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Republic of the Philippines University of Northern Philippines Tamag, Vigan City

College of Nursing Case Study On

PERFURATED RECTUM
Presented to:

Mr. Rex Tomas, RN


Clinical Instructor

In partial fulfillment Of the requirements in

NURSING CARE MANAGEMENT - RLE


St. James Hospital- ICU

Presented by:

GOLDWYN A. ADVERSALO
BSN IV BROMELIADS
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Republic of the Philippines University of Northern Philippines Vigan City

COLLEGE OF NURSING

CASE STUDY GRADING SHEET PARAMETERS Introduction & Objectives Personal Data Nursing History of Past & Present Illness PEARSON Assessment Diagnostic Procedure a. Ideal b. Actual Anatomy and Physiology Pathophysiology a. Algorithm b. Explanation Management a. Medical & Surgical b. NCP with Evaluation c. Promotive & Preventive Mgt. Drug Study Discharge Plan Updates Bibliography Organization TOTAL REMARKS: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ GRADE

5 5 15 5

5 15

5 20 5 5 5 5 2.5 2.5
100

Mr. Rex Tomas, RN CLINICAL INSTRUCTOR


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INTRODUCTION
Scarlet fever is caused by certain strains of the group A streptococci bacteria (which also causes strep throat) and it is common to think of scarlet fever as strep throat with a rash. Symptoms usually develop about 1 to 7 days (incubation period) after being exposed to someone with strep throat or scarlet fever. This is most common in children under 10 years old and begins with a fever and sore throat. Other symptoms can include vomiting, headache, chills and abdominal pain. Many children with this infection have a high fever initially, which may reach 103 to 104 degrees F. Without treatment, the fever may last 5 to 7 days, but usually quickly goes down within a day after starting antibiotic therapy. After 12 to 48 hours of developing symptoms, the infected person will then develop a red rash, which consists of very small red bumps that begin on the neck and groin and then spreads to the rest of the body. The rash has the characteristic feel of sandpaper and typically lasts 5 to 6 days. The rash is sometimes worse on the neck, elbow creases, arm pits (axilla) and groin and once the rash fades, the skin may peel. This peeling may last up to 6 weeks. Although the sandpapery rash does not usually occur on the face, the patients forehead and cheeks may appear red and flushed. In addition to this flushed appearance, there is usually a pale area around his mouth (circumoral pallor).Another common finding is dark, hyperpigmented areas on the skin, especially in skin creases. These areas are called Pastia's lines.The fever and rash is usually also accompanied by a red, swollen throat and tonsils that can have a white coating of pus, swollen glands, decreased appetite and energy level.Another common finding is a red and swollen tongue. At first, the tongue usually also has a white coating on it, and with the red swollen papillae of the tongue protruding through this white coating, it gives the appearance of a strawberry tongue. 3

If scarlet fever is suspected in the patient, the doctor will probably do a throat swab to confirm that there is infection with strep bacteria. This infection requires treatment with antibiotics, usually penicillin. If the patient is no longer be contagious after being on an antibiotic for 24 hours. It is important to take a complete course of antibiotics to prevent patient from getting rheumatic fever.

This case study is focused on a patient named Clendon Ramos, 11 years old, from Amparo Village, Caloocan City, Clendon is an incoming grade six pupil. He was diagnosed first with atypical Kawasaki disease but later on diagnosed with Scarlet Fever. He was confined at National Childrens Hospital in Quezon City.

OBJECTIVES
General Objectives:
After making this case study, the student nurse will be able to acquire knowledge, skills and attitude in caring for the patient with scarlet fever.

Specific Objectives:
To learn and study the case of the patient in detailed to have enough knowledge of the condition, and regarding on its disease process and treatment or cure. To obtain a comprehensive past, present and family history of patients illness. To assess the condition of the patient using systemic way by assessing in a cephalocaudal way to get cues for the plan of care. To make a detailed assessment of the patient being studied following the PEARSON (psychosocial, elimination, activity and rest, safety, oxygenation and nutrition) format. To be familiar with the diagnostic procedure done to the patient and even the actual diagnostics to be done, and to make an appropriate nursing responsibilities for each diagnostic exams and also to study the result and outcome of the procedure to be able to relate it on patients condition. To be able to trace the etiology, by establishing an appropriate Pathophysiology of the disease, this includes the algorithm and its explanation. To familiarized the ideal and actual medical and surgical interventions done to the patient. To be able to provide and implement a nursing care plan for an easy recovery of the patient and to attain goal and objective set using SMART (specific, measurable, attainable, realistic and time frame). To make list of the different drugs taken and is presently taking by the patient with their corresponding dosages, mechanism of action, side effects/ adverse effects and together with the nursing responsibilities. To formulate a discharge plan covering the following areas: METHOD (medications, Exercises, Treatments, Health Teachings, Out-patient department and diet). 5

PATIENTS PROFILE PERSONAL PROFILE

Name: Age: Sex: Civil Status: Religion: Date of Birth: Address: Nationality: MEDICAL PROFILE: Date Admitted: Time Admitted: Ward:

Precentation Torre 73 years old Female Single Roman Catholic February 2, 1939 Binalangayan Sto. Domingo, Ilocos Sur Filipino

June 16, 2012: Saturday 4:45 P.M Intensive Care Unit, B2 pain and tenderness

Medical Institution: St. James Hospital Chief Complaint: (-) Bowel movement for 2 days, abdominal Initial Diagnosis: Acute abdomen secondary to perforated rectum Admitting physician: Final diagnosis: Dr. Paz Perfurated Ischemic Rectum with Santol Seeds

HISTORY OF PAST AND PRESENT ILLNESS A. PAST HISTORY According to the patients mother, she gave birth to Clendon via Normal spontaneous delivery attended by a midwife, Clendon had experienced minor illnesses like common colds, fever and coughs. And whenever he had this signs and symptoms, it was relieved by OTC drugs that are being bought by his mother. His mother added that Clendon has no known allergy to food and drugs, and never been hospitalized, this is his first hospital confinement. There is no history of such hereditary diseases in his mothers side but in his fathers side, the grandfather has a history of hypertension. B. PRESENT HISTORY According to the patients mother, a week before the admission the patient is experiencing fever, and there is a macular rash appeared on the patient associated with itching. The mother misdiagnosed it as measles. The fever was treated with paracetamol. The rash started on the abdomen and gradually spread on the face and other parts of the body, there was a spontaneous resolution of fever. After 2 days fever is still present and the mother noticed that there is a desquamation on patients palms, fingers and toes. Two days after they noticed the desquamation on palms, fingers and toes, the mother noted that there is an abdominal distension but with no complaints of pain. After 1 day, the patient complained epigastric pain that is colicky in nature. So, they decided to bring the patient to the hospital. They brought him first at Tala Hospital located at South Caloocan. But they referred it to National Childrens Hospital. They admitted the patient and put it miscellaneous 3, non- infectious ward bed number 3. He was hooked with D5 IMB 500ml to consume for 24 hours inserted @ Right Metacarpal vein. Series of diagnostic exam was done like: CBC, Blood typing, urinalysis and ASO titer. According to the mother, the patient has decreased hemoglobin so they do series of blood transfusion. Following medications are given: Paracetamol 250mg/5ml; 5ml every 4 hours- for fever Ranitidine 25mg every 8 hours- H2 receptor antagonist 7

Penicillin Na 940,000 every 6 hours ANST(-)- for bacterial infection Nifedipine 5mg PRN for BP >130/100- Calcium channel blocker: for hypertension Enalapril 2.5mg 1tab BID- Angiotensin Coverting enzyme inhibitor; for hypertension Recently they requested for 2D echo and Anti DSDNA but the patient is not yet subjected for this kind of diagnostic procedure due to financial problem.

PEARSON ASSESSMENT

APRIL 26,2011 (10:00am-2:00pm) The patient is 74 years old female, presently living at Sto. Domingo Ilocos Sur She is restless and disoriented. According stage. to Erik Ericksons theory of Psychosocial

APRIL 27, 2011 (10:00am-2:00pm) Upon arrival to the ICU, the patient is still restless and disoriented

Development, patient is under industry versus inferiority He is under industry because; he is able to do simple house works and knows what to do when his mother left them together with his sister specially when going to school.

The oral mucosa of the patient is dry. With NGT opened to drained connected to a bedside botlle with greenish output and minimal discharge. She has an Indwelling Fulley Catheter connected to Hbag draining yellowish output with adequate amount during the entire shift Her urine is being measured hourly. (-) Bowel movement in the entire shift. Patient has a penrose drain

The oral mucosa of the patient is dry. With NGT opened to drained connected to a bedside botlle with greenish output and minimal discharge. She has an Indwelling Fulley Catheter connected to Hbag draining yellowish output with adequate amount during the entire shift Her urine is being measured hourly. (-) Bowel movement in the entire shift. Patient has a penrose drain

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ACTIVITY Patient is on bed restless.

ACTIVITY Patient is on bed restless. The patient cannot able to perform ADL because of restlessness, and restraints. She attempts to get out from bed.

The patient cannot able to perform ADL because of restlessness, and restraints.

She attempts to get out from bed.

REST The patient is restless She gets a period of sleeps when given sedatives . Has no other disturbances during her sleeps except when nurse take hers vital signs.

REST The patient is restless She gets a period of sleeps when given sedatives . Has no other disturbances during her sleeps except when nurse take hers vital signs.

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Patient has a restraints on both upper and lower extremities due to restlessness and she wants to get up from bed. He has no allergy to foods and drugs.

Patient has a restraints on both upper and lower extremities due to restlessness and she wants to get up from bed. He has no allergy to foods and drugs. With body temperature of 38.7 C/ axilla, febrile, skin is warm to touch.

With body temperature of 37.8 C/ axilla, febrile, skin is warm to touch.

With dry dressing on the operative site With dry and crackly lips.

With dry dressing on the operative site With dry and crackly lips. The room of the patient is clean, with fluorescent lights and ventilated with air condition.

The room of the patient is clean, with fluorescent lights and ventilated with air condition.

WBC is 7.7, on its normal range

No CBC done for this day

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RR is 32 cpm initially before the intubation With Oxygen support via face mask regulated to 4-6LPM PR is 140 bpm Difficulty in breathing was observed manifested by grunting. Use of accessory muscles notified.

PR is 120 bpm O2 saturation: 98% Capillary refill time is 2 seconds. No cyanosis in the nail beds and lips was observed. Still with ETT connected to Mechanical Ventilator with the following set-up: AC mode, TV-450ml, BUR- 14, FIO2- 40%, and peak rate of 60.

Oxygen saturation is 100% initially before desaturation occurs Capillary refill time is 2 seconds. No cyanosis in the nail beds and lips was observed. The hemoglobin is 116, in normal range With ETT connected to Mechanical Ventilator with the following set-up: AC mode, TV- 450ml, BUR- 18, and FIO2- 40%

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Diet is NPO With NGT

Diet is NPO With NGT With an IVF of D5 LRS 1L @ 41 drops per minute infusing well @ Left arm.

With an IVF of D5 LRS 1L @ 41 drops per minute infusing well @ Left arm.

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ACTUAL DIAGNOSTIC EXAMS CBC


PARAMETERS Hemoglobin Mass Hematocrit Leukocyte Count Defferential Count Segmenters Lymphocytes Monocytes Eosinophils Reticulocytes Platelet Count 0.40-0.75 0.20-0.40 0.00-0.07 0.00-0.05 0.5-2% 150400x10^9/L Coaglation Studies Prothrombin Time % Activity Active PTT RH typing CRP MCV MCH MCHC Blood type: B <6mg/L 82-92fL 28-32 32-38% 70-120 ----384 -------Increased may indicate inflammation Normal Normal Normal 11-15secs ---0.04 Normal -455 -Increased may indicate malignancy, myeloproliferative disease. -0.66 0.30 Normal Normal Normal 0.40-0.54 5-10x10^9/L 0.26 8.8 NORMAL 140-180g/L 1ST 80
INDICATION

the hemoglobin is decrease which may indicate various anemias. Decreased, may indicate severe anemias Normal

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NURSING RESPONSIBILITIES:

Tell the patient that when the needle is inserted to draw blood, he may feel moderate pain, or only a prick or stinging sensation. Afterward, there may be some throbbing. URINALYSIS
URINALYSIS- is a used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders. It is ordered widely and routinely to detect any abnormalities that require follow up. Often, substances such as protein or glucose will begin to appear in the urine before patients are aware that they may have a problem. It is used to detect urinary tract infections and other disorders of the urinary tract. In patients with acute or chronic conditions, such as kidney disease, the urinalysis may be ordered at intervals as a rapid method to help monitor organ function, status, and response to treatment. PHYSICAL APPEARANCE COLOR AMBER YELLOW REDDISH YELLOW Medications. A number of drugs can darken urine, including the antimalarial drugs chloroquine and primaquine; the antibiotic metronidazole; nitrofurantoin, which treats urinary tract infections; laxatives containing cascara or senna; and methocarbamol, a muscle relaxant. Medical conditions. Some liver disorders, especially hepatitis and NORMAL RESULT IMPLICATION

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cirrhosis, and the rare hereditary disease tyrosinemia can turn urine dark brown. So can acute glomerulonephritis, a kidney disease that interferes with the kidney's ability to remove excess fluid and waste. TRANSPARENCY CLEAR HAZY Turbidity or cloudiness may be caused by excessive cellular material ( such as the presence of RBC's and pus cells) or protein in the urine or may develop from crystallization or precipitation of salts upon standing at room temperature or in the refrigerator. REACTIVITY SPECIFIC GRAVITY ACIDIC 1.000-1.038 CHEMICALS PROTEIN NEGATIVE +3 Indicates proteinuria Protein in the urine ACIDIC 1.010 NORMAL NORMAL

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can be a symptom of kidney stones, inflammation of the kidneys, degenerative kidney disease SUGAR NEGATIVE NEGATIVE NORMAL

MICROSCOPIC RBC NEGATIVE OVER 100/HPF Hematuria is the presence of abnormal numbers of red cells in urine due to: glomerular damage, tumors which erode the urinary tract anywhere along its length, kidney trauma, urinary tract stones, renal infarcts, acute tubular necrosis, upper and lower uri urinary tract infections, nephrotoxins, and physical stress. PUS NEGATIVE 30-35/HPF severe urinary tract infection which may ascend upwards into ureter and kidneys

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EPITHELIAL

NEGATIVE

OCCASIONAL

represent possible contamination of the specimen with skin flora.

AMORPHOUS URATE

FEW

May be due to the process of refrigeration

NURSING RESPONSIBILITIES:
Instruct patient to drink plenty of water Teach patient how to catch urine Instruct patient to bring specimen immediately to the laboratory When results are in refer it to the doctor.

ASO TITER
PROCEDURE ANTI STREPTOLYSIN O TITER REFERENCE VALUE RESULT IMPLICATION

<200IU/ML

400IU/ML

Increase indicates scarlet fever

NURSING RESPOSIBILITIES:

Instruct patient not to eat for 6 hours before the test Tell the patient that when the needle is inserted to draw blood, he may feel moderate pain, or only a prick or stinging sensation. Afterward, there may be some throbbing.

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IDEAL DIAGNOSTIC PROCEDURES

COMPLETE BLOOD COUNT A complete blood count is a non-specific test. It is done to determine the severity of the infection. If the white blood count is very high, this is suspicious for a worse infection, such as bacteremia or sepsis. If there is suspicion of this, a blood culture is needed. A complete blood count also indicates the level of platelets in the blood. A very high level of platelets (above 1,000,000), may indicate Kawasaki disease instead of scarlet fever. Definition A complete blood count (CBC) test measures the following:

The number of red blood cells (RBCs) The number of white blood cells (WBCs) The total amount of hemoglobin in the blood The fraction of the blood composed of red blood cells (hematocrit) The size of the red blood cells (mean corpuscular volume, or MCV)

The CBC test also provides specific information the size and hemoglobin content of individual red blood cells. This is determined from the additional following measurements:

Mean corpuscular hemoglobin (MCH) Mean corpuscular hemoglobin concentration (MCHC)

The platelet count is also usually included in the CBC. Alternative Names Complete blood count How the test is performed Blood is typically drawn from a vein, usually from the inside of the elbow or the back of the hand. The site is cleaned with germ-killing medicine (antiseptic). The health care provider wraps an elastic band around the upper arm to apply pressure to the area and make the vein swell with blood. Next, the health care provider gently inserts a needle into the vein. The blood collects into an airtight vial or tube attached to the needle. The elastic band is removed from your arm. Once the blood has been collected, the needle is removed, and the puncture site is covered to stop any bleeding. In infants or young children, a sharp tool called a lancet may be used to puncture the skin and make it bleed. The blood collects into a small glass tube 20

called a pipette, or onto a slide or test strip. A bandage may be placed over the area if there is any bleeding. How to prepare for the test There is no special preparation needed. How the test will feel When the needle is inserted to draw blood, you may feel moderate pain, though most people feel only a prick or a stinging sensation. Afterward there may be some throbbing or bruising. ,NORMAL VALUES PARAMETERS Hemoglobin Mass Hematocrit Leukocyte Count Defferential Count Segmenters Lymphocytes Monocytes Eosinophils Reticulocytes Platelet Count Coaglation Studies Prothrombin Time % Activity Active PTT RH typing CRP Semi-quantitative CRP <6mg/L 11-15secs 70-120 0.50-0.70 0.20-0.40 0.00-0.07 0.00-0.05 0.5-2% 150-400x10^9/L NORMAL 127-183g/L 0.37-0.54 4.5-10x10^9/L

MCV MCH MCHC

82-92fL 28-32 32-38%

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ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY


ALOGORITHM

EXPLANATION

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MANAGEMENT
MEDICAL AND SURGICAL MANAGEMENTS MEDICAL MANAGEMENT
IDEAL ACTUAL MEDICAL MANAGEMENT IV FLUIDS:

D5 IMB 500ml to run for 24 hours PNSS 500ml to run for 24 hours

MEDICATIONS: Paracetamol 250mg/5ml; 5ml every 4 hours- for fever Ranitidine 25mg every 8 hours- H2 receptor antagonist Penicillin Na 940,000 every 6 hours ANST(-)- for bacterial infection Nifedipine 5mg PRN for BP >130/100- Calcium channel blocker: for hypertension Enalapril 2.5mg 1tab BID- Angiotensin Coverting enzyme inhibitor; for hypertension OTHERS:

Blood transfusion due to decrease hemoglobin count

SURGICAL MANAGEMENT IDEAL SURGICAL MANAGEMENT ACTUAL SURGICAL MANAGEMENT

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PROMOTIVE AND PREVENTIVE MANAGEMENT

A. PROMOTIVE MANAGEMENT
o Provide a soft or liquid diet for a few days until their throat soreness has diminished to prevent dryness of the skin which increases discomfort. Soft liquid diet is less irritating to patients sore throat. o Give analgesic or antipyretic such as acetaminophen or childs ibufropen for pain or fever. o Provide comfort measures because the rash tends to be pruritic. o Complete 10 day coarse of penicillin o Apply calamine lotions or use colloidal baths in lukewarm water as indicated because it help soothe the skin and decreases itching o Instruct patient to press on the itchy area rather than scratch because pressing the area may help to diminished the itching sensation. o Apply cool compress to the area to decrease inflammation, and help soothe the itching sensation. o Encourage the patient to participate in wound dressings, participation of the patient provides purposeful activity and helps to promote a feeling of control. o Provide divertional activities to divert attention from the itch. o Dress the patient in cool, lightweight, cotton clothing because perspiration and overheating worsen itching, further irritating the skin.

B. PREVENTIVE MANAGEMENT
IN AVOIDING COMPLICATION: Although most cases are mild, some children and adults can become very sick with scarlet fever. If left untreated for long enough: o The infection can spread to the blood and cause bacteremia, pneumonia, or sepsis. Meningitis is rare. o If left untreated, even if the illness resolves, the individual can be at risk of developing rheumatic fever or rheumatic heart disease. These are autoimmune diseases where the body starts attacking cells of the body that resemble portions of the Streptococcus bacteria. o Streptococcal glomerulonephritis can occur after a case of strep throat, impetigo, or scarlet fever, usually about 7-14 days afterwards. This disease cannot be prevented with treatment with antibiotics. Fortunately, this disease is usually self-limiting and resolves in about two weeks. IN PREVENTING OCCURENCE OF THE DISEASE: o Avoiding exposure to children who have the disease will help prevent the spread of scarlet fever. o Handwashing is key to the prevention of strep throat. Children with strep throat or scarlet fever should be kept at home, as they are contagious. They remain contagious for about 3-4 hours after antibiotics have reached a steady, effective concentration in their body.

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o This can vary by individual. To ensure the health of other children, children should stay home until at least 24 hours after their first dose of antibiotics. o Adequate and quick treatment of strep throat can prevent most cases of scarlet fever. However, some cases may present with both scarlet fever and strep throat. In some rare cases, scarlet fever may arise without any recognized symptoms of strep throat. Sometimes, scarlet fever occurs as early as one day after the onset of strep throat.

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NURSING CARE PLAN


ASSESSMENT (S&O) SUBJECTIVE: Nahihilo siya, mataas kasi ang BP niya as verbalized by the patients mother DIAGNOSIS ANALYSIS PLANNING 04-26-11 10 AM-2:00PM After 4 hours of nursing interventions, Within the shift, the mother will be able to acquire knowledge regarding the consequences of falling and injury with proper health teachings. P> Injury risk for E> r/t dizziness S> as evidenced by mothers verbalization of Nahihilo siya, mataas kasi ang BP niya . NURSING INTERVENTION Independent: -provide environmental safety -assist patient in walking or going to CR RATIONALE EVALUATION 04-26-11 -to prevent injury LEVEL OF ATTAINMENT: GOAL met as evidenced by: The mother understands the health teachings regarding the risk of injury to the patient.

Causes Presence of health threats (dizziness) Body weakness Risk for falling Possible consequences like injury (med surge Nsg.6th ed)

OBJECTIVE: -fairly active -decrease muscle strength BP- 110/80mmHg V/S taken as follows: BP- 110/80mmHg

-patient is experiencing dizzeness so most likely he is prone to be injured -raising side rails prevents the patient from falling -so that the patient have an assistance in doing activities of daily living -to prevent patient from falling on bed. -rest may relieve the dizziness

-raise side rails if patient is alone -instruct patients significant others not to leave the patient alone -provide pillows if side rails not available -instruct patient to have a rest

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-Have a proper ventilation Collaborative: - Administer medications as indicated ( calcibloc 5mg for BP greater than 130/100).

-it may aid dizziness -this drugs may relieve increase in BP thus decreasing dizziness.

INDEPENDENT: Review disease process, patient or parents expectation.

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Explain all

Provides knowledge base from which patient can make informed therapy

procedures done to the patient. Explain the importance of treatment regimen. COLLABORATIVE: SUBJECTIVE hindi ko alam kung ano yan ang pagkakaalam ko eh tigdas siya as verbalized by the patients mother P> Knowledge deficit regarding condition, treatment, selfcare and discharge needs. E> R/T unfamiliarity with the disease/condition. S> As evidenced by inaccurate follow through of instructions or asking questions regarding the disease. Knowledge deficit is a condition in which the client or the nearest kin dont have enough knowledge about the disease. This is evidenced by lack of skill in performing proper hygiene and or taking inappropriate medications or not participating in 04-26-11 10 AM-2:00PM Within the shift, the nearest kin will be able to understand the disease process and will participate in the treatment regimen. Refer to the physician so that the physician will explain the disease

choices. In order for them to be informed and have knowledge with the procedure. For the faster recovery of the patient. The physician has a wider knowledge about the disease in terms of management and the disease itself.

04-26-11 Level of attainment: Goal met

AEB: the mother acquired sufficient knowledge on the disease process and participates on the care of the patient.

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Mothers verbalization of hindi ko alam kung ano yan ang pagkakaalam ko eh tigdas siya .

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DRUG STUDY
NAME AND DOSAGE Nifedipine 5 mg PRN for BP> 130/100 S.L INDICATION Hypertension MECHANISM OF ACTION Inhibits the influx of calcium ions into cardiac and smooth-muscle cells; reduces strength of heartmuscle contraction, reduces conduction of impulses in the heart and causes vasodilation. Reduces blood pressure and prevents angina. CONTRAINDICATION Contraindicated in patients hypersensitive to drug or any of its components. Use cautiously in patients in those with heart failure or hypotension. Use extendedrelease tablets cautiously in patients with severe GI narrowing because obstructive symptoms may occur. Contraindicated in patients hypersensitive to the drug or other penicillins. 30 ADVERSE EFFECTS CNS: headache, dizziness CV: flushing, heart failure, hypotension GI: abdominal discomfort, diarrhea, nausea NURSING RESPONSIBILITIES Observe the 10 rights in administering the drug. Assess patients condition before during and after therapy Monitor blood pressure regularly thereafter Monitor patients potassium level. Avoid taking drug with grape juice. Do not crush or chew extended release tablet. Do not give the drug if the blood pressure is below 100 or 60

Penicillin Sodium 940,000 units IV Q6

Bacteria(Strept ococcal) infection such as scarlet fever

Inhibits cell wall synthesis during microorganism multiplication. Kills susceptible

CV: thrombophlebitis, Hematologic: hemolytic anemia, leucopenia,thromboc ytopenia

Observe the 10 rights in administering the drug. Assess patients condition before during and after therapy. Obtain history of allergy to penicillin and cephalosporin before giving

bacteria.

Use cautiously in patients with other drug allergies, especially to cephalosporins and cephamycins.

Other: hypersensitivity reactions.

Enalapril 2.5 mg tab BID P.O

Hypertension

Inhibits the action of angiotensin, which results in decreased vasopressor activity and decreased aldosterone secretion. Lowers blood pressure.

Contraindicated in patients hypersensitive to drug or any of its components. In patients with history of angioedema from ACE inhibitor. In patients with renal impairment, especially those with bilateral renal artery stenosis in a single or unilateral renal artery stenosis in a single functioning kidney.

CNS: dizziness, headache, fatigue CV: hypotension GI: abdominal pain, diarrhea

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first dose. Obtain culture and sensitivity before giving the first dose. When given intravenously, inject slowly. Monitor renal and hematopoietic function. Increase fluid intake. Continue the medication even after the disease is gone for 1 week. Observe the 10 rights in administering the drug. Obtain patients blood pressure before giving first dose. If angioedema occur, notify the physician and stop the drug immediately. Monitor patients vital signs specially BP. Instruct patient to avoid sodium substitutes. Monitor potassium level. Monitor CBC before, during and after therapy. Rise slowly to avoid orthostatic hypotension. Report signs of angioedema such as difficulty of breathing and swelling of face, eyes, lips or tongue. Light-headedness can occur

Paracetamol 250 tab Q4 PRN

For mild pain or fever

Relieves pain and reduces fever

Hypersensitivity to drug. Hematologic: hemolytic anemia, leukopenia, In patients with history neutropenia, of liver diseases and pancytopenia, chronic alcoholism. thrombocytopenia Hepatic: liver damage, jaundice Metabolic: hypoglycaemia

especially during first few days of therapy. Observe the 10 rights in administering the drug Assess pts pain or temp. before and during therapy Be alert for adverse reactions and drug interactions. Monitor liver function. Do not take with alcohol. Maybe taken without food. Observe the 10 rights in administering the drug. Assess GI condition before starting the therapy. Take drug with or without food. Take drug once daily at bed time. Should not be taken with antacid, it may interfere the absorption.

Ranitidine 25 mg IV Q8

Self medication for occasional heartburn, acid indigestion and sour stomach

Inhibits the action of H2-receptor sites of parietal cells, decreasing gastric acid secretion. Relieves GI discomforts.

Hypersensitivity to drug or any of its components. Use cautiously in patients with hepatic dysfunction.

CNS: vertigo. GI: abdominal discomfort, constipation,diarrhea, nausea and vomiting Hematologic: reversible leukopenia, pancytopenia, thrombocytopenia Skin: rash Other: anaphylaxis, angioedema, burning sensation at injection site.

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DISCHARGE PLANNING
o Penicillin sodium x 7 days, 8am- for prophylaxis o Enalapril 2.5mg per orem 8am and 6pm- for hypertension o Nifedipine 5mg as needed o Follow strict medication compliance o Avoid not following schedules of medication to prevent drug-resistance o Follow proper order dose of drugs to achieve drug reactions o Avoid OTC drugs that is not prescribed by the physician o moderate exercises: active ROM exercise like: Walking biking o Allow child to play in moderation o Avoid lifting heavy objects o Avoid extraneous activities o Strict medication compliance o Treat signs and symptoms like fever, rash, headache, dizziness o Intake of vitamin c and d to strengthen immune system. o Assistance of the family for physical therapy or activities of the patient o Continuous moderate active ROM exercises

Strict medication compliance Promote proper skin care Promote hand washing to prevent infection Promote proper nutrition Intake of vitamin c to strengthen immune system o Monitor signs and symptoms of infection o Monitor complications like: o o o o o Acute rheumatic fever Bone or joint problems(osteomyelitis,arthritis) Ear infection (otitis media) Inflammation of a gland (adenitis) or abscess Kidney damage (glomerulonephritis) Liver damage (hepatitis) Meningitis

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Pneumonia Sinusitis

Go for follow-up check up and update health by going to regular check-up Continue medications as prescribed by the doctor Go for check up if patients experience dizziness Consult doctor if signs and symptoms of scarlet fever occur

Diet for age with SAP Increase protein intake foods like: egg, meat, beans and

Eating

legumes High carbohydrate diet Low salt low fat diet Foods like: bread, rice and pastries Foods like: fish, meat

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UPDATES

Bibliography
BOOKS
Bare, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical Nursing. 10th Edition Philadelphia: I.B Lippincott Company. 2004.

Nettina, Sandra M., Manual of nursing Practice. 7th Edtion. I.B. Lippincott Company. 2001.

Rozler, Barbara et al. Fundamentals of Nursing. 5th Edition. Newyork: Addison-Weatleylongman, Incorporated. 1998.

Marleb, Elaine N. Essential of Human Anatomy and Physiology. 7th Edition. Singapore. Pearson Education South Asia Pte. Ltd. 2004.

Potter, Patricia and Perry, Anne. Fundamentals of Nursing. 6th Edition Baltimore: C.V. Mosby and Company. 2005.

Doenges, M., Moorhouse, M.F. , Geissler Murr, A. Nurses Pocket Guide, Diagnosis, interventions and rationales, 9th Edition (2004).

Doenges, M., Moorhouse, M.F. , Geissler Murr, A., Nursing Care Plans. Guidelines for Individualizing Patient Care. 6th Edition. F.A. Davis Company, 2002.

INTERNET
http://en.wikipedia.org/wiki/Scarlet_fever

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http://pediatrics.about.com/cs/commoninfections/a/scarlet_fever.htm http://wiki.medpedia.com/Scarlet_Fever http://medical-dictionary.thefreedictionary.com/scarlet+fever


http://kids.emedtv.com/scarlet-fever/scarlet-fever-in-children-p2.html http://www.healthline.com/adamcontent/throat-swab-culture#ixzz1KdJRA7Qb http://www.healthline.com/adamcontent/physical-examination#ixzz1KdKP7WuU http://www.wrongdiagnosis.com/s/scarletina_scarlet_fever/book-diseases-

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