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LICEO DE CAGAYAN UNIVERSITY COLLEGE OF NURSING NCM501202 RELATED LEARNING EXPERIENCE

CARE STUDY TOPIC

SUBMITTED BY

SANRIA O> LUGTU


RLE GROUP CLUSTER I-A11 TERM FINAL
SUBMITTED TO MS. MAYLINDA B. ORO, RN September 29, 2008

INTRODUCTION

This is a case study of an 11month old client admitted at Polymedic

General Hospital with a chief complaint fever for of 2 cough weeks with and and Acute

diagnosed

Bronchitis. Bronchitis means that the tubes that carry air to the lungs (the bronchial tubes) are inflamed and

irritated. When this happens, the tubes swell and produce mucus. This makes you

cough. Acute bronchitis is usually caused by viruses or bacteria and may last

several days or weeks. Acute bronchitis is characterized by cough and sputum (phlegm) production and symptoms related to the obstruction of the airways by the inflamed airways and the phlegm, such as shortness of breath and wheezing. Acute bronchitis symptoms usually start 3 or 4 days after an upper respiratory tract infection. Most people get better in 2 to 3 weeks. But some people continue to have a cough for more than 4 weeks. Infants with bronchitis may have many of the symptoms above, but in many cases they are simply sleepy or have a decreased appetite.

B. OBJECTIVE OF THE STUDY This study aims to convey the patient and significant others with information about the disease process, medication, treatment, diet and its course of medical and nursing intervention. To assess patient thoroughly, identify health problems, plan care, application of plan activities and evaluate its effect to the patient. To present the case study to the group members and clinical instructor and evaluate and learn the outcome of the study to the patient and to the student. To understand the course and essence of the chosen care study and add up additional knowledge and understanding in the Nursing profession.

C. SCOPE AND LIMITATIONS This study in general with limited background and skills of students to care of the patient and problem identified carry through the process of referral to the clinical instructor, staff nurses, and doctors during the 2 days duty in the Pedia Ward. Interventions were rendered gradually depending on the objective assessment of the student. The following information only involves the exact words and answers supported by the client.

II. HEALTH HISTORY A. Patients Profile Name: Age: Sex: Birth date: Birth place: Name of Father: Name of Mother: Civil status: Nationality: Informant: Religion: Address: Allergy: Rossel E. Pabre a.k.a REP 11 months old female October 24, 2007 Cagayan de Oro City Rey Pabre Roseville Pabre Child Filipino Roseville (mother) Roman Catholic Talakag, Bukidnun No known allergy to food and drugs

CLINICAL PROFILE Date of admission: Time of admission: Attending physician: Chief Complaint: Admitting diagnosis: September 15, 2008 12:10 PM Dr. N. Lim, M.D. Cough, fever, acute bronchitis

Diet: Diet as tolerated for age Vital Signs upon admission: T: 39.5 0 C RR: 58 cpm

PR: 145 bpm

B. Patients Health History Rossel E. Pabre, an 11 months old child was born on Cotober 24, 2007. She is the only child of Mr. and Mrs. Pabre. The family is now currently residing at Talakag, Bukidnun. REP and family had no history of asthma, pneumonia or any respiratory problem.

C. History of Present Illness A case of Seanford Luke Montecillo, male, 4 years old experienced cough and fever. Two weeks prior to admission onset of having fever and cough. Consulted to a physician and was given salbutamol and paracetamol. 1 day prior to admission noted with poor appetite due to poor appetite and vomiting. She was brought to the emergency room last September 15, 2008 at 12:10 pm. Vital signs taken Temp.- 39.5 0 C, RR58 cpm, AP- 145 bpm. She was then transferred at Pedia Ward 7th floor PGH.

II. DEVELOPMENTAL HISTORY

Sigmund Freud: Psychosexual Theory


Psychoanalytic theories of human development began in the 1900's with the work of Sigmund Freud. More modern theories of development have now replaced those of Freud. Yet it is still important to be familiar with the basics of Freud's work, as many modern views of human development still have their roots in Freudian theory. Freud developed a general theory of psychological development from infancy to adulthood. He believed that the mind of an infant consists only of primitive drives and instincts, such as the need for food and physical comfort, which he called the "id." The Oral Stage: Birth to 18 Months Anyone familiar with very young babies and children knows that they are focused on their mouths. A baby's first nourishment is received through suckling, and the sucking instinct is usually strong, even in newborns. Freud theorised that an infant's oral focus brought not only nourishment, but pleasure. REP belongs to this stage in which she enjoys sucking and later biting anything that touches the erogenous zone of the lips and mouth. Some infants enjoy this oral activity more than others, while some maybe satisfied by sucking at the breast or bottle, other require pacifiers, toys or other objects that can be orally manipulated.

Erik Erikson: Psychosocial Theory


Erikson's greatest innovation was to postulate not five stages of development, as Sigmund Freud had done with his psychosexual stages, but eight. Erik Erikson believed that every human being goes through a certain number of stages to reach his or her full development, theorizing eight stages, that a human being goes through from birth to death. REP belongs to Trust vs. Mistrust stage. Infancy: Birth to 18 Months Ego Development Outcome: Trust vs. Mistrust Basic strength: Drive and Hope Erikson also referred to infancy as the Oral Sensory Stage (as anyone might who watches a baby put everything in her mouth) where the major emphasis is on the mother's positive and loving care for the child, with a big emphasis on visual contact and touch. If we pass successfully through this period of life, we will learn to trust that life is basically okay and have basic confidence in the future. If we fail to experience trust and are constantly frustrated because our needs are not met, we may end up with a deep-seated feeling of worthlessness and a mistrust of the world in general.

Robert Havighurst: Developmental Task Theory


Robert Havighurst believed that learning is basic to life and that people continue learn throughout life. He described growth and development as occurring during six stages, each associated with six to ten tasks to be learned. Successful achievement of these tasks leads to success and happiness with later tasks, while failure leads to unhappiness in the individual, and difficulty with later tasks. REP belongs to this stage.

Developmental Tasks of Infancy and Early Childhood:


Learning to walk. Learning to take solid foods Learning to talk Learning to control the elimination of body wastes Learning sex differences and sexual modesty Forming concepts and learning language to describe social and physical reality. Getting ready to read

Jean Piaget: Cognitive Theory Swiss biologist and psychologist Jean Piaget (1896-1980) is renowned for constructing a highly influential model of child development and learning. Piaget's theory is based on the idea that the developing child builds cognitive structures--in other words, mental "maps," schemes, or networked concepts for understanding and responding to physical experiences within his or her environment. Piaget further attested that a child's cognitive structure increases in sophistication with development, moving from a few innate reflexes such as crying and sucking to highly complex mental activities. Sensorimotor stage (birth - 2 years old)REP belongs to this stage-- for the child, through physical interaction with his or her environment, builds a set of concepts about reality and how it works. This is the stage where a child does not know that physical objects remain in existence even when out of sight (object permanence).

IV. MEDICAL MANAGEMENT Date September 15, 2008 DOCTORS Order Order Please admit under the service of Dr. Lim TPR q 4 hours Rationale To render proper medical management. To monitor vital signs and note any discrepancies. Labs: CBC Urinalysis IVF D5 0.3% NaCl 500 @ 40 cc/hr.

For laboratory analysis Saline lock; for emergency IVTT drugs used

MEDS: 1. Paracetamol drops 1.1ml q 4hrs. >37.70C 2. Cefuroxime (zinacef) 200mg IVT q 8 (ANST -)
0

To lower fever.

PRN

for

Temp. Bactericidal inhibits synthesis causing cell death. To meet nutritional needs. To monitor unusualities. To reduce fever and infection. of bacterial cell wall,

September 16, 2008

DAT for age Refer accordingly Paracetamol 125mg suppository

12:oo midnight #2 D5 0.3% NaCl 500 @ 40 cc/hr. Salbutamol (ventolin) neb i q 6 Chest X-Ray today To prevent dehydration Treatment for cough as bronchodilator For assessment of the lungs or affected part(s)

DIAGNOSTIC EXAM The following are the laboratory exams as ordered by the patients attending physician. HEMATOLOGY (Sept. 15, 2008) Hematocrit Hemoglobin WBC MCHC Monocytes Basophils RESULT 32.6 vol. % 11.5 10.34 35.3 11.2 1.2 NORMAL 30-40 % 11.7-14 g/dl 5,000-10,000/cc.mm 32-36 % 2-8 % 0.5- 1 %

Clinical Implication: ---Low Hb concentration may indicate anemia, recent hemorrhage, or fluid retention, which can cause hemodilution. ---Low HCT suggests anemia, hemodilution or massive blood loss ---An elevated WBC count commonly signals infection ---Increase monocytes count suggest infection

URINALYSIS (Sept. 15, 2008) Color Yellow

Transparency Odor Protein Glucose Cast Bacteria

clear Aromatic Negative Negative None Not seen

V. ANATOMY, PHYSIOLOGY AND PATHOPHYSIOLOGY

Every time a breath is taken in, the air (20% oxygen) passes through the nose or mouth and then past the larynx or voice box into the windpipe (trachea)

which is about 12.5 cm long. At its lower end the windpipe divides into two main tubes called bronchi. The main air passage in each lung (the bronchus) divides into successively smaller branches which carry inhaled air to all parts of the lung. Each small branch terminates by forming a cluster of very tiny air sacs (the alveoli). A fine network of blood vessels covers the surface of every air sac thereby permitting gas exchange by diffusion. Oxygen from the inspired air passes through the thin tissues to combine with the haemoglobin of the red blood cells. Waste gases, mainly carbon-dioxide, pass from blood into the air sacs and are expelled on breathing out. Each lung is covered by a lubricated lining called the pleura. The inner side of the chest wall is also covered by a similar lining. These two layers of pleura are in contact and slide smoothly over one another during breathing. The act of breathing is mainly due to the diaphragm moving up and down. The diaphragm is a large dome-shaped muscle which separates the chest from the abdominal cavity. When the diaphragm muscle contracts, its dome becomes flattened and draws down the lungs, causing air to enter them; when it relaxes the lungs become smaller and the air in them is expelled. The muscles of the abdomen also help in breathing. When they tighten up, they press the abdominal contents up against the diaphragm and help in expelling air from the lungs; when they relax, they assist the diaphragm in drawing down the lungs as breathing in takes place. The normal rate of breathing at rest is 1618 times a minute. This rate increases considerably with exertion and also with certain diseases, especially those affecting the heart and lungs.

PATHOPHYSIOLOGY

Impaired muscilliary defenses of the lung Increase susceptibility to infection

Mucus production is greater Bronchial walls become thickened and inflamed Obstruct airways, especially during expiration Airways collapse Air is trapped in the distal alveolar ventilation Abnormal ventilation Fall in PaO2 Increase levels of PaCO2

Body compensates for hypoxemia Polycythemia occurs VI. NURSING ASSESSMENT (System Review Chart) EENT:
[ ] Impaired vision [ ] blind [ ] pain redden [ ] drainage

[ ] gums [ ] hard of hearing [ ] deaf burning [ ] edema [ ] lesion teeth [ ] assess eyes ears nose [ ] throat for abnormality [x] no problem RESP: [ ] Asymmetric [ x ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ x ] wheezing [ ] pain [ ] cyanotic [ ] assess resp. rate, rhythm, depth, pattern, breath sounds, comfort [ ] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ]numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain [ ] Assess heart sounds, rate rhythm, pulse, blood pressure, circ., fluid retention, comfort [ x ] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain [ ] assess abdomen, bowel habits, swallowing [ ] bowel sounds, comfort [ x ] no problem GENITO URINARY AND GYNE [ ] pain [ ] oliguria [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [x ] assess urine frequency, control, color, odor, comfort [ ] gyne bleeding [ ] discharge [ x ] no problem NEURO: [ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] treamors [ ] confused [ ] vision [ ] grip [ x ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, speech [ x ] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechie [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] [x] no problem
Body malaise Productive

Skin warm to

With ongoing D5 .3NaCl 500cc @ 40 cc/hr

SUBJECTIVE Communication: __ hearing loss __visual changes _x_denied Comments: Wala man problema sa iya pandungog panlantawas verba lized by pts mother

OBJECTIVE __glasses __languages __contact lens __hearing aide Pupil size: 3mm __speech difficulties Reaction Pupil equally round reactive to light and accomodation Resp. RR: 58cpm Describe: expansion __regular abnormal and x irregular assymmetrical chest

Oxygenation: Comments: ga ubo2x man japon __dyspnea siya pero usahay na__smoking history lang as verba None lized by pts mother _x cough __sputum __denied Circulation: __chest pain __leg pain __numbness of extremities _x denied Comments: Wala man problema sa iya paa og dughan as verbalized by the pts mother

Heart rhythm __regular x_irregular Ankle edema: No edema seen Pulse Car + rad + DP + fem + R: Pulse are palpable L: Pulse are palpable

Nutrition: Diet: Diet as tolerated for age _x_recent change Comments: dili siya gakaon _x_swallowing difficulty og inom pud sa tambalas __denied verbalized by pts mother Elimination: Usual bowel pattern __once daily __ __constipation remedy watery Date of last BM Sept. 16, 2008

__ dentures Upper Lower Full ___ ___ partial ___ ___

_x_none with patient ___ ___

urinary frequency 7 times per day___ __urgency __dysuria __hematuria __ incontinence __ foley in place _ denied

Comments: Bowel sounds: Bowel sounds are audible normoactive Abdominal distention present__yes_x_no Urine (color, odor, Consistency) yellow in Color

Mgt. Of health & illness: __alcohol _x_denied (amount, frequency) N/A_____________________________________ __ SBE last pap smear N/A__________________ LMP: N/A________________________________

Briefly describe the patient's ability to follow treatments (diet, meds, etc.) for chronic health problems The patient has difficulty in taking the medications.

SUBJECTIVE

OBJECTIVES

Skin Integrity: __dry __itching __ other x denied Activity/safety: __convulsion __dizziness x limited motion of joints ability to __ambulate __bathe self __other x denied

Comments: init japon siya kay di man gakawala iyang hilanat. As verbalized by pts mother

_x_dry __cold __pale __flushed _x_warm __moist __cyanotic rashes,ulcers,decubitus (decribe size,location, drainage) there were no presence of rash

LOC and orientation: patient is conscious Comments:sige man siya pa kugos. Kung ibutang Gait: __walker __cane __other mohilak as verbalized by the __steady _x_unsteady pts mother __sensory and motor losses in face or extremities __ROM limitation: patient has limited range of motion

Comfort/sleep/awake: __pain (location, Comments: dali raman siya __nocturia makatulog.as verbalized sleep difficulties by the pts mother x denied Coping: Occupation: N/A Members of household: _5 (father, mother, grandparents and the patient. Most supportive person: _Roseville (mother)

__facial grimaces __guarding __other signs of pain: crying __siderail release form signed ( 60+ years) no side rails _

Observed non-verbal behavior : ______irritability_______________________ The person and his phone number that can be reached any time none

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) 7.6 kg daily weight __________ PT/OT_______________ __________BP q shift __________ Irradiation __________Neuro vs _normal___ Urine test ____________ __________CVP/SG reading_______ __________ 24 hour urine collection Date ordered 9/15/08 9/15/08 Diagnostic/lab exams date done Date ordered Hematology 9/15/08 9/15/08 Urinalysis 9/15/08 9/16/08 I.V/ blood D5 0.3% NaCl D5 0.3% NaCl Date disc. 9/15/08 9/16/08

VII. IDEAL NURSING MANAGEMENT

Diagnosis #1: Ineffective Airway Clearance may be related to thickened mucus secretions as evidenced by tachypnea, productive cough and shallow respiration Interventions: a. Assess rate and depth of respirations and chest movement b. Auscultate lung field, noting areas of decreased/absent airflow and adventitious breath sound, eg. Wheezes, crackles c. Elevate head of bed, change position frequently d. Assist with nebulizer treatments e. Administer medications as prescribed Rationale: a. Tachypnea, shallow respirations and unsymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung. b. Decreased airflow occurs in areas consolidated with fluid. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions and airway spasm/obstruction. c. Lowers diagphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions. d. Facilitates liquefication and removal of secretions e. Aids in reduction of bronchospasm as well as mobilization of secretions.

IDEAL NURSING MANAGEMENT

Diagnosis #2: Impaired Gas Exchange related to cough and fever as evidenced by changes in rate and depth of respiration Intervention: a. Assess respiratory rate, depth and ease; use of accessory muscles b. Monitor body temperature c. Addition/removal of bedcovers, comfortable room temperature, tepid/cool water sponges d. Maintain bedrest e. Elevate head and encourage frequent position changes Rationale: a. Manifestations are dependent on degree of lung involvement and underlying pulmonary/general health status b. High fever greatly increases metabolic demands and oxygen consumption c. Promotes a level of wellness; aids in faster recovery d. Prevents over exhaustion and reduces oxygen consumption/demands e. These measures promote maximal inspiration

IDEAL NURSING MANAGEMENT

Diagnosis #3: Activity intolerance related to decreased pO2 and body malaise Intervention: a. Obtain subjective data from the patient regarding normal activities prior to onset of acute episodes of asthma and current activity status b. Have patient use oxygen immediately prior to activity in the acute setting c. Monitor vital signs and oxygen saturation before and after activity d. Assist with activities as needed e. Pace activities and encourage periods of rest and activity during the day Rationale: a. Helps to determine the effect asthma has had on the patientsity to be active and allows for a better plan for future activity regimen. b. Improves oxygenation and provides for oxygen reserves to be used with increased demand. c. Use the results to indicate when activity may be increased or decreased. d. Conserves energy and reduces oxygen demand. e. Conserves oxygen.

IX. ACTUAL NURSING MANAGEMENT

S O

dili pa gakawala iyang ubo as verbalized by the mother tachypnea, productive cough, and shallow respiration

Ineffective Airway Clearance may be related to thickened mucus secretions as evidenced by tachypnea, productive cough and shallow respiration. At the end of 30 mins, client will be able to demonstrate reduction of congestion with breath sounds clear.

a.

Assessed rate and depth of respirations and chest

movement b. Auscultate lung field, noting areas of decreased/absent airflow and adventitious breath sound, eg. Wheezes, I crackles c. Elevated head of bed, change position frequently d. Assisted with nebulizer treatments e. Administered medications as prescribed At the end of 8 hours, clients breath sound was clear and E was able to expectorate mucous.

galisod siya usahay og ginhawa mao nang d nko ehigda sa higdaanan. as verbalized by the pts mother

tachycardia, cough, and pallor skin, shallow respiration

Impaired Gas Exchange related to cough and fever as A evidenced by changes in rate and depth of respiration At the end of 30 mins, client will be able to display improved P breathing pattern

a. Elevated head using pillows b. Changed position frequently


I

c. Administered medications as prescribed (eg. Brochodilators, expectorants) d. Encouraged adequate rest


At the end of 30 mins, client is able to demonstrate improved

ventilation and oxygenation.

galuya pa siya, d pareho sauna nga magdula-dula as verbalized by the pts mother Wheezing during activities Gasp for breath during activities

Activity intolerance related to decreased pO2

A P
At the end of 30 mins, client is able to perform activities of daily living without wheezing or shortness of breath.

a. Obtained subjective data from the patient regarding normal activities prior to onset of acute episodes of asthma and current activity status b. Has patient use oxygen immediately prior to activity in the acute setting c. Monitored vital signs and oxygen saturation before and after activity d. Assisted with activities as needed e. Paced activities and encourage periods of rest and activity during the day At the end of 8 hours, client is able to state that he is

comfortable with activity performance.

X. EVALUATION/IMPLICATION

The mainstay of nursing and medical treatment with the patient having with such condition is to help the patient to cope, alleviate distress, prevent further complications and help the patient to recover as well as to encourage the patient and the significant others to participate in the therapy. From the initiation of nursing and medical interventions the client showed some signs of recuperation and gradually showed signs of progress. This was evidence form the complete bed rest up to the condition she was given the chance to ambulate gradually as tolerated. From this, my goal was achieved as evidenced by the desire of the patient to go back to his normal daily routine and from the progress of the patient. The clients mother was cooperative enough to stay at the hospital premises and never refuses to go home until the child is not stable. XI. REFERRALS The patient significant other is advice to take his home medication and after 1 week the physician note that any improvement in the clients condition and be back for follow up check up.

XII. BIBLIOGRAPHY Kozier, Erb, Blais, Wilkinson. Fundamentals of Nursing (7th Edition). Philippines: Addison Wesley Longman Inc.1998. Pillitteri, Adelle. Maternal and Child Health Nursing (3rd Edition). Philippines: Lippincott, Williams & Wilkins, Inc. 1999. Doenges, Marilyn et.al. Nursing Care Plans: Guidelines for Planning Patient Care 2ndEd.

DRUG STUDY
Generic Name of ordered drug Brand Name Date Ordered Classification Dose/Frequency/Route Mechanism of Action Ventolin September 16, 2008 Bronchodilator 1 neb/ q6h / steam inhalation Relaxes bronchial smooth muscle by acting on beta2adrenergic receptors; improves ventilation Specific Indication Bronchospam in patients with reversible obstructive airway disease Contraindication To patients hypersensitive to the drug and its components Side Effects Nursing Precaution Effects/Toxic Tremor; palpitations; tachycardia; nausea and vomiting; irritation Perform chest tapping every after nebulization Salbutamol Sulfate

Generic Name of ordered drug Brand Name Date Ordered Classification Dose/Frequency/Route Mechanism of Action

Paracetamol syrup

Two weeks PTA admission Non-opioid analgesic;antipyretic 5ml q 4 hours Per Orem Produces analgesic effect by blocking pain impulses, by inhibiting prostaglandins or pain receptors sensitizers; may relieve fever by acting in hypothalamic heat regulating center

Specific Indication

For mild pain and fever

Contraindication

To patients going long-term therapy for chronic noncongestive angle-closure glaucoma; hyponatremia; hypokalemia; hepatic impairment; adrenal gland failure

Side Effects

hypechloremic acidosis Effects/Toxic Confusion; anorexia; aplastic anemia; rash; renal calculi Report signs of F/E imbalance

Nursing Precaution

Generic Name of ordered drug Brand Name Date Ordered Classification Dose/Frequency/Route Mechanism of Action

Cefuroxime Sodium

Zinacef September 15, 2008 Antibiotic 200mg IVT q 8 hours (ANST -) Bactericidal: inhibits the synthesis of bacterial cell wal causing cell death

Specific Indication Contraindication Side Effects Nursing Precaution

Lower respiratory infections caused by s. pnuemoniae Contraindicated with allergy to cephalosporins

Effects/Toxic Tremor; palpitations; tachycardia; nausea and vomiting; irritation Take full course of therapy even if you are feeling better.