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CLINICAL CASE ANALYSIS Utilizing the (Nursing Process) NCP

I. ASSESSMENT Name: Jhon Angelo Guerrero Time: 11:21pm Address: Brgy. Magsikap Gen. Nakar Date Admitted: 4 1! 1! Diagnoses: "ra#ture #lose #omplete trans$erse mid %rd &emur '() II. NURSING IST!RY

Demographi# Data Date o& Birth: 12 24 *+ Age: 12 Gender: Male ,i$il -tatus: -ingle "ather: Armando Guerrero Mother: Gina Guerrero .eason &or -eeking /ealth ,are: "e$er and skin rashes at the lo0er e1tremities 2er#eption o& /ealth -tate: 3& the parents sees that there is something 0rong in the health o& their #hild that is 4eyond their kno0ledge they #onsult to a physi#ian. 2re$ious 3llness: none III. CLIENT"#AMILY"ME$ICAL STATUS Addi#tion: ' drugs5 al#ohol5 #igarette ) none Dia4etes: none Mental disorder: none Arthritis: none /eart Disease: none -i#kle #ell Anemia: none ,an#er: none /ypertension: none -troke: none ,hromi# (ung Disease: none 6idney Disease: none 3mmuni7ation 81posure to ,ommuni#a4le Disease9 ,omplete 3mmuni7ation Allergies: none I%. PSYC !S!CIAL IST!RY

Al#ohol use: /e does not drink al#ohol To4a##o: /e does not smoke Drug use: none

,a&&eine intake: none %. SEL# PERCEPTI!N"SEL# C!NCEPT "amily -tru#ture9 e1tended .ole in "amily 9 son ,ultural 8thni# Group 9 .oman ,atholi# :##upational ;ork .ole 9 student .elationship 0ith :thers: </e ha$e a good relationship 0ith others5 he is &riendly= %I. ACTI%ITIES !# $AILY LI%ING Type o& Diet: .egular diet >sual ;eight ? 1%kg 8ating 2attern ? % times a day Type o& -na#k ? </e likes &ruits spe#ially 4anana.= "ood likes and Dislikes 9 none "luid 3ntake Amount: 1@!! ml %II. ELLIMINATI!N (USUAL PATTERN) >rinary ? %1 a day Bo0el ? on#e a day %II. SLEEP"REST >sual -leep 9 2attern A hrs .ela1ation Te#hniBue 2attern 9 taking nap A#ti$ity 81er#ise9 2laying 0ith his toys and &riends >sual 81er#ise 2attern ? 2laying 0ith his toys A4ility to 2er&orm -el& ,are A#ti$ities ? /e is assisted 4y his parents I&. RE%IE' !# SYSTEM .espiratory ? 2% #y#le per min. Cesi#ular and 4ron#ho$esi#ular 4reathe sounds 8&&ortless in respiration ,ir#ulatory ? heart rate at rest is 0ithin normal range o& A@ 3ntegumentary ? healthy and smooth skin Mus#uloskeletal ? ha$e a good mus#le tone Neurosensory ? he #an tell names o& #olors at his age -el& Maintenan#e a#ti$ity ? he is assisted 4y his parents

>sual -our#e o& /ealth ,are9 the pt. goes to health #are pro$ider to seek some ad$i#e on her health :ther /ealth Maintenan#e A#ti$ity9 the pt. take some $itamins

&. PAT !P YSI!L!GY The measles $irus initially in&e#ts the respiratory epithelium and is transmitted $ia respiratory droplets. 3t is highly transmissi4le 0ith an in&e#ti$ity rate o& +DE5 e$en greater than that o& $ari#ella. 2rior to the measles $a##ine5 in&e#tion 0ith the measles $irus 0as simply #onsidered a part o& li&e. 3nstead o& repli#ating in the respiratory epithelium5 as 0as on#e thought5 repli#ation appears to o##ur in the regional lymph nodes. .epli#ation in regional lymph nodes e$entually leads to $iremia. 3n&e#tion o& the endothelial #ells ensues5 #ausing an enanthem '6oplik spots). 8pithelial #ells are also in&e#ted5 leading to the 0ell9kno0n #utaneous eruption o& measles. The measles $irus is a single stranded .NA $irus o& the genus Mor4illi$irus and &amily 2aramy1o$iridae. Measles $irus has 2 mem4rane gly#oproteins #alled hemagglutinin and &usion. Both o& these gly#oproteins appear to 4e important &or in&e#tion 0ith the measles $irus. /emagglutinin appears to 4e in$ol$ed 0ith re#eptor 4inding and &usion5 0ith &usion o& the $irus 0ith host #ells. 81pression o& hemagglutinin a#ti$ates the alternati$e #omplement path0ay. The 8dmonston strain o& the measles $irus and $a##ines deri$ed &rom this strain 4ind to the #ell sur&a#e protein ,D4D5 also kno0n as mem4rane #o&a#tor protein. ,D4D is a regulator o& the #omplement a#ti$ation gene and inhi4its a#ti$ation o& the alternati$e #omplement path0ay. "our iso&orms o& ,D4D e1ist in humans5 and all are #apa4le o& 4inding measles $irus. An additional #ellular re#eptor &or the measles $irus has re#ently 4een identi&ied #alled -(AM 'signaling lympho#yte9a#ti$ation mole#ule) or ,D01@! e1pressed on some T and B #ells. -(AM is #apa4le o& 4inding strains o& the measles $irus that also 4ind ,D4D 'the 8dmonston strain) as 0ell as strains that do not 4ind ,D4D su#h as the 6A strain. 3n&e#tion 0ith the measles $irus leads to a prolonged immunosuppression5 0hi#h a##ounts &or mu#h o& the mor4idity and mortality asso#iated 0ith this disease. ,ell9 mediated immunity de#reases5 #lini#ally e$iden#ed 4y the #on$ersion o& positi$e tu4er#ulin skin test results to negati$e &ollo0ing in&e#tion or $a##ination. The me#hanism o& this immunosuppression is 4eing elu#idated.

"ollo0ing in&e#tion 0ith the measles $irus5 a shi&t &rom #ell9mediated immunity 'a T/91 response) to humoral immunity 'a T/92 response) o##urs. 81pression o& the T/92 #ytokine interleukin '3()?2 is in#reased5 supporting anti4ody &ormation5 and T/91 #ytokines 3(925 3(9125 inter&eron '3"N)?gamma de#rease. 3(912 is a #ru#ial #ytokine &or the de$elopment o& #ell9mediated immunity. 3t is ne#essary &or delayed9type hypersensiti$ity5 indu#es produ#tion o& 3"N9gamma5 and plays a role in a#ti$ation o& T #ells and natural killer #ells. 6arp et al &ound that in&e#tion o& mono#ytes5 the primary produ#er o& 3(9125 0ith the measles $irus $ia ,D4D led to de#reased produ#tion o& this #ytokine. "ugier9Ci$ier et al &ound that a#ti$ated dendriti# #ells also had a signi&i#ant de#rease in produ#tion o& 3(9125 leading to proli&eration o& the measles $irus and apoptosis o& in&e#ted dendriti# #ells and T #ells. These &indings support the hypothesis that measles $irus in&e#tion o& antigen9presenting #ells plays a #riti#al role in the immunosuppression o4ser$ed &ollo0ing in&e#tion 0ith the measles $irus. 2rimates are the only hosts &or measles $irus5 and no animal model e1ists that repli#ates the #lini#al &indings o& measles in&e#tion typi#al in #hildren. &I. ME$ICAL " SURGICAL MANAGEMENT F33. D3AGN:-8T3, 2.:,8D>.8 /ematology N:.MA( CA(8>/emoglo4lin M: 1491A ": 1291D .8->(T -3GN3"3,AN,8 3NT8.2.3TAT3:N N>.-3NG 3M2(3,AT3:N A lo0 hemoglo4in #ount indi#ates a lo0 red 4lood #ell #ount 'anemia) A high hemoglo4in le$el indi#ates a possi4ility o& 2oly#ythemia $era 'also kno0n as G8rythremiaG) is a 4lood disorder in 0hi#h the 4one marro0 makes too many red 4lood #ells. 2oly#ythemia $era may also result in the o$erprodu#tion o& 0hite 4lood #ells and platelets. Most o& the health #on#erns asso#iated 0ith poly#ythemia $era are #aused 4y a 4lood9thi#kening e&&e#t that results &rom an o$erprodu#tion o& red 4lood #ells. A lo0 hemato#rit is re&erred to as 4eing anemi#.

11.+g dll

/emato#rit M: 4!9@4E ":%+94+E

%@E

3t also indi#ates a possi4ility o&

poly#ythemia $era. 3& a patient is dehydrated5 the hemato#rit may 4e ele$ated. 3n #ases o& dengue &e$er a high hemato#rit is a danger sign o& an in#reased risk o& dengue sho#k syndrome. 2latelet #ount 1@!94!! mi#roliter o& 4lood (o0 in platelet #ount may indi#ate throm4o#ytopenia and may also in#rease 4leeding risk. /igh in platelet #ount may indi#ate throm4o#ytosis.

%41 mi#roliter o& 4lood

&III. $RUG STU$Y Brand Name Generi# Name 3ndi#ation ,ontraindi#ation

2rostaphilin Ta4 2@!mg B D hours 2harma#ort Ta4 2@mg B D hours

:1a#illin

-taphylo#o##al in&e#tions resistant to 4en7ylpeni#illin. /ydro#ortisone is in a #lass o& drugs #alled steroids. /ydro#ortisone pre$ents the release o& su4stan#es in the 4ody that #ause in&lammation. /ydro#ortisone is used to treat many di&&erent #onditions su#h as allergi# disorders5 skin #onditions5 ul#erati$e #olitis5 arthritis5 lupus5 psoriasis5 or 4reathing disorders.

/ypersensiti$ity to peni#illins. Ciral &ungal in&e#tions5 tu4er#ular or syphiliti# lesions5 4a#terial in&e#tions unless used in #onIun#tion 0ith appropriate #hemotherapy.

/ydro#ortisone

Allerkid -yrup %ml :D

,etiri7ine

hypersensiti$e to A#ute H #hroni# hydro1y7ine. urti#aria5 pruritus5 allergi# rhinitis5 allergi# #onIun#ti$itis. ,lo1a#illin is an anti4ioti# 4elonging to a #lass o& drugs #alled peni#illins. 3t &ights 4a#teria in your 4ody. 3t is used to treat many di&&erent types o& in&e#tions #aused 4y staphylo#o##us 4a#teria.

,lo1a#illin 2@!mg -yrup @ ml

,lo1apen

,alpol -yrup J 91 tsp

2ara#etamol

"or the symptomati# treatment o& mild to moderate pain and &e$er in #hildren.

/ypersensiti$ity to para#etamol. 2atients 0ith se$ere li$er &un#tion impairment.

-an. 2a4lo ,olleges ,ollege o& Nursing

,ase Analysis <-ystemi# Ciral 3n&e#tion German Measles=

-u4mitted By. Mr. Jherome ,oligado -u4mitted To: MaKam >si ..N. MAN ',lini#al 3nstru#tor)

"e4ruary 245 2!1!

F3C. N>.-3NG ,A.8 2(AN

Assessment -L < May rashes siya sa legs at p0et niya5 pero na0a0ala 0ala na5 % days na kase.= :L 0ith &lushy skin Lirrita4le L0ith rashes on the lo0er e1tremities.

Nursing Diagnosis Altered skin integrity related to $iral in&e#tion.

Nursing :4Ie#ti$e To pre$ent &urther #ompli#ations. To alle$iate irritation. /ygiene emphasi7e.

Nursing A#tion 8n#ourage deep 4reathing e1er#ise 6eep the skin dry5 linens dry and 0rinkle &ree. 2romote good hand 0ashing 4y nurse and patient.

.ationale To mo4ili7e lung se#retion To pre$ent skin irritation .edu#es the risk o& #ross #ontamination.