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University of Perpetual Help System-Molino CampusCOLLEGE OF NURSING

Molino III, Bacoor, Cavite

NURSING CASE STUDY

I. HEALTH HISTORY

A. DEMOGRAPHIC (BIOGRAPHICAL DATA)Clients Initial : Z. A

Gender: Female

Age: 1 year old

Religion: Catholic

Occupation: N/A

Usual Source of Care: Hospital

Date of Admission: February 24, 2012 (10:25 pm)

Initial Diagnosis: Dengue Febrile Syndrome

Final Diagnosis: Acute Tonsillopharyngitis

B. SOURCE AND RELIABILITY OF INFORMATIONSince the patient is an infant, the gathered information came from the mother of the patient who was with her

(patient). The mother was reliable enough to answer all the questions asked. Patients mother was also coherent

enough and actively participated during the interview.

Patients chart was also utilized for some additional information

C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTThe Following symptoms prompted the patients parents for hospital admission.

On and off fever for 2 days with 38-39C

Irritability

D. HISTORY OF PRESENT ILLNESS2 days prior to admission the patient was experiencing an on and off fever with the temperature ranging from

38-39C. The patient was given Tempra and temporary relief was achieved. There was no consultation done.

But still the patients fever goes back. The patient doesnt have any diarrhea and no vomiting at all. But the

patient seems weak and irritable due to the fever. So patients parents decided to bring her to the hospital.

E. PAST MEDICAL HISTORYIt was the patient first time to be hospitalized. Patient didnt experience any disease except for

cough, fever and colds. According to patients mother her daughters immunization was not yet complete. As

far as they know, patient dont have existing food or drug allergies.


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F. DEVELOPMENTAL MILESTONE

Trust vs. Mistrust (Infants, Birth to 12-18 Months)

Psychosocial Crisis: Trust vs. Mistrust Virtue: Hope

The first stage of Erik Erikson's theory centers around the infant's basic needs being met by

the parents. The infant depends on the parents, especially the mother, for food, sustenance,and comfort. The child's relative understanding of world and society come from the parents

and their interaction with the child. If the parents expose the child to warmth, regularity, and

dependable affection, the infant's view of the world will be one of trust. Should the parents fail

to provide a secure environment and to meet the child's basic needs a sense of mistrust willresult

.

According to Erik Erikson, the major developmental task in infancy is to learn whether or notother people, especially primary caregivers, regularly satisfy basic needs. If caregivers are

consistent sources of food, comfort, and affection, an infant learns trust- that others are

dependable and reliable. If they are neglectful, or perhaps even abusive, the infant insteadlearns mistrust- that the world is in an undependable, unpredictable, and possibly a dangerous

place. While negative, having some experience with mistrust allows the infant to gain an

understanding of what constitutes dangerous situations later in life.

G. FAMILY HISTORY

LEGEND:


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Patients mother and father are still alive and well. The patient is an only child.

Patients mother is 32 y/o and a housewife. While his father, 33 y/o works as a caregiver.

H. REVIEW OF SYSTEMS

Date of Assessment: February 27, 2012

System Review of

System

Physical Exam Significance

a. General/ Over

All Health Status

>weakness

>fever (temperature of 37.8)

> Warm to touch

>response of the body to an

infection. After the body

detected infection there willbe an immune response

release of pyrogens that will

stimulate the hypothalamus

to release prostaglandin that

is responsible to release

temperature to set point

causing death of certain

opportunistic organism.

> due to fever

1. LABORATORYSTUDIES DIAGNOSTICS

ProcedureIndication

Normal

findings

Actual

findings Implication

Nursing

Responsibilities

Hematology

February 25,2012

>It assesses

the general

status of thepatient. This

helps

RBC

4.50-6.00X10^12/L 4.69 Normal

Pre

- Positively identify

the client

- Inform pt thatthis test can assist

in evaluating the


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determine if

the

component

of the blood

is adequateto sustain the

needs of the

body.

It is an

important

measurement

in the

evaluation of

anemia,

oxygen and

carbondioxide

carried by

the blood as

well as the

acidity, to

determine

the presence

of infection

and allergy

Hemoglobin

120160 g

/ L

128Normal

amount of

hemoglobin in

the blood

- Obtain hx of the

pt compliant- Note any recent

procedure that

can infere the

result

- Obtain list of

current

medication

- No fluid or food

restriction unless

by medical

direction.

Intra

- Observed

standard

precautions

- Maintain asepsis

- Assess pt vital sign

- Cubital vein

commonly used

for venipuncture

- Assist medical

technologist

Post

- Monitor for sign

and symptoms of

vlooding

- Direct preassure

- Observe for

bleeding

- Label vial

- Proper

documentation.

Hematocrit

(Hct)

0.40-0.54 L

0.40Normal

WBC

4.50

10x10^9/L

7.8 Normal

Segmenters

0.50-0.700.59 Normal

Platelet

150400X10^9/L

204 Normal

Monocytes

0.00-0.070.08

Increased

presence of

bacterial

infection

Lymphocyte

0.20-0.400.33 Normal

MCV

80-100 fL85 Normal

MCH26-34 pg

27.3 Normal

MCHC

320-360 g/l322 Normal

IV. PROBLEM LISTS

A. Actual or Active

Problem No. Problem Date Identified


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1. Hypothermia February 27, 2012

2.Ineffective breathing

patternFebruary 27, 2012

B. High Risk or Potential

Problem No. Problem Date Identified

1. Risk for fall February 27, 2012

2. Risk for Imbalanced nutrition February 27, 2012


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NCP

Submitted by:

Shayne Marie Apon BSN 4A

Submitted to:

Ms. Jovy Reano, RN, MAN

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