ABSTRACT
The study shows the analysis of the disease condition and health status of
a 6 year old male from Capitol University Medical Center at the medical
ward station 3. This study aims to draw a conclusion and find appropriate
nursing interventions to improve patient condition and thus, facilitates
promotion of optimal wellness. The author of this study focuses on the
management of Facial /Periorbital cellulitis .
The researcher is interested on this health problem for it entails a
thorough study and assessment for it to be fully understood. The
researcher also wants to know the appropriate care that she has to
provide for a patient having this situation. The study and results are just
based on the actual rendering of care to the patient which lasted for three
days including a thorough assessment of the patients past and present
hospitalization and health problem.
ACKNOWLEDGEMENT
I would like to take this opportunity to express my gratitude and deep
regard to my guide and mentor, Mr. Leo Hamed Fabre RN,MAN, our
Clinical Instructor, for his exemplary guidance, monitoring and constant
encouragement throughout the rotation duty and especially this case
study. The help, guidance and education given by him shall carry me a
long way in the journey of my life on which I am about to embark.
I am also very thankful to our God Almighty, to my parents, and friends for
their constant encouragement. Without them, this assignment would not
be possible.
INTRODUCTION
When you are a nurse you know that every day you will touch a life
or a life will touch yours. Anonymous
We, as health care practitioners, called to the responsibility of
promoting health through providing strategic care to patients and to
actively involve of the development of the nursing profession. In addition
to the conventional nursing duties of observing, assessing and recording
symptoms and treatments, they also provide emotional support to patients
and their families. In each patient we care, we tend to provide quality of
care as if we are taking our own family member and at the end of the day
we are bound to touch a persons life or their life will touch ours.
The chosen patient has a case of Facial Periorbital cellulitis
NURSING PROCESS
PATIENTS PROFILE
Nursing Health History
BIOGRAPHICAL DATA
PAST HISTORY
Patient family history has no known Hypertension on his mother side and
no known diabetes in both sides families. No previous admissions
Patients General Appearance
During assessment patient appeared conscious, coherent, and
awake. Pale, weak in appearance.
FUNCTIONAL HEALTH PATTERN
NUTRITIONAL AND METABOLIC PATTERN
The patient eats everything before he was been admitted. He
drinks 5-7 glasses a day. After diagnosed with Facial periorbital he was
been in hypoallergenic diet.
ELIMINATION PATTERN
According to the patient he usually defecated for at least once a
day with yellowish brown in color, soft formed with no discomfort. During
his illness he defecated once a day.
He urinated with an average of 350ml each day, clear urine.
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Facial swelling
PATHOPHYSIOLOGY
PREDISPOSING
FACTORS
-
PRESIPITATING
FACTOR
Male
Cellulitis
Entry of pathogen through
impaired skin integrity:
commonly S. Aureus and S.
Pneumoniae
Viral agent
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Inflammation
Vasodilation
Increased blood flow
Redness
warmth
Time: 03:51:38PM
RESULT
UNIT
REFERENCE
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19,500
Cell/mm3
5,000-10,000
5.2
10^6/Ul
4.2 5.4
HEMOGLOBIN
14.60
g/dL
12.0 - 16.0
HEMATOCRIT
40.50
37.0 - 47.0
MCV
87.4
fL
82.0 98.0
MCH
27.80
Pg
27.0 31.0
MCHC
31.5
g/dL
31.5 35.0
RDW-CV
12.7
12.0 - 17.0
PDW
10.50
fL
9.0 -16.0
MPV
09.80
fL
8.0 12.0
Lymphocyte (%)
20
17.4 48.2
Neutrophil (%)
52
43.4 76.2
Monocyte (%)
4.5 10.5
Eosinophils (%)
1.0 3.0
0.20
0.0 2.0
1.0 3.0
Cell/mm3
144,000-372,000
DIFFERENTIAL COUNT
Basophils (%)
Bands/Stabs (%)
PLATELET
527,000
INTERPRETATIONS:
1 WBC High white blood cells indicates infection.
Medical Management
Generic Name: cetirizine hydrochloride
Brand Name: -Reactine (CAN)
-Zytec
Classification: Antihistamine
Pregnancy Category B
Dosage: 5-10 mg Adult
6-11yrs 5 or 10mg
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Route: p.o.
Frequency: q8 3times a day
Mechanism of Action: Potent histamine (H1) receptor antagonist; inhibits
histamine release and eosinophil chemotaxis during inflammation, leading
to reduced swelling and decreased inflammatory response
Indication: Management of seasonal and perennial allergic rhinitis
Treatment of chronic, idiopathic urticaria
Treatment of year-round allergic rhinitis and
chronic idiopathic urticaria in infants > 6 mo
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Nursing Management:
Assessment Data
Subjective: Gangulngol akong samad as verbalized by the patient.
Objective Data:
facial grimace (+)
Irritability
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Restlessness
Nursing Diagnosis:
Acute pain related to disruption of the skin
Goals and Objectives:
Goal:
After effective nursing interventions, the clientss pain will decrease
from 5/10 to 2/10.
Objectives:
After 1 hour of nursing interventions, the client will be able to:
1. Perform non-pharmacological management for pain.
2. Demonstrate increased comfortability.
Assessment Data
Subjective: Iya gakaluton pirme iya samad as verbalized by his mother.
Objective Data:
Nursing Diagnosis:
Risk for infection related to breakage of superficial skin
Goals and Objective:
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Assessment Data
Subjective: Dili na sya sakit as verbalized by the patient
Objective Data:
Ambulatory
Normal vital signs
Nursing Diagnosis:
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Evaluation:
Goal met.
As evidenced by patients mother verbalized and understood
discharge needs of the patient.
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that other drugs, such as over the counter drugs that he is taking,
will probably have other effects with the medication given.
Moreover, emphasize the right timing or taking or the right time
intervals of these drugs to maximize its effects and avoid further
complications.
regimen.
Rationale: To be able to provide a list of take home medications for
patient X. This would also help his in the on-time and proper
compliance of maintenance medications.
Exercise
The patient is permitted to resume his former activities and
responsibilities completely once recovered from illness. Until then,
bed rest is recommended.
Treatment
OPD
Encourage patient and family members to consider regular checkups as ordered by the physician to ensure the continuing
management and treatment.
Diet
19
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Having been exposed to the hospital area was not that easy
because we were dealing with the lives of the patients. It is in this rotation
that I felt that I was now moving on towards a more challenging event in
my career. My skills have enhanced due to our day to day duties, I was
introduced to new skills and procedures and how to use and perform
them. I learned how to become responsible and effective nurse when it
comes to giving quality care to patients.
The experience I had was fruitful because I was able to acquire
new knowledge and skills that I need and it was very beneficial in my part
because my capabilities have reach its peak level.
BIBLIOGRAPHY
A Books
Delgin, Judith H., Vallerand, April H. (2007). Davis Drug Guide for
Nurses Tenth Edition. 1915 Arch Street Philadelphia, PA 19103.
B Internet
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http://en.wikipedia.org/wiki/Hemothorax
http://emedicine.medscape.com/article/2047916-overview
http://www.nlm.nih.gov/medlineplus/ency/article/000126.htm
http://www.teleflex.com/en/usa/ucd/thoracic_system_pathology.php
http://www.sciencedirect.com/science/article/pii/S02725231040
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