Dengue

IndirectInguinal Hernia Indirect Inguinal

HerniaIN

3D

Demographic Data

Patient Name : H.M.Age : 10 years oldSex : FemaleBirthday : December 2,2000Civil Status : childAddress : Indang CaviteReligion : Roman CatholicNationality : FilipinoEducational Background : Elementary LevelDate of Admission : September 9,2010Chief Complaint : Fever and abdominal painFinal Diagnose : Dengue Fever SyndromeAttending Physician : Dr. ReyesHospital : Korean Philippines Friendship Hospital

SOURCES AND RELIABILITY OF THE INFORMATION

• The data presented in the case was taken from the hospital chart as well as from the patient mother through nursing patient interaction.

III. Chief Complaint

According to the mother she brought her son the hospital because of high fever with abdominal pain.

• IV. History of Present Illness

• Two days prior to admission the patient experience cough, colds and fever

• V. Past Medical History

• According to the mother all vaccination of his son is completed since at birth and this is the first time she brought her son to the hospital.

Family History

Health Perception and Health Maintenance

According to the patient’s mother she always consulted with the health center whenever her children got sick or not feeling well.

• Self-esteem, Self Concept and Self Perception Pattern

• • According to the mother her child always

telling her everything that happen to her especially what is happening in the school.

• Sleep / Rest Pattern

• According to the mother her child always sleep early during weekdays and even though during weekends.

• • Activity and Exercise• As verbalize by the mother, her child is not

really interested in any kind of activities at home but participated activities at school.

• Nutrition and Elimination Pattern• According to the mother her child eat any

kind of food she prepared and consume junk food also.

• Sexuality• According to segmund freud (psychosocial

theory). He belong in the school age child in the latent phase (children libido appears to be diverted into concrete thingking.)

• • • EnterPersonal Relationship• As verbalize by the mother, her child is a

loving daughter and always has fun with their neighbor.

• • Stress Management / Tolerance Pattern• According to the patient’s mother her child way of

handling pressure especially at school is talking to her and to his father.

• • • Personal Habit• As verbalize by the mother she always reminds her

child on good hygiene and she always follow her instruction.• • Environmental Hazard• The patient live besides the highway, and their place is

prone to accident.

Review of systemsSept. 12, 2010 Sept. 13, 2010

Pale looking, with Abdominal pain scale of 4, Limited movementFebrile- 38.7*C(+) petichae.

Pale looking, with Abdominal pain scale of 4, Limited movementAfebrile- 36.9*C(+) petichae.

(+) petichae, warm skin to touch, flush skin

(+) petichae, warm skin to touch, flush skin

RR= 29cpm, with productive cough

RR= 26cpm, with productive cough

CR= 66bpm,Bp=80/60mmHgNo abnormal sound

CR= 72bpm Bp=90/60mmHg Normal heart sound

Normal bowel and urine output.

Normal bowel and urine movement.

Limited range of movement

Limited range of movement

Scalp intact, no lesions, pale conjunctiva

Teary eyes, pale conjunctiva, normal vision

Blood

Whole blood has two components:(1) blood plasma, a watery liquid matrixthat contains dissolved substances, and

(2) formed elements, which are cells andcell fragments.Blood is about 45% formed elements and 55% plasma. Normallymore than 99% of the formed elements are red-colored red blood cells. Pale colorless white blood cells and platelets occupy less than 1% of total blood volume.

Anatomy and Physiology

Bite from Infected Aedes Aegypti

Dengue Virus Type I(Chikungunya Virus)

IgG adheres to the platelet(initiates destruction of the platelet)

inflammatory response

petechial rash, high fever, headacheabdominal pain)

Normal Results Significance Nursing implimentation

WBC 4.1- 10.9 5.0 Normal Within the normal range

Lympocytes 0.6-4.1 .71 Normal Within the normal range

Segmenters 0.45-.65 .29 Decrease Infection

RBC 4.20-6.30 4.2 Normal Within the normal range

HGB 12.0-18.0 12.9 Normal Within the normal range

Hct 37-51 38 Normal Within the normal range

Platelet count

140-440 139 Decreased Risk for bleeding

Normal Results Significance Nursing implimentation

WBC 4.1- 10.9 6.4 Normal Within the normal range

Lympocytes 0.6-4.1 1.5 Normal Within the normal range

Segmenters 0.45-0.65 .31 Decrease Infection

RBC 4.20-6.30 4.4 Normal Within the normal range

HGB 12.0-18.0 13.2 Normal Within the normal range

Hct 37-51 39 Normal Within the normal range

Platelet count

140-440 135 Decreased Risk for bleeding

Dosage, Frequency and Route

Indication & Contraindication

275mg IV q 4 >I- Treatment of mild to moderate pain and fever does not have antirheumatic effects (analgesics)>C- hypersensitivity to acetaminophen or any component of the formulation: patients with known G6PD deficiency.

Side Effects Mechanism & Action

Anemia, hepatitis, analgesic nephropathy, nephrotoxicity with chronic overdose, sterile pyuria. (limited to important of life threatening symptoms.

Reduce fever by acting on the hypothalamus to cause vasodilatation and sweating.

Nursing Responsibilities

- assess patient for history of liver disease or alcohol abuse (acetaminophen and excessive alcohol may have adverse liver effects)-monitor vital signs and signs of adverse reaction at beginning of therapy and at regular intervals with long term use.-take with food or milk.

Drug Name Classification

Generic Name:ParacetamolBrand Name:Tempra

Honohoid analgesics and antipyretics


Generic Name:Ambrozol HDIBrand Name:Ambrolex

Mucolytic agents



7.5 ml TID >I- Acute and chronic disorders of the respiratory tract associated with pathologically thickened mucus and impaired mucus transport.>C- Hypersensitivity to ambroxol or any ingredient of ambrolex.


>Headache, nausea, vomiting , anoresia, gastric discomfort, diarrhea, GI bleeding and disturbances, skin rash. Bronchospasm, stomatitis, and rhinorrhea. Chills, fever. Hemoptysis. Other isolated reports including dizziness, insomia,palpitation and mild hypoglycemia.

>Reduces the viscosity of bronchial secretions and facilitates expectoration.


>Obtain patients history of cough before therapy and reassess after giving the drugs.> Instruct patient to follow exactly the direction on medication. Stress the importance of not taking more drug than directed.> Advice medical consultation for persistent cought of than more than 7 days.> Adise patient to avoid smoking, smoke filled rooms, perfumes, dust and environmental pollutants, these can increase cough.> Suggest sugarless loznges to decrease throat irritation and cough. Hard candy orgum can be used to prevent dry mouth.



750mg IV q 8 >I- serious respiratory tract in fection, UTI, skin structure infection, bone or joint infection, septicaemia, meningitis, gonorrhoea

preoperative prevention.

>C

- contraindicated in pts hypersensitive to drug or other

cephalosporins.


CV: phlebitis, thrombophlebitis

GI: diarrhea, nausea and vomiting, anorexia.

Second generation cephalosporin that inhibits cell wall synthesis promoting osmotic instability; usually bactericidal.


- before giving drug ask if he is allergic to penicillins or cephalosporins.

-obtain specimens for culture and sensitivity test before giving first dose. Therapy may begin while awaiting results.


Generic Name:Cefuroxime

sodiumBrand Name:zinacef

2nd generation cephalosporin



1 ampule q 8 >I- active duodenal gastric ulcer. -maitenance therapy for duodenal or gastric ulcer -gastro-esophageal reflux -erosive esopahagitis>C- in patients hypersensitivity to drugs and those with acute porphyria


CNS: headache malaise, vertigoEENT: blurred visionHepatic: JaundiceOthers: Anaphylaxis, angioedema, burning and itching at the injection site.

Competitively inhibits action of histamine on the H2 and the receptors site of parietal cells, decreasing gastric acid secretion.


-Assess patient for abdominal pain.-Note presence of blood in emesis, stool, or gastric aspirate.- drug may be added to total parenteral nutrition solutions.-instruct patient to which or without regard to meals because absorption isn’t affected by food


Generic Name:Ranitidine Hydro-chlorideBrand Name:Zantac

H2 receptor antagonist

ACTUAL PROBLEM

PROBLEM DATE IDENTIFIED DATE RESOLVED

1 Fever September 12, 2010 Resolved

2 Ineffective airway clearance September 12, 2010 Resolved

3 Abdominal pain September 12, 2010 Resolved

4 Ineffective tissue perfusion September 12, 2010 Ongoing

PROBLEM NO PROBLEM

1 Risk for bleeding

POTENTIAL PROBLEM

PLANNING

Short TermAt the end of the shift the patient temperature will decrease from 38.7 to 37.

Long TermPrior to dismissal the patient will identify underlying factors & importance of treatment as well as s/sx requiring further evaluation or intervention

EXPECTED OUTCOME

The pt shall have a decreased body temperature from 39.8 to 37The pt shall have identified underlying factors and importance of treatment as well as s/sx requiring further evaluation or intervention

ASSESSMENT DIAGNOSIS

S> “Mainit ang pakiramdam nya” as verbalized by the motherO>

> Temp of 38.7

> Flushed skin

> Skin warm to touch

Hyperthermia related to increase metabolic rate in the body as evidence by temperature of 38.7

Actual Problem “Fever “

http://nurseslabs.com/tag/hyperthermia/

Planning

Short TermAt the end of the shift the patient will be able to maintain airway patency

Long TermAt the end of hospitalization the patient will be able demonstrate behaviors to improve or maintain clear airway.

Intervention Rationale

>Establish Rapport>Monitor Vital Signs

>Encourage deep breathing and coughing exercises.>Elevate the head of the bed or change position. >Increase fluid intake to at least 2000ml/ day.>Auscultate breath sounds and assess air movement.>Encourage opportunities for rest and limit activities to level of respiratory tolerance.

>To gain patient trust>To obtain baseline data

>To incision to maximize effort.>To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of ventilation to different lung segment.>To help liquefy secretion.> To acertain status and note progress.>To promote wellness.

Expected outcomes

The patient will be able to maintain airway patency.

Assessment Diagnosis

S>”Nahihirapan siyang huminga” as verbalized by the mother.O>reproductive cough>with wheezes>with crackles upon auscultation on both lung fields.>RR=29

Ineffective Airway Clearance related to increased mucous production in the bronchial tree as evidence by productive cough

ineffective airway clearance

Planning

Short Term*At the end of the shift the pain will be able to decrease the pain from 6 to 4, which is mild pain.

Long term*At the end of the hospitalization the patient will be able to free from pain

Expected outcome

The patient will able to decrease the pain from 6 to 4.

Assessment Diagnosis

S> “Nasakit ang tiyan niya” as verbalized by the mother.O>facial grimace>Pain scale of 6 with is moderate pain>Irritable

Acute pain alteration in comfort related to asmanifested by facial grimace and verbal report of pain.

Knowledge Deficient

Planning

Short Term At the end of the shift the patient will demonstrate behaviors to improve circulation.

Long Term At the end of hospitalization the pt will demonstrate increased perfusion as appropriate

INTERVENTION RATIONALE

IndependentEstablish RapportMonitor Vital Signs

Assess patient’s condition

Note customary baseline data

Determine presence of dysrhythmias

Perform blanch test

Check for Homan’s sign

Note presence of bleeding

Elevate HOB

Encourage quiet & restful atmosphere

Instruct to avoid tiring activities

Encourage light ambulation

Encourage use of relaxation techniques

DependentAdminister medications

To gain patient trustTo obtain baseline data

To assess contributing factors

For comparison with current findings

To identify alterations from normal

To identify / determine adequate perfusion

To determine presence of thrombus formation

To determine risk of anemia

To promote circulation

To promote comfort & decrease tissue O2 demand

To decrease cardiac workload

To enhance venous return

To decrease tension and anxiety level

To treat underlying cause

EXPECTED OUTCOME

The pt shall have demonstrated behaviours to improve circulationThe pt shall have demonstrated increased perfusion as appropriate

ASSESSMENT DIAGNOSIS

Subjective:“nanghihina sya” as verbalized by the motherObjective:

-decreased WBC

-decreased platelet

-decreased HgB

-decreased capillary refill time

Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to DHF 1

ineffective tissue perfusion

http://nurseslabs.com/tag/dysrhythmias/

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http://nurseslabs.com/tag/anxiety/

http://nurseslabs.com/tag/ineffective-tissue-perfusion/

http://nurseslabs.com/tag/ineffective-tissue-perfusion/

Planning

Short Term

At the end of the shift the patient mother will able to demonstrate safety precaution to avoid potential injury

Long TermPrior to dismissal the patient will able to decrease potential injury

INTERVENTION RATIONALE

IndependentTo monitor vital sign.Apply pressure on the injection site.Instruct to avoid injury from sharp objectsProvide safe environment (pad side rails to prevent fall)Observe stool and emesis for occult blood.DependentAdminister meds care fully, monitor for side effect.

To have baseline data and evaluate efficiency of intervention.Prevent bleeding on the site Provide precautionary measureMinimizes fall and injury if falls occurs.Detect early evidence of bleedingReduces the side effect secondary to damage liver in ability to detoxify.

EXPECTED OUTCOME

Patient will demonstrate safety precaution to avoid potential injury.



Risk for Skin Integrity

Documents

Dengue