LICEO DE CAGAYAN UNIVERSITY R.N. PELAEZ BLVD.KAUSWAGAN, CDO COLLEGE OF NURSING NCM501202 A Case Study of: Jhunienne Matias Name of the Patient As Partial Requirement for NCM501202 Submitted by: Tan, Kevin John T. NCM501202 student Group A2 March 19, 2009 1 TABLE OF CONTENTS Introduction a. Overview of the case b. Objective of the study c. Scope and Limitation of the study II. Profile of the patient III. Developmental Data IV. Health History a. Family and Personal health history b. History of Present Illness V. Nursing Assessment (System Review & Nursing Assessment II) VI. Pathophysiology with Anatomy & Physiology VII. Medical Management a. Medical Orders and Rationale b. Drug study VIII. Nursing Management a. Ideal Nursing Management (NCP) b. Actual Nursing Management (SOAPIE) IX. Referrals and Follow-up X. Evaluation and Implications XI. Bibliography I. 2 I. Introduction a. Overview of the Study Acute diarrhea or gastroenteritis is the passage of loose stools more frequently than what is normal for that individual. This increased frequency is often associated with stools that are watery or semisolid, abdominal cramps and bloating. Acute watery diarrhea is an extremely common problem, and can be fatal due to severe dehydration, in both adults and children, especially in the very young and the old or in those who have poor immunity such as individuals with HIV infection or patients who are using certain medications that suppress the immune system. Gastroenteritis means inflammation of the stomach and small and large intestines. Viral gastroenteritis is an infection caused by a variety of viruses that result in vomiting or diarrhea or both. It is often called the "stomach flu," although it is not caused by the influenza viruses. Persons can reduce their chance of getting infected by frequent handwashing, prompt disinfection of contaminated surfaces with household chlorine bleach-based cleaners, and prompt washing of soiled articles of clothing. If food or water is thought to be contaminated, it should be avoided. Since most cases of acute watery diarrhea are infectious, especially in developing countries, the majority of such illnesses can be prevented by drinking water or eating foods that are not contaminated with infectious agents. Washing hands frequently with non-contaminated water, when caring for a patient with diarrhea as also always before eating is important. Proper storage of food and water is also important to prevent harmful bacteria from contaminating them. 3 loss of appetite. • Improve skills and knowledge as health care providers in the clinical area. adequacy of support systems and care given by the family as well as other health care providers. family members and clinical records. Objective of the Study This study aims to: • • • • Conduct and evaluate an assessment for the client Determine the causes. c. vomiting. Scope and Limitation of the Study This study includes the collection of information specifically to the patient’s health condition. Render series of nursing interventions for the client’s care Provide and disseminate important information as teachings to the client and the significant others to boost the knowing and understanding of the nature of the said health condition. The scope of this study would include: a. Occasionally. and hiccups also may be present. predisposing and precipitating factors that constitute the onset of the disease process. This is the case in phlegm nous gastritis (gangrene of the stomach) where severe abdominal pain accompanied by nausea and vomiting of potentially purulent gastric contents can be the presenting symptoms. The study also includes the assessment of the physiological and psychological status. and bloating. belching. Data collected via assessment.Other symptoms include nausea. b. acute abdominal pain can be a presenting symptom. Fever. interviews with the patient. The diagnosis of acute gastritis may be suspected from the patient's history and can be confirmed histologically by biopsy specimens taken at endoscopy. chills. 4 . Developing a plan of care that will reduce identified predicaments and complications. patient’s chart and nurse on duty. b. assessment and care were only limited to a total of 16 hours (2 days clinical duty. d.b. 5 . An array of factors influencing the limitations of this study includes: a. e. Coordinating and delegating interventions within the plan of care to assist the client to reach maximum functional health. The lack of complete family history obtained was due to lack of laboratory examinations or diagnostic examinations results like x-ray which data or results obtained is in the chart of the client during the time of care. The interaction. Further evaluating the effectiveness of nursing interventions that have been rendered to the client. Data collected is limited only to assessment and interview to the patient. 1 day assessment) with actual nursing intervention done. Actual and ideal problems for 3 days including the initial assessment and its appropriate nursing intervention that would be applied within his stay in the hospital at PGH hospital c. c. 2009 Time of admission: 4:00 PM Chief complaint: LBM Admitting diagnosis: AGE with mild dehydration Attending physician: Dr.5 Kg. Cagayan de Oro City Civil Status: Single Sex: Male Nationality: Filipino Religion: Roman Catholic Weight: 6. Jhunienne Age: 6 months old Birthday: September 17. 2008 Address: Mambuaya. Bacal 6 .II. Informant: Inalen Matias (Mother) Date of admission: Febuary 15. Patients Profile Client’s Name: Matias. Jhunienne Matias belongs to the oral stage wherein an infant’s pleasure centers are in the mouth. early adulthood (19-29 years). Psychosexual Theory of Sigmund Freud The psychosexual stages of Sigmund Freud are five different developmental periods during which the individual seeks pleasure from different areas of the body associated Oral Anal Phallic Latency Genital with sexual Birth to 2 4 6 13 feelings. adolescence (13-18 years). 7 . to to to to and These stages are as follows: 1year 3years 5years 12years Up Basing on this theory. my patient belongs in the infancy and early childhood stage wherein he is learning to distinguish right from wrong and developing a conscience.III. Havighurst has identified six major age periods: infancy and early childhood (0-5 years). and later maturity (61+). Basing on Havighurst’s Theory. it is a nutritive one. middle adulthood (30-60 years). Developmental Data Developmental Task Theory of Robert Havighurst A developmental task is a task which arises at or about a certain period in the life of an individual. This is also the infant's first relationship with its mother. middle childhood (6-12 years). Guilt Industry vs. Each stage signals a task that must be achieved. Isolation Generativity vs. Caregivers who are inconsistent. Inferiority Identity vs. Failure to achieve a task influences the person’s ability to achieve the next task. the development of trust is based on the dependability and quality of the child’s caregivers. Stages of Erikson’s Psychosocial Theory are as follows: Infancy Early Childhood Late Childhood School Age Adolescence Young Adulthood Adulthood Maturity Birth – 18 months 18 months – 3 years 3 – 5 years 6 – 12 years 12 – 20 years 18 – 25 years 25 – 65 years 65 years to death Trust vs. Despair Basing on this theory. As observed the child had already built trust to his mother and his grandmother wherein he only allows his mother and grandmother to cuddled and feed him. emotionally unavailable. If a child successfully develops trust.Psychosocial Theory of Erik Erickson Erik Erickson envisioned life as a sequence of levels of achievement. the healthier the personality of the person. Role Confusion Intimacy vs. or rejecting contribute to feelings of mistrust in the children they care for. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable. Stagnation Integrity vs. Shame Initiative vs. he is still belongs to Infancy based on Erikson’s theory the child developmental task is the “TRUST vs. he or she will feel safe and secure in the world. Mistrust Autonomy vs. MISTRUST” Because an infant is utterly dependent. He believed that the greater that task achievement. 8 . and gains understanding of his or her world through the interaction and influence of genetic and learning factors. This is divided into five major phases: Sensorimotor Phase Pre-conceptual Phase Intuitive Thought Phase Concrete Operations Phase Formal Operational Phase Birth to 2 years 2 – 3 years 4 – 6 years 7 – 11 years 12 – adulthood Basing on this theory.Cognitive Theory of Jean Piaget Cognitive development refers to how a person perceives. 9 . The patient uses memory and imitation act. he can solve basic problems. Jhunienne Matias belongs to the sensorimotor stage in which inventions of new means through mental combinations. thinks. HEALTH HISTORY a. On the father side they had a history of cancer since the father’s aunt died last 2001 due to cervical cancer. Family Health History According to the father regarding the herido-familial history both her mother and father side has a history of hypertension. History of Present Illness A case of Matias. cough and fever. Filipino. Jhunienne. b. The patient was born in JRB Hospital through a normal spontaneous vaginal delivery. 6months old Male. Over the counter medicines such as Paracetamol (Calpol) was used to treat for fever and Dimetapp for colds. The father claimed that his child has not completed the vaccination required and never experiencing major illness that required hospitalization until this Febuary 15. c. admitted for the first time at PGH hospital with a chief complaint of LBM. vomiting. colds and fever that usually lasted for three days. a resident of Mambuaya Cagayan de Oro City. Two days prior to admission he had persistent LBM. Past Health History The father claimed that his child past illnesses were a typical cough. 2008 wherein the patient has been admitted at JRB Hospital having an acute diarrhea but the father denied that his child does not have known allergies to drugs and foods nor his child received a blood transfusion. 10 .IV. EENT: [ ] impaired vision [ ] blind [ ] pain reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion teeth Assess eyes. turgor. comfort [ ] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain Assess abdomen. strength grip. Nursing Assessment (System Review & Nursing Assessment II) Name: Jhunienne Matias Date: 02-15-09 Temp: 38. color.V. control. ears. Indicate the location of the problem in the figure using [X]. comfort [x] no problem GENITO-URINARY AND GYNE: [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia assess urine frequency.6ºC HR: 137bpm BP: N/A Height_____ Weight:6. alignment. odor.3Nacl 500cc Watery Stools 11 . gait. function. LOC. texture. gait. comfort NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip assess motor. swallowing bowel sounds. pulse blood breath sounds. motion. integrity [ ] no problem Sunken eyes Poor appetite Colds Cough Poor skin turgor Hyperactive bowel sounds Hyperthermia =38. nose throat For abnormality [ ] no problem RESPIRATION: [ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [x] cough [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp. rhythm. coordination. speech [x] no problem MUSCULOSKELETAL AND SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [x] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic/moist assess mobility. sensation. rate. bowel habits. joint function skin color.5 kgsRR: 50cpm INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided.6C hooked with IVF of D5 0. [x] regular [ ] irregular Describe: RR is within normal range. odor) urine color is straw.SUBJECTIVE COMMUNICATION: [ ] hearing difficulty [ ] visual changes [x] denied Comments: “Wala man OBJECTIVE [ ] glasses [ ] languages [ ] contact lenses [ ] hearing difficulties due to age [ ] speech difficulties Pupil size:R:3 mm L:3mm Reaction: PERRLA (Pupil Equally Round Reactive to Light and Accommodation) Resp. R: symmetrical to the left lung L: symmetrical to the right lung siya problema sa pandu ngug ug pagtanaw” as verbalized by the mother Comments:”Naa jud siya ubo nabalaka na jud ko ani niya”as verbalized by the mother. consistency. *if they are in place Briefly describe the patient’s ability to follow treatments (diet. etc. amber transparent and faint aromatic odor. N/A. Heart Rhythm [x ] regular [ ] irregular Ankle Edema: No ankle edema is present on both extremities Pulse Car Rad. strong and palpable. Character [ ] recent change in weight [ ] swallowing Difficulty [x] denied ELIMINATION: Usual bowel pattern 5 loose stools per day [ ] constipation remedy Date of last BM December 5. OXYGENATION: [ ] dyspnea [ ] smoking history Non-smoker [x] cough [ ] sputum [ ] denied CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of extremities [x ] denied NUTRITION: Diet: Exclusive B. MGT. [ ] SBE: N/A Last Pap Smear: N/A 12 .F since Birth. DP Fem* R _______+______+_ __ + __not assessed L _____+_____ +_ _____+ not assessed Comments: Right and left pulses are equal. Comments: ”Gina patutoy Raman nako siya” as verbalized by the mother.) for chronic health problems (if present). [x] urinary frequency Diaper [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foley in place [x] denied Comments: ”magsunod sunod jud siya ug kalibanga”as verbalize by the mother. OF HEALTH & ILLNESS: [ ] alcohol [ x ] denied (amount & frequency) ________________________________________. [ ]dentures Complete Upper Lower [] [] [x]none Incomplete [x] [x] Bowelsounds: hyperactive Abdominal Distention Present [ ] yes [x] no Urine* (color. meds. 2008 [ x ] diarrhea [ ] constipation Comments: ”Wala may sakit sa tiil ug dughan akong anak”as verbalized by the mother. [x] facial grimaces [ ] guarding [ ] other signs of pain : Observed non-verbal behavior: the patient restless Phone number that can be reached anytime: refused is SPECIAL PATIENT INFORMATION ____N/A___ PT/OT __ N/A __ ____N/A___ Irradiation __ done _Urine test ___________ __No Order__24 hour Urine Collection VI. drainage: no rashes and ulcers found the the patients body. ANATOMY AND PHYSIOLOGY: 13 . decubitus (describe size. location.SUBJECTIVE SKIN INTEGRITY: [x] dry [ ] other [ ] denied ACTIVITY/ SAFETY: [ ] convulsion [ ] dizziness [ ] limited motion of Joints Limitation in Ability to [ ] ambulate [ ] bathe self [ ] other [x] denied COMFORT/SLE EP/ AWAKE: [ ] pain Comments: ”Mala jud iya panit kay cige ra ug kalibang” as verbalized by the mother. [x] LOC and orientation Patient is normalunconscious oriented Gait: [ ] walker [ ] cane [ ] other [x] steady [ ] unsteady_________ [ ] sensory and motor losses in face or extremities No sensory and motor losses on face or extremities [x] ROM limitations: no ROM limitations (location) Frequency Remedies [ ] nocturia [x]sleep difficulties [ x ] denied COPING: Occupation: N/A Members of household: 2 members of household Most supportive person: Karl William Matias(father) and Inalen Matias(mother) Not ordered _Daily weight _every 2hr ___BP q shift ____N/A___ _ Neuro vs ____N/A_ _ CVP/SG Reading __N/A___ Comments: perminte ra siya ga mata mata tungod ni sa iyang kainit” as verbalized by the mother. ulcers. OBJECTIVE [x] dry [ ] cold [ ] pale [ ] flushed [ ] warm [ ] moist [ ] cyanotic *rashes. Comments: ”kalooy sa ginoo wala jud nag lipong-lipong akong anak ug maka lihok rapud siya” as verbalized by the mother. and pancreas. The alimentary ‘tube’ consist of linked organs that each play their own part in digestion: mouth. which are all linked by ducts to the alimentary canal.packed into the abdominal cavity. The accessory digestive organs consist of the teeth and tongue in the mouth.DIGESTIVE SYSTEM The digestive system consists of two linked parts: the alimentary canal and the accessory digestive organs. with its longest sectionthe intestines. small intestine. The lining of the alimentary canal is continuous with the skin. that extends from the mouth to anus. stomach. so technically its cavity lies outside the body. and the salivary glands. esophagus. some 9 meters (30 feet) long. gallbladder. The alimentary canal is essentially a tube. pharynx. liver. and large intestine. 14 . When full. The chyme enters the small intestine through the pyloric sphincter. mildly increases motility of the GI tract. Most digestive activity occurs in the pyloric region of the stomach. umbilical and left hypochondriac regions of the abdomen. called RUGAE. involved in conversion of pepsinogen to the active enzyme pepsin. it resembles heavy cream and is called CHYME. The pylorus is continuous with the small intestine through the pyloric sphincter. Mucous cells secrete mucus. involved in the absorption of Vitamin B12 for the red blood cell production. Parts of the stomach includes cardiac region which is defined as a position near the heart surrounds the cardioesophageal sphincter through which food enters the stomach from the esophagus. it can hold about 4 L ( 1 galloon) of food. The parietal (oxyntic) cells produce hydrochloric acid. 15 . and relaxes the pyloricsphincter. a hormone that stimulates secretion of hydrochloric acid and pepsinogen. and the pylorus a funnel shaped which is the terminal part of the stomach. it is about the size of a large sausage. the mucosa lies in large folds. fundus which is the expanded part of the stomach lateral to the cardia region.STOMACH It is a J. Enteroendocrine cells secrete stomach gastrin. pepsinogen. contracts the lower esophageal sphincter.shaped enlargement of the GI tract directly under the diaphragm in the epigastric. and intrinsic factor. With the gastric glands lined with several secreting cells the zymogenic (peptic) cells secrete the principal gastric enzyme precursor. When empty. or valve. Secretions of the zymogenic. body is the mid portion. Approximately 10 inches long but the diameter depends on how much food it contains. parietal and mucus cells are collectively called the gastric juice. After food has been processed in the stomach. often with nausea.VI. Pathophysiology with Anatomy & Physiology Diagnosis: AGE with mild DHN Name of the patient: Jhunienne Matias Definition: Acute Gastritis is defined as diarrheal disease of rapid onset. large volume diarrhea Signs & Symptoms: Watery stool Fever 16 . It is an inflammation of the mucous membranes of the stomach often caused by an infection. Coli Invasion of gastric mucosa Penetration of Gastric mucosa Toxins producing pathogens cause watery. abdominal pain and loose bowel movement. Predisposing Factors: Environment Hygiene Stress Precipitating Factors: ~ Ingestion of contaminated food ~ Gender(Male) Ingestion of E. fever. vomiting. Irritation of the Gastric Lining Signs & Symptoms: Vomiting Fluid and Electrolyte imbalance too much Na+ and H2O are expelled from the body Increased fluid loss Signs & Symptoms: Decrease skin turgor Sunken Eyes Dehydration 17 . • Urinalysis To screen the patient’s urine components and to detect any abnormalities. This also serves as a baseline data to evaluate effectiveness of blood transfusions.VII. • SE To screen the patients feces & to detect any abnormalities I & O q shift v/s q4H To measure daily I & O of the client To have baseline data and for comparison of future data / for monitoring of patient’s condition. MEDICAL MANAGEMENT RATIONALE a. 02-15-09 IVF with D5 0. To screen the patient’s blood component and to detect any abnormalities. Bacal At par with age regular diet treatment of condition To provide easy digestion of food without experiencing pain upon digestion Start D5 0. Medical Orders and Rationale DOCTOR’S ORDER 02-15-09 Please admit to pedia ward For further management and under the service of Dr.3NaCL 500ml @ To provide access for intravenous 100cc/hr Labs: • CBC medications.3NaCl 500ml @ To provide access for intravenous 18 . 351/mm3 Fecalysis Character: soft Color: yellow Parasite ascarasis: none seen Trichuris: none seen Hook worm: none seen WBC/hpf: 4-6 RBC/hpf: 6-8 cysts: positive trophosites: none seen 19 .3 gms % 49. Laboratory Results CBC Hemoglobin Hematocrit White Cell Count 17. medications. Preparation for going home To provide access for intravenous medications.100cc/hr 02-016-09 Continue medications For billing today IVF with D5 0.3 NaCl 500cc @ SR To help for fast recovery To provide access for intravenous medications. b.3 NaCl500cc @ To help for fast recovery SR 02-16-09 Continue medications IVF D5 0.6 vol % 14. NURSING PRECAUTION Should be taken with food. Relieves fever. rash. SIDE EFFECTS Anemia.c. SPECIFIC INDICATION For fever. CONTRAINDICATION Contraindicated in patients hypersensitive to drug or its components. lasts longer than 3 days or recurs. SPECIFIC INDICATION Cough CONTRAINDICATION Hypersensitivity to ambroxol or any ingredient of Ambrolex.O CLASSIFICATION Cough and Cold Preparation MECHANISM OF ACTION Ambroxol is a mucolytic agent.5° C. May relieve fever by actingon hypothalamic heat-regulating center.75ml TID P. urticaria. SIDE EFFECTS Mild GI side effects. antipyretic MECHANISM OF ACTION May produce analgesic effect by blocking pain impulses. DRUG NAME AMBROXOL DOSE/FREQUENCY/ROUTE 0. by inhibiting prostaglandin or pain receptor sensitizers. NURSING PRECAUTION Do not administer for fever that’s above 39. Drug study DRUG NAME Paracetamol DOSE/FREQUENCY/ROUTE 500 mg 1 tab q4h PRN for fever CLASSIFICATION Analgesic. jaundice. Expectoration of mucus is thus facilitated. 20 . It acts by increasing the respiratory tract secretion of lower viscosity mucus and exerting a positive influence on the alveolar surfactant system which leads to improved mucus flow and transport. Safe use during pregnancy (category C) or lactation is not established SIDE EFFECTS a. c. or fainting). or unsteadiness. hives. SPECIFIC INDICATION Parenteral use restricted to treatment of serious infections of GI CONTRAINDICATION History of hypersensitivity to or toxic reaction with any aminoglycoside antibiotic. skin tingling. e. or seizures. Draw blood specimens for trough levels just before the next IM or IV dose. little or no urine. b. muscle twitching. an allergic reaction (shortness of breath. and 30 min after completion of a 30–60 min IV infusion. face. clumsiness. d. 21 . NURSING PRECAUTION Draw blood specimens for peak serum gentamicin concentration 30 min–1h after IM administration. Use nonheparinized tubes to collect blood. closing of the throat.DRUG NAME GENTAMYCIN DOSE/FREQUENCY/ROUTE IVT q 8 ANST CLASSIFICATION Amino glycoside MECHANISM OF ACTION Broad-spectrum aminoglycoside antibiotic derived from Micromonospora purpurea. Action is usually bacteriocidal. swelling of the lips. or f. rash. or tongue. decreased hearing or ringing in the ears. numbness. severe watery diarrhea and abdominal cramps. dizziness. causing cell death. SIDE EFFECTS CNS: lethargy seizures CV: CHF GI: stomatitis. B. D. Allergies of penicillin Culture Infected area Take oral drug on empty stomach VIII. CONTRAINDICATION Contraindicated with allergies to penicillin. furry tongue Other: super infections NURSING PRECAUTION A.DRUG NAME Ampicillin DOSE/FREQUENCY/ROUTE 250mg IVT q 8 ANST CLASSIFICATION Antibiotic penicillin MECHANISM OF ACTION Bacterial action against sensitive organism inhibits synthesis of bacterial cell wall. NURSING MANAGEMENT 22 . C. Take this drug Round the Clock.coli. SPECIFIC INDICATION Treatment of infections caused by susceptible strains of E. sore mouth. trimethobenzamide (Tigan). Monitor laboratory studies. Electrolytes are lost in large amounts. stabilizing coagulation and reducing risk of hemorrhage. Hypotension (including postural). Minor alterations in serum levels can result in profound and/or life-threatening symptoms. Indicates excessive fluid loss/resultant dehydration. Note number. magnesium) and ABGs (acid-base balance). Antiemetics. which is necessary for proper skeletal and cardiac muscle function. estimate insensible fluid losses. and diarrhea can also lead to metabolic acidosis through loss of bicarbonate (HCO3).Risk for fluid volume deficit related to excessive losses through normal routes (frequent diarrhea. fever can indicate response to and/or effect of fluid loss. observe for oliguria. Slow-K).g. Inadequate diet and decreased absorption may lead to vitamin K deficiency and defects in coagulation. and bowel disease control.. e. especially in bowel with denuded.g. Note: fluids containing sodium may be restricted in presence of regional enteritis. dipphenoxylate (Lomotil). Assess vital signs (BP.. renal function. Vitamin K (Mephyton) 23 . Used to control nausea and vomiting in acute exacerbations.g. acetaminophen (Tylenol). decreased skin turgor. Determines replacement needs and effectiveness of therapy. Excessive intestinal loss may lead to electrolyte imbalance.g. Administer medications as indicated: Antidiarrheal e.. Reduces fluid losses from intestines. e. Note generalized muscle weakness or cardiac dysrhytmias. e. and amount of stools. loperamide (Imodium).g. potassium. tachycardia. diaphoresis. Colon is placed at rest for healing and to decreased intestinal fluid losses. Stimulates hepatic formation of prothrombin. e. character. Measure urine specific gravity. reducing insensible losses.K-Lyte.. as well as guidelines for fluid replacement. potassium supplement (KClIV. COLLABORATIVE Administer parenteral fluids. Observe for overt bleeding and test stool daily for occult blood. blood transfusions as indicated. prochlorperazine (Comparazine). Indicator of overall fluid and nutritional status. vomiting) IDEAL NURSING MANAGEMENT INTERVENTIONS INDEPENDENT Monitor Intake and Output. bed rest.g. Electrolytes. ulcerated areas. e. slowed capillary refill. pulse. hydroxyzine (Vistaril). Controls fever.g. RATIONALE Provides information about overall fluid balance.. anodyne suppositories. potentiating risk for hemorrhage. Observe for excessively dry skin and mucous membranes.. electrolytes (especially potassium. Antipyretics. temperature).Ideal Nursing Manangement . e. Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia.. Weigh daily Maintain oral restrictions. and lifestyle factors can precipitate symptoms. fluids. frequency. RATIONALE Establishes knowledge base and provides some insight into individual learning needs. Encourage questions. Promotes understanding and may enhance cooperation with regimen. the mother needs to be aware of what foods. Accurate knowledge base provides opportunity for the mother to make informed decisions/choices about future and control of chronic disease. cause/effect relationship of factors that precipitate symptoms. Stress importance of good skin care. they may have outdated information or misconceptions. Although most others know about their own disease process.the significant others will: Verbalize understanding of disease processes. Reduces spread of bacteria and risk of skin irritation/breakdown. infection. and possible side effects. Review medications. IDEAL NURSING MANAGEMENT 24 . and identify ways to reduce contributing factors. Emphasize need for long-term follow-up and periodic reevaluation. treatment. Review disease process. proper handwashing techniques and perineal skin care.Knowledge deficient regarding condition. prognosis. purpose. self-care. Patients with IBD are at risk for colon/rectal cancer. INTERVENTION INDEPENDENT Determine the mother’s perception of disease process. Precipitating/aggravating factors are individual.. Desire outcomes/evaluation criteria..g. and discharge needs as related to unfamiliarity with resources and information misinterpretation. and regular diagnostic evaluations may be required. e. dosage. therefore. possible complications. e.9C. be free of chills. Room temperature/number of blankets should be altered to maintain nearnormal body temperature. or tuberculosis (TB). Note: Use of antipyretics alters fever patterns and may be restricted until diagnosis is made or if fever remains higher that 102F (38. Fever pattern may aid in diagnosis. Monitor environmental temperature. Provide tepid sponge baths. Actual Nursing Management 25 . note shaking chills/profuse diaphoresis. scarlet or typhoid fever. b. limit/add bed linens as indicated. usually higher than 104F-105F (39. May help reduce fever.5C-40C). Used to reduce fever. acetaminophen (Tylenol). Used to reduce fever by its central action on the hypothalamus. remittent fever (varying only a few degrees in either direction) reflects pulmonary infections.9C).g. when brain damage/seizures can occur. avoid use of alcohol. actually elevating temperature.1C) suggests acute infectious disease process.41. fever should be controlled in patients who are neutropenic or asplenic. Chills often precede temperature spikes.patient will: Demonstrate temperature within normal range. sustained or continuous fever curves lasting more than 24 hour suggest pneumococcal pneumonia. Desired outcomes/evaluation criteria. septic endocarditis. e. fever may be benefial in limiting growth of organisms and enhancing autodestruction of infected cells. RATIONALE Temperature of 102F-106F (38..g. intermittent curves or fever that returns to normal once in 24-hour period suggests septic episode. acetylsalicylic acid (ASA) (aspirin). alcohol is very drying to skin. Note: use of ice water/alcohol may cause chills. In addition. Provide cooling blanket. Collaborative Administer antipyretics.. INTERVENTION Independent monitor patient temperature(degree and pattern).Hyperthermia related to dehydration as evidenced by increase in body temperature higher than normal range. However. Administered Ambroxol as prescribed. • To enhance drainage and ventilation to different lung segments 2.Priority number 1 S O A P “Sa wala pa na admit akong anak. • • May compromise airway. • Dependent: 5. Priority number 2 “Nangluspad naman gud akong anak tungod kai daghan na siya nasuka ug gekalibang” as verbalized by the patient’s mother • • Cool extremities Sunken eyes 26 . the patient was able to maintain airway patency. To loosen the secretions 3. I 4. Monitored infant for feeding intolerance. Elevated head of the bed by putting pillow under the head/changed position frequently. ge ubo na siya” as verbalized by the patient’s mother • • • Productive cough Inability to expectorate secretions Restlessness Ineffective Airway Clearance related to productive cough Short Term: At the end of 8 hours. abdominal distention and emotional stress. the patient will be able to maintain airway patency. 1. Encouraged mother to hydrate infant frequently. • To loosen the secretions To prevent vomiting with aspiration to lungs E S O The goal has been met. Positioned appropriately and discouraged use of oil-based products around the nose. Observed for excessively dry skin and mucous membranes.5 kgs) A P Fluid volume deficit related to excessive losses through GI tract secondary to diarrhea Short term: At the end of 8 hours. • • To increase fluid intake To ensure accurate picture of fluid status 2. decreased skin turgor. the patient will be able to restore fluid and electrolyte imbalances • Encouraged the mother to give oral fluid intake. • Indicates excessive fluid loss/resultant dehydration I 4. Monitored intake and output balance.• • • • Dry skin Watery stool Persistent vomiting Weight (Before = 7 kgs. Provided supplement fluids as indicated D5LR 500cc @ 28cc/hr • Fluids may be given in this manner if patient is unable to take oral fluid To note the changes in heart rate and respiration E S O Goal has been met. Monitored vital signs • Dependent: 6. Basa pa gyud iya tae ug sige na siya kalibang” as verbalized by the patient’s mother • • Hyperactive bowel sounds 3-5 loose liquid stools per day 27 . the patient was able to restore fluid and electrolyte imbalances Priority number 3 “Sakit kayo ang tiyan sa bata sig era siya hilak sa kasakit. Now = 6. Weighed daily • Indicator of overall fluid and nutritional status 5. at the end of 8 hours. 3. slowed capillary refill. the patient was unable to manifest signs of decrease fluid volume. assessment of effectiveness of treatment regimen. Referrals and Follow-up Our further Inpatient care includes monitoring of changes in vital signs.Inalen Matias dietary modification of their son. E IX. location. and parents’ 28 . 1.A P Diarrhea related to irritation of the GI tract Short Term: at the end of 8 hours. Did auscultation of abdomen.& Mrs. Encouraged oral fluid intake containing electrolytes. Administered antidiarrheal medications as prescribed. and characteristics of bowel sounds. • To treat infectious process and decrease motility and minimize fluid losses Goals were not met At the end of 8 hours. and the advice regarding the importance of adequate bed rest. • • To maintain fluid and electrolyte balance Because. • Dependent: 5. the patient will reestablish and maintain normal pattern of bowel functioning. compliance with treatment regimen. • To determine the amount of output and fluid replacement needs 2. reinforcement of dietary advice(At par with age regular diet). Weighed infant’s diaper. skin breakdown can occur quickly when diarrhea is present 3. Our further Outpatient care includes instructions of Mr. To check for presence. Provided prompt diaper changes and gentle cleansing I 4. They had also recognized the importance of compliance to treatment regimen in order to manage the condition of their son.participation through reporting of adverse effects of medications to his physician. 7th Edition Pearson Education South Asia PTE LTD Philippines 2004 o Smeltzer. X. 11th edition. The parent was also instructed to have a regular check-up at PGH Hospital with their son in order to monitor the current condition. With the help of health teachings and other interventions.B. I was able to identify potential problems and specific nursing interventions were provided. Jhunienne Matias. 2007 29 . Parents of Jhunienne Matias were able to learn how to recognize signs and symptoms and other risk factors of the condition of their son. Evaluation and Implications Within the span of 2 day of rendering care to Jhunienne Matias. Medical-Surgical Nursing. B. et al Fundamentals of Nursing. Medical-Surgical Nursing. Lippincott William & Wilkins. XI. The Parents of Jhunienne Matias was able to verbalized the importance of giving medications to their son. Saunders Company (1987) o Kozier. 3rd Edition W. BIBLIOGRAPHY: o Luckman and Sorensen. 2005 o Doengoes. Elesevier Mosby. Davis.com 30 .mims. 2004 o www. 9th edition.org o www. Mosby’s Nursing Drug Reference.wikipedia.A. Nurse’s Pocket Guide. F.o Mosby.