Intestinal

Parasitism
with Erratic
Migration ;
Pneumonia

A
Grandcase
presentation

Presented
by :

BSN 3 - A

General Objective:
Within 4 hours of General Case
Presentation, we will be able to convey
an accurate picture of a 2 year old
pediatric
client
diagnosed
with
Intestinal Parasitism with Erratic
Migration;
Pneumonia,
and
the
corresponding
medical-surgical
management and nursing interventions
for
identified
priority
nursing

Specific Objectives:
1.To
provide
comprehensive
information
regarding the medical diagnosis.
2.To present the nursing history, which is
reflective of the client’s background data
e.g. baseline, present history of illness,
past medical history, lifestyle, nutrition,
and socioeconomic status.
3.To justify physical assessment findings as
manifestations of the disease process
4.To correlate laboratory tests or diagnostic
studies done with corresponding medical-

5.To
present
administered
medications
throughout the course of the therapy and
their corresponding drug actions.
6.To present the pathophysiology of the
disease process through comparison with
the normal anatomy and physiology of
involved body systems.
7.To identify priority nursing diagnoses based
on defining cues.
8.To identify nursing interventions appropriate
for each respective nursing diagnosis.
9.To evaluate the effectiveness of the nursing

10. To provide an in depth rationalization of
suggested activities of daily living,
nutrition, personal hygiene, medications,
special treatments, and follow up visits
with the prepared discharge plan.

Spot
Map

Legend:
Client’s House
Household
Tree
Car
Main Road

Legend:
Client’s House

Bridge
Ricefield

Household
Tree
Car
Main Road

Jaro Plaza

LHS

Jaro Plaza
Land Heights Subd
Track

LHS

Jaro Plaza

Brgy.
Balabago,
Jaro,
Iloilo City

Nursing
Health
History

Biographic Data
Name: A.D.
Age: 2 years old
Sex: Female
Address: Zone 4 Balabago, Jaro,
Iloilo City
Date of Birth: May 7, 2006
Nationality: Filipino
Religion: Roman Catholic

Date of admission: November 5, 2008
Time of Admission: 10:00 pm
Attending physician: Dr. J.B.
Chief complaint: Vomiting and
abdominal pain
Diagnosis: Intestinal parasitism with
erratic migration; pneumonia

Prenatal History

Mrs. R.A.D. had her first menstruation
when she was 12 years old. She has a regular
menstrual cycle with an average of 28 days. She
can consume 3-4 pads a day but she prefers not
to use a sanitary napkin because she feels more
comfortable when her menstruation drains or
flows out directly. On August 31,2005, she
noticed that her menses was delayed. She was
23 years old when she got pregnant on her third
baby. On her first month of pregnancy, she
experienced nausea and vomiting upon waking up
in the morning. She also had cravings for

She slept more frequent and longer than the
usual sleeping habit. When R.A.D was pregnant,
she would sleep at 8pm and wake up at 7am.
What she experienced what not that unusual to
her because it is her third time to be pregnant.

She had two prenatal check-ups, first when
she was three months pregnant and the second
was when she was five months pregnant. Both
check-ups were done in their health center
facilitated by the midwife. As relayed to her by
the midwife, the baby was in cephalic
presentation and in good condition. She did not
have a shot of tetanus toxoid during her prenatal
visits. She received tetanus toxoid injection when
she was about to deliver her baby in the hospital
which is the same with her past pregnancies. The
doctor in the health center prescribed ferrous
sulfate 325mg per capsule daily because she was

She consumed a total of 1 stub containing
10 capsules taken irregularly.
She had not experienced any serious illness
or complication on her pregnancy except for
fever which lasted for 1 day when she was 4
months pregnant. She said she felt warm and
hot. She also had cough and runny nose when
she was 6 months pregnant and lasted for a
week. She did not take any medicines to remedy
the above mentioned rather she drank more
water.

Natal History
Mrs. R.A.D. delivered her baby at
Western
Visayas
Medical
Center,
Mandurriao, Iloilo City facilitated by the
resident doctor on duty (name not recalled)
on May 7, 2006 at about 8 am. The baby
was delivered in a Normal Spontaneous
Vaginal
Delivery
(NSVD)
in
cephalic
presentation after the bag of water has
ruptured. She had difficulty in delivering
the baby but there was no complications

Neonatal History
After delivery, baby A.D. is
pinkish in color and covered with
minimal amount of whitish cheesy
substance (vernix caseosa). She also
noticed the fine downy hairs sparsely
distributed on the neonate’s body.
She weighed 6.2 lbs. while the length
could not be recalled by the mother.
The
baby
cried
loudly
and

Postnatal History
Due to exhaustion, she fell asleep after
giving birth. The baby had good sucking
reflex during breastfeeding. The vernix
caseosa gradually diminished as they bathe
the baby. They also noticed the bluish spots
on her right buttocks and right thigh
(mongolian spots). As relayed by the mother,
the baby first defecated 12 hours after
delivery. The stool (meconium) was greenish
and minimal in amount. They stayed in the
hospital for one day. Mrs. RAD was happy

Nutritional History
The mother started to breastfeed her baby
right after giving birth until one and a half year
old. She breastfed her baby 8-10 times a day.
She has not bottlefed her child with any other
milk products. She started to give “su-am” or
rice am, about 150 ml per feeding, when A.D.
was 6 months old. She can consume 5-6 bottles
of it daily. At 5 months, A.D. started to eat
soft foods like lugaw or porridge and mashed
banana. At 1 and a half years old, she noticed
her child eating more frequently. At same age,

The mother prepares their food but
sometimes they would buy cooked food in the
market. A.D. has her own serving of food
eats 3 times a day. Her usual diet includes:
rice, powdered milk and adobong kangkong for
breakfast. For lunch, rice, laswa and an 9ounce softdrink, and for dinner, they would
eat egg, dried fish and rice. A.D. also likes to
eat cheese curls, lollipop and drink mountain
dew. Her food preference is “utan” and fried
chicken. The family’s usual food is “utan” and
rice. She could drink as much as 12 glasses of

Her mother supplements A.D. with tiki-tiki
0.6ml once a day at 2 months old, but they
stopped giving it when they noticed that A.D.
was gaining weight by about 3 months old.

Growth and Development
A.D. has a birth weight of 6.2 lbs and
currently she weighs 10 lbs and stands 81 cm.
In terms of her developmental milestone, during
the first 2 months, A.D. was exhibiting the
following reflexes like grasp reflex and moro
reflex. At 5 months, her first 2 lower incisors
erupted and for the following month, her 2 upper
incisors erupted. During her 6th month, she
began to crawl. At 7th month, she started to
speak her first words like “aa” and “baba”. Also,
during this month, she was able to sit alone
without support and by 11 months, she was able

With regards to her elimination pattern, she
tells her mother that she wanted to urinate or
defecate and this started when she was at her 1
year and 3 months of age. However, until now,
she is unable to defecate or urinate by herself
and she still asks her mother to accompany her.
Due to her separation anxiety, she is scared
when left with someone she doesn’t know or not
acquainted to. Currently, she can utter 4-6
words in a sentence. She loves to play
housekeeping toys plastic cooking utensils. When
she is playing, most of the time her mother
caught her eating leaves and places her dirty

Social Condition
 
The client lives in a rural area within a
family compound. The family is of nuclear type,
composed of the father, mother, and their four
children (1 son which is the eldest and 3
daughters). Her parents were married through a
civil wedding. At that time, R.A.D. was 18 years
old and pregnant to their eldest child and R.D. was
20 years old. Their house is attached to A.D.’s
grandparents’ house. It is made of “amakan”,
plywood and galvanized iron with a dirty floor. It
measures approximately 3 meters by 2 meters and
2 meters high. It is 4 meters apart from other

They sourced out their water used for
drinking and cooking from a jetmatic pump situated
almost 2 meters right in front of their house. It
is connected to a deep well 20 meters away from
their house. The well is chlorinated but not
routinely examined. They then store the water in
a covered blue container right there in the
jetmaticpump. Next to their source of water is a
muddy canal filled with black, foul smelling muck.
They do not boil the water they use for drinking.
Their food preparation includes washing of cooking
utensils, raw vegetables, and meat with tap water.
Their toilet is classified as an antipolo type, with

They burn their garbage including dry leaves,
waste and plastic materials 10 meters away
from their house everyday and sells used bottles
and cans.
R.D. has finished his 2nd year in high
school at Balasan National High School. He
works as a driver of a track that is used in the
delivery
of
candies,
automobiles
for
transportation and earns 3000 php a month
utilized for their daily needs.
His income is not enough for their daily
expenses so they would sometimes ask R.D.’s
aunt who is a elementary public teacher for

R.A.D. is an elementary graduate of
Balabago Elementary School at Jaro, Iloilo City
and a housewife. Their eldest child is 6 years
old and currently in kinder 2. Second child is 5
years old, while the third (A.D) and fourth child
is 2 and 1 year old respectively. They do not
own the land where they live and rents for it for
10php per month. They are in good terms with
their neighbors who are also their relatives.
A.D. usually sleeps at 8:00 in the evening and
wakes up at 6:00 in the morning.
A.D.
sometimes takes a nap for 3 hours or spends the
whole afternoon playing with her playmates

A.D. sometimes joins her grandfather in
drinking coffee for breakfast. They do not have
electricity at home for almost 1 year already
because they lack money to pay their electric
bill instead, they use oil lamp.
A.D. would
sometimes watch television in their neighbor’s
house.
They do not hear Sunday mass regularly
but they would usually attend the weekly service
at the chapel presided by a Baptist pastor
every Sunday at 2 to 4 o’clock in the afternoon.
If they would go to church, they usually go to

History of Present Illness
On November 3, 2008, Monday, 3 pm, BHW
of the health center presented a scored tablet to
the mother as a dewormingmedicine.
Specific
name of the drug was not mentioned by the BHW
as verbalized by the mother. Knowing that her
child has intestinal parasites, R.A.D. allowed the
BHW to administer the tablet to A.D. At 10 pm,
the child woke up and cried complaining itchiness
on her throat as if something was moving. The
mother soothed her child’s throat by rubbing the
neck.

“Deworming
tablet”
presented
and given by
the BHW to
the mother

The next day at 1 am, A.D. vomited
approximately 3 cups of vomitusconsisting of the
her previous meal which includes rice and fish.
She vomited twice until 2 am. After which she
fell asleep and woke up at 7 am. Several minutes
after eating lugaw for breakfast, she vomited
again of approximately 3 cups of vomitus. The
vomitus is greenish in color with 5-6 cylindrical,
glistening, whitish worms about 5 cm in length.
Her father, R.D. gave lugaw again to A.D. but
she only ate 3 tablespoons of it.

non-specific abdominal pain. Pain subsided after
several minutes. They observed body malaise,
A.D. rested and slept. She did not take her
pale and dryness of lips. Her mother continued
lunch so her father prepared hydrite solution
to give her hydrite solution. By 7 pm, she ate
(Oresol) and let her child drink. R.D. diluted 1
lugaw again. By 8:30, A.D. she defecated soft,
tablet of hydrite to a pitcher of water about 1
brownish stool with 5-6 worms.
liter. She only consumed ½ pitcher about 500
ml. By 2 pm, A.D. complained of non specific
November 5, 2008 (Wednesday)
abdominal pain. The pain subsided after several
Mr. R.D. gave again A.D. hydrite solution
minutes. They observed body malaise, pale skin
(Oresol) but consumed only ½ liter (500 ml). At 8
and dryness of lips. Her parents continued to
am Mrs. R.A.D. cooked lugaw but A.D. refused
give hydrite solution. By 7 pm, she ate “lugaw”.
to eat. She has no appetite to eat any food, so
By 8:30pm, A.D. defecated soft, brownish
they just continue to give hydrite. By nighttime,
stool, with 5-6 worms.
about 8:30 pm, they brought A.D. to her

On November 5, 2008, Mr. R.D. prepared
again hydrite solution (Oresol) 1 liter but she
only consumed 1 glass of it. At 8 am, Mrs.
R.A.D cooked “lugaw” but A.D. refused to eat.
She has no appetite to any food, so they just
continued to give hydrite. By night time about
8:30 pm, A.D vomited again about 4 cups and
with a bolus of worms. They were so alarmed so
they brought her immediately to WVMC
emergency department. They arrived to the
hospital at 9 pm and admitted at 10 pm.
A.D. arrived at the WVMC emergency
department, cuddled by father with a chief

She was diagnosed with acute gastroenteritis
with severe dehydration and intestinal
parasitism with erratic migration. An IVF of D5
0.3 NaCl 500cc x 62 cc/hr was inserted at
right metacarpal vein.
Dr. B ordered administration of Ampicillin
250 mg IVTT q6h ANST and laboratory tests
such as urinalysis, Fecalysis, Chest x-ray,
Hematolgy and Serum Na and K.

Family Medical History
 
The heredo-familial diseases on the client’s
paternal side are hypertension, diabetes mellitus,
and heart disease. Her father’s uncle died due
to diabetes mellitus at the age of 42 years old.
At the age of 75, her grandmother died because
of hypertension. Mr. R.D.’s father died at the
age of 54 due to heart disease. No other
immediate family member died of disease or its
complication.
On Mrs. R.A.D.’s side, they do not have any
heredo-familial disease.

Past Medical History
A.D has completed her immunizations however,
the mother could not recall the specific vaccines
given. Her yellow card was lost during the typhoon
Frank. She has a scar on her right deltoid showing
the possibility that she had received BCG vaccine.
She has experienced usual sickness like fever,
cough and colds which usually lasted for not more
than one week. Mrs. R.A.D. would give A.D. overthe-counter drugs like 1 tablespoon of Calpol every
6 hours for fever and perform tepid sponge bath.
She has no known allergies such as to food or
animal dander and other environmental agents. A.D.

She was hospitalized once prior to her present
confinement last April 2007 due to pneumonia
as relayed by the mother. A.D. experienced
itching of her throat, rapid breathing, and
vomiting. She vomited almost half the meal
she took with 3-4 whitish, long, cylindrical
glistening worms. She was brought to the
Western Visayas Medical Center (WVMC)
Mandurriao, Iloilo and was admitted for 2
weeks. She received antibiotic therapy and
IVF therapy, but Mrs. R.A.D. nor Mr. R.D.
could not recall any specific medication given
to their child.

Physical
Assessment

Pre- Physical
Assessment
Date Performed:
November 6, 2008

General survey
Generally weak, lying in crib, Height is 82.5
cm, and weighs 10 kilograms, malnourished, body
mass index of 14.69, irritable, coordinated
movement, animated facial expressions, foul body
odor, no halitosis noted, pale, cooperative, strong
voice when crying, poor appetite. Temperature is
37.7 oC per axilla, slightly febrile cardiac rate of
110 beats per minute, respiratory rate of 22
breaths per minute, and blood pressure of 90/70
mmHg. With IVF of D50.3NaCl 500 cc x 62
mgtts/min at the level of 125 cc inserted at the

Skin
Brown in color, generally uniform except for
the palms, soles and lips, which are pale. Body
hair is thin and evenly distributed. Moisture
noted on the forehead, axilla, and back but
generally dry With profuse sweating noted, no
edema noted, rough in texture, has various
interruptions in skin integrity such as scar,
crusts, ulcerations noted, particularly on the
lower and upper extremities, presence of white
spots on the forehead, vary in size. Scar noted
below the left elbow, on the lateral portion and
central portion of the right knee, on the

above the right ankle characterized by redness,
presence of pus, and formation of hard brown
scabs at the periphery, bluish discoloration
noted at the anterior portion of the buttocks
and left gluteus medius (Mongolian spot),
numerous pinpoint sized lesion characterized by
redness, inflammation and pus formation at the
soles of the feet. Skin temperature uniform all
over the body and warm to touch, poor skin
turgor since skin springs back to previous state
for 5 seconds.

Nails
Convex curvature, pale pink in color, smooth in
texture, pus noted on the nail root of the right
thumb, tissues surrounding other nails are intact,
nails untrimmed and dirty, good capillary refill,
returns to original color after 2 seconds
Head
Normocephalic and symmetrical with frontal,
parietal, and occipital prominences, smooth skull
contour 37.5 cm in circumference, scalp same color
as the facial skin, no flakes or infestation, hair
brownish in color, short, thin, dry, straight and
evenly distributed, facial features symmetrical,
palpebral fissures equal in size, symmetrical

Eyes
Eyebrows symmetrically aligned and evenly
distributed, eyelashes slightly curved outward,
eyelids intact and close symmetrically, no
excessive
blinking,
palpebral
and
bulbar
conjunctiva pale, slightly sunken eyeballs, sclera is
anicteric with presence of pinpoint sized macule,
dark brown in color at the right sclera. Cornea is
shiny and smooth. Pupils black in color, equal in
size (approximately 2 mm) and both reactive to
light and accommodation, can see objects at the
periphery, both eyes moves in unison, no
periorbital edema or tenderness over the lacrimal

Ears
Same color as the facial skin, symmetrical and
aligned with the outer cantus of the eye. Hair
follicles noted in the ear canal, presence of dry and
yellowish cerumen in both ears, scant in amount.
Auricles recoils immediately after it is folded, no
tenderness noted. Normal voice tones audible at 5
meters, whispered words audible at the range of 6
inches.

Nose and sinuses

External nose straight and symmetrical, presence
of clear watery nasal discharge, scant in amount,
uniform in color, non tender and no lesions noted. Both
nares patent, nasal mucosa pinkish in color, nasal

Mouth and Oropharynx
Lips has symmetrical contour, pale pink in color,
soft, dry, and smooth in texture. Able to purse lips,
facial nerve intact. Inner lips and mucosa uniform pink in
color, moist, smooth, glistening and elastic in texture,
with 20 sets of teeth, yellowish in color, 4 upper incisors
noted with presence of dental carries, gums pinkish, moist
and firm, tongue is in central position, no lesions, moist,
appears rough and with thin whitish coating at the
surface. Papillae raised, tongue moves freely base of the
tongue smooth. Soft palate is smooth and light pink in
color. Hard palate lighter pink in color and has irregular
texture. Uvula positioned at the midline, oropharynx
pinkish and uniform in color. Tonsils pinkish and smooth,
no discharge and of normal size. Gag reflex present,

Neck

Neck muscles equal in size, head centered, head
movement coordinated, with no discomfort, head flexes,
hyperextends, flexes laterally and rotates laterally, lymph
nodes not palpable, trachea placed at the midline of the
neck. Thyroid isthmus rises when client swallow, thyroid
gland not visible on inspection, smooth, nontender
nonenlarge, lobes of thyroid gland cannot be palpated,
jugular veins not visible, carotid pulse palpable.

Chest

Chest and breasts are symmetrical, color is lighter than
the extremities, and areolas are darker on breasts, no lumps
and masses noted on the breast and axilla upon palpation. With
normal breath sounds heard upon auscultation all over lung fields,
respiratory rate of 22 breathes per minute, not labored, tactile

Heart
Apical pulse present on the 5th intercostals
space midclavicular line. Dullness heard upon
percussion, heart sounds heard on cardiac
landmarks, no thrills and murmurs heard upon
auscultation, Cardiac rate of 110 beats per
minute, rhythm is regular.
 

Back
No redness, no mass and swelling, no bone
deformity, spine and posture is straight,
thoracic expansion is symmetrical, tactile

Abdomen
Protuberant, distended, with circumference
of 53 cm, umbilicus not bulging, presence of
lesion with diameter of 0.5 cm below the right
rib. Presence of normoactive bowel sounds heard
at the right lower quadrant at 12 cycles per
minute, dullness heard on the right upper
quadrant, no pain upon palpation.

Genitals
No unusual discharges, Perineum is intact,
rashes characterized by redness at the anal
opening, Pruritus ani. Wound marks are also

The right and left inguinal lymph nodes
palpable approximately 0.6 cm in diameter.
Defecates 2 times a day to a yellowish, mucoid
stool, with visible ascaris of 4-7 worms. And
voids approximately 7 times a day with light
yellow urine, approximately 100 cc in amount per
voiding.

Extremities
Upper extremities
Numerous skin lesions noted on arms,
shoulder, elbow, wrist and fingers, has full range
of motion, with quick capillary refill within 2

Lower extremities
Presence of lesions distributed all over the
legs and thigh, varicosities are absent in both
feet. Knees and ankles have full range of motion.
Knees can flex as well as the ankle. Both can
rotate without pain, toes can abduct and hyper
extend. Popliteal, Dorsalis pedis, Posterior tibial
pulses present.

Anatomy of
Digestive
System

Anatomy of
Respiratory
System

Pathophysiology

Intestinal Parasitism with Erratic
Migration; Pneumonia
Predisposing Factor

vAge
(Children are more prone to acquire
the disease)

Precipitating Factors

vPoor hygiene
vImproper food preparations
vEnvironment

Ascarid eggs swallowed from contaminated raw
fruits or vegetables and soiled hands
Eggs pass through the stomach and arrive in the duodenum

Becomes a larvae after 18 days; depending on the
environmental condition

Larvae burrow through
n of the bowel, abdominal discomfort intestinal lining and into the
tissue underneath

Invades the blood vessels and
carried in the blood stream

Liver

Heart

Hepatic damage (hepatitis)

Lungs
Larvae matures for 10-14 days

Larvae penetrates alveolar walls

Minimal hemorrhage, hemoptysis

Inflammatory response

Accumulation of fluids in the lungs

Ascaris
Pneumonia

Edema, crackles

After maturing in the lungs, it ascends to the tracheobronchial tree

Pharynx
Coughed up/swallowed into the esophagus
s, distention, abdominal cramping

Stomach

Small Intestine (grow and develop into mature worms)

Intestinal obstruction

Adult worms mature and mate

Female adult lays eggs and go with the stools. Stool
becomes contaminated with Ascarid eggs

MedicalSurgical

Interventions

MEDICAL MANAGEMENT
LABORATORIES
• Laboratory examinations were ordered to
determine the cause of the disease. This
includes fecalysis, urinalysis, hematology and
blood chemistry. The physician ordered for
the request of Serum Sodium and Potassium
to determine if the electrolyte level is below
normal.

FECALYSIS
Fecalysis is also known as stool
analysis. It refers to a series of laboratory
tests done on fecal samples to analyze the
condition of a person's digestive tract in
general. It is also performed to check for
parasites, the presence of any reducing
substances such as white blood cells (WBCs),
sugars, or bile and signs of poor absorption.
This is done on the client to help the doctor
determine the presence of intestinal parasite
through microscopic examination.

URINALYSIS
Urinalysis is a diagnostic physical,
chemical, and microscopic examination of a
urine sample (specimen). It is done on the
client to determine various properties (color,
specific gravity, ph, glucose, etc.) and
abnormal constituents as seen under a
microscope.

HEMATOLOGY
Hematology is the study of blood and its
disorders. Hematologists, board-certified
internists,
look
specifically
at
blood
components such as blood count, and blood

This tests can help diagnose anemia.
Common hematological test includes white
blood cell count, red blood cell count,
platelet count, hematocrit red blood cell
volume, and hemoglobin concentration. A
blood test that shows you have an increased
number of a certain type of white blood cell
(eosinophils) may indicate the presence of an
intestinal parasite.

BLOOD CHEMISTRY
Blood chemistry measures the levels of a
number of chemical substances that are

The amounts of these chemicals in the blood
may reflect abnormalities in the tissues
secreting them. On the client’s case, the serum
sodium and serum potassium is measured to
determine possible dehydration.

Chest X-Ray
It is a projection radiograph of the thorax
which is used to diagnose problems with that
area. A chest x-ray may be ordered when a
person's symptoms include a persistent cough,
coughing up blood, chest pain, a chest injury, or
difficulty in breathing. The test is also used when
tuberculosis, lung cancer, or other chest or lung

INTRAVEOUS FLUID THERAPY
• The doctor ordered IV fluids such as D5 0.3
NaCl 500cc to run at 62-63 cc/hr or 15-16
gtts/min x 6 hours, then the next day it was
D5 0.3 NaCl 500cc + 10 mEqs of KCl at 6263 cc/hr x 8 hours. In case of Gastrointestinal loss, the doctor ordered to replace
it
volume/volume
of
PLNSS
to
avoid
dehydration.

This is usually ordered by the physician
to maintain or replace body stores of water,
electrolytes, vitamins, protein, calories, and
nitrogen in the client who cannot maintain
adequate intake by mouth, restore acid base
balance, replenish blood volume and provide
avenues for keeping the vein open for easy
administration of drugs whenever the condition
becomes severe or the client cannot able to
take medications orally, it is given through IV
for the medications to take effect as rapidly as
possible.

1.D5 0.3 NaCl 500cc x 62-63 cc/hr
D5 0.3% NaCl is typically the
choice for maintenance fluid for pedia
patients. Dextrose and sodium chloride
solutions are used as sources of
electrolytes, calories and water for
hydration. Sodium and chloride ions are
responsible for regulating the acidbase balance of the body.

Dextrose is a source of calories. It is
readily
metabolized
and
helps
to
decrease losses of body protein and
nitrogen. It also promotes glycogen
deposition and decreases or prevents
ketosis.
2.D5 0.3 NaCl + 10 mEq KCl x 62-63
cc/hr
Potassium chloride is used in the
treatment of hypokalemia and associated

3.D5 IMB (hypertonic solution) 500 cc x 4142 cc/hr
Hypertonic solution has higher osmotic
pressure than that of plasma drawing fluid into
the cell. It is also used in repairing electrolyte
and acid/base imbalances, and also include total
and partial parenteral nutrition solutions.
4. Plain NSS
It is an effective method of supplying fluids
directly into the intravenous compartments. It

MEDICATIONS
•For the medications, the doctor ordered for
Ampicillin 250 mg IVTT q6h and a go home
medication which is the Cotrimoxazole 80
mg/5ml to prevent infection.
NUTRITIONAL SUPPORT
•For the nutrition of the client, the doctor
ordered Diet as Tolerated with Strict Aspiration
Precaution to maintain the nourishment of the
client and to prevent aspiration pneumonia.

Nutritional Support provides necessary
energy needed for cell metabolism; protein helps
repair worn out tissues, vitamins and minerals
necessary for transmission of neuromuscular
activity, prevents vitamin D deficiency disease,
cell metabolism and oxidation.
A strict aspiration precaution means that
the doctors feel this patient is at risk for some
medical reason, of this happening and feeding
would be limited and watched. It means the
person is at a big risk of throwing up and it
getting into their lungs which can cause

Nursing Management
v When the client was admitted, the nurse
administered D5 0.3 NaCl 500 cc + 10
mEq
KCl x 62-63 cc/hr as ordered
v Vital signs were checked every 4 hours.
v Careful intake and output monitoring for the
client was done.
v Stool and vomiting count was made and a
sheet was placed on the bedside.
v Ordered medications were given.
v After 3 days, the IVF was changed to D5
IMB regulated at 41-42 cc/hr as ordered.

v Health Teachings was given to the folks to
create awareness about the disease and to
prevent reinfection. Proper handwashing of
hands before and after eating was
emphasized.

Laboratory
Results and
Diagnostic
Tests

URINALYSIS
Definition: Urinalysis is a diagnostic test

used as screening because it can help
detect substances or cellular material in
the urine associated with different
metabolic and kidney disorders. It is
ordered widely and routinely to detect
any abnormalities that should be followed
upon.

Preparation:

The specimen can be

collected anytime of the day. Collect
midstream clean catch urine specimen
in a clean, dry, wide mouth plastic cup
or container. Collected specimen must
not be less than 30ml. Bring it to the
laboratory
immediately
after
collection. Label the specimen cup with
the client’s name, and ward/room
number.

Physical
Properties
Color

Result

Normal Values Significance

Pale
straw

Pale straw

Normal

Transparency Slightly Clear to
Normal
hazy
slightly hazy
Reaction
Acidic Acidic
Normal
Specific
Gravity

1.012

1.010-1.025 Normal

Result
Chemical
test
Sugar
Protein

Normal Values Significance

Negative Absence of
sugar

Normal

Negative Absence of
protein

Normal

Result

Normal
Values

Significance

RBC

0-1

Very
occasional

Normal

Pus

0-1

None

Cast

None

None

Indicates early
infection in the
genitourinary
tract
Normal

Normal
Crystal

Few

None to few

Normal

Microscopic

Result

Normal
Values

Significance

Squamous
Few
epithelial cells

few

Normal

Round
None
epithelial cells

None

Normal

Bacteria

None to
few

Normal; presence of
few bacteria may be
possible due to
improper handling of
specimen and dirty
container.

Microscopic

Few

Result

Normal
Values

Mucous
threads

None

None to few Normal

Yeast cells

None

None

Normal

Parasite

None

None

normal

Microscopic

Significance

Interpretation: From the results of the
urinalysis indicated above, AD does not
suffer from any urinary tract or renal
disorder. There is a very slight deviation
from the normal values as in the presence of
few bacteria which is due to improper
handling of specimen.

FECALYSIS (Direct fecal smear)
Name: A.D

Received: 11-6-08

Age: 2 y.o

Ward/Room No.: Pedia Apex

Sex: Female

Lab No.: 2-7

Requesting Physician: Dr. B.

Definition: Stool analysis is used to determine
the various constituents of the stool for
diagnostic purposes such as diseases of the
gastrointestinal tract. It is done to make
adequate, gross and microscopic examination.

Purpose: Its purposes are to detect the

presence of parasites and identify certain
types of bacteria that can cause disease. It
determines the cause of symptoms affecting
the digestive tract, including prolonged
diarrhea, bloody diarrhea, an increased
amount of gas, nausea, vomiting, loss of
appetite, bloating, abdominal pain and
cramping, and fever.

Preparation:

The specimen can be collected
anytime of the day. Place the fecal matter
in a clean, dry, wide mouth plastic cup or
container. The fecal specimen must be at
least the size of the thumb. Bring it to the
laboratory immediately after collection,
preferably one hour after defecating. Label
the specimen cup with the client’s name, and
ward/room number.

Result

Normal Values Significance

Physical
Properties
Color

Brown

Brown

Normal; due to
bacterial
degradation of
bile pigments
to stercobilin.

Consistency

Mucoid

Soft; Formed

Abnormal; due
to increased
gastric motility
and presence
of bacteria

MICROSCOPIC Result
EXAM

Normal
Values

Significance

Ascaris
lumbricoides

More than none
12
ova/slide

Indicates
intestinal
parasitism;
ascariasis

Hookworm

none

none

Normal

Trichuris
trichiura

0-1
ova/slide

none

Intestinal
parasitism;
trichuriasis

Trichomonas
hominis

few

none

Indicates intestinal
parasitism

Entamoeba
coli

5 ova/slide

none

Entamoeba
histolytica

More than 12
cyst/slide

none

RBC

2-4/hpf

none

Pus cells

0-1/hpf

none

Indicates intestinal
parasitism;
amoebiasis
Indicates intestinal
parasitism;
amoebiasis
Increased; due to
GI tract
inflammation
Presence indicates
bacterial infection

Ascaris
lumbricoides

Trichuris trichura

Trichomonas hominis

Entamoeba coli

Entamoeba histolytica

Interpretation: From the results of stool
analysis indicated above, it showed that
A.D. experiences severe intestinal parasitism
with the presence of the following parasites
and
helminthes:
ascaris
lumbricoides,
trichuris trichiura, trichomonas hominis.
Results also showed intestinal amoebiasis due
to the presence of Entamoeba hystolytica.
Because of the reaction to bacterial
infection, it ensued to an increased level of
RBC and WBC.

ROENTGENOLOGICAL REPORT
Case No: 19596-cj
Date: 11-5-2008
Name: D. A.
Age: 2 y.o.
Examination: Chest APL
Sex: Female
Department: APEX
Requesting Physician: Dr. B.

Findings:
Chest APL shows parachilar and peribronchial
haziness.
Heart is not enlarged.
Trachea is at midline.
Hemidiaphragm and costrophrenic angles

IMPRESSION:
Parachilar and peribronchial inflammatory
process, non-specific. Ileus.
SIGNIFICANCE:
Parachilar and peribronchial inflammation
was noted on the client’s result. Parachilar
and peribronchial haziness or cuffing which
may indicate pleural effusion.

BLOOD CHEMISTRY
Name: A. D.
C.S.: Single
Ward: Pedia Apex
Age: 2
Examinationdesired: Na+, K+ Sex: Female
Physician: Dr. R. B.
Date:11-07-08
HospitalNo: 45174
Lab No: 5-27
Results
Normal Values
Electrolytes
Serum Sodium
140.1
(Na+)
Serum Potassium 4.19
(K+)

135.143 mmol/L
3.5-6.3 mmol/L

SIGNIFICANCE:

Results shows that sodium-potassium
level is within the normal range, no
indication of electrolyte imbalance.

HEMATOLOGY
Definition:

provides information about
blood components and other particles like
serum electrolytes. This to determine
any alterations brought by a specific
disease. Complete blood count is used as
broad screening test to check for
disorders such as anemia, infection and
any other diseases.

Name: A. D.
C.S.: Single
Ward: Pedia Apex
Age: 2
Examination requested: CBC, APC Sex: Female
Physician: Dr. R. B
Date:11-05-08
HospitalNo: 45174
Results
Normal
Significance
Values
Hemoglobin

12.9 g/dL

12.3-15.3
g/dL

Normal

WBC

8.1x109/L

4.4-11.0
x109/L

Normal

Results
Neutrophils

0.63

Segmenters
Lymphocytes

0.63
0.37

Normal
Values
0.59-0.68

Significance

Slightly
0.32-0.62 increased,
0.25 – 0.33 Increased;
indicates in
response
to
inflammatory
presence
disease of
microorganisms
, possible
infection

Results

Normal
Values
Hematocrit
0.38 vol. % 0.37-0.47
vol. %
Platelet count 363 x
150-450 x
109/L
109/L

Significance
Normal
Normal

Significance:

Based
on
the
findings,
A.D.
manifests
inflammatory disease and infection
as evidenced by slight increase of
antigen presenting cells such as
segmenters and lymphocytes.

Drug
Study

Name of
Drug

Classification Indication

Generic
Antibiotic
Name:
Ampicillin
Brand
Name:
Principen

For GIT
infection

Action

Inhibits
cell wall
synthesis
during
microorgani
sm
multiplicati
on.

Special Precautions

Contraindications

Use cautiously in
patients with other
drug allergies,
especially to
cephalosporins
(possible crosssensitivity) and in
those with
mononucleosis)

Contraindicated in clients
with hypersensitivity to
drug or other penicillins.

Adverse Reactions and Dosage
Side Effects
250 mg IVTT q6h ANST
SE:
(-)
Vein irritation, nausea 6-12-6-12
and vomiting, diarrhea
AR:
Availability:
Thrombophlebitis,
Capsule: 250mg, 500 mg
thrombocytopenia,
Infusion: 500mg, 1g, 2g
urticaria,
Injection: 25mg, 250mg,
hypersensityivity
500mg, 1g, 2g
reaction, anaphylaxis Oral suspension:
125mg/5ml,

Nursing Responsibilities

Observe 10 Rights in giving medications.

Obtain history of patient’s infection before
therapy.

Ask patient or folks about previous allergic
reaction to penicillin

Perform skin test before giving the medication.

Be alert for adverse reactions and drug
interactions.

Monitor hydration status.

Give at least 2 hour before bacteriostatic
antibiotic.

Stop drug immediately if anaphylaxis occurs.

Name of
Drug

Classification Indica- Action
tion

Generic
Name:
Potassium
Chloride
(KCl)

Potassium
Supplement

For
Aids in
preventi transmitting
on of nerve impulses,
hypoka- contracting
lemia cardiac and
skeletal muscle,
and maintaining
intracellular
metabolism, acid
base balance,
and normal renal

Special Precautions

Use cautiously in
clients with cardiac
disease or renal
impairment.

Contraindications
Contraindicated in clients
with hyperkalemia, other
conditions linked to
extensive tissue
breakdown or severe
renal impairment with
oliguria, anuria, or
azotemia.

Adverse Reactions and
Side Effects

Dosage

Dosage
SE:
Paresthesia, listlessness,KCl 6 mEq incorporated to
300 cc D5 0.3 NaCl x
confusion, n/v,
62-63 mgtts/min
abdominal pain,
diarrhea, cold skin,
Availability:
oliguria
Capsule: 8mEqs, 10mEqs
 
Injection: 0.5meqs/ml,
AR:
2meqs/ml
Arrhythmias, heart
Oral liquid: 20meqs/15ml
block, cardiac arrest,
Powder: 15meqs/packet,
GI ulcerations, and

Nursing Responsibilities

Observe 10 Rights in giving medications.

Assess patient’s condition before start of therapy.

Be alert for adverse reactions

Monitor fluid input and output, creatinine and BUN
levels.

Give cautiously because different potassium
supplements deliver varying amounts of potassium.

Drug is commonly given with potassium-wasting
diuretics to maintain pottasium levels.

Advise to eat potassium rich foods.

Don’t give postoperatively until urine flow is
established.

Name of
Drug

Classification Indication

Generic
Antibiotic
Name:
Cotrimoxa
zole

For
susceptible
microorgani
sms

Action

Sulfamethoxaz
ole inhibits
formation of
dihydrofolic
acid from
PABA;
trimethoprim
inhibits
dihydrofolate
reductase.
Both decrease
bacterial folic
acid synthesis

Special Precautions

Contraindications

Use with caution and Contraindicated in clients
reduce dose in client with megaloblastic anemia
with hepatic
caused by folate
impairment, CrCl of deficiency, severe renal
15-30 ml/min, severeimpairment, or
allergy or asthma,
hypersensitivity of the
G6PD deficiency, or drug
blood dyscrasia

Adverse Reactions and
Side Effects

Dosage and
Availability

SE:
Dosage:
Headache, abdominal
pain, diarrhea, anorexia, 80mg/5ml
muscle weakness
AR:
Thrombocytopenia,
leukopenia, anaphylaxis,
hepatic necrosis

Nursing Responsibilities
Observe 10 Rights in giving medications.

Assess client’s infection before and after
therapy.

Before giving first dose, obtain specimen for
culture and sensitivity tests. Begin therapy
pending results.

If adverse GI reactions occur, monitor hydration
status.

Monitor MIO. Ensure urine output is at least 1.5
L daily. Inadequate urine output leads to
crystalluria.

For full absorption, give with a full glass of

Nursing
Care Plan

List of Priority Nursing
Diagnosis
Fluid volume deficit

Altered Nutrition, less than
body requirements

Hyperthermia

Impaired skin integrity

NURSING DIAGNOSIS
Fluid volume deficit related to active
fluid loss as evidenced by 5 episodes of
vomiting with approximately 100cc of semisolid vomitus which contains previously taken
foods; defecated 2 times a day with a
yellowish, mucoid stool, skin warm to touch,
dryness of skin in palms and sole of the feet,
skin turgor of 4 seconds, dryness of lips, pale
bulbar and palpebral conjunctiva, temp= 37.7
degrees celcius, slightly sunken eyeballs and
profuse sweating. Mrs. RAD verbalized that,

GOAL
Within 4 hours of effective
nursing intervention, client will
display improvement on
hydration status to a functional
level such as good skin turgor
and stable vital signs.

NURSING
INTERVENTIONS

RATIONALE

INDEPENDENT:
1. Monitor vital signs -Vital signs serve as
every 4 hours including patient’s baseline
the intake and output data. Monitoring fluid
and note the strength intake and output
of peripheral pulses. enables us to evaluate
the degree of fluid
volume deficit.

2. Estimate procedural -To note the volume
fluid losses and
of insensible fluid
possible route of
losses for proper
insensible fluid losses. replacement.

3. Note client’s
-This will help in
preferences concerning encouraging the client
foods with high fluid to increase her fluid
content such as papaya intake.
and jelly ace.
4. Encourage the
parents to increase
client’s fluid intake
approximately 2-3
liters per day as
tolerated.

-Increasing fluid
intake will replace
fluid losses and help
maintain fluid volume
at functional level.

5. Instruct the
parents to secure
available drinking
water at the bedside.

-This is a preparation if
the client will crave for
water. The availability
of fluids is a good way
to respond immediately
to the physiological
needs of the client.

6. Give crackers or
ice chips to the
client.

-This is a nonpharmacologic
management to reduce
nausea.

Dependent:
1.Administer
medications as
ordered

Ampicillin 250 mg
IVTT q6h
6am-12nn-6pm-12pm

-Ampicillin is a broad
spectrum antibiotic that
kills parasites by
interfering their ability
to form cell walls, thus
they will break up and
die.

2.Infuse IV fluids as
ordered and regulate
at prescribed rate:

D5 0.3% NaCl 500 cc
x 62 – 63 cc/hr

Collaborative
1. Monitor laboratory
data such as
hematocrit,
electrolytes and
specific gravity of
urine.

-this is given to
counteract hypotonic
dehydration and to
maintain the balance in
fluids and electrolytes in
the client’s system.
-to note if there are
progress in client’s
condition as to her fluid
volume.

EVALUATION

Goal met. A.Dwas able to
improve her hydration status to a
functional level after 4 hours of
effective nursing interventions as
evidenced by good skin turgor of 2
seconds and stable vital signs.

Nursing
Diagnosis
Altered Nutrition, less than the body requirements

related to Inability to Absorb Nutrients due to Biological
Factors (Intestinal Parasites) as evidenced by BMI of
14.69 (malnourished), persistent vomiting approximately
5 times prior to admission from November 3 to
November 5, 2008 approximately 100cc per episode of
vomiting, dryness of lips, pale palpebraland bulbar
conjunctiva with slightly sunken eyeballs, hair is brown
in color, thin and dry, pallor, protuberant and distended
stomach, weakness, ,presence of intestinal parasites as
laboratory results revealed, presence of Ascaris
lumbricoides (more than 12 ova per slide), Trichuris
trichuria (0-1 ova per slide), Trichomonas hominis (few),
Entamoeba coli (5 ova per slide), Entamoeba histolytica
(more than 12 cyst per slide), RBC 2-4hph, presence of

Goal

Within 14 days of
effective nursing interventions,
client will demonstrate
progressive weight gain from
4-7 kilograms to achieve
normal Body Mass Index of
20-24.

Nursing
Interventions
Rationale
Independent:

Helps to determine
1. Assess age, body
build, activity and rest nutritional needs.
level.

2. Reassess weight.
Assess BMI.
3. Establish a minimum
weight goal with the
client of approximately
4-7 kilograms within
time span.

To establish baseline
parameter.

- Provides comparative
baseline data for
effectiveness of therapy.
Improved nutritional
status enhances activity
tolerance and physiologic

4. Review the nutritional
history including quality of
food taken and meal eaten
per day.

- Identify the
deficiencies and
suggest proper daily
intake.

5. Weigh regularly and
record results.

6. Identify and manage
underlying causative factors
such as food preparations,
proper hygiene and
environmental sanitation
including the present

To monitor
effectiveness of
nursing interventions.

- To determine the
amount that should be
added in the diet and
monitor the food
preferences of the
client.

7. Evaluate the total •Reveal possible cause
daily food intake
of malnutrition and
including caloric intake, changes that could be
patterns and time of
done to be made in
eating.
client’s intake.


8. Provide small
frequent meals and
supplemental snacks
like boiled kamote
which is readily
available in the client’s
backyard.

- Gastric dilation can
occur and if refeeding
is too rapid and can
lead to gastric reflux.
 

9. Use flavoring agents - To enhance food
minimal in amount such satisfaction and
as salt, pepper and
stimulate appetite.
other herbs in food as
preferred.

10. Ensure minimal
Increase gastric
intake of foods that
motility leading to
cause intolerances such reflux and diarrhea
as foods that are gas
forming and avoid too
hot/cold or spicy
according to client’s

11. Promote adequate

Replace fluid loss due
and timely fluid intake as
to diarrhea and
tolerated by the client
vomiting. Limiting fluid
preferably 2-3L. Limit
intake prior to meal
fluids 1 hour as possible
prevents early satiety.
prior to meal.

12. Recommend eating May enhance intake
and reduce sensation of
in upright position.
abdominal fullness.

To promote pleasant
13. Minimize unpleasant atmosphere that can
odors or sight including increase and stimulate
scent of spoiled and raw intake.

14. Schedule activities •Conserve energy and
with adequate rest
reduces caloric needs

periods and promote
relaxation technique.
15. Monitor laboratory •To monitor the
results
condition of the client
and any alterations
associated to client’s
status like presence of
intestinal parasites.

Dependent
Administer IVF of D5 Provide parenteral
0.3% NaCl 500cc x 62- nutrition and replace GI
63 cc/hr as ordered. loses.

Interdependent:
Refer to dietician for
specific meal plan.

- To meet proper daily
nutritional needs.

2. Refer to physician
prescription of
antihelmenthic drugs.

To eliminate parasites
in the GI tract.

Parasites such as
entamoeba hystolytica
and ascaris lumbricoides
competes with the
nutrition acquired by
the client causing not
enough nutrition being
acquired by the body.

Evaluation
Goal met. Within 14
days of effective nursing
interventions, client was able
to gain weight of 4kg with
BMI of 20.56.
 

Nursing Diagnosis
Hyperthermia related to Disease
Process (Intestinal Parasitism) as
evidenced by temperature of 37.7o,
warm to touch, pale palpebral and
bulbar conjunctiva with slightly sunken
eyeballs, dry lips, exhibited pallor,
weakness,andMr. RAD verbalized ,
“Mainit ang akun nga bata.”

Goal
Within one hour of

nursing effective nursing
interventions, client will be
able to maintain core
temperature of 36-37.5 oC
of per axilla.

Nursing
Interventions

Rationale

Independent:
Monitor client’s
temperature prior to
therapy.

- To provide comparative
baseline data.

2.Monitor vital signs
every 15 minutes.

-To note any alterations
in the current condition
and monitor effectivity
of nursing interventions.

3. Perform tepid
sponge bath.
 
4. Limit bed linens.

Promotes heat loss
through the process of
conduction and
evaporation.

- Number of linens
should be minimized to
maintain near body
temperature by allowing
heat loss.

5. Instruct folks to
-Tight clothes trap
let client wear loose- moisture coming from

6. Monitor sources of - Noting excessive
fluid loss such as urine sweating may cause
output and sweating. dehydration.
 
7. Encourage increase

in fluid intake
Help promote normal
preferably 1.5-2 liters body temperature as
per day as tolerated. fluids specifically water
helps in the cooling
system of the body.
-Replaces fluid losses.

EVALUATION
Goal met. Within one
hour of effective nursing
intervention, client’s
temperature subsided from
37.7 o C to 36.8 o C .

Nursing Diagnosis
Impaired skin integrity related to
injuring mechanical factors (scratching)
as evidenced by untrimmed nails,
multiple scars, lesions and ulcerations
with redness, pus and warm to touch at
the different areas on the upper and
lower extremities. Mrs. RDA verbalized
“sa sobra ya ka kalot sang iya nga
samad, muna nga nag lala siya”.

Goal
Within 5 days of nursing
interventions, the client will be
able to achieve timely healing of
lesions without complications.

Nursing Interventions Rationale

Independent
1.Identify the
underlying conditions,
the cause and the
nature of the skin
lesions, ulcerations and
scars.

-Identifying the
condition, cause, and
the nature of the skin
lesions will determine
appropriate nursing
interventions.

2.Instruct mother to
clean the lesions with
soap and water.

-Washing the lesion site
with antiseptic soap and
water cleanses it and
prevents bacterial

3.Encourage proper
-It inhibits the
hygiene such as taking a bacterial colonization
bath regularly for at
and prevents further
least two times a day, infection of lesions
changing clothes if it is
soiled, wet or dirty.
4. Advise mother to
use antiseptic solutions
-Antiseptic solution
(povidone iodine) in
(povidone iodine)
cleaning and
disinfecting the lesion. facilitates faster
wound drying and
healing.

5. Instruct mother to
provide A.D. with
Vitamin C – rich food
like calamansi and suha.

6. Instruct mother to
feed A.D. protein rich
food such as fish and
legume, string beans,
mongo and kadyos.

- Protein-rich food
facilitates skin
regeneration thus
promoting healing.
-vit. C rich food boosts
the immune system thus,
preventing infections and
eventually maintaining good
skin integrity.
-Protein-rich food
facilitates skin
regeneration thus
promoting healing.

7. Instruct mother to
apply herbal medicine
such as guava leaves
and found in their
vicinity.
 
8. Instruct mother to
have her child wear
appropriate footwear
like slippers with
garter.

-This herbal medicines
are accessible, available
and DOH-recommended
for wound healing.
 
-To protect the soles of
the feet from injury.

9. Instruct mother to -to protect the soles of
have her child wear
the feet from injury.
appropriate footwear
like slippers with garter

Interdependent
1. Refer to the nearest
- Brgy. Health Centers
brgy. Health center
are equipped with
(Balabago Health
professional health care
Center).
team to provide
therapeutic management
to their client.

Evaluation

Goal partially met. Some
lesions were still noted on the
upper and lower extremities
but still on the stage of
healing.

POST-PHYSICAL
ASSESSMENT
Date Performed:
November 20, 2008

A.D.

General survey
Alert, ambulatory, Body mass index:
20.56, calm, coordinated movement, animated
facial expressions, absence of body odor,
cooperative, good appetite. Temperature = 36.8
0C per axilla, height is 82.5 cm, weighs 13 kg,
cardiac rate of 110 beats per minute,
respiratory rate = 23 breaths per minute.

Skin
Brown, generally uniform in color, body
hair is thin and evenly distributed, skin is moist,
no edema noted, rough in texture, has various
interruptions in skin integrity such as scars,
crusts, ulcerations particularly on the upper and
lower extremities with signs of healing in various
stages. Ulcerations noted on the left tarsal with
evidence of healing process. Bluish discoloration
noted at the anterior portion of the buttocks
and left gluteus medius (Mongolian spot),
presence of pinpoint marks on the soles of the
feet. Skin temperature uniform all over the

Nails
Convex curvature, pinkish in color, smooth in
texture, tissue surrounding the nails are intact.
Nails are untrimmed and dirty, good capillary
refill, returns to original color after 2 seconds.

Head
Normocephalic and symmetrical with frontal,
parietal, and occipital prominences, smooth skull contour
37.5 cm in circumference, scalp same color as the facial
skin, no flakes or infestation, hair brownish in color,
short, thin, dry, straight and evenly distributed, facial
features symmetrical, palpebral fissures equal in size,
symmetrical nasolabial folds, no masses nor nodules

Eyes
Eyebrows symmetrically aligned and evenly
distributed, eyelashes slightly curved outward,
eyelids intact and close symmetrically, no
excessive
blinking,
palpebral
and
bulbar
conjunctiva are pinkish, sclera is anicteric with
presence of pinpoint sized macule, dark brown in
color at the right sclera. Cornea is shiny and
smooth. Pupils black in color, equal in size
(approximately 2 mm) and both reactive to light
and accommodation, can see objects at the
periphery, both eyes moves in unison, no

Ears
Same color as the facial skin, symmetrical
and aligned with the outer cantus of the eye.
Hair follicles noted in the ear canal, presence
of dry and yellowish cerumen in both ears,
scant in amount. Auricles recoils immediately
after it is folded, no tenderness noted. Normal
voice tones audible at 5 meters, whispered
words audible at the range of 6 inches.

Nose and sinuses
External nose straight and symmetrical,
presence of clear watery nasal discharge, scant
in amount, uniform in color, non tender and no
lesions noted. Both nares patent, nasal mucosa
pinkish in color, nasal septum intact and at the
midline,
Facial
sinuses
non-tender,
can
distinguish smell of a cologne.

Mouth and Oropharynx
Lips has symmetrical contour, pink in color, soft,
moist, and smooth in texture. Able to purse lips, facial
nerve intact. Inner lips and mucosa uniform pink in
color, moist, smooth, glistening and elastic in texture,
with 20 sets of teeth, yellowish in color, 4 upper
incisors noted with presence of dental carries, gums
pinkish, moist and firm, tongue is in central position, no
lesions, moist, appears rough and with thin whitish
coating at the surface. Papillae raised, tongue moves
freely base of the tongue smooth. Soft palate is
smooth and light pink in color. Hard palate lighter pink
in color and has irregular texture. Uvula positioned at
the midline, oropharynx pinkish and uniform in color.
Tonsils pinkish and smooth, no discharge and of normal

Neck
Neck muscles equal in size, head centered,
head movement coordinated, with no discomfort,
head flexes, hyperextends, flexes laterally and
rotates laterally, lymph nodes not palpable,
trachea placed at the midline of the neck.
Thyroid isthmus rises when client swallow,
thyroid gland not visible on inspection, smooth,
nontender nonenlarge, lobes of thyroid gland
cannot be palpated.

Chest
Chest and breasts are symmetrical, color
is lighter than the extremities, and areolas are
darker on breasts, no lumps and masses noted on
the breast and axilla upon palpation. With normal
breath sounds heard upon auscultation all over
lung fields, respiratory rate of 23 breathes per
minute, not labored, tactile fremitus is equal on
both sides of the thorax, axillary lymph nodes
not palpable, thoracic expansion is symmetrical,
abdominal breathing noted.

Heart
Apical pulse present on the 5th intercostals
space
midclavicular
line.
Dullness
upon
perscussion. Heart sounds heard on cardiac
landmarks, no thrills and murmurs heard upon
auscultation, Cardiac rate of 110 beats per
minute, rhythm is regular.

Back
No redness, no mass and swelling, no bone
deformity, spine and posture is straight,
thoracic expansion is symmetrical, tactile

Abdomen
Protuberant,
not
distended,
with
circumference of 49 cm, umbilicus not bulging,
presence of lesion with diameter of 0.5 cm
below the right rib. Presence of normoactive
bowel sounds heard at the right lower quadrant
at 7 cycles per minute, dullness noted at right
upper quadrant, no pain noted upon palpation.

Genitals
No unusual discharges, Perinuem intact,
wound marks noted, absence of redness at the
anal opening. Presence of sticky clear discharges
noted at the vaginal opening. Right and left
inguinal lymph nodes slightly palpable. Defecates
two times a day to a yellowish formed stool
without the presence of worms(ascaris) and voids
approximately 7 times a day to a light yellow urine
approximately 100 cc in amount per voiding. The
right and left inguinal lymph nodes slightly
palpable.

Extremities
Upper extremities
Numerous skin lesions noted on arms,
shoulder, elbow, wrist and fingers and on various
stages of healing, has full range of motion, with
quick capillary refill within 2 seconds.

Lower extremities
Presence of lesions distributed all over the
legs and thigh, varicosities are absent in both
feet. Knees and ankles have full range of
motion. Knees can flex as well as the ankle.
Both can rotate without pain, toes can abduct

Discharge
Plan

I. General Objectives:
 To provide continuity of care at home in
the absence of a health care provider.

II. Specific Objectives
1.

To discuss to the folks of the client some
information about the client’s illness,
including
its
background,
etiology,
epidemiology, and signs and symptoms.

2.

To help the folks assist the client in
dealing with her personal hygiene so as to

3.

To guide the folks of the client by
instructing the ADLs listed and practice it so
that the
client can avoid any complications
again and live normally as a child.

4.
To provide a list of nutritional foods that is
appropriate to the client and teach folks how to
prepare, store and cook it properly.
5.

To help the folks interpret and understand
the medications and herbal medicines listed.

6.
To inform the folks when will be the
appropriate time to return for follow-up check
up and repeat laboratory exams as requested.

III. Health Teachings
A)Knowledge about the Illness
The intestinal parasitism is an endemic
clinical condition that prevails in nations with
the population's severe imbalances social and
economic, where vast sectors they lack the
basic services of education, health, housing,
and recreation.
Etiology
Among these parasites, the ascaris
lumbricoides is a nematode which is one of the

A lumbricoides is the most prevalent and
the largest of the intestinal nematodes that
infect humans This illness is characterized by
variable symptomatology ; it is generally
asymptomatic in the adult, and it is in children
where we see the most florid clinical
presentation and the complications of this
illness.
As most of the intestinal parasite
infections, the ascariasis prevails and is endemic
in areas lacking of sanitary infrastructure, with
precarious housings, poverty and ignorance. This
helminthic infection is acquired by the ingestion

They ascend for the respiratory tree and
then continuing go up for later to be swallowed
and arrive to the small intestine where they
become adults.
Epidemiology
The form of more frequent presentation is
the chronic infection, which mostly contributes to
the process that takes to the malnutrition. It can
happen to any age, being more frequent in
children of school age and persisting in the
adulthood. Every year, 60.000 deaths are
attributed directly to this infection.

The clinical illness is restricted to subject
with important load of parasites. This minority
represents from 1,2 to 2 million cases with
clinical manifestations in the world, being
considered around 50.000 deaths a year for
severe illness caused by ascaris lumbricoides.

Signs and Symptoms
The infested patients could not have any
symptom, or to manifest low of weight, chronic
abdominal colic pain, nausea, vomiting and the
elimination of parasites by stools. Children could
have retardation related growth and weight, and

Most of children have the antecedents of
ascaris expulsion by rectum, and patients with
intestinal obstruction is common to records
parasites expulsion by mouth, which help as an
element to keep in mind for making a right
diagnosis. The diagnosis is carried out by means
of the visualization of the eggs in the direct
exam of fecal matter. The mature females can
also be visualized in feces. In few cases that
the infection is only for males, there are not
eggs in the stools, and an abdomen x-ray allows
visualizing the parasites in the intestine.

Erratic Migration
One of the peculiarities that characterize
the massive infestation conditioned by these
worms is the enormous capacity that they
possess to invade spaces, organs, conduits and
cavities of the human body where it is not
normal to find them, for what this extensive
chapter
has
been
denominated
in
the
international literature as “erratic or ectopic
ascariasis”. As consequence of the erratic
localizations, the presence of parasites has been
described in biliar ducts, nasal graves, hearings,
fallopian tubes, gallbladder, among others.

All these presentations are strange, but
they can cause difficulties at the time of
making the diagnosis. Cases of gastric bezoar
have
been
reported
by
ascaris.
The
extraintestinal migrations of the ascaris
lumbricoides is clearly described, and they can
end up being solved medical and surgically.

Rationale: To supply the folks of the client
with all information and gain knowledge by
understanding the background of the disease.

B.) Personal Hygiene

1. Sanitary disposal of human feces and good
personal hygiene.
2. Washing of hands before and after eating and
after going to the comfort room, or handling
pets.
3. Keep fingernails short and clean because
parasites can live for two months under the
fingernails.
4. Keep environment neat and clean by doing a
general cleaning thrice a week together with the
family.
5. Do not walk barefoot on warm moist soil, or
while playing in the backyard because parasites

6. Proper oral care like tooth brushing after
eating in order to prevent dental carries.
7. Take a bath everyday.
8. Change bed sheets and dry it under the sun as
necessary as possible.

Rationale: To be able to prevent such
diseases by doing preventive measure by
maintaining a good hygiene practiced at
home.

C.) Activities of Daily Living
1.Eating:
a)Before and after eating, make sure to
wash hands properly using a soap and
clean water because proper hand
washing may prevent the spread of
microorganisms.
b)Encourage to avoid eating foods from
streets like fish balls, fried chicken,
ice candy, and other foods which are
sold on the nearby streets since we

These foods may not be cleaned
properly, or may be already
contaminated.
c) Encourage to boil water at least
5-15 minutes if they use water from
the faucet in order to destroy
microorganisms present in the water.
2. Bathing, Grooming, and Clothing:
a) Wearing of shoes or slippers
properly outside and inside of the
house.

c) Counsel not to allow children to be
licked or kissed by pets that are not
dewormed regularly.
d) Discourage nail-biting and scratching
the anal area.
e) Have children change into a clean
underwear each day to prevent infection.
3) Eliminating/ Toileting
a) It is necessary to wash hands after
toileting for infection control and to
wipe perineum from front to back to

b) Encourage not to ignore the urge to void so
that the bacteria from the urinary tract
will be flushed out.
c) It is also necessary to defecate in a day to
remove toxins from the body.

Rationale: To guide the folks of the
appropriate ADL that must be performed
and practiced by the client daily.

D.) Nutritional Status
1.Wash thoroughly and cook food
particularly fruits and vegetables.

3. Encourage to drink more clean water by
boiling it 15-30 minutes or to boiling point.
4. Eat Vitamin C rich foods and high in protein
and calories to replace weight loss like
oranges, and other citrus fruits, milk, meat,
and fish.
5. Prepare food properly to enhance appetite of
the child.
6. Light soups, rice and eggs are good foods to
eat during recovery.
7. Sugar and sweetened foods should be avoided
because parasites thrive on it.
8. Take large doses of plant derivatives

Rationale: To take foods appropriately and
avoid foods that is restricted.

E.) Medication,
Procedures

Treatment

and

Special

1.Instruct the folks of the client to
follow physicians order –take home
medications, correct dose, preparations
or for any laboratory exam like
fecalysis.
2.Let bowel rest by drinking only clear

3. Avoid taking OTC medications or other drugs
without asking a knowledgeable health care
provider regarding it.
4. Comply
with
antibiotic
medications.
Cotrimoxazole 2.5 ml BID,(8am and 6pm) PO,
for 7 days. Give with full glass of water, 1 to
2 hours after meals.
5. Suggest herbal medicines.
Preparation:
• Boil Star apple leaves for 10 minutes
• Strain the extract and get rid of the
leaves and residue
• Cool the extract for 5 min

Rationale: To subject client for medications
and special procedures to enhance health.

F.) Follow-up Visit
Encourage the folks of the client to return
for follow-up visit after 1 week after discharge
November 16, 2008, WVMC OPD 8:00 am to
monitor condition or health status or if needed
or necessary.

Rationale: To inform the folks and the client
went to go back to monitor the status and

Ward

Observation

Doctor’s Order Sheet
Dr. B made the following orders:
• please admit patient at pedia apex down
- this is to monitor patient's condition and
provide necessary care and interventions
related to patient's diagnosis. Pedia apex
down is used for the admission of patients
with
infectious
diseases
particularly
gastrointestinal diseases
•TPR every 4 hours and record
- to monitor and note any alterations that
may need or elicit prompt referral and
immediate intervention

•DAT with SAP
- the patient is two years old and should be
required to be in SAP and because the
patient has experienced vomiting and should
be cautioned for aspiration
•Continue Na K
- A laboratory examination performed to
determine and correct fluid electrolyte
imbalance caused by previous episodes
vomiting and diarrhea
•Fecalysis
- a routine laboratory examination intended
to identify parasites present in the
gastrointestinal tract and the extent of

•Urinalysis
- to provide information about the basic
properties of a urine sample and aid in diagnosis.
Measures the pH and concentration, check for
glucose, protein, the presence of blood
•APC chest x-ray right and left lung
- to identify extent of damage to the lungs due to
erratic migration of the parasites to the organ
•IVF D5 0.3 NaCl 500cc x 6h to run at 62-63
cc/hr or 15-16 gtts/min; reassess at 4am
- an isotonic solution that can be used as initial
fluid for hydration because it provides more
water
than
sodium;
commonly
used
as
maintenance fluid

• Medication: Ampicillin 250mg IVTT every 6
hours –ANST

- an antibiotic intended to fight the infection
caused by the parasite invading the organs

• MIO every shift and record include stool and
vomiting count at bedside

-to monitor GI losses in order to know how
much is to be replaced based on the output
and to note characteristics of stool to
identify gastrointestinal function
-

•Replace GI loss volume/volume with PNSS

-to prevent hypovolemia
electrolyte imbalance)

and

fluid

and

-

•Refer accordingly

- to prevent any complication or untoward
incidents that may need immediate medical or
surgical interventions

November 6, 2008

A.D.
7-3 Shift

7:00am Awake, lying in crib with IVF of D5
0.3 NaCl 500cc x 62-63 cc/hr at
right metacarpal vein at the level of
125 cc/hr, patent and infusing well.
Still for fecalysis, and on DAT with
SAP. Hematology, blood typing and
urinalysis laboratory results in.
Vital signs taken and recorded.
Temperature per axilla=37.7OC,
CR=110 beats /min, RR=22
breaths/min.

7:30am Lips dry, dirty nails and untrimmed,
good capillary refill, poor skin turgor,
springs back after 4 seconds, pale
bulbar and palpebral conjunctiva, no
adventitious breath sounds, abdomen
distended 53cm, normoactive bowel
sounds in all 4 quadrants with 7
cycles/min., no abdominal pain upon
palpation, has not defecated since
after admission, separation anxiety
evident, Mongolian spots on right
buttocks and thigh about 5cm in
diameter. Skin lesions on right knee and

8:00am
8:15am
9:00am
8:30am
9:15am

TSB done.
Breakfast taken. Consumed 1/2 cup
of rice, ½ bowl of chicken soup and
approximately
of chocolate
IVF consumed 240cc
and followed
with
drink
well-tolerated.
the same IVF of D5 0.3 NaCl
Temperature
rechecked.
Temp.
per
500cc and regulated to the desired
0C. TSB done
axilla=37.5
rate.
continuously.
Wound dressing done.

9:30am

Defecated in CR but the mother failed
get a stool
Stool
is
10:00am to
Instructed
folkspecimen.
to follow-up
x-ray
formed,
yellow in color with 4-6 white,
result.
10:30am Voided in the comfort room
about
4-5ininch
long
worms.
10:15am round,
Defecated
again
the
comfort
room
approximately 80cc, straw-colored
once
urine.to mucoid stool, yellow in color,
with 5-7 ascaris adult worms. Stool
specimen submitted to the laboratory
for fecalysis.

11:45am
12:15pm
12:20pm

Vital signs taken. Temperature per
O C, CR=110 beats /min,
axilla=37.3
Lunch taken. Consumed 1 piece of
RR=23
breaths/min.
fish,
½
cup ofrounds
rice and
Dr. B. made
andapproximately
new orders.
180cc
of follow
water,D5
well-tolerated.

IVF to
0.3 NaCl 500cc+
10mEq KCl at 62-63 cc/hr x 8 hours
(reassess at 8pm)

continue medications

follow up chest x-ray result

please request fir serum Na and K

1:00pm
2:00pm

Voided in the comfort room
approximately 80 cc, straw-colored urine.
Endorsed to staff nurse on duty with
IVF of D5 0.3 NaCl 500cc x 62cc/hr
with the remaining amount of 200cc.

INPUT
Date

Time

11/6/08 8am
12nn

IV

PO

NGT

total

x

x

x

x

295cc

420cc

x

715cc

OUTPUT
Date
Time
11/6/0 8am
12nn
8

urine
stool
x
x
Approximat 2
ely
160cc(w/o
diaper)

total
x
160cc

•After endorsement, based on the nurses notes
and doctor’s order sheet,
At 4:00pm, skin test for Ampicillin done by the
staff nurse for sensitivity testing.
Time

Temperature
(per axilla)

CR

RR

4pm

37.5OC

not taken not taken

8pm

36.3OC

not taken not taken

•At 4:35pm, Skin test result is negative. AD did
not show any sign of allergy to Ampicillin.

•At 11:50pm, Dr. B. made rounds and order:
- Start IVF of D5 0.3 NaCl 500cc + 10mEq
KCl to regulate at 62-63 cc/hr x 8hours
(reassess at 7am)
•Due medicines given by the staff nurse on duty.
Ampicillin 250mg IVTT every 6 hours (-)
ANST.
Time
Temperature( CR
RR
per axilla)
12am
36.7OC
not taken not taken
4am
37.0OC
not taken not taken

November 7, 2008

A.D.
7-3 Shift

7:00am Asleep, lying in crib with IVF of

D5 0.3 NaCl 500cc + 10 mEq
KCl x 62-63 cc/hr at right
metacarpal vein at the level of
390 cc/hr, patent and infusing
well.
Still for on DAT with SAP and
fecalysis. No specimen available
but with specimen bottle at

8:00am Vital signs taken and recorded.
Temperature per axilla=37OC, CR=106
beats /min, RR=21 breaths/min.
Lips pinkish, dirty nails, good capillary
refill, good skin turgor, pinkish bulbar
and palpebral conjunctiva, no
adventitious breath sounds, abdomen
distended 53cm, normoactive bowel
sounds in all 4 quadrants, no abdominal
pain upon palpation, separation anxiety
evident, Mongolian spots on right
buttocks and thigh about 5cm. Still
with skin lesions on right knee and left

Breakfast taken. Consumed 1
8:15am bowl arroz caldo and 80cc of
water and well-tolerated.
10:00am Instructed folk to follow-up
x-ray result. Had in11:30am Lunch
taken. Consumed 2
between-meals.
pieces of banana and 30cc of
water, well tolerated.

12:00nn Vital signs taken. Temperature
O C,nurse
1:00pm Endorsed
to staff
on
per axilla=37.4
CR=110
duty
IVF
of D5 0.3
beatswith
/min,
RR=22
NaCl
500cc + 10 mEq KCl x
breaths/min.
62 cc/hr with the remaining
amount of 10cc.

INPUT
Date

Time

11/7/08 8am
12nn

IV

PO

NGT

Total

x

x

x

x

380

110cc

x

490cc

OUTPUT
Date

Time

11/7/08 8am
12nn

Urine

Stool

Total

x

x

x

240cc

0

240cc

•After endorsement, based on the nurses notes
and doctor’s order sheet,
•At 2:10pm, Dr. Y. made rounds and made new
orders. 
• request IVF D5 IMB 500cc at 41-42 cc/hr,
continue Ampicillin
• Co serum Sodium, Potassium
• follow up fecalysis result
•Due medicines given by the staff nurse on
duty, Ampicillin 250mg IVTT every 6 hours ANST. Vital signs checked and recorded.
Time
Temperature CR
RR
(per Oaxilla)
4pm
37.0 C
not taken not taken
8pm
35.8OC
not taken not taken

•Due medicines given by staff nurse on duty.
Ampicillin 250mg IVTT every 6 hours -ANST.
Vital signs checked and recorded.
Time

Temperature( CR
per axilla)

12am
4am

37.2OC
35.3 O C

RR

not taken not taken
not taken not taken

November 8,2008

A. D.
7-3 Shift

7:00am Asleep, lying in crib with IVF of

D5 IMB 500cc x 41-42 cc/hr at
right metacarpal vein at the level
of 280 cc/hr, patent and infusing
well.
Still for on DAT with SAP and
check fecalysis result. .
Laboratory results for urinalysis,
fecalysis, chest x-ray,
hematology, blood typing, and

8:00am Vital signs taken and recorded.
Temperature per axilla=37.4OC, CR=112
beats /min, RR=22 breaths/min.
Increased appetite, untidy appearance,
lips pinkish, dirty nails, good capillary
refill, good skin turgor, pinkish bulbar
and palpebral conjunctiva, no
adventitious breath sounds, abdomen
distended 50cm, normoactive bowel
sounds in all 4 quadrants, no abdominal
pain upon palpation, separation anxiety
evident, Mongolian spots on right
buttocks and thigh about 5cm. Still

8:15am
8:45am

Breakfast taken. Consumed 1 cup of
rice, 1 bowl pancit molo and 80cc of
water,
well-tolerated.
Hair care
done. Nails cleaned and

9:10am

Snacks taken, 2 pieces crackers.

cut short.

11:00am Lunch taken. Consumed 1 cup of
rice, 1 bowl pancit molo, 120cc of
milk, and 200ml juice, well
.
12:00nn tolerated
Vital signs
taken. Temperature per

axilla=36.5OC, CR=116 beats /min,
RR=22 breaths/min.

12:20pm Seen by Dr. Y. No new orders made.
1:40pm

2:00pm

Above IVF of D5 IMB x 41-42 cc/hr
consumed and followed up with D5
IMB x 41-42 cc/hr.
Endorsed to staff nurse on duty with
IVF of D5 IMB 500cc x 41-42 cc/hr
at the level of 490 cc.

INPUT
Date

Time

11/8/08 8am
12nn

IV

PO

NGT

x

x

x

280cc

400cc

x

Total
680cc

OUTPUT
Date
Time
11/8/08 8am
12nn

urine
stool
x
x
approx.
0
280cc(w/out
diaper)

total
x
280cc

..End..

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