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STI COLLEGE SOUTHWOODS Lot 2A Maduya, Carmona, Cavite COLLEGE OF HEALTH CARE T/C Typhoid Fever; Post VP Shunt 2 Hydrocephalus and 2 Meningocele 2008 Presented By: Capistrano, Reggie Foroneas, Karen Nono, Ma. Franine Alyssa Sobrevega, Reysie BSN 3rd year Level-Group 3 Presented To: Herald Clarence Ambayec, R.N March 18, 2010 Division of Labor Part of the Case Study_ Person to Discuss A. Introduction = Marcus Dale Belisario B. Biographical Data = Marcus Dale Belisario C. Nursing History = Marcus Dale Belisario D. Current Health Status = Reggie Capistrano E. Psychological Development = Reysie Sobrevega F. Physical Examination = Ma. Franine Alyssa Nono G. Laboratory Examination = Karen Foroneas H. Medical Plan of Care = Karen Foroneas I. Anatomy and Physiology = Reggie Capistrano J. Pathophysiology = Marcus Dale Belisario K. Drug Study = Ma. Franine Alyssa Nono L. Nursing Care Plan = Karen Foroneas M. Discharge Plan of Care = Reysie Sobrevega N. Health Teaching Plan = Reysie Sobrevega/ Reggie Capistrano O. Summary of Clients Status as of Last Day Contact = Reysie Sobrevega INTRODUCTION: Typhoid fever, also known as enteric fever, bilious fever, Yellow Jack or commonly just typhoid, is an illness caused by the bacterium Salmonella enterica serovar Typhi. Common worldwide, it is transmitted by the ingestion of food or water contaminated with feces from an infected person. The bacteria then perforate through the intestinal wall and are phagocytes by macrophages. Salmonella Typhi then alters its structure to resist destruction and allow them to exist within the macrophage. This renders them resistant to damage by PMN's, complement and the immune response. The organism is then spread via the lymphatic while inside the macrophages. This gives them access to the Reticulo-Endothelial System and then to the different organs throughout the body. The organism is a Gram-negative short bacillus that is motile due to its peritrichous flagella. The bacterium grows best at 37 °C/99 °F – human body temperature. Salmonella Typhi lives only in humans. Persons with typhoid fever carry the bacteria in their bloodstream and intestinal tract. In addition, a small number of persons, called carriers, recover from typhoid fever but continue to carry the bacteria. Both ill persons and carriers shed S. Typhi in their feces (stool). You can get typhoid fever if you eat food or drink beverages that have been handled by a person who is shedding S. Typhi or if sewage contaminated with S. Typhi bacteria gets into the water you use for drinking or washing food. Therefore, typhoid fever is more common in areas of the world where handwashing is less frequent and water is likely to be contaminated with sewage. Typhoid fever is characterized by a sustained fever as high as 40 °C (104 °F), profuse sweating, gastroenteritis, and non-bloody diarrhea. Less commonly a rash of flat, rose- colored spots may appear. Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache and cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in the number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a positive diazo reaction and blood cultures are positive for Salmonella Typhi or Paratyphi. The classic Widal test is negative in the first week. In the second week of the infection, the patient lies prostrated with high fever in plateau around 40 °C (104 °F) and bradycardia (Sphygmo-thermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and abdomen in around 1/3 patients. There are rhonchi in lung bases. The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to pea-soup. However, constipation is also frequent. The spleen and liver are enlarged (hepatospleenomegaly) and tender and there is elevation of liver transaminases. Blood cultures are sometimes still positive at this stage. In the third week of typhoid fever a number of complications can occur: Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually non-fatal. Intestinal perforation in distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in. Encephalitis Metastatic abscesses, cholecystitis, endocarditis and osteitis The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is delirious (typhoid state). By the end of third week defervescence commences that prolongs itself in the fourth week. Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid does not affect animals and therefore transmission is only from human to human. Typhoid can only spread in environments where human feces or urine are able to come into contact with food or drinking water. Careful food preparation and washing of hands are therefore crucial to preventing typhoid. STI COLLEGE SOUTHWOODS Lot 2A Maduya, Carmona, Cavite COLLEGE OF HEALTH CARE PATIENT’S HISTORY A. Biographical Data Name: Baby Pops Age: 2 years old and 5 months Gender: Male Status: Pedia Address: San Pablo City, Laguna Dialect/Language Spoken: Tagalog and English Chief Complaint: On and off fever x 6 days with poor oral intake Admitting Diagnosis: T/C Typhoid Fever; Post VP Shunt 2 Hydrocephalus, 2 Meningocele B. NURSING HISTORY 1. History of Present Illnesses Last January 16, 2010 Baby Pops experience a fever with 39C consistent of 6 days and self medicated by his mother and given Paracetamol syrup p.o without any consultation to the doctor. Then 6 days of fever the mother decided to go to the hospital and having consultation, when they arrived to the hospital and consulted by the doctor, the mother advised to admit Baby Pops. 2. Family History Male: Female: Patient: -Hirshprung -No disease abnormality -Diabetes -Hydrocephalus -Lumbuscral Myelomeningocele 3. Childhood Illnesses According to the mother, Baby Pops had only a cough and colds and fever. 4. Hospitalization History First Admission When Baby pops was 9 months old and diagnosed Pneumonia at PPL San Pablo, Laguna Second Admission When Baby Pops was 1 year old and 4months and admitted at the PGH Manila December 11, 2008 Lumbuscral Myelomeningocele December 24, 2008 Inserting VP Shunt C. CURRENT HEALTH STATUS A. Activity Frequency and regularity of exercise: Baby Pops always wants to bend, to crawl and to play basketball with his dad. Duration and Length of Exercise: “Malimit” o “Maya’t maya” is how his mother describes the duration of his exercise. While if his playing basketball, he plays at least 2 hours Limitation of Activity: Baby Pops mother limited him to walk and to play with relatives especially his cousins, causing him to be tease. Any Complaints and Discomfort: Baby Pops doesn’t have any discomfort or complaints related to the activity. B. Rest Usual no. of hours of sleep and rest at night/at day time: At night, Baby Pops usually sleeps 10 hours and while in day time, he usually sleeps at around 10:30am-1:30pm but sometimes, kit depends on the environment. No. of hours of sleep and rest to feel rested: Usually, Baby Pops sleeps 4 hours to feel rested. Change in sleep/rest pattern: Baby Pops doesn’t have any changes in sleeping, but sometimes it depends on the situation. Discomfort or difficulty going to sleep: He doesn’t have any discomfort going to sleep but sometimes he get easily destructed when stranger hold his IV line or touch him, because his mother and his grandmother can only touch him. Remedy done with the comfort: The only remedy done with this discomfort was “yapos lang ng nanay ang gusto niya”, said by the mother. No. pillows use when sleep: He had 4 pillows when sleeping; 1 for the head, 1 on each side and a hotdog pillow to embrace. C. Nutritional Metabolic Pattern Food Preference: Baby Pops loves to eat rice and “bulanglang” a kind of mixed vegetables, that popular in Bisaya. Volume and type of fluid taken per day: He drinks 18oz of milk twice a day, with “sabaw ng buko and mais” Source of drinking water: The mother gets water for Baby Pops on a Wilkins mineral water Medication used (if any): At home, the mother gives multivitamins like Growee and Propan TLC, for protection and for rapid growth. D. Elimination Pattern i. Bladder Frequency and amount of urination per day: Baby Pops usually uses 2 (XL) diapers a day. Color and odor of urine: He had light yellow color urine and with aromatic odor which indicates of the normal findings. Any discomfort of urination: The child also doesn’t have any complaints in urination. ii. Bowel Frequency of bowel movement: Baby Pops usually defecate 1 or 2 times a day. Consistency and color of stools: Baby Pops had a soft stool and scanty odor and slightly brownish color as alleged. Changes in bowel elimination: After surgery, he had experienced bowel movement difficulty. E. Fluids and Electrolytes Skin turgor: Baby Pops was found to have a normal skin turgor when pinched, within 1-2 seconds skin returns to normal prior to the assessment. Condition of mucous membrane: Baby Pops mucous membrane was good with some mild pinkish mucous membrane. Edema: There were no evident edemas observed on the pt. face and on the lower and upper extremities. K, Ca, Na, and supplementation: The present fluid supplement upon assessment was D5IMB solution. F. Senses There are no disturbances or difficulty aside from touch, he just got easily destructed and disturbed when somebody holds or touch him. G. Skin Integrity Pigmentation: Baby Pops had fair skin pigmentation. Temperature: He was cold to touch due to expose and direct air thru window. Smooth (+) Rough (-) Soft (+) Dry (-) H. Neurologic Function Level of Consciousness: Baby Pops was conscious and coherent. Orientation: Baby Pops easily becomes irritable when he sees stranger going close to him. Gait: Baby Pops had disturbances due to his plantar flexion of foot. Posture: He had a plantar flexion of foot. Changes in facial: He also had a downward deviation of the eye (sun setting). Role Function Mode Type of family structure: Their family structure was extended. How many members in the family: They were composed of 5 family members. Who is the bread winner: The present breadwinner in their family was the father and the grandmother. Who is the decision maker: Also, when it comes to decision making it was the father and the grandmother, who decides in their family. How does the family feel about the illness: The family feels sad but very supportive, when it comes to Baby Pops’ hospitalization. D. PSYCHOLOGICAL DEVELOPMENT INTERPERSON PSYCHOSEXUAL PSYCHOSOCIAL COGNITIVE MORAL SPIRITUAL AL (Freud) (Erickson) (Piaget) (Kohlberg) (Fowler’s) (Sullivan) Anal: 18 mos.- Autonomy vs. Pre- Childhood: Level1: Pre- Stage 1: 3yrs. Old Shame and operational: 18 mos. – conventional Initiative- Doubt: 18 2-4yrs. Old 6yrs old Stage 1: Age Projective mos.- 3yrs. old 2-3 years old Faith: Toddler/ Pre- -pleasure is -Impulsitivity, school through determination -no cause and -learn to delay -punishment elimination or and compulsion effect need or obedience -No retention of -curious to reasoning, gratification (heteronymous spiritual feces everything that egocentrism; morality) concept -behaviors: their body use of Baby Pops -a child does but control of secretes symbols; doesn’t have the right involves holding on and - significant magical control in his things because parents on letting go. relation: Parents thinking defecation, a parent tells religion -develop would have a him or her to and concepts of Baby Pops is a 2 Baby Pops was hard time avoid spiritual power, years old, he able to imitate developing his punishment. beliefs. punishment, already have the different so called ambivalence, authority to activities sense of Baby Pops Baby Pops concern with command what demonstrated power as he knows how to already cleanliness or he wants to do to him such as attempts to be an obedient knows how being dirty. even it is throwing the control himself child to his to pray dangerous. And ball, asking and his mother. But and always Baby Pops was he also wants to him to run environment. sometimes, go to a 2years and 5 be beside of his after you, This sense of the child church months old mother. hides and power can learns not to every child, he still seeks an also be used follow the task Sunday uses diaper, he example of to please the that given to with his can already mental mother. He him. And a parents control his feces representation. also learns to punishment but he even his in the interact with will be given to doesn’t hospital. The the other child him. know very resolution of the to play and well about patient was build to have the Shame and friends. concept of Doubt, due to religion anxiety with and strangers. spiritual beliefs that his parents taught to him. E. PHYSICAL EXAMINATION Date performed: January 22, 2010 No. of hospital Days: 2 days 1. Vital signs : a. Temperature: 36.4C b. Pulse Rate: 103bpm c. Respiratory Rate: 25cpm 2. Regional Examination: Methods of Assessment Regions of the body Results (IPAP) a. Hair Inspection Short, slightly oily hair b. Head Oblong shape, open anterior fontanel at the frontal area, Inspection (+) VP Shunt tube located at Palpation the right temporal, (-) mass, (+) scar at least 1 inch at the right occipital area. c. Face Symmetrical, with slight Inspection bulging at the top of head, downward deviation of eyes. d. Eyes “Sunsetting” eye, watery color of the eye is black, constricted, (eyes do not follow in response to head Inspection movement) can focus on objects 7-8 inches away, can follow up to midline, Eyelids-fully cover eye when close and partially raise when open (blink reflex present), placement in eye socket-normally placed. e. Nose Flat nose, smooth, (-) Inspection distress, (-) nasal flaring f. Mouth and pharynx Lip color-normally pinkish, open evenly when cry, soft and hard palate intact, tongue slightly heart shape, Inspection freely movable and does not protrude, milk teeth present, but upper teeth in front are decayed. g. Neck Symmetric, flexible and movement of the head Inspection equally to both sides, supported by pillows when eating, (+) lymph nodes h. Chest wall ( Symmetric, clavicles Anterior) straight, (-) fractures, heart Inspection rate heard at the mid Auscultation clavicular space at fourth intercostal space (103bpm), (-)murmur i. Chest wall (Posterior) (-) fracture, spine is aligned, (-) murmur. At the midline Inspection of lumbar area (+) scar 1 ½ Auscultation inch long due to lumboscral myelomeningocele j. Breast and Axilla Nipple are prominent, well Inspection formed and symmetrical place k. Heart 103bpm, apical pulse and Auscultation respiratory rate identified, normal rhythm l. Abdomen Inspection (-)kidney and spleen Auscultation enlargement, (+) burborgymi sounds (18p/m), globular, , (-) masses m. Skin and nails Skin- (-)dry, (+) smooth Nails- short nails with some Inspection dirt at the “singit” inside nails n. Anus and Rectum (+)patent anus, (-)rashes, (- Inspection )hemorrhoids BM- 1x o. Extremities (lower) Rating: 5 normal, there is an *include ROM and active resistance with simple muscle strength motion Inspection -equal in length, five Palpation fingers on each feet, but the both foot is in plantar flexion (equinus) p. Extremities (upper) Rating: 5 normal, there is an *include ROM and Inspection active resistance with simple muscle strength Palpation motion, complete fingers on both hands q. Urinary Color- light yellow Transparency- turbid Specific Gravity- 1.005 Reaction- acid Albumin- ++ Sugar- negative Inspection Pus Cell- TNTC RBC- 2-4hpf Bacteria- + Epithelial Cell- few Crystals- Amorphous Urates(+) Void- 2 diapers per day r. Genitals Inspection (-) hernia s. Musculoskeletal - (-) weakness, equal size on Inspection both side of the body, smooth and coordinated movements - (+) equinus (plantar flexion of foot) - no tenderness, swelling of joints - (+) gait problems t. Hematology Based on laboratory Refer to Lab results If applicable please include Neuromuscular Vital signs / assessment F. LABORATORY EXAMINATION Purpose of Nursing the responsibiliti Date and Results of examinatio Normal es Type of the Interpretation n to the Values (before, Examination examination patient’s during , case after) 1-22-10 -to detect Color: Color: light All of the results Before: Check the Urinalysis normal yellow- yellow in the urinalysis chart of the versus straw/amber that are pt. And carried out abnormal significant is the doctor’s urine Transparen Transparenc presence of pus order During: component cy: clear y: turbid cells Explain the -to detect procedure to the pt. And glycosuria Specific Specific The urine of the its -to aid in the Gravity: Gravity: patient was importance. Assist client diagnosis of 1.010-1.020 1.005 diluted due to with the a renal less specific urine collection as failure gravity needed Reaction: Reaction: Obtain history of 4.5-8.0 acidic excess amount of certain foods Albumin: Albumin: CSF was such as Negative ++ composed of carrots, rhubarb protein After: Sugar: Sugar: Provide Comfort to Negative Negative the pt. After the procedure. Pus Cell: Pus Cell: Wait for the 3-4 too numerous result to count RBC: 1-2 RBC: 2-4 Bacteria: Bacteria: Due the VP shunt Negative Positive the patient have Epithelial Epithelial Cells: Cells: few Negative Crystals: Crystals: Due to his Negative amorphous hydrocephalus and the VP Shunt Urates: Negative Hematology - to check HGB- (110- HGB- (94.6 Before: the blood 165 g/L) g/L) Check for component CBC order for any HCT- (0.35- HCT- (0.26 Due to the Carry Out abnormality 0.50 g/L) g/L) decrease Doctors - to check pressure in his Order the volume Platelet Platelet VP Shunt During of RBC’s in count- count- (226 Explain the blood (150-450 x x 10 g/L) the 10 g/L) procedure WBC- (12.0 An increase in to the pt. WBC- (5.0- x 10 g/L) WBC which and what 10.0 x 10 signifies a is to be g/L) current infection withdrawn from the Differential Differential blood. count- count- Assess Segmenter Segmenters client for s- (43.0- - (60.7%) signs/symp 76%) toms of allergies Lymphocyt Lymphocyte such as es- (17- s- (32.7%) tearing, 48%) runny nose and rashes Leukocytes Leukocytes- After - (4.0- (6.6%) Wait for 10.0%) the result TYPHIDOT To IgM: IgM: Positive Implication for Before: determine Negative the presence of Check for the IgM antibodies CBC order presence of IgG: IgG: includes previous Carry Out Salmonella Negative Negative infection or Doctors typhi which relapsed or re- Order is the infection, During causative therefore; it is Explain agent of important that the typhoid interpretation be procedure fever made together to the pt. with the clinical and what symptoms to is to be diagnosed if the withdrawn patient is from the currently having blood. typhoid fever. After Wait for the result G. MEDICAL PLAN OF CARE Date of the Responsibility of the Purpose of the Doctor’s order order nurse with the order given order 1-21-10 - pls. admit to Pedia ward - for admission (Misc) under Dr. Mamasig - Secure Consent - Ask if the Doctor had - for legal purposes already inform her and had signed the consent - TPR q shift and recorded - Monitor V/S every 4 -as baseline data hours - Soft diet - Inform the mother the - To know the proper diet for the proper nutrition for patient the patient - Labs: - To further know CBC with platelet - Executes as per the other Doctor’s order complications to the U/A - Refer to Medical disease Technologists - To assess for any abnormalities within the urinary system as well as for systemic problems that may manifest symptoms through Typhi dot the urinary tract. -To detect Typhoid fever and any other - Tx - Executes as per salmonella D5 0.3 NaCl 500ml x Doctor’s order infection. 55ugtts/min - Carried out Chloramphenicol 300mg TIV (-) ANST every 6 hours Paracetamol 125/5ml every 4 hours p.o - TSB inform PROD of the admission 1-22-10 - Pls. re-insert IV - Carried out - Pls. give chloramphenicol IV drip for 15 units - Refer 8:00 am - IVF TF #2 D5IMB 500ml x 8 hours 1-23-10 - Continue meds - Carried out - TF #3 D5IMB 500ml x 8 hours 1-24-10 - Continue meds - Carried out - Pls. re-insert IV now - Warm compress on IV sites 1-25-10 - IVF TF #4 D5IMB 500 x 8 - Carried out hours - Continue meds - Refer 1-26-10 - IVF TF #5 D5IMB 500 x 8 - Carried out hours - Continue meds - Refer 1-27-10 - IVF TF #6 D5IMB 500 x 8 - Carried out hours - executes as per - Continue meds Doctor’s order 1-28-10 - IVF TF #7 D5IMB 500 x 8 - Carried out hours - executes as per - To consume IV Doctor’s order chloramphenicol; shift to cefixime 20mg/ml 2x a day - Refer H. ANATOMY AND PHYSIOLOGY The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules). On the way to the stomach: the esophagus After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down. In the stomach The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. In the small intestine After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food. In the large intestine After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon. The end of the process Solid waste is then stored in the rectum until it is excreted via the anus. Digestive System Glossary: Anus - the opening at the end of the digestive system from which feces (waste) exits the body. Appendix – a small sac located on the cecum. Ascending colon - the part of the large intestine that run upwards; it is located after the cecum. Bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine. Cecum - the first part of the large intestine; the appendix is connected to the cecum. Chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion. Descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon. Duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum. Epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe. Esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the stomach. Gallbladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small intestine. Ileum - the last part of the small intestine before the large intestine begins. Jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum. Liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins. Mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process (breaking down the food). Pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and proteins in the small intestine. Peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you to eat and drink while upside-down. Rectum - the lower part of the large intestine, where feces are stored before they are excreted. Salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules. Sigmoid colon - the part of the large intestine between the descending colon and the rectum. Stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the stomach, it is churned in a bath of acids and enzymes. Transverse colon - the part of the large intestine that runs horizontally across the abdomen. I. PATHOPHYSIOLOGY A. Diagram Precipitating Factors: Predisposing Factor: Environment Age: 2years and 5 months old Street Foods Sex: Male (contaminated) Unboiled water Genes Salmonella Typhi Enter the G.I tract (jejunum, ileum, colon) Enters bloodstream via lymphatics (peyer’s patch) Penetrate cell with little lysis Multiply in lamina propia Systemic Local spread Infection Release of endogenous pyrogens (prostaglandin E1) from neutrophils and macrophages (specialized form of leukocytes) Resetting the thermostatic set point (prostaglandin E2) The hypothalamus initiates heat production behaviors (shivering and vasoconstriction) FEVER B. Tabular Signs and Signs and Definition of the Symptoms Evaluation or Symptoms found in diseases manifested by the comparison the book patient Typhoid Fever A general infection Signs and Signs and These means that the caused by Symptoms in book: Symptoms in signs and symptoms in Salmonella typhi, a Fever patient: the book about typhoid gram negative Anorexia fever (6 days) fever are seen to the motile and Diaphoresis anorexia patient. nonspore- forming Weakness constipation bacillus. It is a Myalgia cough general infection Malaise that primarily Moist crackles involves the Peyer’s Second week: patches of the small 104F, evening intestines chills Delirium Increasing abdominal pain Diarrhea or constipation Maculopapular rash cough J. DRUG STUDY Name of Drug, Classification, Nursing Responsibility Drug Indication Drug Action Route, Frequency (before, during , after) and Dosage Chloramphenicol Haemophillus Inhibits bacterial Use cautiously in (anti-infective) influenzae protein synthesis patient with impaired R: TIV Meningitis by binding to the hepatic or renal function, F: q6 hours Acute Salmonella 50 sub-unit of the acute intermittent D: 300mg typhi infection ribosome; phorphyria and G6PD Bacteremia bacteriostatic deficiency; also use Other severe cautiously with other infections caused by drugs that cause bone sensitive Salmonella marrow suppression or species blood disorders Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin pending results. Obtain plasma levels maintain levels at 5-20 mcg/ml Monitor CBC, platelets, iron and reticulocytes before and every 2 days during this therapy. Stop immediately if anemia occurred. Name of Drug, Classification, Nursing Responsibility Drug Indication Drug Action Route, Frequency (before, during , after) and Dosage Paracetamol Mild pain or fever Thought to produce Use liquid form for (analgesics) analgesia by children and patients (antipyretics) blocking pain who have difficulty R: p.o impulses by swallowing. F: q4 hours PRN inhibiting synthesis In children, don’t D: 4ml of prostaglandin in exceed five doses in 24 the CNS or of other hours. substances that Tell parents to consult sensitize pain prescriber before giving receptors to drug to children younger stimulation. The than age 2. drug may relieve Advise parents that fever through drug is only for short- central action in the term use; urge them to hypothalamic heat- consult prescriber if regulating center. giving to children for longer than 5 days or adults for longer than 5 days or adults for longer than 10 days. Name of Drug, Classification, Nursing Responsibility Drug Indication Drug Action Route, Frequency (before, during , after) and Dosage Cefixime Uncomplicated UTI Cefixime binds to Check if the patient is (anti-infective) caused by E. coli one or more of the allergy to cephalosporins R: p.o and proteus mirabilis penicillin-binding Use cautiously in F: BID Otitis media proteins (PBPs) patient with impaired D: 2ml caused by which inhibits the hepatic or renal function, Haemophillus final acute intermittent influenzae transpeptidation phorphyria and G6PD step of deficiency; also use peptidoglycan cautiously with other synthesis in bacterial drugs that cause bone cell wall, thus marrow suppression or inhibiting blood disorders biosynthesis and Obtain specimen for arresting cell wall culture and sensitivity assembly resulting test before giving first in bacterial cell dose. Therapy may begin death. pending results. Obtain plasma levels maintain levels at 5-20 mcg/ml Monitor CBC, platelets, iron and reticulocytes before and every 2 days during this therapy. Stop immediately if anemia occurred. Nursing Prioritization and Competencies Date NO. Nursing Diagnosis Nursing Competencies Identified Ineffective Gastrointestinal Tissue Communication Perfusion r/t normactive bowel Health Teaching 1 sounds as manifested by burborgymi Safe and Quality Nursing Jan.22,2010 sounds (18p/m) Care Ethico-Moral Responsibility Communication Impaired physical mobility r/t loss of Health Teaching 2 integrity of bone structure as Safe and Quality Nursing Jan.22,2010 manifested by plantar flexion of foot. Care Ethico-Moral Responsibility Knowledge Deficient r/t typhoid fever Communication as evidenced by unfamiliarity to the Health Teaching 3 Jan.22,2010 causative factor of the disease Safe and Quality Nursing Care Communication Health Teaching Severe anxiety r/t unfamiliar person 4 Safe and Quality Nursing Jan.22,2010 as evidenced by crying Care Ethico-Moral Responsibility Communication Risk for infection r/t open anterior Health Teaching fontanel as manifested by scratching 5 Safe and Quality Nursing Jan.22,2010 of the head Care Ethico-Moral Responsibility K. NURSING CARE PLAN Cues Nursing Nursing (subjective/objectiv Objectives Intervention Evaluation Diagnosis e) and Rationale S: Ineffective After 4 hours - V/S monitored Goal is met. “Malimit siya maging Gastrointestinal of nursing and checked for After 4 hours tampulan ng tukso ng Tissue intervention baseline data of nursing mga pinsa niya” as Perfusion r/t the patient - Determine intervention verbalized by the normactive will be able to whether the patient patient’s mother bowel sounds decreased condition is will be able to as manifested burborgymi permanent or decreased O: by burborgymi sounds from temporary to burborgymi - (+) burborgymi sounds 18p/m to enhance sounds from sounds (18p/m) acceptance 18p/m to (18p/m) - Establish a - Body malaise patient-nurse - Brownish color relationship to of stool convey an attitude of caring and develop sense of trust - Auscultate bowel sounds to determine problems in abdomen Encourage rest after meals to enhance digestion Cues Nursing (subjective/objecti Nursing Diagnosis Objectives Intervention Evaluation ve) and Rationale S: Impaired physical After 5 - V/S taken Goal is met. “ Malaro siya kaso mobility r/t loss of hours of and recorded After 5 hours hindi talaga siya integrity of bone nursing for baseline of nursing pinapayagan na structure as intervention data. intervention makipaglaro dahil manifested by the patient - Provided the patient madali siya mainis at plantar flexion of will able to safety and was able to sumungin” as foot. demonstrate security for demonstrate, verbalized by the , the safety of participation patient’s mother participation the child in activities, in activities - Encouraged command by O: command by participation his mother or - limited ROM his mother is self care; relatives. - difficulty of or relatives. to encourage turning side to self concept side and sense of - (+) plantar independenc flexion of foot e - Difficulty to - Encouraged move adequate intake of fluids and nutritious food; to promote well-being and maximize energy production - Instructed proper hygiene for cleanliness of the patient to avoid spread of infection - Provide quiet and calm environment to promote relaxation Cues Nursing Nursing (subjective/objectiv Objectives Intervention Evaluation Diagnosis e) and Rationale S: - Knowledge After 2 hours - V/S taken Goal is “ Hindi namin alam Deficient r/t of nursing and partially met. kung paano siya typhoid fever intervention recorded After 2 hours nilagnat ng mataas” as evidenced the patient will for baseline of nursing as verbalized by the by be able to data. intervention patient’s mother unfamiliarity to understand the - Explain to the patient the causative related factors the relative will be able to O: factor of the about the of patient understand - Unfamiliarity to disease present illness the the related the causative condition of factors about factor of the the patient the present disease - Discuss illness - Restlessness related - irritability factors about the present disease - Encourage them to read some books about the disease and causative agent Cues Nursing Nursing (subjective/objectiv Objectives Intervention Evaluation Diagnosis e) and Rationale S: Severe anxiety r/t After 4 hours - V/S Goal is met. “Madali siya matakot unfamiliar person of nursing monitored After 4 hours sa mga taong as evidenced by intervention and recorded of nursing ngayonlang niya crying the patient will as baseline intervention nakita” as verbalized be able to data the patient by the patient’s mother develop sense - Provide will be able to of trust. adequate develop sense O: rest to of trust. - crying promote - (+) stranger relaxation anxiety - Build a - With poor eye trusting contact relationship - With extraneous with the movement patient to - (+) facial promote grimace rapport. - Encourage patient to play to promote therapeutic empathy to the patient - Provide physical contact to the patient as well as being truthful to soothe fears. Cues Nursing Nursing (subjective/objectiv Objectives Intervention Evaluation Diagnosis e) and Rationale S: Risk for infection After 4 hours - monitor V/S Goal is met. “ Lagi niya gusto r/t open anterior of nursing every 4 hours After 4 hours kamutin yung nasa ulo fontanel as intervention as baseline of nursing niya’ as verbalized by manifested by the pt will able data intervention the patient’s scratching of the to know what - soft diet the pt was able grandmother head are the instructed to to know what intervention to avoid the O: prevent the restraining intervention to - afebrile risk of and easily to prevent the - irritability infection. swallow risk of infection - restlessness - monitored IVF is. - (+) open and IV rates anterior - kept back dry fontanel to prevent - Scar on the occurrence of right side of the other disease head - kept - Scratching of environment the head well ventilated - emphasized hygiene - provide safety and security such as don’t leave the child unattende d put pillows each side of the bed - monitor I/O to prevent reoccurrence of other disease - Health teaching instructed such as; Hygiene measures Safety measures ( tell patient not to scratch site of VP shunt) to prevent risk of infection Diet instructed L. DISCHARGE PLAN OF CARE Key Area Plan of Care 1. Nutrition Continue advice of soft diet as prescribed by the physician, encourage patient to eat nutritious food, and avoid street foods to avoid possible of having typhoid fever. 2. Activity Encourage patient or instruct mother of daily exercise, avoid sleeping late hours, prevents activity that causes trauma or injury 3. Self Care / knowledge on Instructed hygienic measures (e.g. proper hand washing, before treatments and after eating and urinate and defecate, as well as proper grooming) 4. Medication Advise to continue medication as prescribed by the doctor. 5. Follow up check ups To comeback as prescribed by the doctor. Have a daily consultation to neuro and physical therapist for the VP Shunt and for plantar flexion of foot. M. HEALTH TEACHING PLAN Methods of Topic Objective Visual aids Evaluation Teaching 1. Choosing Right After 30 mins of Discussion - Sample After 30 mins of Foods discussion the Explanation Procedures discussion the mother of the pt. mother of the pt. will be able to was able to know know the the importance importance and and understanding, understanding, choosing foods choosing foods to eat to eat 2. Importance After 30 mins of - Picture of After 30 mins of of clean and discussion the Discussion nutritious discussion the safe foods mother of the pt. Explanation foods mother of the pt. for the will able to know - List of right will able to know family the importance and affordable the importance of clean and safe foods of clean and safe foods for the foods for the family family 3. Proper Boiling After 30 mins of - Notes of of Water discussion the Discussion importance of After 30 mins of relative of the Explanation clean and safe discussion the pt. will be able foods relative of the pt. to know the was able to know proper boiling of the proper water to kill the boiling of water microorganism to kill the in the water. microorganism in the water. 4. Safety and After 1 hour of Demonstration - pictures Security of nursing care and Explanation needed for After 1 hour of Child health teaching demonstration nursing care and the mother of such as pillows, health teaching the pt. will able things that the mother of to know the could harm your the pt. was able safety measures child (e.g. knife, to know the needed by the holder and pins) safety measures child needed by the child N. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT Date: January 23, 2010 The condition of the Baby Pops on the last day of duty in the Pedia ward had no signs of distress, afebrile and cooperative. He still afraid of strangers especially when touching him. Baby Pops was still under observation and possible for MGH the next day.