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Pneumonia is the inflammation of the lung
caused by bacteria in which the air sacs
become filled with inflammatory cells and thelung becomes solid. The symptoms include
those of any infection (fever, malaise,
headache, etc.,) together with cough andchest pain.
It is estimated that, worldwide, some 4 million
children under five years of age, die each
year from acute respiratory infection (ARI)
with the most of these deaths caused
by pneumonia in developing countries.
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In 1989, when the program for ControlAcute Respiratory Infections (CARI) of
the Philippines was launched, the death tollfrom pneumonia among children under the ageof five years was 25,000. The latest statistics(2006) disclosed that almost 60 out of 1000
children under five children sufferfrom pneumonia and five in every 11,000 diefrom the disease. The Department ofHealth believes that if health workers used a
standard method of detecting and managingARIs specially pneumonia, infant deaths couldbe cut by half, saving 50,000 lives a year.Pneumonia can be categorized by type of
infiltrate: lobar pneumonia and
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Acute gastroenteritis is usually caused bybacteria and protozoan. In the Philippines, one
of the most common causes of acutegastroenteritis is E. histolytica. The pathologicprocess starts with ingestion of focallycontaminated food and water. The organism
affects the body through direct invasion and byendotoxin beingreleased by the organism. Through these twoprocesses the bowel mucosal lining is
stimulated and destroyed the eventually lead toattempted defecation or tenesmus as the bodytries to get rid of the foreign organism in thestomach.
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The client with acute gastroenteritis may
also report excessive gas formation that
may leads to abdominal distention andpassing of flatus due to digestive and
absorptive malfunction in the system.
Feeling offullness and the increase motility of the
gastrointestinal tract may progress to
nausea and vomiting and increasing
frequency of defecation. Abdominal pain
and feeling of fullness maybe relieved only
when the
patient is able to pass a flatus.
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These are the two illnesses diagnosed
by the client in this Case Study; the client
is experiencing Acute Gastroenteritis withMild Dehydration accompanied by
Pneumonia. Based on Statistics
conducted Las 2010 of January involvingall countries all over the world, these two
disease are seldom seen together at a
time, but is possible. Furthermore, allthese diseases are can be easily cured but
if not treated accordingly, about 58-65%
may lead to Death.
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General Objective:
Upon presentation of the case
Acute Gastroenteritis with mild
dehydration and Bronchopneumonia,Group 2 of BSN 3A will be able to
facilitate learning in the delivery of
quality nursing care to a patient withAcute Gastroenteritis with mild
Dehydration and Bronchopneumonia.
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Specific ObjectivesKNOWLEDGE:
1. Define Acute Gastroenteritis with mild Dehydration
and Bronchopneumonia.
2. List the clinical manifestations present in a client with
Acute Gastroenteritis with mild Dehydration and
Bronchopneumonia.
3. Enumerate predisposing and precipitating factors of
Acute Gastroenteritis with mild Dehydration and
Bronchopneumonia.
4. Discuss the disease process of Acute Gastroenteritiswith mild
5. Dehydration and Bronchopneumonia.
6. Evaluate the effectiveness of the nursing interventions
rendered to the client.
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SKILLS:
1. Present a clear and precise case study
about Acute Gastroenteritis.
2. Provide an environment conducive for
learning and discussion.
3. Expound a thorough and completeassessment data obtained from the client.
4. Maximize the time allocated for the case
presentation.5. Employ critical thinking in answering
questions thrown during the case
presentation.
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ATTITUDE:1. Maintain privacy and confidentiality of the
client at all times.2. Observe proper behaviour although out the
case presentation.3. Observe punctuality in initiating the case
presentation.4. Accept corrections, suggestions and
comments as means of improvement.5. Ask for spiritual guidance before and after
the case presentation.6. Establish collaborative and harmonious
relationship within the group.
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Date of admission: September 19, 2011
Time of admission: 10:45 am
Chief complaint: LBM and VomitingAdmitting diagnosis: Acute Gastroenteritis
with mild Dehydration
Principal diagnosis: Acute Gastroenteritiswith mild Dehydration and
Bronchopneumonia
Attending physician: Dr. B Weight: 11 kgs
Height: 0.73 m
BMI: 20.75 kgs/m2
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VITAL SIGNS UPON ADMISSION:
Cardiac Rate- 92 bpm
TEMP- 38.7 OC
RR- 43 cycles per minute
DIET: (24 Hour DIET Recall)
BREAKFAST: Rice and hotdog with milk
(Breastfeed)
LUNCH : Rice, fried fish, smashed squash
DINNER: Rice, milk and one pc. Banana
and water
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GENERAL APPEARANCE
The patient was lying on bed, she is weakand flushing of skin especially on the face
noted. The childs height and weight is normal
for her age. Curly and short hair with twoupper incisor of the tooth lacking, sunken and
sleepy eyes, her skin are drying especially on
her oral mucousa. The child doesnt want to
eat and with frequent episodes of cough, thechild is continuously raising her both
shoulders up and down, an indication that she
has Difficulty in Breathing.
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The patient was first admitted at
VGDH when she was 7 months old
and was diagnosed of having acute
gastroenteritis. During her first
admission, she was confined at the
hospital for 3 days. Several days after
discharged from the hospital, mother
verbalized that her daughter was
experiencing frequent coughs and
fever. The child is not allergic to any
drug administered during her
confinement nor to an food re ared.
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The night before the patient was
admitted at VGDH last September 19, 2011,
the mother verbalized Gabi-I kay
nakulbaan na jud ko, sunod-sunod na iyang
pagkalibang tubig, gahilanat pa pagka
dasun galibug akong ulo kung nganong
nabudlayan na siyag gulpig hangup ughangin.
Before the illness developed, the child
was experiencing continuous productive
cough that leads to difficulty of breathing.
The mother stated that the childs illness
was due to the water she drinks from the
deep well. The child was not able to eat her
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Th hild b tf d b h th til
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The child was breastfed by her mother up until
the age of 10 months. The child was fed with
vegetables like squash and eggplants at the age of
11 months. She prefers to eat fruits like bananas andmangoes. For her 24 hour diet recall, her breakfast
consists of bread, one banana and a bottle of milk.
She does not have any solid food for lunch, she just
consumes another bottle of formula milk. For dinner,meat or vegetables cut into small pieces are usually
offered to the child in small amounts. Another
banana is also eaten by the child. Her sleeping
pattern varies, especially during nights when thereare episodes of coughing. The child sleeps for 10
hours if there are no episodes of coughing. In the
afternoon, she takes a nap for 2 hours. She usually
la s with their nei hbors children but tires easil .
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DISEASE MATERNAL PATERNAL
HYPERTENSION - +
DIABETESMELLITUS - -
ASTHMA
+ -
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HEENT:
Head: Head has no lesions, scaling and
tenderness, face is symmetric. Ears: External ears are symmetrical, ear
canals are patent with no lesions and
deformities. Eyes: Sunken eyeballs, white sclera, pupils
constrict to light, eyelids are intact with no
lesions. Nose: Presence of mucous secretions
Throat: There is absence of soreness and
tenderness of throat. No lesions are
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RESPIRATORY:
With increased respiratory rate of 43cpm which is already above normal for a 1
yr and 6 month old child of 20-40cpm only.
This means that the child is a fast breather.
Use of accessory muscles when
coughing noted such as rising of both
shoulders simultaneously. Upon
auscultation there were faint cracklesheard, with wheeze and rales can also be
heard upon getting the childs cardiac rate.
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CARDIOVASCULAR:
The pulse rate is normal ( 92bpm). Upon
auscultation of the childs cardiac heart rate,sounds like rales and wheeze can still be
heard. Regular Cardiac Rhythm,
Hemoglobin- 11.2 gms% and Hematocrit-30.0 %, Peripheral Circulation: nail beds and
conjunctivas are pale, Capillary refill: 3
seconds
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MUSCULOSKELETAL:
Patient has limited range of motion and
cannot fully extend arms and legs.Decreased muscle strength was also noted.
The muscles of the mouth and TMJ can
open 1-2 times as the time weve asked thechild to open her mouth
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INTEGUMENTARY:
Face was pale. Skin was dry and soft
and warm touch with no lesions. Small red
spots noted on the left side of the childs
face.Poor skin turgor. Arms, Hands, and
Fingers skin color is fair as with the otherbody parts.
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GASTROINTESTINAL:
No abdominal tenderness
palpated and with normoactive, a
little fading like-borborygmi bowelsound upon auscultation.
Abdominal Circumference: 25.5cm
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GENITOURINARY:
Has no bladder distention.
Amount of urine notedapproximately 40cc per hour.
NEUROLOGIC
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NEUROLOGIC
The child still withdrawing a smile to other people coming
near him, but becomes restless when the mother is not around,
she usually cries. For the cranial nerve functions, her sense ofsmell was normal and active (olfactory nerve). His vision was
normal (optic nerve) since he can still recognize people around
like her mother and father. Both of his eyeballs were moving
bilaterally (occulomotor, trochlear, and abducens nerve). Pupils
also react to light (occulomotor). Patient was able to move his
facial muscles. He can smile, frown, puffed out cheecks and
raise and lower eye brows (facial nerve). She was able to open
mouth and move jaw from side to side (trigeminal). Hearing was
active and can respond to sounds (vestibulocochlear). The childdoesnt want to eat because she cant seem to taste the food she
eate due to fever as stated by the mother (glossopharyngeal
nerve). The child produces sound like crying whenever her
mothers not around (vagus nerve). The chid is using her
shoulders and abdomen when breathing(spinal accessory
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NORMAL VALUE RESULTS NURSINGIMPLICATIONS
NURSING CONSIDERATIONSRBC 4.5-5.0x
109
/dL
4.0 X
10X109
/L
Decreased in
amount mayindicate
Anemia
Encourage the
mother to let her childtake Iron
supplementations
WBC 5-10 x 109/L 12.5x109/L An increase inamount may
indicate
Infection
*Stress to the mother
the importance of
taking antibiotics as
prescribed for the
child.
*Encourage the
mother to increasechilds Vit.C intake
like calamansi and
oranges.
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NORMAL
VALUERESULTS NURSING
IMPLICATIONSNURSING CONSIDERATIONS
NEUTROPHIL
S60-70% 41% A decrease in
amount is due to
infection.
Pathogens
invade the body
that alters
neutrophil count
*Encourage the S.O to
provide a well-balanced
diet.*encourage SO childs
Oral Fluid Intake and Vit.
C Supplementations.LYMPHOCYT
ES 25-33% 53% An Increase inamount mayindicate
infection.
*Emphasize to the S.Othe importance of
hygiene and sanitation
to the child and home.
*Instruct the mother to
provide the child withfruits rich in vit. C like
calamansi and
Oranges.
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NORMAL
VALUERESULTS NURSING
IMPLICATIONSNURSING
CONSIDERATIONSEOSINOPHIL
S1-3% 6% May indicate
allergic reaction
and developing
infection
*Administer anti-
allergy as indicated.*Instruct mother to
observe personal
hygiene.
BASOPHILS 0.25-50% 1.5% May indicateallergic
reaction and
indicative of
infection
*Administer anti-
histamine as
indicated.
*Increasing Oral
Fluid intake andprovide food that
is properly
prepared.
NORMAL
VALUE
RESULTS NURSINGIMPLICATIONS
NURSING CONSIDERATIONS
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VALUE IMPLICATIONSHEMOGLOBIN 14-
16gms%
11.2
gms%
A decrease in
amount may
indicate
Anemia and
dietary
deficiency
*Encourage the mother
to provide a
comfortable place for
the childs adequate
rest and sleep.
*Increase intake of Iron
supplementations as
prescribed.
HEMATOCRIT 42+- 5% 36.0% A decrease in
amount may
indicate blood
loss andanemia
*Instruct mother to
maintain the childs
taking of Iron
supplementations.
*Provide dairy
products like milk and
eggs for childs nucleic
acid production
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The digestive system consists of two linked parts:the alimentary canal and the accessory digestiveorgans. The alimentary canal is essentially a tube,
some 9 meters (30 feet) long, that extends from themouth to anus, with its longest section- the intestines-packed into the abdominal cavity. The lining of thealimentary canal is continuous with the skin, so
technicallyits cavity lies outside the body. Thealimentary tube consist of linked organs that each playtheir own part in digestion: mouth, pharynx,esophagus, stomach, small intestine, and largeintestine. The accessory digestive organs consist ofthe teeth and tongue in the mouth; and thesalivaryglands, liver, gallbladder, and pancreas, which are alllinked by ducts to the alimentary canal.
STOMACH is a J- shaped enlargement of the
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STOMACH 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 ofa 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 (1galloon) 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 theesophagus; 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.)
sphincter or valve With the gastric
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sphincter, or valve. With the gastric
glands lined with several secreting cells
the zymogenic (peptic) cells secrete theprincipal gastric enzyme
precursor, pepsinogen. The parietal
(oxyntic) cells produce hydrochloricacid, involved in conversion
of pepsinogen to the active enzyme
pepsin, and intrinsic factor, involved inthe absorption of Vitamin B12 for the
red blood cell production. Mucous cells
secrete mucus.
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Secretions of the zymogenic, parietal andmucus cells are collectively called the gastric
juice. Enteroendocrine cells secrete stomachgastrin, a hormone that stimulates secretionof hydrochloric acid and pepsinogen,contracts the lower esophageal sphincter,
mildly increases motility of the GI tract,andrelaxes the pyloricsphincter. Most digestiveactivity occurs in the pyloric region of thestomach. After food has been processed in
the stomach, it resembles heavy cream andis called CHYME. The chyme enters thesmall intestine through the pyloric sphincter.
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Difficulty Of Breathing
Loose Bowel Movement Fever
Body Weakness Cough
PROBLEMS RANKCUES PHYSIOLOGIC BEHAVIORAL
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ACTUAL POTENTIAL ACTUAL POTENTIAL
Ineffectiv
e
Breathing
Pattern r/t
retained
secretion
s
Risk for
Ineffective
tissue
perfusion r/t
impaired
transport of
oxygen
Disturbed
Sleep
Pattern r/t
shortness
of breath
Risk for
powerlessnes
s r/t lack of
adequate
sleep
Deficient
fluid
volume r/t
passage
of watery
stools
Risk for
Imbalanced
Nutrition:
Less than
body
requirementsr/t frequent
passage of
watery stools
Powerles
sness r/t
inadequat
e
Nutritional
status
Risk for
Social
Isolation r/t
frequent
passing out
of waterystools
PROBLEMS RANK
Difficulty
ofBreathing
1
Frequent
passage
of Watery
Stools
2
CUES
Murag tubig
na katin-awonang iya
ginkalibang.
Pag-admit
namon sa
buntag,
gasuka-sukana siya katulo
jud
Objectives:
Poor Skin
Turgor
Pallor
Sunken
Eyeballs
Dry Buccal
Mucosae
PHYSIOLOGIC BEHAVIORAL
PROBLEM RANK PHYSIOLOGIC BEHAVIORAL
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OS
Fever 3
Adequat
e Sleep
4
ACTUAL POTENTIAL ACTUAL POTENTIAL
Ineffective
Thermo
regulation r/tinflammation
of Bowel
mucosal lining
Risk for
disorganized
infantbehaviour r/t
discomfort of
elevated body
temperature
Impaired
Comfort r/t
fluctuations inBody
Temperature
Risk for
Activity
Intolerance r/tweakness
Sleep
Deprivation r/t
breathing
difficulty and
frequent
passage of
watery stools
Risk for
delayed
development
r/t lack of
adequate
sleep.
Impaired
Social
Interactions r/t
weakness due
to lack of
sleep
Risk for
impaired
attachment r/t
inability to
initiate
parental
contact due to
altered
behavioural
organization
S O OG C O
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General Objective:
-To facilitate the maintenance of supply ofoxygen to all body cell.
CUES NURSINGDIAGNOSIS EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION
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SUBJECTIV
E:
Murag tubig
na katin-aw
iyaginakalibang,
Pag-admit
namu sa
buntag, ga
suka-suka na
siyag mga ika
tilo jod
Tapos ambot
naunsa pod ky
di namn sya
kaginhawagmaayu nuon
Ineffective
BreathingPattern r/t
INFLAME
D
BRONCHI
AL TISSUE
Within 2 days
of Nursing
Interventions
the patient
will be ableto:
*Maintain
Effective
breathing
pattern
*Maintain
Patent airway
with absence
of mucous
secretions
INDEPENDE
NT:
>Auscultate
breath sounds.
Noteadventitious
breath sounds,
e.g. wheezes,
crackles and
rhonchi.
>Some degree
ofbronchospasm
is present with
obstructions
in airway and
may not bemanifested in
adventitious
breath sounds,
e.g. scattered,
moist crackles(bronchitis) or
faint, with
expiratory
wheezes
(emphysema)
After 2 days
of Nursing
Interventions,
goals are
Partially Metas Evidenced
by:
*Accessory
muscles like
shoulders are
seldom used.
*Coughing
with
secretions isminimal
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OBJECTIVE
:
*Presence of
adventitiousbreath sounds
such as rales
and wheezes
upon
auscultation
*Poor Skin
turgor
*S.O verbalize
understanding
of cause and
therapeutic
managementregimen to the
patient
*S.O verbalize
sense of
comfort andcontentment of
the patients
Health
Improvement
*S.O may
report
improvement
in sleep and
rest pattern of
the patient
>Assess/
Monitor
respiratory
Rate. Noteinspiratory/exp
iratory ratio.
>Tachypnea is
usually present
in some degree
and may be
pronounced onadmission or
during stress
on current
acute process.
Respirations
may beshallow and
rapid. Chronic
emphysema
patients
usually have
prolonged
expiration in
comparison to
inspiration.
*Slight
improvement
of the S.O
towardsunderstanding
therapeutic
management
regimen to the
patient.
*Slight
improvement
about sense of
comfort
according to
the S.O
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* Pallor
*Sunken
eyeballs
*Dry buccalmuscles
*Accessory
muscles like
shoulder and
abdomen are
used in
breathing
*Passing out
of watery
stool 5x a
day.
>Monitor
Vital Signs
>Monitorrespirations
and breath
sounds
noting rate
and sounds.
>Determine
Presence of
factors/physi
calconditions as
noted in
related
factors.
>to establish
baseline data.
>Indicativeof distress or
accumulation
of secretions
>To
determine
causes of
breathingimpairments
*The child is
able to sleep
at night with
10-12 hours
and at least 2
hours rest in
the
afternoon.
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*Cardiac
Rate- 92
bpm
*TEMP-38.7 OC
*RR- 43
cpm
*WBC-
12.5x10
9
/L*RBC-4.0 X
10X1012/L
*Hemoglobi
n: 11.2
gms%
*Hematocrit
: 36.0%
>Position
head
appropriate
for age andcondition.
>Observe for
signs/sympto
ms and
infections
(increase
dyspnea with
onset of
fever)
>To
maintain
patent
airway in atrest or
compromise
d individuals
>To identify
secretions
process and
promote
timely
interventions
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DEPENDENT
>Administer
Salbutamol
and
ALBUTEROLE SULFATE
via inhalation
as prescribed
every 4 hours
and as needed.
>Administer
O2 Inhalation
at 2L via face
mask asprescribed.
>Inhaled
adrehergic
against. And a
first linetherapies for
rapid
symptomatic
improvement
in severe
bronchiconstipation.
>Relaxes
smooth muscle
and reduce
localcongestion
reducing
airway spasm
and mucous
production.
CUES NURSINGDIAGNOSIS EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION
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COLLABOR
ATIVE:
>Monitor
laboratory
results asindicated
>Administer
replacement of
fluids and
electrolytes asordered.
REFERENCE:
-NANDA (12TH )
-Edition. Pp 80-
84, 151- 155
>To determine
altered lab.
Results
>To support
circulating
volume and
tissue
perfusion.
REFERENCE:
-NANDA (12TH )
-Edition. Pp 80-
84, 151- 155
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General Objective:
-To facilitate the maintenance of fluid
and electrolyte balance.
CUES NURSINGDIAGNOSIS PATHOPHY
SIOL
EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION
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SIOL
OGYSUBJECTIV
E:
Murag tubig
na katin-awiya
ginakalibang,
Pag-admit
namu sa
buntag, ga
suka-suka nasiyag mga ika
tilo jod
Tapos
ambot naunsa
pod ky di
namn syakaginhawag
maayu nuon
Deficient
fluid
volume r/t
passage
of watery
stools
Within 2days
of Nursing
Interventions
the patient will
be able to:
*Maintain
fluid Volume
level at
functional
level
*Minimize
episodes of
passing out of
water stools
from more than
5 times to 2
times a day.
INDEPENDE
NT:
>Assess Vital
Signs.
>NoteComplains and
physical signs
associated with
fluid loss (poor
skin turgor)
>For baseline
data, fevertachycardia
may indicate
severe fluid
loss.
>To assess ordetermine if
there is
alterations on
patients
condition and
provideimmediate
action.
After 2days of
Nursing
Interventions
goals areMET, as
Evidenced by:
*Maintenanceof Volume at a
functional
level, urine
output of
approx.40 cc
and frequentintake of at
least 8 glasses
of water a day.
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OBJECTIVE:
*Presence of
adventitious
breath soundssuch as rales
and wheezes
upon
auscultation
*Poor Skin
turgor
*Maintain
Good Skin
Turgor
*Mother willverbalize
understanding
of causative
factor and
purpose ofintervention
done.
>Instruct the
mother to
increase oral
fluid intake ofthe child at
least 6-8
glasses a day
as tolerated.
>To restore
fluid
balance.
*The childs
Stool output
was reduced
to two times aday not so
watery,
smooth-well
formed stool.
*Moist Oral
mucosa andgood skin
turgor, with
skin goes back
a little bit
slowly when
pinchvertically on
the abdomen.
CUES NURSINGDIAGNOSI
S
PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION
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S* Pallor
*Sunken
eyeballs
*Dry buccal
muscles*Accessory
muscles
like
shoulder
and
abdomenare used in
breathing
*Passing
out of
watery stool
5x a day.
DEPENDENT:
>Administer
IOPERAMIDE-
MAALOX, 1mg.P.O. tid on the
first day. As
ordered by the
physician.
>Administer and
Regulate IVF asordered by the
physician.
>Proper dosage
of the medicine
ensures recoveryand prevents
diarrhea causing
dehydration.
>To ensure
adequate fluidreplacement.
*S.O
verbalizes
understanding
of causativefactors and
purpose of
interventions
and
medications
with propercompliance on
the dosage
and timing.
CUES NURSINGDIAGNOSIS PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION
*Cardiac COLLABORA
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Cardiac
Rate- 92
bpm
*TEMP-
38.7 OC
*RR- 43cpm
*WBC-
12.5x109/L
*RBC-4.0
X
10X1012/L
*Hemoglob
in: 11.2
gms%
*Hematocri
t: 36.0%
COLLABORA
TIVE:
>Monitor
clients intake
and output asendorsed.
>Monitor every
Laboratory
Results
conducted tothe patient.
REFERENCE:
NANDA 12th
edition pp. 372-
375, 756- 763
>Provide
information about
over-all fluidbalance.
> To know
clients progress
and alteration in
condition.
REFERENCE:
NANDA 12th
edition pp. 372-
375, 756- 763
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General Objective:
-To promote safety through prevention
of accident, injury or other traumaand through the prevention of thespread of infection.
CUES NURSINGDIAGNOSIS PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTIO
NRATIONALE EVALUATION
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SUBJECTI
VE:
Murag
tubig na
katin-aw
iya
ginakaliba
ng, Pag-
admit
namu sa
buntag, ga
suka-suka
na siyag
mga ika
tilo jod
Tapos
ambot
naunsa pod
ky di namn
sya
kaginhawa
g maayu
nuon
Ineffective
Thermoregulation r/t
inflammatio
n of
Gastrointesti
nal Tractsecondary to
Acute
Gastroenteri
tis
Within 2
days of
nursing
intervention,the patient
will be able
to:
*Restore
temperature
to a normal
level of 36.5-
37.5 C
INDEPEN
DENT:
>Assess
neurological response,
noting
level of
consciousn
ess and
orientation
and
reaction to
stimuli,
reaction of
pupils, and
presence of
posturing or
seizures.
>For proper
assessmentof the
severity of
the problem.
CUES NURSINGDIAGNOSI
SPATHOPHYSIO
LOGY EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION
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OBJECTI
VE:
*Presence
of
adventitiou
s breath
sounds
such as
rales and
wheezes
upon
auscultatio
n
*Poor Skin
turgor
*Diminish
flushing of skin
which is an
indication of
hyperthermia
*Reduce heat of
the skin to
normal warmth
*Reduce
excessive
sweating.
>Assess
environment
for possible
sources ofheat gain
through
evaporation,
conduction,
convection,or radiation.
>To
minimize
risk of heat
gain.
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*Cardiac
Rate- 92
bpm
*TEMP-
38.7 OC
*RR- 43
cpm
*WBC-
12.5x109/L
*RBC-4.0
X
10X1012/L
*Hemoglo
bin: 11.2
gms%
*Hematocr
it: 36.0%
>Monitor
heart rate and
rhythm
>Provide
tepid spongebath but avoid
using alcohol
as a solution.
>Dysrrhythmia
s and ECG
changes are
common due toelectrolyte
imbalance.
>May help
reduce fever.Ice water and
alcohol may
cause chills
actually
elevating
temperature
CUES NURSINGDIAGNOSIS PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTION
RATIONALE EVALUATION
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>Promote
surface
cooling by
undressingor not
double
wrapping
the infant.
DEPENDE
NT:
>Administe
r
PARACET
AMOL
120 mg P.O
q4 to 6
PRN
>To promote
heat loss in
the body
> Proper
dosage of
the medicine
ensuresrecovery.
CUES NURSINGDIAGNOSIS
PATHOPHYSIOLOGY EXPECTEDOUTCOME NURSINGINTERVENTION RATIONALE EVALUATION
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>Administer and
Regulate IVF as
ordered by the
physician.
COLLABORATIVE
:
>Monitor
laboratory studies
such asABCs,
electrolytes,
cardiac and liver
enzymes, glucose
urinalysis, and
coagulationprofile.
REFERENCE:
NANDA 12th
edition pp. 372-
375, 756- 763
>To ensure
adequate fluid
replacement.
>May reveal
tissue
degeneration,myoglobinuria,
proteinuria, and
hemoglobinuria
.
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CLASSIFICATION IMPLICATION MECHANISM OFACTION
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*DEXOMETHOR
PAN
HYDROBROMID
E
Robitussin
Pediatric
Timing: Q8 (8
am, 4pm and
12am)
120mg a day
Expectorants
and antitussives
Productive
cough
individualized
dozes
Antitussive that
suppresses the
cough reflex by
direct action on
the cough center
in the medulla
SIDE/ADVERSEEFFECTS NURSINGCONSIDERATIONS PATIENTS TEACHING REFERENCE
S G
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CN: drowsiness,
dizziness
G.I nausea,
stomach pain
*Dont use when
cough is a
valuable
diagnostic signor is beneficial
(as after thoracic
surgery)
*Monitor Vital
signs especiallyRespirator and
Cardiac Rate.
*Use drug with
chest percussion
and vibration.
*Monitor cough
type and
frequency
*Instruct themother to give
drug to the
patient exactlyas prescribed.
*Instruct the
mother to report
adverse
reactions.*Tell the S.O to
report nausea,
abdominal pain
or discomfort
NURSING 2007DRUG
HANDBOOK
LippincottWilliams andWilkins
CLASSIFICATION IMPLICATION MECHANISM OFACTION
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*IOPERAMIDE
MAALOX
>1mg. P.O. tid
on the first day.
Anti -diarrheals Loose Bowel
Movement
Inhibits
peristaltic
activity,
prolonging
transit and
intestinal
contents
SIDE/ADVERSEEFFECTS NURSINGCONSIDERATIONS PATIENTS TEACHING REFERENCE
CNS d i *Ski T t t b *I t t th t NURSING 2007
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CNS: drowsiness,
fatigue and
dizziness
G.I: dry mouth,abdominal pain,
distention or
discomfort,
constipation,
nausea and
vomiting.
Skin: Rash,
hypersensitivity
reactions.
*Skin Test must be
done to monitor
clients possible
allergic reaction tothe drug.
*Contraindicated
in patients with
bloody diarrhea
with fever greater
than 39C.
*Drug is likely to
be effective if no
response occurs
within 48 hours.
*Monitor childclosely for CNS
effects, children
are more sensitive
to these effects
than adults
*Instruct mother to
report alterations
noted from the
child.*Encourage the
mother to follow
frequent timing of
taking
medications
prescribed.
*Tell the mother
the necessity of
drug compliance.
*Note if the patient
is experiencingbloody stool and
immediately ask
the mother to
report if this
happen.
NURSING 2007DRUG
HANDBOOK
LippincottWilliams andWilkins
CLASSIFICATION IMPLICATION MECHANISM OFACTION
*ALBUTEROL
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*ALBUTEROL
E SULFATE
2.5 mg t.i.d. bynebulizer for 10
mins as needed
not exceeding
2.5 mg
Bronchodilators For patientswith obstructive
airway and
Difficulty of
breathing
Relaxes
bronchial andvascular smooth
muscles for
patent airway
SIDE/ADVERSEEFFECTS NURSINGCONSIDERATIONS PATIENTS TEACHING REFERENCE
D d i it t d *C t i di t d t I t t th t NURSING 2007
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Dry and irritated
nose, cough ,
hypersensitivity
reactions.CNS:Headache
CV:palpitations
G.I: heartburn,
increased appetite
*Contraindicated to
patients with
hypersensitivity to
drug or itsingredients.
*Monitor Vital
Signs Especially
Respiratory rate
Instruct mother to
shake the inhaler
and clear nasal
secretions.*Tell the mother to
remove canister and
wash inhaler with
warm water every
after use.
*Report alterations
in the administration
of drug
*Teach the S.O the
proper position for
the patient in takingthe drugs and follow
promptly doctors
order of dosages.
NURSING 2007
DRUG
HANDBOOK
Lippincott
Williams and
Wilkins
CLASSIFICATION IMPLICATION MECHANISM OFACTION
*PARACETA
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*PARACETA
MOL
120 mg 1 tsp.
P.O q4 to 6
PRN
AntipyreticsFever
Relieve fever
through central
action in the
hypothalamic
heat-regulating
center
SIDE/ADVERSEEFFECTS NURSINGCONSIDERATIONS PATIENTS TEACHING REFERENCE
H t l i I hild d t *T ll t t NURSING 2007
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Hematologics:
hemolytic
anemia,
neutropeniaandleucopenia
Hepatic: Jaundice
Skin: Rash
In children, dont
exceed five doses
in 24 hrs.
*Monitor Vital
Signs especially
checking of
temperature every
15 mins.
*Perform TSB
and provide warm
and comfortable
environment to
the patient
*Tell parents to
consult prescriber
for children
younger than 2.
*Advice parents
that drug are only
for short term use.
*Advice mother
to report
immediately
alterations and if
the fever still
persists
NURSING 2007
DRUG
HANDBOOK
Lippincott
Williams and
Wilkins
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PROBLEM HEALTHTEACHING
RATIONALE
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Hygiene:
1. Daily bath
2. Nail care
3. Oral care
4. Hand washing
Activity
Walking exercises astolerated.
Adequate rest and
sleep.
Active range ofmotion exercises like
flexion and
extension.
Recurrence of LBM
PROMOTIVE:Encourage the
mother for the daily
bath if the patient.
Encourage the
client to have
adequate rest and
sleep for at least 8
hours per day.
Encourage to
perform active range
of motion exercises
like flexion and
extension of thearms and legs for at
least 15-30 min/day.
To promote well
being and for the
client to feel
comfortable.
To regain
strength and
energy.
These exercises
maintain or
increase muscle
strength andendurance and
help to maintain
cardio-respiratory
function.
.
Diet CURATIVE:
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Maintain oral fluid
intake.
Low fiber dietVit. C
(calamansi,guava)
High Iron Intake
Instructions:
Take medications
as prescribed.
Follow upchecked up 1
week after
discharged.
Instruct client to
takemedications as
prescribed by
the physician. Instruct client to
have a follow up
checked up 1
week after
discharged
For fast
recovery.
To preventrecurrence of
the condition
and to note
further
complication.
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One day is never more challenging than the
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One day is never more challenging than the
next
As we ascend to higher levels oflearning, we have learned that to gain
progress is never a petty thing to take for
granted. Great and insurmountable amountof effort must be infused with determination.
Now that we have reached our 2nd year of
learning and loving this course, we, theGroup 1, is yet to be initiated to enter the
world of a student nurse.
This Medical Case Study is our stepping
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This Medical Case Study is our stepping
stone towards attaining a sense of fulfilment
and growth. Fulfilment, for we have nowapplied what knowledge we have gained for
these past semesters and we have known
that working as a team would really result toa greater achievement. Growth, in a sense
that as great and complicated tasks litter our
everyday lives, our own understanding and
open- mindedness also grows and matures.
In the making of this Case Study, we
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In the making of this Case Study, we
have come to an agreement that each
member of the Group should take part andfuse all knowledge and the lessons they
have learned to come up with a great
presentation. The preparation is really never
easy. The sleepless nights, headaches,
stress and struggles we have experienced
bonded as even more closely. A great deal
of suffering was also incorporated, for thiscase study demands our utmost time,
dedication, finances and most of all effort.
But this did not hinder us to finish this task.
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Despite all these hindrances, we are still able
to smile and share jokes to lessen the stress
we have experienced. As we finished this
case study, a great wave of fulfilment and pride
washed over us. We believe that we have
presented our case study clearly andeffectively. Yes, more great and overwhelming
tasks are still up ahead for us to face, but with
our determination, teamwork, our instilled
knowledge and the amount of effort we are
ready to give, we can conquer all of this and
reach the higher echelons of the nursing
course.
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Prepared by:
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Prepared by:
Prepared by:
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Prepared by: