Case Study on Scarlet Fever12

7/29/2019 Case Study on Scarlet Fever12

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Republic of the Philippines

University of Northern Philippines

Tamag, Vigan City

College of Nursing

Case Study

On

PERFURATEDRECTUM

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 GRADE

Introduction & Objectives 5

Personal Data

Nursing History of Past & Present Illness5

PEARSON Assessment 15

Diagnostic Procedure

a. Ideal

b. Actual

5

Anatomy and Physiology 5

Pathophysiology

a. Algorithm

b. Explanation

15

Management

a. Medical & Surgical

b. NCP with Evaluation

c. Promotive & Preventive Mgt.

5

20

5

Drug Study 5

Discharge Plan 5

Updates 5Bibliography 2.5

Organization 2.5

TOTAL 100

REMARKS:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

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.
http://pediatrics.about.com/od/symptoms/a/1006_strep_symp.htmhttp://pediatrics.about.com/od/symptoms/a/1006_strep_symp.htm


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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.
http://pediatrics.about.com/od/childhoodinfections/ig/Strep-Throat-Tests/index.htmhttp://pediatrics.about.com/od/childhoodinfections/ig/Strep-Throat-Tests/index.htm


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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 enoughknowledge of the condition, and regarding on its disease process and

treatment or cure.

To obtain a comprehensive past, present and family history of patientsillness.

To assess the condition of the patient using systemic way by assessing ina cephalocaudal way to get cues for the plan of care.

To make a detailed assessment of the patient being studied followingthe PEARSON (psychosocial, elimination, activity and rest, safety,

oxygenation and nutrition) format.

To be familiar with the diagnostic procedure done to the patient andeven 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 appropriatePathophysiology of the disease, this includes the algorithm and its

explanation.

To familiarized the ideal and actual medical and surgical interventionsdone to the patient.

To be able to provide and implement a nursing care plan for an easyrecovery 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 thepatient 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).


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PATIENTS PROFILE

PERSONAL PROFILE

Name: Precentation TorreAge: 73 years old

Sex: Female

Civil Status: Single

Religion: Roman Catholic

Date of Birth: February 2, 1939

Address: Binalangayan Sto. Domingo, Ilocos SurNationality: Filipino

MEDICAL PROFILE:

Date Admitted: June 16, 2012: Saturday

Time Admitted: 4:45 P.M

Medical Institution: St. James Hospital

Ward: Intensive Care Unit, B2

Chief Complaint: (-) Bowel movement for 2 days, abdominal

pain and tenderness

Initial Diagnosis: Acute abdomen secondary to perforated

rectum

Admitting physician: Dr. Paz

Final diagnosis: Perfurated Ischemic Rectum with Santol

Seeds


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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 hisfathers 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 doseries of blood transfusion. Following medications are given:

Paracetamol 250mg/5ml; 5ml every 4 hours- for fever Ranitidine 25mg every 8 hours- H2 receptor antagonist


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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; forhypertension

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.


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PEARSON ASSESSMENT

APRIL 26,2011 (10:00am-2:00pm) APRIL 27, 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 to Erik Ericksons theory of Psychosocial

Development, patient is under industry versus inferiority

stage. 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.

Upon arrival to the ICU, the patient is

still restless and disoriented


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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.

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.

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.

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.

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.

The room of the patient is clean, with fluorescent lights and

ventilated with air condition.

WBC is 7.7, on its normal range

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 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.

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.

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%

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.


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Diet is NPO

With NGT

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

Left arm.

Diet is NPO

With NGT

With an IVF of D5 LRS 1L @ 41 drops per

minute infusing well @ Left arm.


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ACTUAL DIAGNOSTIC EXAMS

CBCPARAMETERS NORMAL 1ST INDICATION

Hemoglobin

Mass

140-180g/L 80 the hemoglobin is decrease which may

indicate various anemias.

Hematocrit 0.40-0.54 0.26 Decreased, may indicate severe anemias

Leukocyte

Count

5-10x10^9/L 8.8 Normal

Defferential Count

Segmenters 0.40-0.75 0.66 Normal

Lymphocytes 0.20-0.40 0.30 Normal

Monocytes 0.00-0.07 Normal

Eosinophils 0.00-0.05 0.04

Normal

Reticulocytes 0.5-2% -- --

Platelet Count 150-

400x10^9/L

455 Increased may indicate malignancy,

myeloproliferative disease.

Coaglation

Studies

-- --

Prothrombin

Time

11-15secs -- --

% 70-120 -- --

Activity -- --

Active PTT -- --

RH typing -- --

CRP


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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.

URINALYSISURINALYSIS- 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

NORMAL RESULT IMPLICATION

COLOR AMBER YELLOW REDDISH YELLOW Medications. Anumber of drugs

can darken urine,

including the

antimalarial drugs

chloroquine and

primaquine; the

antibiotic

metronidazole;

nitrofurantoin,

which treatsurinary tract

infections;

laxatives

containing

cascara or senna;

and

methocarbamol,

a muscle relaxant.

Medical

conditions. Some

liver disorders,

especially

hepatitis and


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cirrhosis, and the

rare hereditary

disease

tyrosinemia canturn urine dark

brown. So can

acute

glomerulonephritis,

a kidney disease

that interferes with

the kidney's abilityto 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 ACIDIC ACIDIC NORMAL

SPECIFIC GRAVITY 1.000-1.038 1.010 NORMAL

CHEMICALS

PROTEIN NEGATIVE +3 Indicates

proteinuria

Protein in the urine


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can be a

symptom of

kidney stones,

inflammation ofthe kidneys,

degenerative

kidney disease

SUGAR NEGATIVE NEGATIVE NORMAL

MICROSCOPIC

RBC NEGATIVE OVER 100/HPF Hematuria is the

presence ofabnormal

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 TITERPROCEDURE REFERENCE VALUE RESULT IMPLICATION

ANTI STREPTOLYSIN

O TITER


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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 orsepsis. 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
http://wiki.medpedia.com/Bloodhttp://wiki.medpedia.com/Sensitivity_and_Specificityhttp://wiki.medpedia.com/Sepsishttp://wiki.medpedia.com/Kawasaki_Diseasehttp://www.healthline.com/galecontent/blood-counthttp://www.healthline.com/adamcontent/hemoglobinhttp://www.healthline.com/adamcontent/hematocrithttp://www.healthline.com/adamcontent/rbc-indiceshttp://www.healthline.com/adamcontent/platelet-counthttp://www.healthline.com/adamcontent/platelet-counthttp://www.healthline.com/adamcontent/rbc-indiceshttp://www.healthline.com/adamcontent/hematocrithttp://www.healthline.com/adamcontent/hemoglobinhttp://www.healthline.com/galecontent/blood-counthttp://www.healthline.com/galecontent/blood-counthttp://wiki.medpedia.com/Kawasaki_Diseasehttp://wiki.medpedia.com/Sepsishttp://wiki.medpedia.com/Sensitivity_and_Specificityhttp://wiki.medpedia.com/Blood


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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 orbruising.

,NORMAL VALUES

PARAMETERS NORMAL

Hemoglobin Mass 127-183g/L

Hematocrit 0.37-0.54

Leukocyte Count 4.5-10x10^9/L

Defferential Count

Segmenters 0.50-0.70

Lymphocytes 0.20-0.40

Monocytes 0.00-0.07

Eosinophils 0.00-0.05

Reticulocytes 0.5-2%

Platelet Count 150-400x10^9/L

Coaglation Studies

Prothrombin Time 11-15secs

% 70-120

Activity

Active PTT

RH typing

CRP

Semi-quantitative CRP


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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; forhypertension

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 becausepressing 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 thespread 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.
http://wiki.medpedia.com/Bacteremia?action=edit&redlink=1http://wiki.medpedia.com/Pneumoniahttp://wiki.medpedia.com/Meningitishttp://wiki.medpedia.com/Autoimmune_Diseaseshttp://wiki.medpedia.com/Cellshttp://wiki.medpedia.com/Glomerular_Diseaseshttp://wiki.medpedia.com/Impetigohttp://wiki.medpedia.com/Clinical:Hand_Washing:Why,_When,_and_Howhttp://wiki.medpedia.com/Clinical:Hand_Washing:Why,_When,_and_Howhttp://wiki.medpedia.com/Impetigohttp://wiki.medpedia.com/Glomerular_Diseaseshttp://wiki.medpedia.com/Cellshttp://wiki.medpedia.com/Autoimmune_Diseaseshttp://wiki.medpedia.com/Meningitishttp://wiki.medpedia.com/Pneumoniahttp://wiki.medpedia.com/Bacteremia?action=edit&redlink=1


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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 anyrecognized 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 PLANASSESSMENT

(S&O)

DIAGNOSIS ANALYSIS PLANNING NURSING

INTERVENTION

RATIONALE EVALUATION

SUBJECTIVE:

Nahihilo siya,

mataas kasi ang

BP niya as

verbalized by the

patients mother

OBJECTIVE:

-fairly active

-decrease

muscle strength

V/S taken as

follows:

BP- 110/80mmHg

P> Injury risk for

E> r/t dizziness

S> as evidenced

by mothers

verbalization of

Nahihilo siya,mataas kasi ang

BP niya .

BP- 110/80mmHg

Causes

Presence of

health threats

(dizziness)

Body weakness

Risk for falling

Possible

consequences

like injury

(med surge

Nsg.6th ed)

04-26-11

10 AM-2:00PM

After 4 hours of

nursing

interventions,

Within the shift,

the mother willbe able to

acquire

knowledge

regarding the

consequences of

falling and injury

with proper

health teachings.

Independent:

-provide

environmental

safety

-assist patient in

walking or goingto CR

-raise side rails if

patient is alone

-instruct patients

significant others

not to leave the

patient alone

-provide pillows if

side rails notavailable

-instruct patient to

have a rest

-to prevent injury

-patient is

experiencingdizzeness 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 fromfalling on bed.

-rest may relieve

the dizziness

04-26-11

LEVEL OF

ATTAINMENT:

GOAL met as

evidenced by:The mother

understands the

health teachings

regarding the risk

of injury to the

patient.


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-Have a proper

ventilation

Collaborative:

- Administer

medications as

indicated (

calcibloc 5mg for

BP greater than

130/100).

INDEPENDENT:

Review disease

process,

patient or

parents

expectation.

Explain all

-it may aid

dizziness

-this drugs may

relieve increase

in BP thus

decreasing

dizziness.

.

Provides

knowledge

base fromwhich patient

can make

informed

therapy


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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, self-

care and

discharge needs.

E> R/T unfamiliarity

with the

disease/condition.

S> As evidenced

by inaccurate

follow through of

instructions orasking 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 takinginappropriate

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.

procedures

done to the

patient.

Explain the

importance of

treatment

regimen.

COLLABORATIVE:

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 ofthe 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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29

Mothers

verbalization of

hindi ko alam

kung ano yan

ang

pagkakaalam ko

eh tigdas siya

.


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30

DRUG STUDY

NAME AND

DOSAGE

INDICATION MECHANISM OF

ACTION

CONTRAINDICATION ADVERSE EFFECTS NURSING RESPONSIBILITIES

Nifedipine

5 mg PRN for

BP> 130/100 S.L

Hypertension Inhibits the influx of

calcium ions into

cardiac and

smooth-muscle

cells; reducesstrength of heart-

muscle

contraction,

reduces

conduction of

impulses in the

heart and causes

vasodilation.

Reduces blood

pressure and

prevents angina.

Contraindicated in

patients

hypersensitive to

drug or any of its

components. Use cautiously in

patients in those

with heart failure or

hypotension.

Use extended-

release tablets

cautiously in

patients with severe

GI narrowing

because obstructive

symptoms may

occur.

CNS: headache,

dizziness

CV: flushing, heart

failure, hypotension

GI: abdominaldiscomfort, diarrhea,

nausea

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 duringmicroorganism

multiplication.

Kills susceptible

Contraindicated in

patientshypersensitive to the

drug or other

penicillins.

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


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31

bacteria. Use cautiously in

patients with other

drug allergies,

especially to

cephalosporins and

cephamycins.

Other: hypersensitivity

reactions.

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.

Enalapril

2.5 mg tab BID

P.O

Hypertension

Inhibits the actionof angiotensin,

which results in

decreased

vasopressor

activity and

decreased

aldosterone

secretion.

Lowers blood

pressure.

Contraindicated inpatients

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 singlefunctioning kidney.

CNS: dizziness,headache, fatigue

CV: hypotension

GI: abdominal pain,

diarrhea

Observe the 10 rights inadministering 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 suchas difficulty of breathing and

swelling of face, eyes, lips or

tongue.

Light-headedness can occur


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32

especially during first few days of

therapy.

Paracetamol

250 tab Q4 PRN

For mild pain or

fever

Relieves pain and

reduces fever

Hypersensitivity to drug.

In patients with history

of liver diseases and

chronic alcoholism.

Hematologic: hemolytic

anemia, leukopenia,

neutropenia,

pancytopenia,

thrombocytopenia

Hepatic: liver damage,

jaundice

Metabolic: hypoglycaemia

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.

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.

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.


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33

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 strengthenimmune system.

o Assistance of the family for physical therapy

or activities of the patient

o Continuous moderate active ROM exercises

o Strict medication compliance

o Promote proper skin care

o Promote hand washing to prevent infectiono Promote proper nutrition

o Intake of vitamin c to strengthen immune

system

o Monitor signs and symptoms of infection

o Monitor complications like:

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
http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003940/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000437/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001243/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000638/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001353/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000484/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001154/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000680/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000680/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001154/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000484/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001353/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000638/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001243/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000437/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003940/


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34

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

Eating foods like: egg, meat, beans and

legumes

High carbohydrate diet

Foods like: bread, rice and pastries

Low salt low fat diet

Foods like: fish, meat
http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000145/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000647/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000647/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000647/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000145/


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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. , GeisslerMurr, A. Nurses Pocket Guide,

Diagnosis, interventions and rationales, 9th Edition (2004).

Doenges, M., Moorhouse, M.F. , GeisslerMurr, A., Nursing Care Plans.

Guidelines for Individualizing Patient Care. 6th

Edition. F.A. DavisCompany, 2002.

INTERNET

http://en.wikipedia.org/wiki/Scarlet_fever
http://en.wikipedia.org/wiki/Scarlet_feverhttp://en.wikipedia.org/wiki/Scarlet_feverhttp://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-
http://pediatrics.about.com/cs/commoninfections/a/scarlet_fever.htmhttp://pediatrics.about.com/cs/commoninfections/a/scarlet_fever.htmhttp://wiki.medpedia.com/Scarlet_Feverhttp://wiki.medpedia.com/Scarlet_Feverhttp://medical-dictionary.thefreedictionary.com/scarlet+feverhttp://medical-dictionary.thefreedictionary.com/scarlet+feverhttp://kids.emedtv.com/scarlet-fever/scarlet-fever-in-children-p2.htmlhttp://kids.emedtv.com/scarlet-fever/scarlet-fever-in-children-p2.htmlhttp://www.healthline.com/adamcontent/throat-swab-culture#ixzz1KdJRA7Qbhttp://www.healthline.com/adamcontent/throat-swab-culture#ixzz1KdJRA7Qbhttp://www.healthline.com/adamcontent/physical-examination#ixzz1KdKP7WuUhttp://www.healthline.com/adamcontent/physical-examination#ixzz1KdKP7WuUhttp://www.healthline.com/adamcontent/physical-examination#ixzz1KdKP7WuUhttp://www.healthline.com/adamcontent/throat-swab-culture#ixzz1KdJRA7Qbhttp://kids.emedtv.com/scarlet-fever/scarlet-fever-in-children-p2.htmlhttp://medical-dictionary.thefreedictionary.com/scarlet+feverhttp://wiki.medpedia.com/Scarlet_Feverhttp://pediatrics.about.com/cs/commoninfections/a/scarlet_fever.htm

Documents

Case Study on Scarlet Fever12