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
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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.
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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.
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Other symptoms include nausea, vomiting, loss of appetite, belching, and bloating. Occasionally, acute abdominal pain can be a presenting symptom. 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. Fever, chills, and hiccups also may be present. The diagnosis of acute gastritis may be suspected from the patient's history and can be confirmed histologically by biopsy specimens taken at endoscopy. b. Objective of the Study This study aims to: •
Conduct and evaluate an assessment for the client
•
Determine the causes, predisposing and precipitating factors that constitute the onset of the disease process.
•
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.
•
Improve skills and knowledge as health care providers in the clinical area. c. Scope and Limitation of the Study This study includes the collection of information specifically to the patient’s
health condition. The study also includes the assessment of the physiological and psychological status, adequacy of support systems and care given by the family as well as other health care providers. The scope of this study would include:
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a. Data collected via assessment, interviews with the patient, family members and clinical records. b. 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. Developing a plan of care that will reduce identified predicaments and complications. d. Coordinating and delegating interventions within the plan of care to assist the client to reach maximum functional health. e. Further evaluating the effectiveness of nursing interventions that have been rendered to the client. An array of factors influencing the limitations of this study includes: a. Data collected is limited only to assessment and interview to the patient, patient’s chart and nurse on duty. b. The interaction, assessment and care were only limited to a total of 16 hours (2 days clinical duty, 1 day assessment) with actual nursing intervention done. c. 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.
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II.
Patients Profile
Client’s Name: Matias, Jhunienne Age: 6 months old Birthday: September 17, 2008 Address: Mambuaya, Cagayan de Oro City Civil Status: Single Sex: Male Nationality: Filipino Religion: Roman Catholic Weight: 6.5 Kg. Informant: Inalen Matias (Mother) Date of admission: Febuary 15, 2009 Time of admission: 4:00 PM Chief complaint: LBM Admitting diagnosis: AGE with mild dehydration Attending physician: Dr. Bacal
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III.
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. Havighurst has identified six major age periods: infancy and early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18 years), early adulthood (19-29 years), middle adulthood (30-60 years), and later maturity (61+). Basing on Havighurst’s Theory, my patient belongs in the infancy and early childhood stage wherein he is learning to distinguish right from wrong and developing a conscience. 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
with
sexual
feelings.
These
stages
Oral
Birth to
to
1year
Anal
2
to
3years
Phallic
4
to
5years
Latency
6
to
12years
Genital
13
and
Up
are
as
follows:
Basing on this theory, Jhunienne Matias belongs to the oral stage wherein an infant’s pleasure centers are in the mouth. This is also the infant's first relationship with its mother; it is a nutritive one.
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Psychosocial Theory of Erik Erickson Erik Erickson envisioned life as a sequence of levels of achievement. Each stage signals a task that must be achieved. He believed that the greater that task achievement, the healthier the personality of the person. Failure to achieve a task influences the person’s ability to achieve the next task. Stages of Erikson’s Psychosocial Theory are as follows: Infancy
Birth – 18 months
Trust vs. Mistrust
Early Childhood
18 months – 3 years
Autonomy vs. Shame
Late Childhood
3 – 5 years
Initiative vs. Guilt
School Age
6 – 12 years
Industry vs. Inferiority
Adolescence
12 – 20 years
Identity vs. Role Confusion
Young Adulthood
18 – 25 years
Intimacy vs. Isolation
Adulthood
25 – 65 years
Generativity vs. Stagnation
Maturity
65 years to death
Integrity vs. Despair
Basing on this theory, he is still belongs to Infancy based on Erikson’s theory the child developmental task is the “TRUST vs. MISTRUST” Because an infant is utterly dependent; the development of trust is based on the dependability and quality of the child’s caregivers. If a child successfully develops trust, he or she will feel safe and secure in the world. Caregivers who are inconsistent, emotionally unavailable, 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. 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.
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Cognitive Theory of Jean Piaget Cognitive development refers to how a person perceives, thinks, 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
Birth to 2 years
Pre-conceptual Phase
2 – 3 years
Intuitive Thought Phase
4 – 6 years
Concrete Operations Phase
7 – 11 years
Formal Operational Phase
12 – adulthood
Basing on this theory, Jhunienne Matias belongs to the sensorimotor stage in which inventions of new means through mental combinations. The patient uses memory and imitation act, he can solve basic problems.
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IV.
HEALTH HISTORY
a. Family Health History According to the father regarding the herido-familial history both her mother and father side has a history of hypertension. On the father side they had a history of cancer since the father’s aunt died last 2001 due to cervical cancer. b. Past Health History The father claimed that his child past illnesses were a typical cough, colds and fever that usually lasted for three days. 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, 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. The patient was born in JRB Hospital through a normal spontaneous vaginal delivery. c. History of Present Illness A case of Matias, Jhunienne, 6months old Male, Filipino, a resident of Mambuaya Cagayan de Oro City, admitted for the first time at PGH hospital with a chief complaint of LBM. Two days prior to admission he had persistent LBM, vomiting, cough and fever.
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V.
Nursing Assessment (System Review & Nursing Assessment II)
Name: Jhunienne Matias Date: 02-15-09 Temp: 38.6ºC HR: 137bpm BP: N/A Height_____ Weight:6.5 kgsRR: 50cpm INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X]. EENT: [ ] impaired vision [ ] blind [ ] pain reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion teeth Assess eyes, ears, 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. rate, rhythm, pulse blood breath sounds, comfort [ ] 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 [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia assess urine frequency, control, color, odor, comfort NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip assess motor, function, sensation, LOC, strength grip, gait, 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, motion, gait, alignment, joint function skin color, texture, turgor, integrity [ ] no problem
Sunken eyes Poor appetite Colds Cough Poor skin turgor Hyperactive bowel sounds
Hyperthermia =38.6C hooked with IVF of D5 0.3Nacl 500cc
Watery Stools
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SUBJECTIVE COMMUNICATION: [ ] hearing difficulty [ ] visual changes [x] denied
OXYGENATION: [ ] dyspnea [ ] smoking history Non-smoker [x] cough [ ] sputum [ ] denied CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of
Comments: “Wala man
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.
[ x ] diarrhea [ ] constipation
Resp. [x] regular [ ] irregular Describe: RR is within normal range. R: symmetrical to the left lung L: symmetrical to the right lung
Heart Rhythm [x ] regular [ ] irregular Ankle Edema: No ankle edema is present on both extremities Pulse Car Rad. DP Fem* R _______+______+_ __ + __not assessed L _____+_____ +_ _____+ not assessed Comments: Right and left pulses are equal; strong and palpable.
Comments: ”Gina patutoy Raman nako siya” as verbalized by the mother.
[ ]dentures
[x ] denied
Date of last BM December 5, 2008
[ ] 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)
Comments: ”Wala may sakit sa tiil ug dughan akong anak”as verbalized by the mother.
extremities
NUTRITION: Diet: Exclusive B.F since Birth. Character [ ] recent change in weight [ ] swallowing Difficulty [x] denied ELIMINATION: Usual bowel pattern 5 loose stools per day [ ] constipation remedy
OBJECTIVE
[x] urinary frequency Diaper [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foley in place [x] denied
MGT. OF HEALTH & ILLNESS: [ ] alcohol [ x ] denied (amount & frequency) ________________________________________.
[x]none
Complete
Incomplete
Upper
[]
[x]
Lower
[]
[x]
Comments: ”magsunod sunod jud siya ug kalibanga”as verbalize by the mother.
Bowelsounds: hyperactive Abdominal Distention Present [ ] yes [x] no Urine* (color, consistency, odor) urine color is straw, amber transparent and faint aromatic odor. *if they are in place
Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). N/A.
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[ ] SBE: N/A
Last Pap Smear: N/A
SUBJECTIVE
OBJECTIVE
SKIN INTEGRITY: [x] dry [ ] other
Comments: ”Mala jud iya panit kay cige ra ug kalibang” as verbalized by the mother.
[x] dry [ ] cold [ ] pale [ ] flushed [ ] warm [ ] moist [ ] cyanotic *rashes, ulcers, decubitus (describe size, location, drainage: no rashes and ulcers found the the patients body.
Comments: ”kalooy sa ginoo wala jud nag lipong-lipong akong anak ug maka lihok rapud siya” as verbalized by the mother.
[x] LOC and orientation Patient is normalunconscious oriented Gait: [ ] walker [ ] cane [ ] other
Comments: perminte ra siya ga mata mata tungod ni sa iyang kainit” as verbalized by the mother.
[x] facial grimaces [ ] guarding [ ] other signs of pain :
[ ] denied ACTIVITY/ SAFETY: [ ] convulsion [ ] dizziness [ ] limited motion of Joints Limitation in Ability to [ ] ambulate [ ] bathe self [ ] other [x] denied COMFORT/SLE EP/ AWAKE: [ ] pain
(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___
[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
Observed non-verbal behavior: the patient restless Phone number that can be reached anytime: refused
SPECIAL PATIENT INFORMATION ____N/A___ PT/OT __ N/A __ ____N/A___ Irradiation __ done _Urine test ___________ __No Order__24 hour Urine Collection
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is
VI.
ANATOMY AND PHYSIOLOGY:
DIGESTIVE SYSTEM The digestive system consists of two linked parts: the alimentary canal and the accessory digestive organs. The alimentary canal is essentially a tube, some 9 meters (30 feet) long, that extends from the mouth to anus, with its longest sectionthe intestines- packed into the abdominal cavity. The lining of the alimentary canal is continuous with the skin, so technically its cavity lies outside the body. The alimentary ‘tube’ consist of linked organs that each play their own part in digestion: mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The accessory digestive organs consist of the teeth and tongue in the mouth; and the
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salivary glands, liver, gallbladder, and pancreas, which are all linked by ducts to the alimentary canal.
STOMACH It is a J- shaped enlargement of the GI tract directly under the diaphragm in the epigastric, umbilical and left hypochondriac regions of the abdomen.
When
empty, it is about the size of a large sausage; the mucosa lies in large folds, called RUGAE. Approximately 10 inches long but the diameter depends on how much food it contains. When full, it can hold about 4 L ( 1 galloon) of food. 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; fundus which is the expanded part of the stomach lateral to the cardia region; body is the mid portion; and the pylorus a funnel shaped which is the terminal part of the stomach. The pylorus is continuous with the small intestine through the pyloric sphincter, or valve. With the gastric glands lined with several secreting cells the zymogenic (peptic) cells secrete the principal gastric enzyme precursor, pepsinogen.
The
parietal (oxyntic) cells produce hydrochloric acid, involved in conversion of pepsinogen to the active enzyme pepsin, and intrinsic factor, involved in the absorption of Vitamin B12 for the red blood cell production. Mucous cells secrete mucus. Secretions of the zymogenic, parietal and mucus cells are collectively called the gastric juice. Enteroendocrine cells secrete stomach gastrin, a hormone that stimulates secretion of hydrochloric acid and pepsinogen, contracts the lower esophageal sphincter, mildly increases motility of the GI tract, and relaxes the pyloricsphincter. Most digestive activity occurs in the pyloric region of the stomach. After food has been processed in the stomach, it resembles heavy cream and is called CHYME. The chyme enters the small intestine through the pyloric sphincter.
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VI.
Pathophysiology with Anatomy & Physiology
Name of the patient: Jhunienne Matias
Diagnosis: AGE with mild DHN
Definition: Acute Gastritis is defined as diarrheal disease of rapid onset, often with nausea, vomiting, fever, abdominal pain and loose bowel movement. It is an inflammation of the mucous membranes of the stomach often caused by an infection.
Predisposing Factors: Environment Hygiene Stress
Precipitating Factors: ~ Age(6 Months) ~ Gender(Male)
Ingestion of E. Coli Invasion of gastric mucosa Penetration of Gastric mucosa Toxins producing pathogens cause watery, large volume diarrhea
Signs & Symptoms: Watery stool Fever
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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
Dehydration
Signs & Symptoms: Decrease skin turgor Sunken Eyes
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VII.
MEDICAL MANAGEMENT
a. Medical Orders and Rationale DOCTOR’S ORDER 02-15-09
RATIONALE
Please admit to pedia ward For further management and under the service of Dr. Bacal At par with age regular diet
treatment of condition To provide easy digestion of food without experiencing pain upon digestion
Start D5 0.3NaCL 500ml @ To provide access for intravenous 100cc/hr
To screen the patient’s blood
Labs: •
medications.
CBC
component and to detect any abnormalities. This also serves as a baseline data to evaluate effectiveness of blood transfusions.
•
Urinalysis
To screen the patient’s urine components and to detect any abnormalities.
•
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.
02-15-09 IVF with D5 0.3NaCl 500ml @
To provide access for intravenous
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100cc/hr 02-016-09 Continue medications
medications.
For billing today IVF with D5 0.3 NaCl500cc @ To help for fast recovery Preparation for going home
SR 02-16-09
To provide access for intravenous
Continue medications
medications.
IVF D5 0.3 NaCl 500cc @ SR To help for fast recovery To provide access for intravenous medications.
b. Laboratory Results CBC Hemoglobin Hematocrit
17.3 gms % 49.6 vol %
White Cell Count
14,351/mm3
Fecalysis Character: soft
WBC/hpf: 4-6
Color: yellow
RBC/hpf: 6-8
Parasite ascarasis: none seen
cysts: positive
Trichuris: none seen
trophosites: none seen
Hook worm: none seen
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c. Drug study
DRUG NAME Paracetamol DOSE/FREQUENCY/ROUTE 500 mg 1 tab q4h PRN for fever CLASSIFICATION Analgesic; antipyretic MECHANISM OF ACTION May produce analgesic effect by blocking pain impulses, by inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by actingon hypothalamic heat-regulating center. Relieves fever. SPECIFIC INDICATION For fever. CONTRAINDICATION Contraindicated in patients hypersensitive to drug or its components. SIDE EFFECTS Anemia, jaundice, rash, urticaria. NURSING PRECAUTION Do not administer for fever that’s above 39.5° C, lasts longer than 3 days or recurs. DRUG NAME AMBROXOL DOSE/FREQUENCY/ROUTE 0.75ml TID P.O CLASSIFICATION Cough and Cold Preparation MECHANISM OF ACTION Ambroxol is a mucolytic agent. 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. Expectoration of mucus is thus facilitated. SPECIFIC INDICATION Cough CONTRAINDICATION Hypersensitivity to ambroxol or any ingredient of Ambrolex. SIDE EFFECTS Mild GI side effects. NURSING PRECAUTION Should be taken with food.
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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. SPECIFIC INDICATION Parenteral use restricted to treatment of serious infections of GI CONTRAINDICATION History of hypersensitivity to or toxic reaction with any aminoglycoside antibiotic. Safe use during pregnancy (category C) or lactation is not established
SIDE EFFECTS a. an allergic reaction (shortness of breath; closing of the throat; hives; swelling of the lips, face, or tongue; rash; or fainting); b. little or no urine; c. decreased hearing or ringing in the ears; d. dizziness, clumsiness, or unsteadiness; e. numbness, skin tingling, muscle twitching, or seizures; or f. severe watery diarrhea and abdominal cramps.
NURSING PRECAUTION Draw blood specimens for peak serum gentamicin concentration 30 min–1h after IM administration, and 30 min after completion of a 30–60 min IV infusion. Draw blood specimens for trough levels just before the next IM or IV dose. Use nonheparinized tubes to collect blood.
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VIII.
NURSING MANAGEMENT
Ideal Nursing Manangement - Risk for fluid volume deficit related to excessive losses through normal routes (frequent diarrhea, vomiting) INTERVENTIONS INDEPENDENT Monitor Intake and Output. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria. Assess vital signs (BP, pulse, temperature).
RATIONALE
Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.
Hypotension (including postural), tachycardia, fever can indicate response to and/or effect of fluid loss. Indicates excessive fluid loss/resultant dehydration.
Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill.
Indicator of overall fluid and nutritional status. Colon is placed at rest for healing and to decreased intestinal fluid losses. Inadequate diet and decreased absorption may lead to vitamin K deficiency and defects in coagulation, potentiating risk for hemorrhage. Excessive intestinal loss may lead to electrolyte imbalance, e.g., potassium, which is necessary for proper skeletal and cardiac muscle function. Minor alterations in serum levels can result in profound and/or life-threatening symptoms.
Weigh daily
Maintain oral restrictions, bed rest.
Observe for overt bleeding and test stool daily for occult blood.
Note generalized muscle weakness or cardiac dysrhytmias.
COLLABORATIVE Administer parenteral fluids, blood transfusions as indicated.
Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. Note: fluids containing sodium may be restricted in presence of regional enteritis. Determines replacement needs and effectiveness of therapy.
Monitor laboratory studies, e.g., electrolytes (especially potassium, magnesium) and ABGs (acid-base balance).
Reduces fluid losses from intestines.
Administer medications as indicated: Antidiarrheal e.g., dipphenoxylate (Lomotil), loperamide (Imodium), anodyne suppositories.
Used to control nausea and vomiting in acute exacerbations.
Controls fever, reducing insensible losses.
Antiemetics, e.g., trimethobenzamide (Tigan), hydroxyzine (Vistaril), prochlorperazine (Comparazine); Antipyretics, e.g., acetaminophen (Tylenol);
Electrolytes are lost in large amounts, especially in bowel with denuded, ulcerated areas, and diarrhea can also lead to metabolic acidosis through loss of bicarbonate (HCO3).
Stimulates hepatic formation of prothrombin, stabilizing coagulation and reducing risk of hemorrhage.
Electrolytes, e.g., potassium supplement (KCl-IV;KLyte, Slow-K);
Vitamin K (Mephyton)
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Knowledge deficient regarding condition, prognosis, treatment, self-care, and discharge needs as related to unfamiliarity with resources and information misinterpretation. Desire outcomes/evaluation criteria- the significant others will: Verbalize understanding of disease processes, possible complications. INTERVENTION INDEPENDENT Determine the mother’s perception of disease process. Review disease process, cause/effect relationship of factors that precipitate symptoms, and identify ways to reduce contributing factors. Encourage questions.
Review medications, purpose, frequency, dosage, and possible side effects. Stress importance of good skin care, e.g., proper handwashing techniques and perineal skin care.
RATIONALE Establishes knowledge base and provides some insight into individual learning needs. Precipitating/aggravating factors are individual; therefore, the mother needs to be aware of what foods, fluids, and lifestyle factors can precipitate symptoms. Accurate knowledge base provides opportunity for the mother to make informed decisions/choices about future and control of chronic disease. Although most others know about their own disease process, they may have outdated information or misconceptions. Promotes understanding and may enhance cooperation with regimen. Reduces spread of bacteria and risk of skin irritation/breakdown, infection.
Emphasize need for long-term follow-up and periodic reevaluation. Patients with IBD are at risk for colon/rectal cancer, and regular diagnostic evaluations may be required..
IDEAL NURSING MANAGEMENT 23
Hyperthermia related to dehydration as evidenced by increase in body temperature higher than normal range. Desired outcomes/evaluation criteria- patient will: Demonstrate temperature within normal range, be free of chills. INTERVENTION Independent monitor patient temperature(degree and pattern); note shaking chills/profuse diaphoresis.
Monitor environmental temperature; limit/add bed linens as indicated. Provide tepid sponge baths; avoid use of alcohol. Collaborative Administer antipyretics, e.g., acetylsalicylic acid (ASA) (aspirin), acetaminophen (Tylenol).
Provide cooling blanket.
RATIONALE Temperature of 102F-106F (38.9C- 41.1C) suggests acute infectious disease process. Fever pattern may aid in diagnosis; e.g., sustained or continuous fever curves lasting more than 24 hour suggest pneumococcal pneumonia, scarlet or typhoid fever; remittent fever (varying only a few degrees in either direction) reflects pulmonary infections; intermittent curves or fever that returns to normal once in 24-hour period suggests septic episode, septic endocarditis, or tuberculosis (TB). Chills often precede temperature spikes. Note: Use of antipyretics alters fever patterns and may be restricted until diagnosis is made or if fever remains higher that 102F (38.9C). Room temperature/number of blankets should be altered to maintain nearnormal body temperature. May help reduce fever. Note: use of ice water/alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to skin. Used to reduce fever by its central action on the hypothalamus; fever should be controlled in patients who are neutropenic or asplenic. However, fever may be benefial in limiting growth of organisms and enhancing autodestruction of infected cells. Used to reduce fever, usually higher than 104F-105F (39.5C-40C), when brain damage/seizures can occur.
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b. Actual Nursing Management Priority number 1
S O A P
“Sa wala pa na admit akong anak, 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, the patient will be able to maintain airway patency.
1. Elevated head of the bed by putting pillow under the head/changed position frequently. •
To enhance drainage and ventilation to different lung segments
2. Monitored infant for feeding intolerance, abdominal distention and emotional stress. •
May compromise airway.
3. Encouraged mother to hydrate infant frequently.
I
•
To loosen the secretions
4. Positioned appropriately and discouraged use of oil-based products around the nose. •
To prevent vomiting with aspiration to lungs
Dependent: 5. Administered Ambroxol as prescribed. •
E
To loosen the secretions
The goal has been met; the patient was able to maintain airway patency.
Priority number 2
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S
O A P
“Nangluspad naman gud akong anak tungod kai daghan na siya nasuka ug gekalibang” as verbalized by the patient’s mother •
Cool extremities
•
Sunken eyes
•
Dry skin
•
Watery stool
•
Persistent vomiting
•
Weight (Before = 7 kgs; Now = 6.5 kgs)
Fluid volume deficit related to excessive losses through GI tract secondary to diarrhea Short term: At the end of 8 hours, the patient will be able to restore fluid and electrolyte imbalances •
Encouraged the mother to give oral fluid intake. •
To increase fluid intake
2. Monitored intake and output balance. •
To ensure accurate picture of fluid status
3. Observed for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill. •
I
Indicates excessive fluid loss/resultant dehydration
4. Weighed daily •
Indicator of overall fluid and nutritional status
5. Monitored vital signs •
To note the changes in heart rate and respiration
Dependent: 6. Provided supplement fluids as indicated D5LR 500cc @ 28cc/hr •
Fluids may be given in this manner if patient is unable to take oral fluid
E
Goal has been met; at the end of 8 hours, the patient was able to restore fluid and electrolyte imbalances
Priority number 3
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S
“Sakit kayo ang tiyan sa bata sig era siya hilak sa kasakit. Basa pa gyud iya tae ug sige na siya kalibang” as verbalized by the patient’s mother
O A P
•
Hyperactive bowel sounds
•
3-5 loose liquid stools per day
Diarrhea related to irritation of the GI tract
Short Term: at the end of 8 hours, the patient will reestablish and maintain normal pattern of bowel functioning. 1. Weighed infant’s diaper. •
To determine the amount of output and fluid replacement needs
2. Encouraged oral fluid intake containing electrolytes. •
To maintain fluid and electrolyte balance
3. Provided prompt diaper changes and gentle cleansing
I
•
Because, skin breakdown can occur quickly when diarrhea is present
4. Did auscultation of abdomen. •
To check for presence, location, and characteristics of bowel sounds.
Dependent: 5. Administered antidiarrheal medications as prescribed. •
To treat infectious process and decrease motility and minimize fluid losses
E
IX.
Goals were not met At the end of 8 hours, the patient was unable to manifest signs of decrease fluid volume.
Referrals and Follow-up
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Our further Inpatient care includes monitoring of changes in vital signs, assessment of effectiveness of treatment regimen, reinforcement of dietary advice(At par with age regular diet), and the advice regarding the importance of adequate bed rest. Our further Outpatient care includes instructions of Mr.& Mrs.Inalen Matias dietary modification of their son, compliance with treatment regimen, and parents’ participation through reporting of adverse effects of medications to his physician. The parent was also instructed to have a regular check-up at PGH Hospital with their son in order to monitor the current condition.
X.
Evaluation and Implications
Within the span of 2 day of rendering care to Jhunienne Matias. I was able to identify potential problems and specific nursing interventions were provided. With the help of health teachings and other interventions, Parents of Jhunienne Matias were able to learn how to recognize signs and symptoms and other risk factors of the condition of their son. The Parents of Jhunienne Matias was able to verbalized the importance of giving medications to their son. They had also recognized the importance of compliance to treatment regimen in order to manage the condition of their son, Jhunienne Matias.
XI. BIBLIOGRAPHY:
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o
Luckman and Sorensen, Medical-Surgical Nursing. 3rd Edition W.B. Saunders Company (1987)
o Kozier, B, et al Fundamentals of Nursing. 7th Edition Pearson Education South Asia PTE LTD Philippines 2004 o Smeltzer, Medical-Surgical Nursing. 11th edition, Lippincott William & Wilkins, 2007 o Mosby, Mosby’s Nursing Drug Reference, Elesevier Mosby, 2005 o Doengoes, Nurse’s Pocket Guide. 9th edition, F.A. Davis, 2004 o www.wikipedia.org o www.mims.com
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