Date ordered Hematology 9/15/08 9/15/08 Urinalysis 9/15/08 9/16/08 I.location.V/ blood D5 0.SUBJECTIVE OBJECTIVES Skin Integrity: __dry __itching __ other x denied Activity/safety: __convulsion __dizziness x limited motion of joints ability to __ambulate __bathe self __other x denied Comments: “init japon siya kay di man gakawala iyang hilanat.ulcers. drainage) there were no presence of rash LOC and orientation: patient is conscious Comments:”sige man siya pa kugos. IDEAL NURSING MANAGEMENT .3% NaCl Date disc. Kung ibutang Gait: __walker __cane __other mohilak” as verbalized by the __steady _x_unsteady pt’s mother __sensory and motor losses in face or extremities __ROM limitation: patient has limited range of motion Comfort/sleep/awake: __pain (location.decubitus (decribe size. 9/15/08 9/16/08 VII.” As verbalized by pt’s mother _x_dry __cold __pale __flushed _x_warm __moist __cyanotic rashes. grandparents and the patient. mother.”as verbalized sleep difficulties by the pt’s mother x denied Coping: Occupation: N/A Members of household: _5 – (father. Most supportive person: _Roseville (mother) __facial grimaces __guarding __other signs of pain: crying __siderail release form signed ( 60+ years) no side rails _ Observed non-verbal behavior : ______irritability_______________________ The person and his phone number that can be reached any time none SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) 7.3% NaCl D5 0.
Lowers diagphragm. noting areas of decreased/absent airflow and adventitious breath sound. aeration of lung segments. Crackles. change position frequently d. and wheezes are heard on inspiration and/or expiration in response to fluid accumulation. Aids in reduction of bronchospasm as well as mobilization of secretions. d. Decreased airflow occurs in areas consolidated with fluid. promoting chest expansion. rhonchi. shallow respirations and unsymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung. Tachypnea. IDEAL NURSING MANAGEMENT . c. crackles c. mobilization and expectoration of secretions. thick secretions and airway spasm/obstruction.Diagnosis #1: Ineffective Airway Clearance may be related to thickened mucus secretions as evidenced by tachypnea. Wheezes. Assess rate and depth of respirations and chest movement b. Facilitates liquefication and removal of secretions e. productive cough and shallow respiration Interventions: a. Administer medications as prescribed Rationale: a. Elevate head of bed. b. Assist with nebulizer treatments e. eg. Auscultate lung field.
These measures promote maximal inspiration IDEAL NURSING MANAGEMENT . Maintain bedrest e. Elevate head and encourage frequent position changes Rationale: a. Promotes a level of wellness. Prevents over exhaustion and reduces oxygen consumption/demands e. Manifestations are dependent on degree of lung involvement and underlying pulmonary/general health status b. Addition/removal of bedcovers. depth and ease. High fever greatly increases metabolic demands and oxygen consumption c. aids in faster recovery d. comfortable room temperature. use of accessory muscles b. Monitor body temperature c. tepid/cool water sponges d. Assess respiratory rate.Diagnosis #2: Impaired Gas Exchange related to cough and fever as evidenced by changes in rate and depth of respiration Intervention: a.
Assist with activities as needed e. Obtain subjective data from the patient regarding normal activities prior to onset of acute episodes of asthma and current activity status b. Conserves oxygen. IX. Helps to determine the effect asthma has had on the patient’sity to be active and allows for a better plan for future activity regimen. ACTUAL NURSING MANAGEMENT . Monitor vital signs and oxygen saturation before and after activity d. Conserves energy and reduces oxygen demand. e. Have patient use oxygen immediately prior to activity in the acute setting c. b. Improves oxygenation and provides for oxygen reserves to be used with increased demand. c. Use the results to indicate when activity may be increased or decreased.Diagnosis #3: Activity intolerance related to decreased pO2 and body malaise Intervention: a. Pace activities and encourage periods of rest and activity during the day Rationale: a. d.
Administered medications as prescribed At the end of 8 hours. Elevated head of bed. noting areas of decreased/absent airflow and adventitious breath sound. productive cough and shallow respiration. Auscultate lung field. I crackles c. Assessed rate and depth of respirations and chest movement b. Assisted with nebulizer treatments e. client will be able to demonstrate reduction of congestion with breath sounds clear. clients’ breath sound was clear and E was able to expectorate mucous. Wheezes. . change position frequently d. productive cough. and shallow respiration A Ineffective Airway Clearance may be related to thickened mucus secretions as evidenced by tachypnea. At the end of 30 mins. eg. P a.S O “dili pa gakawala iyang ubo” as verbalized by the mother tachypnea.
client is able to demonstrate improved E ventilation and oxygenation. client will be able to display improved P breathing pattern a.” as verbalized by the pt’s mother O tachycardia. cough. Administered medications as prescribed (eg. expectorants) d. . Brochodilators. shallow respiration Impaired Gas Exchange related to cough and fever as A evidenced by changes in rate and depth of respiration At the end of 30 mins. Elevated head using pillows b. Changed position frequently I c.S “galisod siya usahay og ginhawa mao nang d nko ehigda sa higdaanan. Encouraged adequate rest At the end of 30 mins. and pallor skin.
d pareho sauna nga magdula-dula” as verbalized by the pt’s mother Wheezing during activities Gasp for breath during activities O Activity intolerance related to decreased pO2 A P At the end of 30 mins. Assisted with activities as needed e. X. client is able to state that he is I E comfortable with activity performance. Obtained subjective data from the patient regarding normal activities prior to onset of acute episodes of asthma and current activity status b.S “galuya pa siya. a. client is able to perform activities of daily living without wheezing or shortness of breath. Has patient use oxygen immediately prior to activity in the acute setting c. EVALUATION/IMPLICATION . Monitored vital signs and oxygen saturation before and after activity d. Paced activities and encourage periods of rest and activity during the day At the end of 8 hours.
Pillitteri. my goal was achieved as evidenced by the desire of the patient to go back to his normal daily routine and from the progress of the patient. Philippines: Lippincott. Inc. From the initiation of nursing and medical interventions the client showed some signs of recuperation and gradually showed signs of progress. 1999. The client’s mother was cooperative enough to stay at the hospital premises and never refuses to go home until the child is not stable. alleviate distress. Erb.al. Williams & Wilkins. BIBLIOGRAPHY Kozier. Adelle. From this. Doenges. Nursing Care Plans: Guidelines for Planning Patient Care 2ndEd. Wilkinson.1998. prevent further complications and help the patient to recover as well as to encourage the patient and the significant others to participate in the therapy. Maternal and Child Health Nursing (3rd Edition). XI. . REFERRALS The patient significant other is advice to take his home medication and after 1 week the physician note that any improvement in the clients condition and be back for follow up check up. Marilyn et. XII. Fundamentals of Nursing (7th Edition). Blais. This was evidence form the complete bed rest up to the condition she was given the chance to ambulate gradually as tolerated.The mainstay of nursing and medical treatment with the patient having with such condition is to help the patient to cope. Philippines: Addison Wesley Longman Inc.
improves ventilation Specific Indication Bronchospam in patient’s with reversible obstructive airway disease Contraindication To patient’s hypersensitive to the drug and its components Side Effects Nursing Precaution Effects/Toxic Tremor. palpitations. 2008 Bronchodilator 1 neb/ q6h / steam inhalation Relaxes bronchial smooth muscle by acting on beta2adrenergic receptors. may relieve fever by acting in hypothalamic heat regulating center Specific Indication For mild pain and fever . by inhibiting prostaglandins or pain receptors sensitizers. irritation Perform chest tapping every after nebulization Salbutamol Sulfate Generic Name of ordered drug Brand Name Date Ordered Classification Dose/Frequency/Route Mechanism of Action Paracetamol syrup Two weeks PTA admission Non-opioid analgesic.antipyretic 5ml q 4 hours Per Orem Produces analgesic effect by blocking pain impulses.DRUG STUDY Generic Name of ordered drug Brand Name Date Ordered Classification Dose/Frequency/Route Mechanism of Action Ventolin September 16. tachycardia. nausea and vomiting.
renal calculi Report signs of F/E imbalance Nursing Precaution Generic Name of ordered drug Brand Name Date Ordered Classification Dose/Frequency/Route Mechanism of Action Cefuroxime Sodium Zinacef September 15. tachycardia. nausea and vomiting. rash. aplastic anemia. adrenal gland failure’ Side Effects hypechloremic acidosis Effects/Toxic Confusion. hypokalemia. . hyponatremia.Contraindication To patient’s going long-term therapy for chronic noncongestive angle-closure glaucoma. irritation Take full course of therapy even if you are feeling better. pnuemoniae Contraindicated with allergy to cephalosporins Effects/Toxic Tremor. 2008 Antibiotic 200mg IVT q 8 hours (ANST -) Bactericidal: inhibits the synthesis of bacterial cell wal causing cell death Specific Indication Contraindication Side Effects Nursing Precaution Lower respiratory infections caused by s. anorexia. hepatic impairment. palpitations.
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