Pres. Diosdado Macapagal Blvd.

, Metropolitan Park, Pasay City

Nursing Process

STEVENS-JOHNSON SYNDROME

Submitted to:

Manila Doctors College of Nursing

Submitted by: Apolonio, Aimee Marie B. Campo, Kriza Camille T. Diosanta, Nacel D. Gonzales, Bianca Paige C. Zamudio, Charmane Langkay, Carlos Miguel L. Magbojos, Veodel S. Rivera, Michael Anthony S. Marasigan, Roselene Mae

Group: SCN IV A 01 MANILA TYTANA COLLEGES Nursing Process

I. Assessment A. General Data

Patients Name: DG Address: Valenzuela City Age: 47 2011 Sex: Male wheelchair Date of Birth: July 11, 1964 Civil Status: Married Occupation: Company Messenger Informant: Wife of patient Date of admission: Sept. 20, Order of Admission: via

B. Chief complaints
"Dinala ko na siya sa ospital dahil sobrang dami niya ng rashes sa katawan at dahil na din sa sore eyes, sore throat at lagnat niya as verbalized by the wife of the patient.

C. History of Present Illness

1 year ago the patient sought medical consultation because he experienced joint pain at his lower extremities specifically at his knees and foot. The doctor gave him allopurinol 1 tablet for 2 weeks. After taking the prescribed medication for two weeks, he felt no more pain on his joints and foot. 3 weeks prior to hospitalization he felt pain again on his knees so he bought 14 tablets of allopurinol which he took once a day thus relieving the pain. 1 week prior to admission the patient had sore eyes on both eyes but did not seek consultation. Instead he self-medicated with gentamycin three times a day. 3 days prior to hospitalization the patient had sore throat with scant amount of rashes on his chest but did not seek consultation; sore eyes still present. 2 days prior to hospitalization the patient consulted a physician in a nearby clinic because of sore throat and presence of rashes all over his body and fever. He was advised to seek consultation at dermatologist; still with sore eyes. 1 day prior to hospitalization the patient seeks consultation at Lourdes Hospital and was advised to be confined but he did not comply due to financial problem; above symptoms are still present. 6 hours prior to hospitalization the patient seek consultation at MCU, above symptoms are still present and he was diagnosed to have an allergy

to his medicine, he was advised to be confined but there is no available room. 1 hour prior to hospitalization the patient was brought to Valenzuela General Hospital with a chief complaint of sore eyes, sore throat, rashes all over his body and fever. The patient was then subsequently admitted.

D. Past History
1. Childhood Illness: chickenpox 2. Adult Illness: hypertension 3. Operations: none 4. Serious Injuries: none 5. Medication prior to admission: gentamycin 1gtt 3x/day, allopurinol 1x/day for 14 days. 6. Allergies: Tuyo

A. System Review - Gordons Eleven Functional Areas

1. Health Perception Health Management Prior to confinement, the wife of the patient verbalized that her husbands general health is good though he had some cold and flu for the last six months, he also have a hypertension which he inherit from his parents and he was diagnosed just lately to have an arthritis. She also said that Mr. DG doesnt take any medication for his hypertension, but he takes alupurinol for his arthritis which is prescribed by the doctor. She also said that the patient doesnt take any vitamins or food supplements, she also said that the patient doesnt have a regular checkup because they are financially incapacitated, thus she said that her husband exercise every day to make his body strong and healthy. Mr. DG doesnt smoke but occasionally drinks beer. During hospitalization, Mrs. SD verbalized that her husbands health is weak due to his illness, she verbalized that they were advised not to drink any medicines that her husband is taking prior to admission. She also said that her husband can no longer perform his usual activity instead he just lies on bed' Mrs. SD also verbalized that her husband cant eat or talk because his lips are swell and it hurts when its touched even by just a single drop. nag ka na siya dahil lagi lang siya naka-higa. She also added that her husband lose some weight because he cant eat because of his swell lips, sore throat and high fever (37.7). 2. Nutritional Metabolic Pattern

Prior to hospitalization, Mrs. SD verbalized that her husband has a big appetite. He eats 4 times a day, breakfast, lunch, snack and dinner. She verbalized that her husband eats everything that she served except for tuyo because her husband is allergic to it. She also said that her husband drinks a lot of liquid' either water or juice because he easily gets thirsty. She also verbalized that her husband doesnt have a problem in eating or drinking not until her husband got his sore throat that he just eats soup or any soft

food. During hospitalization, Mrs. SD verbalized that pumayat siya kasi hindi pa siya nakaka-kain 4 na araw na dahil hindi niya maigalaw yung lips niya kasi sobrang sakit daw. Kahit mapatakan lang ng tubig nasasaktan na siya, instead her husband gets his energy from his dextrose. 3. Elimination Pattern

Prior to hospitalization, the wife of the patient verbalized that Mr. DG doesnt have any problem urinating and defecating. He urinates every day and its yellowish in color and his stool is foul in odor and is semi formed depending on what he eats. She verbalized that her husband doesnt use any laxative. He defecates once a day usually in the morning. During hospitalization the patient is assisted by his wife when urinating. He uses bedpan to urinate but he is not yet defecating since the day he was admitted, he was not prescribed with any laxative. Mrs. SD verbalized that the patient doesnt feel any pain while urinating but he cant go to the bathroom because his foot are swollen and it aches when moved with a pain scale of 9/10, he was not prescribed with pain reliever. 4. Activity & Exercise

Prior to hospitalization, the patient has an active lifestyle' he works as a company messenger so he walks a lot. The wife of the patient verbalized that her husband has a sufficient energy for his everyday activity. Aside from walking, stretching in the morning and push-ups is her husbands form of exercise. She also verbalized that her husbands working schedule is from Monday - Friday so when her husband is at their home he usually rest a lot or plays with their children. During hospitalization, the wife of the patient verbalized that wala siyang ibang ginagawa kundi humiga dahil hindi siya gaanong maka-kilos dahil masakit yung paa niya. The patients feet are swollen and it aches when moved so the patient can barely move and he needs to be assisted if he wants to change his lying position. Nagka-paltos na ata siya dahil lagi lang ata kasi siyang nakahiga, as verbalized by patients wife. She also verbalized that her husband cant stretch because his foot aches. 5. Cognitive Perceptual Prior to hospitalization, the wife of the patient verbalized that the patient doesnt have any problem in his senses. He can see, hear, smell, feel and taste well. He can read small texts and can hear whisper words. He can also distinguish different tastes. During hospitalization, Mrs. SD verbalized that her husband experienced a problem in his sight because of his sore eyes. The patient cant open his eyes widely because its full of discharges and the patient feels pain when it is removed. But aside from it, there are no problems anymore. She verbalized that her husband expressed his thoughts through gestures. 6. Sleep/Rest

Prior to hospitalization, the wife of the patient verbalized that the patient doesnt have a problem in sleeping; he usually sleeps at around 10 to 10:30 in the evening and wakes up at 4 in the morning because he has to go to work. Mrs. SD verbalized that the patient doesnt take any medication to put him to sleep, and when he wakes up at the middle of the night' he doesnt have a problem going back to sleep. When he doesnt have a work he takes the whole day to rest or have a bonding time with his family. During hospitalization, the wife of the patient verbalized that the patient had a hard time to sleep because of his bedsore which aches upon his movement. She also verbalized that the patient keeps on complaining about pain on his lips which added to his impairment of sleep. Nahihirapan siya makatulog kasi masakit yung mga paltos niya, as verbalized by patients wife. 7. Self Perception Prior and during hospitalization, the wife of the patient verbalized that the patient doesnt have a problem with himself' thus he feels good about himself. Although the patient had this rare case of illnesses, the patient still feels good about his self. Role Relationship Prior to hospitalization, the wife of the patient verbalized that the patient is a good husband and a good father to his children. He is also a good friend and brother to his family. Mrs. SD verbalized that the patient doesnt involve himself to any trouble thus he is a friendly and jolly person. He has a good relationship with his family and neighbors. During hospitalization, the wife of the patient verbalized that Mr. DG doesnt have a problem in dealing with the people in the hospital. Its also alright for him to be interviewed even to be taken a picture. 9. Sexuality Reproductive Prior to hospitalization, the wife of the patient verbalized that the patient is sure of his sexuality. She also mentioned that they sexual life is active and is satisfying. They are blessed with 2 kids. Mrs. SD also verbalized that the patient doesnt have a problem mingling with the opposite sex. During hospitalization the wife of the patient verbalized that the patient is not active because of his illness. He cant speak or have a communication to other people because he have a hard time doing it. He just expresses his thoughts through hand gestures. 10. Coping Stress Prior to hospitalization, the wife of the patient verbalized that when the patient is in-stressed he just sleeps and after that he forget about what makes him stressed. Sometimes he invites some friend and have a male bonding with alcoholic beverages and this what makes him fine.

During hospitalization, the wife of the patient verbalized that the patient just sleeps because he cant do anything else aside from sleeping or resting. The wife of the patient verbalized that the patient is irritable because of the pains that he feel. 11. Values/Beliefs

Prior to hospitalization, the wife of the patient verbalized that they are both catholic and they are both GOD fearing persons. They also believe to things that cant be seen by bare eyes. During hospitalization, the wife of the patient verbalized that their faith in GOD becomes stronger and she also said that they always pray for her husbands progression.

B. Family Assessment
Name Relation to the patient Age Sex Occupation Educational attainment

SD MD JD

Wife 1st son 2nd daughter

54 14 8

F M F

Factory worker -

College Graduate High school student Grade school student

A. Heredo Familial Illness

Maternal: Paternal: diabetes, hypertension, Lung Cancer, Hypertension

A. Developmental History
Theorist Eric Ericson (Psychosocial) Sigmund Freud (Psychosexual) Age 47 Task Generativi ty vs. Stagnatio n Genital Stage Patient description The patient is very hard working and values his work very much. He supports his family and helps other if he can The patient has a good relationship with his family and friends; he is the type of person that is full of life and energy that his family and friends have known. The patient is able to decide for his own and always thinks of the future especially for his family. Awareness of truth from a variety of view points The patient doesnt make judgment by seeing just

47

Jean Piaget (Cognitive Development) James Fowler (Spiritual Theories)

47 47

FormalOperation al Stage Conjuncti ve Faith

one side. Instead hes open to all possibilities, weighing them and then making

A. Physical Examination
Date: September 24, 2011 Time: 1:00 PM General Appearance The patient was untidy during the interview. He was conscious and coherent, oriented to time, date, place and people around him. He was lying on bed with limited range of motion, and positive with erythematous. Initial Vital Signs: PR- 83 bpm RR- 20 cpm BP- 130/90 mmHg A. Skin Inspection: Skin generally brown in color with presence of red spots all over the body. Skin is dry; has blisters & lesions, erythematous skin. Patient has a poor skin turgor (+) rashes; (+) blisters; (+) lesions Palpation: Warm to touch Poor skin turgor B. Nails Inspection: Have a dark brown pigmentation Fingernails are dirty and untrimmed Palpation: Capillary Refill Test: finger nail of the patient is pressed the color goes back within 2 seconds. C. Head and Face Inspection: face.

Initial Weight: 64 Kg. Latest Weight: 59 Kg. Temperature- 37.7C

No head injuries, round in shape and with oily Face: (+) rashes There are no tenderness when palpated; (+) pain

Palpation:

D. Eyes:

Inspection: Pupil: dark brown Sclerae: slightly yellowish (+) discharge Palpation: There are no tenderness noted; (+) pain E. Ears Inspection: Dry skin Scant amount of ear wax found in ear canal Auricle aligned with outer canthus of eye Hearing is good (+) skin rashes Palpation: There is no tenderness when the ears were palpated; (+) pain Pinna recoils after folded F. Nose Inspection: The patients nose is symmetric and straight (+) nasal discharge Discoloration with (+) skin rashes Palpation: No tenderness noted when palpated in the nose and facial sinuses. (+) pain G. Mouth and Pharynx Inspection: Lips: Dark in color Unable to purse lips (+) sloughy skin of lips and buccal mucosa Teeth: Not inspected Tongue: Swollen, White patches surrounding the tongue, weak in movement Tonsils Inflammed tonsils (as verbalized by patients wife) Palpation: Lips and Tongue: Not performed H. Neck

Inspection: Patients neck is head centered With difficulty in moving his head No lumps or swollen gland (+) rashes Palpation: There are no palpable lymph nodes I. Spine Inspection: (+) skin rashes Palpation: Not performed J. Thorax and Lungs Inspection: The patients chest is symmetric (+) rashes and blisters Palpation: Full and symmetric chest expansion K. Heart/Cardiovascular Inspection: No visible pulsations or heaves Palpation: Palpable peripheral pulses Auscultation: Audible S1 and S2 Heart rate: 83 bpm L. Breast Chest area: (+) rashes, (+) blisters M. Abdomen Inspection: (+)rashes, (+)blisters Palpation: (+) pain on skin irritations N. Extremities: Upper Inspection:

With IV inserted on left metacarpal vein Able to grasp object With lessen range of motion (+) rashes

Palpation: Warm to touch in the left and right hand Pain upon palpation on legs and feet Lower Inspection: Able to move with restrictive range of motion (+) rashes inflamed lower extremities Palpation: Warm to touch O. Genitals Patient refused to inspect with (+) rashes as verbalized by patients wife P. Rectum and Anus Patient refused to inspect patients wife Q. Neurological Exam: Level of consciousness Patient is alert, conversant and coherent and was able to respond to questions through hand gestures and facial grimace Behavior and Appearance Looks uncomfortable and irritable because of (+) rashes all over the body Finger nails are dirty and untrimmed Language Can express himself by gestures able to understand and answer by gestures but with (+) rashes as verbalized by

II. Personal/ Social History

Habits: The patients hobbies are reading newspaper and watching TV Vices: The patient occasionally drinks liquor Social Affiliation: none Clients Usual Day Like: The wife of the patient verbalized that her husband usually wakes up at 8 in the morning if he doesnt have a work. He have his breakfast together with his family and after that he enjoys his coffee while reading newspaper. After that, he will either clean their garage or watch television. Then they will have their lunch at 12nn, they will eat together so they can

have a family bonding, after lunch the patient will just rest for a while then he will have his nap and he will wake up at 4 or 5 in the afternoon then he will play with his children or help them do their assignments. They will eat their dinner at 7 in evening while watching television. Then he will sleep at 10 or 10:30 in the evening. Rank in Family: father Travel: none

Modifiable Factors - Medication

Non- Modifiable Factors - Condition

Etiology: Idiopathic

Drug-Induced Production of Tumor Necrosis Recruitment & Augmentation III. Pathophysiology (Theoretical-Based) Factor of T-Lymphocyte Proliferation Killer Effector Molecule Activation of Cytotoxic Lymphocytes Release of Granzyme B and Perforin Kills target cells by forming polymers & tubular structures Death of Keratinocyte Causes separation of epidermis from dermis

Appearance of Skin Lesions (Oral, Nasal, Eye, Vaginal, Urethral)

Cough

Headache

Fever

Aching

Followed by red rash across face and trunk of body which continues to spread to other parts of the body Rash can form to blisters (Eyes, Mouth, Vaginal/Urethral)

Inflammed Skin peels away in sheets Infection

Death

IV. Pathophysiology
Modifiable Factors - Medication

(Book-Based)
Non- Modifiable Factors - Condition

Etiology: Idiopathic Drug-Induced Production of Tumor Necrosis Factor Killer Effector Molecule Activation of Cytotoxic Lymphocytes Release of Granzyme B and Perforin Kills target cells by forming polymers & tubular structures Causes separation of Death of Keratinocyte epidermis from dermis Appearance of Skin Lesions (Oral, Nasal, Eye) Recruitment & Augmentation of T-Lymphocyte Proliferation

Cough Headache Fever Aching Followed by red rash across face and trunk of body which continues to spread to other parts of the body Rash can form to blisters (Eyes, Mouth, Abdominal Area) Inflammed Skin peels away in sheets Infection

IV. Laboratory Results

Hematology Result Form Age: 47y/o Date: 21 September 2011 1720H Examination Results Reference Value 9 WBC 4.8 X 10 /L 5.0-10.0 X 109/L RBC 4.78 X 1012/L 4.5-5.5 X 1012/L HGB 140 g/L 125-160 g/L HCT 42.4 % 38.0-50.0 % MCV 88.7 fL 80.0-100.0 fL MCH 29.3 Pg 27.0-32.0 Pg MCHC 330 g/L 320-360 g/L 3 PLT 339 x 10 /WL 150-400 x 103/WL LY MO GR RDW PCT MPV PDW 14.8 11.2 74.0 14.9 0.6 4.9 18.9 11.0-49.0 0.0-9.0 42.0-85.0 11.5-14.5 0.08-1.0 6.0-10.0 10.0-15.0

Flag Below Normal Normal Normal Normal Normal Normal Normal Normal Normal High Normal Above Normal Below Normal Below Normal Above Normal

Clinical Chemistry Section Age: 47y/o Date: 21 September 2011 1123H Test Results Reference BUN Creatinine Uric Acid Sodium Potassium 7.86 mmol/L 88.79 umol/L 0.39 mmol/L 137.0 mmol/L 3.67 mmol/L 2.50-6.50 mmol/L 80.00-115.00 umol/L 0.21-0.42 mmol/L 135-148 mmol/L 3.5-5.3 mmol/L Flag High Normal Normal Normal Normal

IX. List of Priority Problem

1. Hyperthermia related to Illness 2. Activity Intolerance related to Generalized Weakness 3. Impaired Skin Integrity related to Physical Immobilization 4. Sleep Deprivation related to Prolonged Physical Discomfort 5. Imbalanced Nutrition less than Body Requirements related to Inability to swallow as evidenced by sore and inflamed buccal cavity

Cues/Dat a

Nursing Diagnosis

Rationale High fever in patients ma be caused by infection of the respiratory or urinary tract, drug reactions. Slight elevation of temperature may be caused by dehydration. Such elevations must be controlled, because the increased metabolic demands of the brain can exceed cerebral circulation and oxygenation, resulting in cerebral deterioration. The patients temperature is monitored frequently.
Reference: Brunner Suddarths Textbook & of

Plans & Objectives

Nursing Interventions

Rationale

Evaluation

Subjectiv e: Hindi bumabab a ang lagnat niya simula nung naadmit siya, as verbalize d by the patients wife. Objective : T: 37.7 C -Skin is warm to touch Hyperther mia related to illness

After 30 minutes of nursing interventions, the client will be able to decrease temperature from 37.7C to 37.0 C

1. Promote surface cooling by Heat loss by means of undressing; cool conduction, convection, environment and/or fans; cool evaporation. tepid sponge bath. 2. Encourage patient increase fluid intake to To dehydration

3. Monitor / record all sources of fluid loss such as urine 4. Note presence/absence of sweating as body attempts to increase heat loss by evaporation, conduction and diffusion. 5. Maintain bed rest.

After 30 minutes of nursing intervention s, the goal was fully prevent met as evidenced by temperature of 37.0 C

- To reduce metabolic demands/oxygen consumption

Medical-Surgical Nursing; Eleventh Edition; P.1976 & 2167

Cues/Data

Nursing Diagnosis

Rationale

Plans & Objectives

Nursing Interventions

Rationale

Evaluation

Subjective: Activity Wala siyang Intolerance ibang related to ginagawa Generalized kundi humiga Weakness dahil hindi siya gaanong makakilos dahil masakit yung paa niya, as verbalized by the wife of the patient. Objective: Pain scale of 8/10 upon palpation of patients legs

Patients with SJS with involvemen t of large areas ok skin require care that is similar to that of patients with thermal burns. Patients may experience weakness that may result to decrease in mobility.

After 24-72 hours of nursing interventions, the patient will be able to verbalize wellness as evidenced by: participate willingly in necessary activities report measurable increase in activity tolerance.

1. Evaluate clients actual - Provides comparative and perceived limitations. baseline and provides information about needed 2. Note clients report of intervention weakness - Symptoms may be result to intolerance of activity 3. Ascertain ability to move and degree of - To determine current assistance needed status and needs associated with 4. Plan care to carefully participation in desired balance rest periods with activity activities - To reduce fatigue 5. Provide comfort measures and provide - To enhance ability to relief of pain participate in activities 6. Encourage patient to - To enhance sense of maintain positive attitude; well-being encourage to participate in activities appropriate for situation 7. Give patient information

After 72 hours of nursing intervention s, the goal was partially met.

and feet. Patient needs to be assisted upon movement

Reference: Brunner & Suddarths Textbook of MedicalSurgical Nursing; Eleventh Edition; P.1976

that provides evidence of daily progress

Cues/Data

Nursing Diagnosis

Rationale

Plans & Objectives

Nursing Interventions

Rationale

Evaluation

Subjective: Patients Nagka-paltos Impaired with SJS are na ata siya Skin usually dahil lagi lang Integrity prone to siyang related to having skin nakahiga, as Physical problems verbalized by Immobilizat such as patients wife ion as blisters, evidenced rashes etc., Objective: by skin because of lesions, the illness. - (+) blisters wounds and bed - (+) separation sores of dermis and epidermis - Dry & cracked skin

After 3 days of nursing interventio ns, client will be able to gain fast wound healing

1. Inspect skin on daily basis, describing lesions and changes observed. 2. Use appropriate padding devices when indicated

To monitor progress of wound healing - To reduce pressure on/enhance circulation to 3. Instruct patient/significant compromised other with proper skin hygiene tissues. 4. Encourage early ambulation

After 3 days of nursing interventions, the goal was met as evidenced by manifestations of timely healing of skin lesions and Promotes bedsores circulation and without 5. Emphasize importance of reduces risks complications. proper fit clothing, use of barrier associated with dressings and skin protective immobility. agents. - To protect the 6. Advise to have a turning wound or position every 2 hours surrounding tissues - To prevent having bedsores

- Rashes all over the body

Cues/Data

Nursing Diagnosis

Rationale

Plans & Objectives

Nursing Interventions

Rationale

Evaluation

Subjective: Nahihirapa n siya makatulog kasi masakit yung mga paltos niya, as verbalized by patients wife Objective: - irritability - daytime drowsiness - pain scale: 8/10 - facial grimace Sleep Deprivation related to Prolonged Physical Discomfort

Offering emotional support and reassuranc e and implementi ng measures that promote rest and sleep are basic in achieving pain control. As the pain diminishes and the patient may have more

After 8 hours of nursing interventions, the client will be able to reduce pain and improve sleep/rest pattern.

1. Administer analgesics, as to maintain After 8 hours of indicated, to maximum acceptable level of nursing dosage, as needed. pain. interventions, the client was 2. Educate client on ways of able to reduce avoiding/minimizing pain pain to 6/10. 3. Determine clients usual provides sleep pattern comparative baseline 4. Distinguish clients beneficial bedtime habits from detrimental ones. 5. Provide comfort measures - to promote nonpharmacological 6. Note environmental factors pain management affecting sleep. 7. Provide clean and well ventilated room

physical and emotional energy.

Reference: Brunner & Suddarths Textbook of MedicalSurgical Nursing; Eleventh Edition; P.1976

8. Provide quiet environment

Cues/Data

Nursing Diagnosis

Rationale

Plans & Objectives

Nursing Interventions

Rationale

Evaluation

Subjective: Pumayat siya kasi hindi pa siya nakakakain ng 4 na araw dahil hindi niya maigalaw yung labi niya kasi sobrang sakit daw. Kahit mapatakan lang ng tubig nasasaktan na siya, as Imbalanced Nutrition less than body requiremen ts related to inability to swallow as evidenced by sore and inflamed buccal cavity

Oral lesions may result in dyshagia (difficulty in swallowing) ; Swelling of facial structure may make it difficult for the patient to open the mouth.

After 3 days of nursing interventions, the patient will verbalize wellness as evidenced by:

1. Determine ability to chew, - All factors than swallow and taste food. can affect ingestions of 2. Assess weight of patient. nutrients. 3. Instruct patient to try eating foods which are easy to swallow. For digestion.

- Progressive weight gain 4. Instruct patient to use toward goal. alternative utensils such as straw. - Be free of signs of 5. Maintain patency and dehydration. regulate IV fluid as ordered.

After 3 days of nursing interventions, the goal was partially met as evidenced by latest weight of 59 Kg but showed signs of easier improvement of skin from dehydration.

To maintain proper hydration.

verbalized by the wife of the client. Objective: - Sore and inflamed buccal cavity - Weakness of muscles required for swallowing and mastication -Initial Wt: 64 Kg. - Dry skin

Reference: Brunner & Suddarths Textbook of MedicalSurgical Nursing; Eleventh Edition; P.1976; P1146

XI. Ongoing Appraisal - The patient was admitted last September 20, 2011 at 9:10 in the evening with a chief complaint of rashes all over his body, sore eyes, sore throat and fever. He was brought to the ER and was diagnosed to have Steven Johnsons Syndrome. He was hooked with D5NSS to run for 8 hours. BP: 130/80; PR: 86; RR: 24; Temp: 38.2 - September 20, 2011, 11:40 in the evening, he was requested to have laboratory examinations of CBC, APC, BUN crea, ESR, BUA, NA, K and CXR. The physician advised that the patient may have sips of water and be observed for aspiration, he should also be placed on a high back rest. Ophthalmic Drops were instilled to both eyes and he was given with Paracetamol through IV 300 mg. - September 21, 2011, 7:00 in the morning, patient complaint of pain on both eyes; ointment instilled. The patient is still in fever 37.7 sponge bath was done by the wife of the patient. 4pm patients temperature was 38.4 and was given Paracetamol through IV and sponge bath was done to the patient by his wife. - September 22, 2011, 8:00 in the morning, the physician ordered general liquid diet for the patient. There are still rashes all over the patients body still with sore eyes, sore throat and fever. - September 23, 2011 the patient was noted to have difficulty in swallowing. Still with sore eyes, sore throat, rashes and fever. - September 24, 2011 above symptoms are still present. Latest temperature is 37.7. - September 25, 2011 temperature went down to 37.0 C - September 27, 2011, with continuous medications; the patient was able to open his eyes widely and was able to move his lips and speak. - September 28, 2011, the patient was able to stand and go to the bathroom with assistance from his wife.

XII. DISCHARGE PLAN M Medications Medications prescribed by the physician should be taken properly, to help patient lessen unusual condition. E Exercise Encourage relatives to help the patient to have an active range of motion exercises thrice daily to maintain his/her muscle strength. Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse. T Treatment Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed. Treatment is one of the main factors in restoration of health and curing of the failure in the body system. Treatments are given to the patient for specific time until treatment is not more needed by the patient. H-- Health Education Encourage relatives of the patient to wash hands. The hands come in daily contact with germs that can cause infections. These germs enter ones body when he touch his eyes or rub his nose. Washing hands through and often can help reduce the risk. O OPD follow-up Keep all of follow- up appointments, even though the patient feels better. Its important to have the doctor monitor his progress. D Diet Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs. Advice the patient not to eat foods that is high in cholesterol such as the fatty portion of the pork that may increase level of his/her blood pressure but to eat more green and leafy vegetables. S Signs and Symptoms Inform the physician if the patient have a fever, rash or sores in the mouth after starting a new medicine and if the skin is red and hurts.