FATHER SATURNINO URIOS UNIVERSITY NURSING PROGRAM Butuan City
An Individual Case Study On
Bondoc, James Aurelle S. Student Nurse
Ms. Edgracia Airrane A. Vega, RN Supervising Clinical Instructor
Introduction Typhoid fever , otherwise known as enteric fever, is an acute illness associated with fever caused by the Salmonella typhi bacteria. S. typhosa is a short, plump, gram negative rod that is flagellated and actively motile. Contaminated food or water is the common medium of contagion. The disease follows four stages. The first stage is known as incubation period, usually 1014 days in occurrence. In this stage generalization of the infection occurs. In the second stage, aggregation of the macrophages and edema in focal areas indicates bacterial localization (embolization) and resultant toxic injury which disappear after few days. The third stage of disease is dominated by effects of local bacterial injury especially in the intestinal tract, mesenteric lymph nodes, spleen, and liver. The fourth stage, or the stage of lysis, is the stage wherein the infectious process is gradually overcome. Symptoms slowly disappear and the temperature gradually returns to normal. The symptoms of typhoid fever include high fever, chills, cough, muscle pain, weakness, stomach pain, headache and a rash made up of flat, rose-colored spots. Diarrhea is a less common symptom of a typhoid fever, although it is a gastrointestinal disease. Sometimes there are mental changes, know as ‘typhoid psychosis’. A characteristic feature of typhoid psychosis is plucking at the bedclothes if patient is confined to bed. Risk factors for acquiring typhoid fever likely include improper food handling, eating food from outside sources like carinderia, drinking contaminated water, poor sanitation and even poor hygiene practices. War and natural disasters as well as weak, non existent of health care infrastructure may also contribute. Both genders do have equal chances on acquiring such disease. Asian, African and Americans are at greatest risks of acquiring the disease since geographical locations play a part. Complications of typhoid fever are secondary conditions, symptoms, or other disorders that are caused by typhoid fever. Complications include overwhelming infection, pneumonia, intestinal bleeding, and intestinal perforation may eventually lead to death. Typhoid fever is one of the most protean of all bacterial diseases thus laboratory procedures are usually depended on to confirm or disprove suspicion of such disease. The place of blood culture, serologic studies and bacteriologic examination feces and urine are useful in establishing the diagnosis. Agglutination (Widal) for typhoid fever is done to determine antibody response against different antigenic fractions of organisms. Typhoid fever is treated with antibiotics which kill the Salmonella bacteria. Several antibiotics are effective for the treatment of typhoid fever. The choice of antibiotics needs to be guided by identifying the geographic region where the organism was acquired and the results of cultures once available. Two new vaccines are currently licensed and widely used worldwide, a subunit (Vi PS) vaccine administered by the intramuscular route and a live attenuated S typhi strain (Ty21a) for oral immunization. In most cases, typhoid fever is managed at home with antibiotics and bed rest. For hospitalized patients, effective antibiotics, good nursing care, adequate nutrition, careful attention to fluid and electrolyte balance, and prompt recognition and treatment of complications are strategies to avert the possibility of death. I choose this topic since it catches my interest from the time being I was able to handle patient having typhoid fever. It gives me the motivation to look for the things that governs such disease. Typhoid fever as my case study allows me to find for ways to contribute something for the alleviation of the condition of its victims may it be in my own little ways perhaps. May this case study of mine serves as advent to understand more fully the existence of such disease and the proper interventions needed to be rendered upon to address such condition looking to a new perspective of life.
Nursing health history is the first part and one of the most significant aspects in case studies. It is a systematic collection of subjective and objective data, ordering and step-bystep process inculcating detailed information in determining client’s history, health status, and functional status and coping pattern. These vital informations provide a conceptual baseline data utilized in developing nursing diagnosis, subsequent plans for individualized care and for the nursing process application as a whole. It is needed for solving and determining a client’s problem and for the nurse to know what interventions to be applied and rendered upon and what may be the cause of the illness. It aims to determine the biographic data of the client, chief complaint history of present illness, social data psychological data, lifestyle patterns and se of health care systems among others It was the 19th day of April, 2010 when our group was first exposed to the world of pediatric nursing. Under the supervision of Ms. Edgracia Airrane A. Vega, RN, all of us practiced our skills by applying the concepts we learned from school. Then we were told by our C.I to make an individual case study regarding on the cases of the children we were able to care with. I was able to care patient with typhoid fever last April 20, 2010. So I chose to work on the case of typhoid fever after obtaining the permission of the patient as well to her significant others For the purpose of confidentiality and respect to the identity of my patient, I decided to withhold her real identity and decided to address her as Patient R. We will also address her mother as Mother A, grandmother as Grandmother B and aunt as Aunt C. Patient R is a native of Agusan and true Filipino in blood. She first saw the light last October 11, 1995. She is fourteen years old at present and an Iglesia ni Cristo in faith. Prenatal History The pregnancy of Patient R was expected by the couple. “Wala man ko nasakit adtong nagbuntis ko niya” as verbalized by Mother A when asked about any history illnesses during pregnancy. According to her, she took iron supplements such as Ferrous Sulfate during the course of pregnancy as prescribed to her. She also had her regular check up to the barangay health center and vaccinated with tetanus toxoids respectively. Mother A gave birth to 7 lbs baby girl on the 11th day of October, 1995 through Normal Spontaneous Vaginal Delivery at Agusan del Norte Provincial Hospital, Libertad, Butuan City. According to Mother A, the labor took for three days and the length of hospitalization was also three days. She was then breastfed hours after birth. Breastfeeding continued up to 6 months of life of Patient R. “Kumpleto jud na siya ug bakuna” as verbalized by Mother A when asked about immunization status of the patient. Developmental Milestones Between the 1st and 2nd months, client M can already flex her elbows. She was about 3 months old when the first smile was noted by Mother A. On the 4th month of life, she can lift upper part of he body while in prone position. She was about 5 to 6 months old when client M can already rest weight on her forearm when in prone position. She can also turn from front to back. “Sige man to siya ug hilak basta magligid- ligid siya” as verbalized by Mother A. Her first tooth erupted at the age of 6 months. It was between the 7th and 8th month when Patient R can already crawl as what being mentioned by Mother A. Between the 9th to 11th months, client M can sit momentarily but with support from her mother. “Mohilak gale siya kung kugoson sa uban” as verbalized by Mother A. when asked bout the client’s reaction if held by others.
At the age of 1, Patient R can already walk but with support. She was 1 year and 2 months old where she can already walk without support. She was then toilet trained at the age of 2. She was able to dress herself at the age of seven. Family History of Illness Patient R is the 2nd child among the 5 siblings. Brother D , the eldest, is 17 years of age and currently working as a miner. “Okey ra man to siya, wala man to siya’y balatian” as verbalized by Mother A. Brother E, the 3rd sibling, is 13 years of age. According to Mother A, he is in good health condition. . Sister F, the fourth sibling, is 7 years of age at present. According to Mother A, she is in good health condition at present and she didn’t have any health problems. Brother G is 4 years old and still in good health condition at present. “Kanang hypertension man ang problema o sakit sa amo kaliwat” as verbalized by Mother A. “Wala man ko’y nahibaw an nga sakit sa side sa akong bana” as verbalized by Mother A when asked about any health problems from the family. Social Data According to Mother A, the family relationships they have are strong and stable. She seldom quarrels with her husband. Mother A ensures that all her children are on the right track as much a possible. “Wala jud ko nagkulang ug pahinumdum ug hatag tambag sa akong mga anak” as verbalized by Mother A. Being an Iglesia ni Cristo in faith, the family goes to church every Thursday and Sunday. Patient R graduated at Guiasan Elementary School during her elementary years at the year 2007. “Dili man ko apil sa honor roll sa among klase sa elementary ko maski karon sa high school” as verbalized by Patient R when asked about her academic achievements. She is presently enrolled at Pipisan Maug National High School at Tagum City. “Simple ra man among kinabuhi, kanang okey ra ang kadak on sa sa among panimalay para sa among pamilya” as verbalized by Patient R when asked about their way of living or present economic status. According to Mother A, her income along with his husband’s income is just enough to sustain the family’s basic needs. Lifestyle “Hilig ra man na siya ug dula- dula uban iya mga amigodidot sa Davao”, as verbalized by Aunt C when asked about play activities of the patient. Patient R is socially interactive in nature as observed. Pertaining to diet preference, Patient R is fun of eating fruits, vegetables and loves eating ‘kinilaw’. “Na hilig jud na siya ug kaon kinilaw”,as verbalized by Mother A. When it comes sleep/rest patterns of the patient, Patient R verbalized that “Matulog ko ug 9 sa gabie ug mumata dayon ko ug 6 sa buntag..Mao na ako naandan. Dili kayo ko tigtulog ug hapon.” When it comes to her recreational activities, she added “Laag lag kauban sa akong mga amigo ug apil ug mga activities sa among lugar”. Past Health History When talking about childhood illnesses, Patient R only experienced common cough and colds. She also experienced mumps and chicken pox. “Wala man na siya niagi ug grabe nga sakit. Bale first time niya mahospital karon”, as verbalized by Grandmother B. When Patient R was asked about allergies, she verbalized that, “Wala man ko’y mga allergy, maski unsa gale akong imnon ug kaonon”. There were no also reported accidents and injuries wherein she has been subjected to. “Vitamins ra man iya ginatumar sukad sauna ra”, as verbalized by Mother A when asked about medications taken by Patient R from the past years up to the present. History of Present Illness Naghilanat man ko adtong nagbakasyon ko sa Magallanes” as verbalized by Patient R. She experienced fever and chils for about 9 days which started last April 12, 2010. According to Aunt C, she observed that Patient R would complain of headache, lethargy, fatigue, body weakness and pain”. Pateint R also experienced diarrhea. “Ako nahinumduman , nagkaon man me adto ug kinilaw kadtong naa pa ko sa Davao mao kadtong pag anhi nako sa Magallanes nagsugod na dayon akong hilanat ug apil takig” she verbalized. She was then brought to Agusan del Norte Provincial Hospital last April 20, 2010. She got admitted that day around 12:40 in the afternoon under the management of Dr. Bungabong. She was admitted at ARI( Acute Respiratory Infection) Ward .
It was on the 20th day of April, 2010, wherein our group had our duty at the Pediatric Ward of Agusan del Norte Provincial Hospital. On the same day, Patient R was admitted to the said hospital. Her admitting impression was to consider typhoid fever basing form the chief complaint of fever associated with chills. Her temperature upon admission was 38.8 C and weight of 40.5 kgs. At 1:00 pm, Dr Bungabong made the following orders: .> TPR q4h > DAT except dark colored foods > IVF PNSS 1L @ 30 gtts/min > IVF TF PLR 1L @ 20 gtts/min > Paracetamol 500mg 1 tab P.O now, then q4h PRN for fever > Chloramphenicol 500mg 1 tab P.O now q6h > CBC with platelet count > UA/ SE > Widal test, BSM Patient R was received on bed on left side lying position; awake and coherent with IVF # 1 PNSS [email protected]
the level of 900 cc, regulated at 30 gtts/min hooked @ right metacarpal vein, infusing well around 4:10 in the afternoon. Patient R was observed grimacing, diaphoretic and self-focusing. Initial vital signs were taken and recorded as follows: T: 37.5oC RR: 24 bpm PR: 97 bpm BP: 90/70 mmHg “Ngutngot akong kamot ganiha ra ni siya human gisuksukan… Mga 5 kung sukdon.”Patient R verbalized when asked about discomfort felt upon admission. With the cues noted, a nursing care plan was formulated with a nursing diagnosis of Acute Pain related to presence of traumatized tissue from IV insertion. Independent interventions were rendered to address such problem like changing bed positions, positioning patient’s affected arm, emphasizing to client not to use affected arm unnecessarily. Around 6:00 pm, widal and CBC results was brought to the station. I referred the laboratory results to Dr. Bungabong. There were no doctor’s orders being carried out. Around 9:30 in the evening, patient R was observed weak. Upon assessment, her skin was warm to touch, flushed skin and is not diaphoretic. Mucous membrane was dry and lips were cracked and dried. Vital signs were taken and recorded as follows: T: 39.2oC RR: 28 bpm PR: 99 bpm BP: 90/70 mmHg “Init napud balik akong paminaw” patient R verbalized. With the cues, another problem was identified with a diagnosis of hyperthermia related to underlying disease process. Independent interventions were being rendered like initiating tepid sponge bath, encouraging adequate fluid intake and promoting surface cooling by means of removing some body covers from the patient’s body. On the second day of duty, Dr. Amoroso made the following orders around 8:30 in the morning as follows: ➢ Cotrimoxazole 800 mg 1 tab P.O BID ➢ Paracetamol 500 mg 1 tab RTC ➢ Continue chloramphenicol P.O ➢ Ascorbic acid 500 mg 1 tab P.O OD Around 4:10 in the afternoon, I received patient R lying on bed on supine position, awake and coherent with IVF #2 PLR 1 liter at the level of 400 cc; regulated at 20 gtts/min hooked at the right metacarpal vein; infusing well. Vital signs were taken and recorded as follows: T: 36.5oC RR: 24 bpm PR: 71 bpm BP: 90/60 mmHg “Wala pa ko kalibang gikan adtong gi-admit ko”as verbalized by patient R. patient R was observed with dry skin, absence of sweating and claimed having positive flatus that day. She also needs assistance upon getting up/out in bed. Patient R refused to get up on bed and slowed movement noted.
With the cues gathered, a problem was identified with a diagnosis of “Risk for Constipation related to insufficient physical activity. Independent nursing interventions were rendered to address the said problem like encouraging intake of balanced fiber and bulk in diet such as fruits, vegetables and whole grain; emphasizing DAT except for dark colored foods and encouraging activity/exercise within limits of individual activity. Due oral medications were given in due timing. Around 9:30 in the evening, above IVF #2 was terminated and followed up with IVF #3 D5NM 1 liter regulated at 20 gtts/min as ordered. At 10:00 pm, patient R verbalized that “init napud balik akong paminaw… arang inita.”As observed, patient R’s skin was warm to touch, flushed skin, dry lips, not diaphoretic, poor skin turgor and slowed movement were observed. Vital signs were taken and recorded as follows: T: 38oC RR: 29 bpm PR: 91 bpm BP: 90/70 mmHg Another problem was identified with a diagnosis of Hyperthermia related to underlying disease process was formulated. Interventions were rendered to the patient to address the problem. On April 22, 2010, around 4:20 in the afternoon, I received patient lying flat on bed with IVF #3 D5NM 1 liter regulated at 20 gtts/min hooked at the right metacarpal vein at level of 50 cc which was temporarily stopped from the time being. Vital signs were taken and recorded as follows: T: 37.4oC RR: 24 bpm PR: 8 bpm BP: 110/70 mmHg Upon interaction, patient R was noted with slowed movement, body weakness and yawning. Poor skin turgor was observed and dry skin is noted. She needed assistance upon getting up in bed. When I asked patient to perform range of motion exercises and to walk upon the hospital’s vicinity, she refused to do so while saying “kapoy ibakod.” With the gathered cues, a problem was identified with a diagnosis of Impaired Physical Mobility related to reluctance to initiate movement. Interventions were rendered to address the said problem like positioning patient on bed comfortably, explaining importance of ambulation to avoid possible skin breakdown and encouraging patient to have adequate rest periods every activity performance. Around 5:30 in the afternoon, Dr. Amoroso made the following order: ➢ D5NM 1 liter at same rate Around 6:10 in the evening, above IVF #3 was consumed and followed up with IVF #4 D5NM 1 liter regulated at 20 gtts/min. IVF was regulated properly and frequently checked. At 10:00 pm, patient R experienced flushed skin and drying of lips. Her skin was warm to touch. Poor skin turgor in noted. Dry mucous membrane was observed along with slowed movement. “Nag-init na pud balik akong pamati,”as verbalized by patient R. Hyperthermia related to underlying disease process was identified. On April 23, 2010, Dr. Amoroso made the following orders at around 8:00 in the morning: ➢ TWC ➢ Continue all oral meds ➢ For billing ➢ DAT Around 4:00 in the afternoon, patient R was received lying supine on bed, awake and coherent; with IVF #4 D5NM 1 liter regulated at 20 gtts/min hooked at right metacarpal vein at the level of 100 cc; infusing well. Vital signs were taken and recorded as follows: T: 37oC RR: 28 bpm PR: 81 bpm BP: 90/60 mmHg Upon interaction with the patient, she verbalized that “Gusto nako diretso akong tulog inig gabie bahala ug igang ug saba.”As observed, patient R was frequently yawning. Body weakness, slowed movement and reaction were noted. A nursing problem was identified basing from the cues gathered. Nursing care plan was made with a diagnosis of Readiness for Enhanced Sleep. Interventions and health teachings were given to address such problem like recommending patient to limit intake of chocolate and caffeine or alcoholic beverages prior to sleep, instructing significant others to ensure quiet environment and instructing client to limit/avoid afternoon naps as possible.
Around 6 in the evening, above IVF was consumed and terminated as ordered aseptically. Due oral medications were given and IVF was regularly checked and regulated. On April 24, 2010, around 8:00 in the morning, Dr. Bungabong made the following orders: ➢ Re-insert IVF D5LR 1L at 20 gtts/min ➢ Hold chloramphenicol P.O ➢ Continue cotrimoxazole ➢ DAT No interaction was made since our group was having activities such as NCP conference, annotated reading reporting and quiz respectively at the conference hall. On April 25, 2010, around 8 o’clock in the morning, Dr. Bungabong made the following order: ➢ D5NM 1 liter at same rate In our second week of duty, we had our morning shift. Around 8 o’clock in the morning, Dr, Bungabong made the following order: ➢ MGH w/ chloramphenicol P.O meds to continue at home At 8:30 in the morning, Patient R was received lying on bed on supine position, awake and coherent with IVF #6 D5NM regulated at 20 gtts/min hooked at the left metacarpal vein at the level of 600 cc; infusing well. Vital signs were taken and recorded as follows: T: 36.5oC RR: 28 bpm PR: 91 bpm BP: 90/60 mmHg Patient R was seen calm and interactive upon interaction. No problems were being identified. As instructed, discharge plan was written and instructed to patient and to the significant others. Significant other (grandmother) was instructed to process papers. On April 27, 2010, patient R was received around 8:20 in the morning; sitting on chair without IVF. Vital signs were taken and recorded as follows: T: 36.8oC RR: 25 bpm PR: 81 bpm BP: 90/70 mmHg No doctor’s orders were made. Patient was seen walking in the vicinity together with her grandmother. At 2:00 pm, patient R was discharged with home medications. The total length of stay in the hospital was 7 days.
PHYSICAL ASSESSMENT Physical examination follows a methodical head to toe format in the cephalocaudal assessment. This is done systematically using the techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer, sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure, I made every effort to recognize and respect the patient’s feelings as well as to provide comfort measures and follow appropriate safety precautions.
Physical assessment is a systematic, comprehensive, continuous collection, validation and communication of the patient’s data using a variety of methods. The purposes of the physical assessment are as follows: -to collect data and establish a need for continued physical assessment; -to ascertain patient’s level of health condition and physiological functioning; -to identify factors facing the patient at risk; and -to determine the areas of preventive nursing. The physical assessment of Patient R was done last April 21, 2010 at ARI ( Acute Respiratory Infection) Ward of Agusan del Norte Provincial Hospital around 6 ‘clock in the evening. The student nurses used the cepholocaudal approach in assessing the patient. The student brought with him bp apparatus, temperature, stethoscope, wristwatch, ballpen, and notebook General Survey: Patient R was lying on bed; awake and coherent, with D5NM 1L hooked @ right metacarpal vein, regulated @ 20 gtts/ min @ the level of 400 cc; infusing well. She stands 5 feet and 2 inches in tall and weighs 40.5 kgs with limited body movements noted. Vital Signs: TEMPERATURE: 36. 5 C HEART RATE: 81 beats/ min RESPIRATORY RATE: 24 breaths/ min BP: 90/60 mmHg Skin: The skin was brown in color. Muscle tone present. Few abrasions are noted but nevertheless, the skin was dry. Skin goes back slowly in less than 2 seconds when pinched back. Head: The head circumference measures 50 cm, round in shape. The scalp is free from inflammation and is lighter in color of that of the complexion of the skin. Hair is long, thick and coarse, straight and evenly distributed. Scalp is smooth and white in color, minimal lesions were noted. Dandruff and lice were not seen. Ears: Ears were symmetrical, free of abrasions. Color was good, same with the rest of the body with no pale manifestations. Minimal cerumen noted at both ears. Patient can hear normally when spoken softly Eyes: Eyes are rounded in shape. Inspection of conjunctiva was done by pulling the lower eyelid slightly down with the finger tip and are pink in color. Eyebrows and eyelashes are evenly distributed. The scleras of both eyes were clear, equally round and reactive to light accommodation. The eyes involuntarily blink. Nose: With narrow nose bridge, there were no discharges noted upon inspection. No swelling of the mucous membrane and presence of nasal hairs were seen. No discharges or flaring noted.
Lips: Lips are dry but with no pale manifestations. Cracking of lips noted. Mouth: She has a complete set of teeth with minimal dental caries noted. Oral mucosa and gingival are pink in color, moist and there were no lesions nor inflammation noted. Tongue is pinkish and is free of swelling and lesions. Lips are symmetrical, appears pale without bits noted upon observation. Neck
Lymph nodes noted. Neck has strength that allows movement back and forth, left and right. Patient is able to freely move her neck.
Chest: Chest circumference measures 43 cm. Color is brown, the same with the rest of the body. Breasts are symmetrical and rounded in shape. No inflammation or deformities noted. Lungs and Thoracic Region No reports of pain during the inhalation and exhalation. Absence of adventitious sounds upon auscultation noted . Respiratory rate 24 breathes per minute from the normal range of 20-40 breaths per minute Heart Patient R has an audible heart sound. PMI is heard between 4th - 5th intercostals space upon ausculation. Heart is pumping well with a pulse rate of 81 bpm from the normal rate of 60-100 beats per minute.
Abdomen: Abdomen is rounded in shape while in sitting position and flat when in supine position. The rest of the abdomen is of the same color and with no abrasions. Bowel sounds re hears at 15 bowel sounds per minute upon auscultation. Upon palpation, no distention noted. Back: No inflammations and lesions observed. No abrasions are noted. Upper Extremities: Both hands can be flexed and moved freely. Fingers are symmetrical with no abrasions. Nails are not trimmed, manifested with dirt. Skin: Brown in color; no presence of marks/scars of wounds in the arms, neck and legs. Skin was dry. Skin goes back slowly in less than 2 seconds when pinched back Hands: Medium in size with 5 fingernails in each side. Nails are short, small dusty particles are present. Arms: Able to move through active ROM. Able to extend arms in front or push them out to the side Lower Extremities: Ten fingers are present. Toes are symmetrical, nails are not trimmed. No deformities and inflammation noted upon inspection. Both feet can be flexed and moved freely. Fingers are symmetrical with no abrasions. Bowel and Urine Excretion: Genitals were not assessed due to patient’s refusal. Patient is able to urinate twice and not defecated since day of admission. Neurologic Status: Behavior – Patient is silent but is conscious and coherent upon interaction. She sits and walks if she wants to. She has good eye contact upon interaction and is able to follow simple instructions. She speaks clearly in a soft, moderate voice. Motor Functioning – Patient R is able to move extremities through active ROM. She is able to extend arms front and resist active as pushed down/up on his hands. Reflexes - Reflexes were present such as the blinking reflex and deep tendon reflex. Swallowing reflex is evident when patient was asked to drink a glass of water. Sensory Functioning – Patient’s sensory system is intact, she was able to distinguish touch, pain, hot and cold. She was able to read letter ‘E’ when positioned 10 feet away.
Anatomy and Physiology Gastrointestinal system To aid in understanding the disease process, Anatomy and Physiology provides the necessary information about the normal function of certain body components, its structure and function. Anatomy and physiology are always related. Anatomy is the study of the structure and shape of the body and body parts and their relationships to one another. Physiology is the study of how the body pars work or function. The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break down food into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of faeces). In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms of nausea, vomiting, diarrhoea, malabsorption, constipation or obstruction. Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives.
Basic structure The gastrointestinal tract is a muscular tube lined by a special layer of cells, called epithelium. The contents of the tube are considered external to the body and are in continuity with the outside world at the mouth and the anus. Although each section of the tract has specialised functions, the entire tract has a similar basic structure with regional variations.
The wall is divided into four layers as follows:
Mucosa The innermost layer of the digestive tract has specialised epithelial cells supported by an underlying connective tissue layer called the lamina propria. The lamina propria contains blood vessels, nerves, lymphoid tissue and glands that support the mucosa. Depending on its function, the epithelium may be simple (a single layer) or stratified (multiple layers). Areas such as the mouth and oesophagus are covered by a stratified squamous (flat) epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or glandular epithelium lines the stomach and intestines to aid secretion and absorption. The inner lining is constantly shed and replaced, making it one of the most rapidly dividing areas of the body! Beneath the lamina propria is the muscularis mucosa. This comprises layers of smooth muscle which can contract to change the shape of the lumen. Submucosa The submucosa surrounds the muscularis mucosa and consists of fat, fibrous connective tissue and larger vessels and nerves. At its outer margin there is a specialized nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and submucosa. Muscularis externa This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibres separated by the myenteric plexus or Auerbach plexus. Neural innervations control the contraction of these muscles and hence the mechanical breakdown and peristalsis of the food within the lumen. Serosa/mesentery The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium.
Individual components of the gastrointestinal system Oral cavity The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified squamous oral mucosa with keratin covering those areas subject to significant abrasion, such as the tongue, hard palate and roof of the mouth. Mastication refers to the mechanical breakdown of food by chewing and chopping actions of the teeth. The tongue, a strong muscular organ, manipulates the
food bolus to come in contact with the teeth. It is also the sensing organ of the mouth for touch, temperature and taste using its specialised sensors known as papillae. Insalivation refers to the mixing of the oral cavity contents with salivary gland secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity also plays a limited role in the digestion of carbohydrates. The enzyme serum amylase, a component of saliva, starts the process of digestion of complex carbohydrates. The final function of the oral cavity is absorption of small molecules such as glucose and water, across the mucosa. From the mouth, food passes through the pharynx and oesophagus via the action of swallowing. Salivary glands Three pairs of salivary glands communicate with the oral cavity. Each is a complex gland with numerous acini lined by secretory epithelium. The acini secrete their contents into specialised ducts. Each gland is divided into smaller segments called lobes. Salivation occurs in response to the taste, smell or even appearance of food. This occurs due to nerve signals that tell the salivary glands to secrete saliva to prepare and moisten the mouth. Each pair of salivary glands secretes saliva with slightly different compositions.
Parotids The parotid glands are large, irregular shaped glands located under the skin on the side of the face. They secrete 25% of saliva. They are situated below the zygomatic arch (cheekbone) and cover part of the mandible (lower jaw bone). An enlarged parotid gland can be easier felt when one clenches their teeth. The parotids produce a watery secretion which is also rich in proteins. Immunoglobins are secreted help to fight microorganisms and a-amylase proteins start to break down complex carbohydrates. Submandibular The submandibular glands secrete 70% of the saliva in the mouth. They are found in the floor of the mouth, in a groove along the inner surface of the mandible. These glands produce a more viscid (thick) secretion, rich in mucin and with a smaller amount of protein. Mucin is a glycoprotein that acts as a lubricant. Sublingual The sublinguals are the smallest salivary glands, covered by a thin layer of tissue at the floor of the mouth. They produce approximately 5% of the saliva and their secretions are very sticky due to the large concentration of mucin. The main functions are to provide buffers and lubrication. Oesophagus The oesophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. It extends from the pharynx to the stomach after passing through an opening in the diaphragm. The wall of the oesophagus is made up of inner circular and outer longitudinal layers of muscle that are supplied by the oesophageal nerve plexus. This nerve plexus surrounds the lower portion of the oesophagus. The oesophagus functions primarily as a transport medium between compartments. Stomach
The stomach is a J shaped expanded bag, located just left of the midline between the oesophagus and small intestine. It is divided into four main regions and has two borders called the greater and lesser curvatures. The first section is the cardia which surrounds the cardial orifice where the oesophagus enters the stomach. The fundus is the superior, dilated portion of the stomach that has contact with the left dome of the diaphragm. The body is the largest section between the fundus and the curved portion of the J. This is where most gastric glands are located and where most mixing of the food occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are expelled into the proximal duodenum via the pyloric sphincter. The inner surface of the stomach is contracted into numerous longitudinal folds called rugae. These allow the stomach to stretch and expand when food enters. The stomach can hold up to 1.5 litres of material. The functions of the stomach include: 1. The short-term storage of ingested food. 2. Mechanical breakdown of food by churning and mixing motions. 3. Chemical digestion of proteins by acids and enzymes. 4. Stomach acid kills bugs and germs. 5. Some absorption of substances such as alcohol. Most of these functions are achieved by the secretion of stomach juices by gastric glands in the body and fundus. Some cells are responsible for secreting acid and others secrete enzymes to break down proteins. Small intestine The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-caecal valve separating the ileum from the caecum. The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity. The duodenum is the proximal C-shaped section that curves around the head of the pancreas. The duodenum serves a mixing function as it combines digestive secretions from the pancreas and liver with the contents expelled from the stomach. The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the majority of digestion and absorption occurs. The final portion, the ileum, is the longest segment and empties into the caecum at the ileocaecal junction.
The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. These secretions enter the duodenum at the Ampulla of Vater. After further digestion, food constituents such as proteins, fats, and carbohydrates are broken down to small building blocks and absorbed into the body's blood stream. The lining of the small intestine is made up of numerous permanent folds called plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is covered by epithelium with projecting microvilli (brush border). This increases the surface area for absorption by a factor of several hundred. The mucosa of the small intestine contains several specialised cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions. Large intestine
The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, caecum, ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. The caecum is the expanded pouch that receives material from the ileum and starts to compress food products into faecal material. Food then travels along the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli). The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before it passes through the anorectal canal to the anus. Thick bands of muscle, known as sphincters, control the passage of faeces.
The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal surface is flat with several deep intestinal glands. Numerous goblet cells line the glands that secrete mucous to lubricate faecal matter as it solidifies. The functions of the large intestine can be summarised as: 1. The accumulation of unabsorbed material to form faeces. 2. Some digestion by bacteria. The bacteria are responsible for the formation of intestinal gas. 3. Reabsorption of water, salts, sugar and vitamins. Liver The liver is a large, reddish-brown organ situated in the right upper quadrant of the abdomen. It is surrounded by a strong capsule and divided into four lobes namely the right, left, caudate and quadrate lobes. The liver has several important functions. It acts as a mechanical filter by filtering blood that travels from the intestinal system. It detoxifies several metabolites including the breakdown of bilirubin and oestrogen. In addition, the liver has synthetic functions, producing albumin and blood clotting factors. However, its main roles in digestion are in the production of bile and metabolism of nutrients. All nutrients absorbed by the intestines pass through the liver and are processed before traveling to the rest of the body. The bile produced by cells of the liver, enters the intestines at the duodenum. Here, bile salts break down lipids into smaller particles so there is a greater surface area for digestive enzymes to act. Gall bladder The gallbladder is a hollow, pear shaped organ that sits in a depression on the posterior surface of the liver's right lobe. It consists of a fundus, body and neck. It empties via the cystic duct into the biliary duct system. The main functions of the gall bladder are storage and concentration of bile. Bile is a thick fluid that contains enzymes to help dissolve fat in the intestines. Bile is produced by the liver but stored in the gallbladder until it is needed. Bile is released from the gall bladder by contraction of its muscular walls in response to hormone signals from the duodenum in the presence of food. Pancreas Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its head communicates with the duodenum and its tail extends to the spleen. The organ is approximately 15cm in length with a long, slender body connecting the head and tail segments. The pancreas has both exocrine and endocrine functions. Endocrine refers to production of hormones which occurs in the Islets of Langerhans. The Islets produce insulin, glucagon and other substances and
these are the areas damaged in diabetes mellitus. The exocrine (secretrory) portion makes up 8085% of the pancreas and is the area relevant to the gastrointestinal tract. It is made up of numerous acini (small glands) that secrete contents into ducts which eventually lead to the duodenum. The pancreas secretes fluid rich in carbohydrates and inactive enzymes. Secretion is triggered by the hormones released by the duodenum in the presence of food. Pancreatic enzymes include carbohydrases, lipases, nucleases and proteolytic enzymes that can break down different components of food. These are secreted in an inactive form to prevent digestion of the pancreas itself. The enzymes become active once they reach the duodenum. LABORATORY RESULTS
Name of Test Serology ( Widal Test) Complete Blood Count Urinalysis Fecalysis
Ordering Physician Dr. Bungabong
Date Ordered April 20, 2010
Date Done April 20, 2010
April 20, 2010
April 20, 2010
Dr. Bungabong Dr. Bungabong
April 20, 2010 April 20, 2010
April 21, 2010 April 22, 2010
Serology Date Ordered: April 20, 2010 1:20 1:40 1:80 1:160
O HT3 H2 +1 Trace
H HT3 H2 +1 Trace
AH H2 +1 Trace neg
BH H2 +1 Trace neg
Hematology Complete Blood Count Date Ordered: April 20, 2010 Test Definition Hemoglobin
It is the main component of red blood cells. Its main function is to carry oxygen from the lungs to the body tissues and to transport Carbon Dioxide, the product of cellular metabolism, back to the lungs. It is the measurement of the percentage of red blood cells in the total volume of blood. It is expressed as the percentage of red cells in the total blood volume. The total white blood count (WBC) is the absolute number of white blood cells (leukocytes) circulating in a cubic millimeter of blood. Also called thrombocytes, are large, nonnucleated cells derived from the megakaryotes produced in the bone marrow. They promote coagulation.
Decreased level denotes for hemorrhage, anemia or hemodilution ( overhydartion).
Decreased level may account for anemia, acute blood loss or hemodilution.
(205) x 10 ˆ g/L
Differential Count Test
They play a role in allergic reactions, possibly inactivating histamine. They play a role in our immune response. They contain histamine and heparin and appear to be involved in immediate hypersensitivity
Reference Range (0.00-0.06)
reactions. They are the second line of defense against bacterial infections and foreign substance. Most numerous circulating WBC’s and they respond more rapidly to the inflammatory and tissue injury sites than other types of WBCs.
URINALYSIS Date Ordered: April 20, 2010 Property/Constituents
Color Transparency PH
It is the hydrogen concentration of the urine. It is a measurement of the acid or alkaline status of he urine. it is the measurement of the concentration of urine Protein found in the urine albumin, a serum protein that normally does not leak into the glomerular filtrate It is the principal cation of the extracelluar fluids and is the most important antelectrolyte in the maintenance of fluid balance in the body. It is one of the major electrolytes in the body fluid that is responsible for maintaining life-sustaining
Light straw to dark amber yellow Clear 4.5-8.0
Normal Normal .
Qualitative Analysis > negative
Quantitative Analysis > 10-100 mg/24 h Not indicated
neuromuscular functioning. Microscopic Examination of Urinary Sediment Constituents
WBC and WBC casts
Casts are formed within the kidney tubules from agglutination of protein cells, of red and white cells of epithelial cells. Casts are formed within the kidney tubules from agglutination of protein cells, of red and white cells of epithelial cells. Casts are formed within the kidney tubules from agglutination of protein cells, of red and white cells of epithelial cells.
RBC and RBC casts
Reference Value > 4 per lower power field
Clinical significance Accumulation of white cells casts occurs in glumerolonephritis, pyelonephritis,and Rickey inflammation.
Fecalysis Date Ordered: April 20, 2010 Property/constituent
Consistency Color Pus cells RBC Fat globules
RESULT: No intestinal parasites/ ova seen
Drug Name Chloramphenicol
Date Ordered April 20, 2010
Ordering Physician Dr. Bungabong
April 20, 2010
April 21, 2010
DRUG STUDY NO. 1 Name of Drug: Chloramphenicol Brand Name: Eticlob Classification: Anti- Bacterial Date Ordered: April 20, 2010 Dose and Frequency: 500 mg q6h Mechanism of Action: Binds to 50s ribosomal subunits which interferes with or inhibits protein synthesis. . Indications: Infections caused by S. typhi Contraindications: Hypersensitivity, renal disease, severe heapaic disorders, minor infections Adverse Reactions: Anemia, thrombocytopenia, optic neuritis, nausea, vomiting, diarrhea, abdominal pain, itching, rashes, headache and depression
– – – – – –
Alert SO and patient for signs of infection like inflammation, redness, swelling and presence of pus. Assess patient’s infection before and regularly throughout therapy. Review patient’s history of allergies. Monitor patient for adverse reactions. Obtain culture and sensitivity of specimen. Monitor renal function, PT and platelet count.
DRUG STUDY NO. 2 Name of Drug: Acetaminophen Brand Name: Paracetamol Classification: Non-opioid analgesic, anti-pyretic Date Ordered: April 20, 2010 Dose and Frequency: 500 mg every 4 hours or PRN Mechanism of Action: Blocks pain impulses, probably inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by acting on hypothalamic heat-regulating center. Indications: Mild pain or fever Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in patients with a history of chronic alcohol abuse because hepatotoxicity may occur. Adverse Reactions: Hematologic: hemolytic anemia, leukopenia Hepatic: liver damage, jaundice Metabolic: hypoglycemia Skin: rash, urticaria Nursing Considerations: • Assess patient’s pain and temperature before giving any drugs. • Assess patient’s drug history and calculate daily dosage accofdingly. • Be alert for adverse reactions and drug interactions. • Assess patient and family’s knowledge of drug use. • Tell patient not to use drug for fever higher than 103 degrees Fahrenheit or lasts longer than 3 days or recurs. • Te patient to keep track of daily acetaminophen intake.
DRUG STUDY NO. 3 Name of Drug: Cotrimoxazole Brand Name: Timizole Forte
Classification: Antibiotic Date Ordered: April 21, 2010 Dosage/ Frequency: 800 mg, BID Mechanism of Action: Inhibits susceptible bacteria, including S. typhi Indications: Urinary Tract Infection Contraindications: Hypersensitivity to trimethoprim or sulfonamides and severe renal impairment. Adverse Reactions: Headache, imsonia, agranulocytosis, muscle weakness, oliguria, anuria, nausea, vomiting and diarrhea
Nursing Considerations: – – – – – –
Alert SO and patient for signs of infection like inflammation, redness, swelling and presence of pus. Assess patient’s infection before and regularly throughout therapy. Review patient’s history of allergies. Monitor patient for adverse reactions. Obtain culture and sensitivity of specimen. Monitor renal function, PT and platelet count.
NURSING CARE PLAN A nursing care plan outlines the nursing care to be provided to a patient. It is a set of action the nurse will implement to resolve nursing problems identified by assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care. Problem list is a means of problem prioritization. The methods used in prioritizing the identified problems are: • the date the problem identified • ABC (Airway, Breathing, Circulation) • Maslow’s Hierarchy of Needs Patient’s Name: Patient R Age: 14 years old Chief complaint: on and off fever for 9 days associated chills Problem No. 1
Nursing Problem Acute Pain r/t presence of traumatized tissue
Date Identified April 20, 2010
Date Evaluated April 20, 2010
2 3 4
5 6 7
resulting from insertion of IV Hyperthermia r/t underlying disease process Risk for Constipation r/t insufficient physical activity Hyperthermia r/t underlying disease process Impaired Physical Mobility r/t reluctance to initiate movement Hyperthermia r/t underlying disease process Readiness for Enhanced Sleep
April 20, 2010
April 20, 2010
April 21, 2010
April 21, 2010
April 21, 2010
April 21, 2010
April 22, 2010
April 22, 2010
April 22, 2010
April 22, 2010
April 23, 2010
April 23, 2010
Nursing Care Plan No. 1 Problem Identified: Acute Pain Date Identified: April 20, 2010 Subjective Cues: “Ngutngot akong kamot ganina ra ni siya human gisuksukan. Mga 5 kung sukdon” Objective Cues: ➢ ➢ ➢ ➢ ➢ ➢
Grimacing Diaphoretic Self focused Weak looking Guarding behavior With initial v/s taken as follows: T: 37.5 C R: 24 cpm
P: 97 bpm BP: 90/70 mmHg
Nursing Diagnosis: Acute Pain r/t presence of traumatized tissue resulting from insertion of IV Planning: Within 6 hours of nursing interventions and giving of health teachings, the patient will be able to verbalize reduction of felt pain from a scale of 5 to 1. Interventions: 1. Determine possible pathophysiologic/ psychologic causes of pain. R: To assess etiology precipitating contributing factors. 2. Observe for non verbal cues. R. Observations may/ may not be congruent with verbal reports. 3. Accept client’s description of pain. R: Pain is subjective experience and cannot be felt by others. 4. Encourage verbalization of feelings about pain.
R: To assist client to explore methods to control/ alleviate pain. 5. Encourage us of relaxation techniques such as deep breathing exercises. R: To assist client to explore methods to control/ alleviate pain 6. Encourage participation in diversional activities like socialization or listening to music. R: To assist client to explore methods to control/ alleviate pain 7. Provide patient with a quiet environment and calm activities. R: To assist client to explore methods to control/ alleviate pain 8. Instruct patient to position affected arm properly. R: To promote comfort. 9. Instruct patient to not use affected arm unnecessarily. R: To prevent complications Collaborative: 10. Administer analgesics as indicated. R: Inhibits prostaglandin synthesis by decreasing an enzyme needed for biosynthesis. 11. Notify physician for unusualities. R: For prompt management. Evaluation: Goal Met. After 3 hours of nursing interventions, the patient was able to verbalize reduction of felt pain from a scale of 5 to 1 as evidenced by the verbalization of “ Wala na’y sakit akong gitusukan nga kamot”. Date Evaluated: April 2O, 2010 Nursing Care Plan No. 2 Problem Identified: Hyperthermia Date Identified: April 20, 2010 Subjective Cues: “Init napud balik akong paminaw” Objective Cues: ➢ ➢ ➢ ➢ ➢ ➢
Skin warm to touch Flushed skin Dry, cracked lips Absence of sweating Slowed movement With initial v/s as follows: T: 39.2 C P: 99bpm
R: 28 cpm
BP: 90/70 mmHg
Nursing Diagnosis: Hyperthermia r/t underlying disease process Planning: Within 2 hours of nursing interventions, the patient will be able manifest reduction of core temperature from 39.2 to a normal range of 36.5 C- 37.5 C Interventions: 1. Monitor patient’s vital signs. R: Serves as baseline data for future comparison. 2. Note chronological and developmental age of client. R: Assess for causative/ contributing factor. 3. Note presence/ absence of sweating. R: To assess degree of hyperthermia. 4. Initiate tepid sponge bath. R: Facilitates heat through conduction and evaporation. 5. Promotes surface cooling through undressing or removing extra linens. R: Facilitates heat loss by radiation 6. Encourage adequate fluid intake. R: To promote heat loss and hydration. 7. Encourage adequate bed rest. R: To reduce metabolic consumption and oxygen demands. 8. Instruct patient and SO to report signs and symptoms of hyperthermia like flushed skin, increasing respiratory rate and body temperature. R: To promote wellness
9. Maintain patent airway and pad or raise siderails upon turning and positioning. R: To promote safety. 10. Provide high calorie diet unless contraindicated. R: To meet increased metabolic demands. 11. Instruct patient and SO to record all sources of fluid loss such as urine, vomiting and diarrhea. R: It potentiates fluid and electrolyte losses. Collaborative 12. Administer paracetamol 500mg, 1 tablet for fever as ordered. R: Relieves fever by acting in hypothalamic heat regulating center. 13. Administer replacement fluid and electrolytes as needed. R: To support circulating volume and tissue perfusion. 14. Notify physician for unusualities. R: For prompt management.
Evaluation: Goal Unmet. After 1 hour and 45 minutes of nursing interventions, the patient was not able to manifest reduction of core temperature from 39.2 to normal range with latest temperature of 38.5 C.
Date Evaluated: April 20, 2010
Nursing Care Plan No. 3 Problem Identified: Risk for Constipation Date Identified: April 21, 2010 Subjective Cues: “Wala pa ko kalibang gikan atong gi admit ko” Objective Cues: ➢ ➢ ➢ ➢ ➢ ➢ ➢
Dry skin Absence of sweating Needs assistance upon getting up in bed Refused to ambulate or to do ROM exercises Slowed movement (+) flatus Defecates 3-4 times per week
Nursing Diagnosis: Risk for Constipation r/t insufficient physical activity Planning: Within 6 hours of nursing interventions and giving of health teachings, the patient will be able to verbalize understanding of risk factors and appropriate interventions/ solutions to individual situation. Interventions: 1. Auscultate abdomen for presence, location, and characteristics of bowels sounds. R: Reflects bowel activity. 2. Ascertain client’s belief and practices about bowel elimination. R: To identify individual risk factors/ needs. 3. Ascertain client’s usual elimination pattern. R: To assess client’s individual risk factors/ needs. 4. Encourage intake of balanced fiber and bulk in diet. R: To improve consistency of stool and facilitates passage through colon. 5. Promote increase in fluid intake unless contraindicated. R: to promote moist/ soft stool. 6. Encourage participation in activity/ exercise within limits of own ability. R: To stimulate contractions of intestines. 7. Instruct patient to respond to urge to defecate. R: To promote comfort and prevent complications. 8. Instruct client and SO to ascertain frequency, color, consistency of stool once defecated. 9. Advise patient to have elimination diary if appropriate R: To help monitor bowel pattern. Collaborative: 10. Notify physician for unusualities. R: For prompt management Evaluation: Goal Met. After 4 hours of nursing interventions, the patient was able to verbalize understanding of risk factors and appropriate interventions/ solutions to individual situation as evidenced by the verbalization of “ Mobakod nako diri sa higdaanan ug maglakaw lakaw na dayon ko human” and patient was able to defecate during the shift of duty. Date Evaluated: April 21, 2010
Nursing Care Plan No. 4 Problem Identified: Hyperthermia Date Identified: April 20, 2010 Subjective Cues: “Init napud balik akong pamati…arang inita” Objective Cues: ➢ ➢ ➢ ➢ ➢ ➢
Skin warm to touch Flushed skin Dry, cracked lips Absence of sweating Slowed movement With initial v/s as follows: T: 38 C P: 91bpm
R: 29 cpm
BP: 90/70 mmHg
Nursing Diagnosis: Hyperthermia r/t underlying disease process Planning: Within 2 hours of nursing interventions, the patient will be able manifest reduction of core temperature from 38 C to a normal range of 36.5 C- 37.5 C. Interventions: 1. Monitor patient’s vital signs. R: Serves as baseline data for future comparison. 2. Note chronological and developmental age of client. R: Assess for causative/ contributing factor. 3. Note presence/ absence of sweating. R: To assess degree of hyperthermia. 4. Initiate tepid sponge bath. R: Facilitates heat through conduction and evaporation. 5. Promotes surface cooling through undressing or removing extra linens. R: Facilitates heat loss by radiation 6. Encourage adequate fluid intake. R: To promote heat loss and hydration. 7. Encourage adequate bed rest. R: To reduce metabolic consumption and oxygen demands. 8. Instruct patient and SO to report signs and symptoms of hyperthermia like flushed skin, increasing respiratory rate and body temperature. R: To promote wellness 9. Maintain patent airway and pad or raise siderails upon turning and positioning. R: To promote safety. 10. Provide high calorie diet unless contraindicated. R: To meet increased metabolic demands. 11. Instruct patient and SO to record all sources of fluid loss such as urine, vomiting and diarrhea. R: It potentiates fluid and electrolyte losses. Collaborative 12. Administer paracetamol 500mg, 1 tablet for fever as ordered. R: Relieves fever by acting in hypothalamic heat regulating center. 13. Administer replacement fluid and electrolytes as needed. R: To support circulating volume and tissue perfusion. 14. Notify physician for unusualities. R: For prompt management.
Evaluation: Goal Met. After 1 hour and 45 minutes of nursing interventions, the patient was able to manifest reduction of core temperature from 38C to normal range with latest temperature of 37.5 C.
Date Evaluated: April 21, 2010
Nursing Care Plan No. 5 Problem Identified: Impaired Physical Mobility Date Identified: April 22, 2010 Subjective Cues: “Kapoy ibakod sa higdaanan” Objective Cues: ➢ Slowed movement
➢ ➢ ➢ ➢
Body weakness noted Refused to ambulate or to do ROM exercises Needs assistance upon getting up/ out in bed Prefers to lie down on bed
Nursing Diagnosis: Impaired Physical Mobility r/t to reluctance to initiate movement Planning: Within 4 hours of nursing interventions and giving of health teachings, the patient will be able to verbalize willingness to and demonstrate participation in activities. Interventions: 1. Determine degree of mobility. R: To assess functional ability 2. Assess nutritional status and energy level. R: To identify causative/ contributing factors. 3. Ascertain client’s perception of activity/ exercise needs. R: To identify causative/ contributing factors. 4. Have client reposition self on regular schedule as indicated. R: To promote optimal level of functioning. 5. Instruct in use of siderails upon positioning. R: To promote safety. 6. Schedule activities with adequate rest periods during the day. R: To prevent/ reduce fatigue. 7. Encourage client to participate in self care activities. R: Enhances self- concept and sense of independence. 8. Identify energy- conserving techniques for ADL’s. R: Limits fatigue, maximizing participation. 9. Instruct patient to promote / have ambulation as necessary. R: To prevent skin breakdown and maximizes energy production. 10. Instruct patient to eat nutritious foods and drink adequate fluid intake. R: promotes well being and maximizes energy production. Evaluation: Goal Met. After 2 hours of nursing interventions, the patient was able verbalize willingness to and demonstrate participation in activities as evidenced the verbalization of “Mubakod nako ug maglakaw lakaw dayon paghuman aron dlil ko luyahon ug samot”. Date Evaluated: April 22, 2010
Nursing Care Plan No.6 Problem Identified: Hyperthermia Date Identified: April 22, 2010 Subjective Cues: “Nag-init napud balik akong pamati” Objective Cues: ➢ ➢ ➢ ➢ ➢ ➢
Skin warm to touch Flushed skin Dry, cracked lips Absence of sweating Slowed movement With initial v/s as follows: T: 38.8 C P: 91bpm
R: 25 cpm
BP: 90/70 mmHg
Nursing Diagnosis: Hyperthermia r/t underlying disease process Planning: Within 2 hours of nursing interventions, the patient will be able manifest reduction of core temperature from 38.8 to a normal range of 36.5 C- 37.5 C Interventions: 1. Monitor patient’s vital signs. R: Serves as baseline data for future comparison. 2. Note chronological and developmental age of client. R: Assess for causative/ contributing factor. 3. Note presence/ absence of sweating. R: To assess degree of hyperthermia. 4. Initiate tepid sponge bath. R: Facilitates heat through conduction and evaporation. 5. Promotes surface cooling through undressing or removing extra linens. R: Facilitates heat loss by radiation 6. Encourage adequate fluid intake. R: To promote heat loss and hydration. 7. Encourage adequate bed rest. R: To reduce metabolic consumption and oxygen demands. 8. Instruct patient and SO to report signs and symptoms of hyperthermia like flushed skin, increasing respiratory rate and body temperature. R: To promote wellness 9. Maintain patent airway and pad or raise siderails upon turning and positioning. R: To promote safety. 10. Provide high calorie diet unless contraindicated. R: To meet increased metabolic demands. 11. Instruct patient and SO to record all sources of fluid loss such as urine, vomiting and diarrhea. R: It potentiates fluid and electrolyte losses. Collaborative 12. Administer paracetamol 500mg, 1 tablet for fever as ordered. R: Relieves fever by acting in hypothalamic heat regulating center. 13. Administer replacement fluid and electrolytes as needed. R: To support circulating volume and tissue perfusion. 14. Notify physician for unusualities. R: For prompt management.
Evaluation: Goal Unmet. After 1 hour and 45 minutes of nursing interventions, the patient was not able to manifest reduction of core temperature from 38.8 to normal range with latest temperature of 38.3 C.
Date Evaluated: April 22, 2010
Nursing Care Plan No. 7 Problem Identified: Readiness for Enhanced Sleep Date Identified: April 23, 2010 Subjective Cues: “Gusto nako diritso akong tulog inig gabie bahala igang ug saba” Objective Cues: ➢ ➢ ➢ ➢ ➢
Yawning noted Finds way to promote sleep like turning on the electric fan Slowed movement Doesn’t practice afternoon naps Sleeps 6-8 hours a day
Nursing Diagnosis: Readiness for Enhanced Sleep Planning: Within 4 hours of nursing interventions and giving of health teachings, the patient will be able to verbalize understanding on ways to promote sleep. Interventions: 1. Listen to client’s reports of sleep quantity and quality. R: Reveals client’s expectations and experiences. 2. Obtain feedback from client and SO about usual bedtime, desired rituals and routine. R: To determine usual sleep pattern and provide comparative baseline data. 3. Note client’s report of potential for alteration for habitual sleep time. R: Helps identify circumstances that are known to interrupt sleep patterns. 4. Arrange care as necessary. R: to provide for uninterrupted periods for rest.
5. Explain to patient the necessity of disturbances for hospital procedure like v/s taking. R: Allows for longer periods of uninterrupted sleep. 6. Provide quiet environment prior to sleep. R: To promote relaxation and readiness to sleep. 7. Instruct patient to practice proper hygiene practices like washing of hands and feet before sleeping. R: To promote relaxation and readiness to sleep. 8. Instruct patient to limit intake of chocolate and caffeine/ alcoholic beverages prior to bedtime. R: Substances are known to impair falling or staying asleep. 9. Instruct patient to limit fluid intake in evening. R: To reduce need for nighttime elimination. 10. Discuss patient’s usual bedtime rituals, expectations for obtaining good sleep time. R: Provides information on client’s management of the situation and identifies areas that might be modified. Evaluation: Goal Met. After 2 hours of nursing interventions, the patient was able to verbalize understanding on ways to promote sleep as evidenced by the verbalization of “Dili nako makalimot ug hinlo sa akong lawas adisir ko matulog inig gabie”
Date Evaluated: April 23, 2010
DISCHARGE PLANNING M – Medication - Advise patient to take home medication following right drug, frequency, dosage and timing as prescribed by the physician such as follows: > Chloramphenicol, 500mg 1 tablet taken every six hours - Encourage patient to follow drug regimen especially antibiotics. E – Environment - Instruct patient to stay in calm, quiet environment. - Home environment must be free from slipping or accident hazards. - Instruct SO to provide patient with well ventilated room so that patient can rest well. T – Treatment - Inform patient to have a follow-up check up after 1- 2 weeks H – Health Teachings Inform patient to about proper food handling techniques as necessary. - Stress the importance of proper hygiene like handwashing, toileting, toothbrushing and bathing. - Encourage client to engage to range of motion exercises. - Instruct patient to drink only purified drinking water or have drinking water boiled as necessary. - Advise patient to increase adequate fluid intake for hydration purposes. - Encourage patient not to participate in strenuous activities - Tell patient not to hesitate to ask for assistance when waking up in bed or when going to comfort room. - Promote rest periods among the client but also encourage ambulation. - Advise patient to avoid eating foods from outside sources like carinderia.
- Encourage deep breathing and coughing exercises among the client. O – Observable Signs and Symptoms - Instruct patient to report signs and symptoms of typhoid fever like high grade fever, generalized aches and pain, lethargy, fatigue, headache, diarrhea and rashes for prompt management and to avoid further complications. D– Diet - Encourage client to increase intake of fiber to avoid constipation - Instruct to increase fluid intake - Instruct to increase intake of nutritious foods rich in Vitamin C such as fruits and vegetables to boost one’s immune system. S- Spirituality – Advise patient to keep believing on God’s holy will so that he could be spiritually motivated. – Tell patient to constantly participate to religious activities so that his faith could be more strengthened.
LEARNING OUTCOMES Life is indeed full of surprises. Things happen as what expected to them to happen. No one ever travels the highway of success without ever crossing the road of failures instead. All we need to is to follow path that leads us to the unknown road. But we should always be glad that as we get stumbled along the road, we learn to stand on our own feet putting our heads up. From those experiences, we learn to grow as a person accountable for every action we take. That’s how learning process takes place. It comes naturally as it may seem. How could I ever forget the experience I have acquired upon exposure to the Pedia Ward of Agusan del Norte Provincial Hospital. It was the 19 th day of April, 2010, when I first entered the innocent world of pediatric nursing. I have to admit on my part that I got anxious and nervous as I found out that our group was assigned to the pedia ward knowing children really are stubborn in nature and truly demand for extra attention. Preparations were being made. I also reviewed my lecture notes on pediatric nursing within that short span of time, if that would be possible. As day progressed, I have gained new learnings and insights most especially during exposure to the said area. It’s just that in pedia ward , there is no room for mistakes perhaps. A student nurse must practice good therapeutic communication skills in order to gain the trust of those sick young individuals. It entails cooperation and presence of mind as one engages to the world of pedia. But patience and dedication area somewhat virtues to keep, so one should keep the fire burning. When engagimg oneself to duty, one should be fully prepared. One must be assertive enough to do all things needed to be carried out. One must be fully equipped with the knowledge, skills and attitude before exposing to the area so that one could be productive and useful perhaps since we aim for the recovery of those children. One should really pay attention so that things would run smoothly. Upon exposure, I was able to appreciate the call of duty since caring for the young ones are somewhat a challenging task to be tackled upon. It somehow made me appreciate myself and lot more becoming a part of the health care team. What a big relief on my part
seeing my patient, wearing a happy smile on his/her face after rendering nursing care to such patient. “When you are a nurse, you know that every day you will touch a life or a life will touch yours”-a quotation on worth to lived for. As for now, I should live my life doing good things not just for myself but also for others. I should bear in mind that I should not count the number of times I felt better just because I made them happy. Two weeks of exposure may be short enough yet with the experiences and learnings I gained, the hardships were all worth it. The experience was truly superb and remarkable indeed.