NURSING CARE PLAN

Pt. Crusit, Brylle Matthew Age: 1 year and 6 months Cues S: Medyo dili na kaayo basa iya tae pero sige pa siya libang, as verbalized by the mother. O: 2 watery stools noted -restless at times Nursing Diagnosis Diarrhea related to underlying disease process Objectives/Evaluating Criteria Within 30 of nursing interventions, the clients mother will be able to demonstrate appropriate behavior to assist with reduction of causative factors such as proper food preparation and avoidance of irritating foods. Nursing Intervention Rationale Evaluation Goal met. After 30 of nursing interventions, the clients mother was able to demonstrate appropriate behavior to assist with resolution of causative factors such as proper food preparation and avoidance of irritating foods.

1) Observe and record stool - Helps differentiate individual frequency characteristics, disease and assess severity of amount and precipitating episode. factors; 2) Identify foods and fluids - Avoiding intestinal irritants that precipitate diarrhea and promotes intestinal tract hest. 3) weigh infants diapers - To determine amount of output and fluid replacement needs 4) Restart oral fluid intake - Provides colon rest, gradual gradually, offer clear consumption of liquids may liquids and avoid cold prevent cramping and fluids recurrence of diarrhea, and to avoid hydration, cold liquids can increase intestinal motility. 5) Encourage to eat foods - fruits that are stool former like smashed banana and apple Dependent/Collaborative - to treat infections process, 6) Give medications as decrease motility and absorb ordered water.

NURSING CARE PLAN

Date Identified: Date Evaluated: Cues O: Productive cough noted changes in respiratory rate RR 26 bpm crackles breath sounds on both lung fields difficulty of breathing claimed restlessness with O2 inhalation at 2 LPM February 15, 2011 February 15, 2011 Nursing Diagnosis Ineffective airway clearance related to retained secretions in the bronchi Objectives/ Evaluating Nursing Intervention Criteria Within 30 of 1) Auscultate breath sounds and nursing assess air movement interventions, the 2) Monitor vital signs, noting patient will be to blood pressure/pulse changes maintain airway 3) Assess for commitment patency. discomfort 4) Position head midline with flexion appropriate for age/condition 5) Elevate head of bed and change position every 2 hours as needed Rationale Evaluation Goal met. After 30 of nursing interventions, the patient was able to maintain airway patency.

- To ascertain status and note progress - For baseline data and for early intervention - This may limit respiratory effort - To open or maintain open airway in at rest or compromised individual - To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage/ventilation to different lung segments. 6) Encouraged deep breathing - To maximize effort and to and coughing exercises assist client in taking control of the situation 7) Increase fluid intake to at - To help liquefy secretions least 2000ml/day within level of cardiac tolerance 8) Administer oxygen at lowest - To facilitate deeper concentration indicated for respiratory effort and to respiratory underlying present respiratory distress pulmonary condition

9) Provide information about the - To examine and report necessity of raising and changes in color and amount expectorating secretions versus swallowing them 10) Provide opportunities for - To limit fatigue rest periods Collaborative 11) Administer calciblock - Used as a quick-relief agent 5mg/tab 1 neb BID for acute brochospasm and for prevention. Respiratory smooth muscle relaxant

NURSING CARE PLAN

Date Identified: Date Evaluated:
Cues S: Sakit akong tiyan O: grimace noted 5 out 10 pain scale restlessness irritability Nursing Diagnosis Acute pain related to underlying disease process Objectives/ Evaluating Criteria Within 30 of nursing interventions, the patient will be to demonstrate use of relaxation skills and diversional activities as indicated for individual situation. Nursing Intervention 1) Monitor vital signs 2) Assess for referred pain as appropriate 3) Observe non-verbal cues such as how clients hold body; sits, facial expression 4) Work client to prevent pain and instruct client to report pain as soon as it begins. 5) Provide comfort measures such as back neb, change of position. 6) Perform pain assessment each time pain occurs. Note and investigate changes from previous reports. 7) Encourage to have adequate rest periods 8) Accept clients description of pain 9) Encourage right-brain stimulation with activities such as love, laughter, and music 10) Note when pain occurs Rationale - usually altered in acute pain - to help determine possibility of underlying condition - observation may not be congruent with verbal reports indicating need for further evaluation. - as timely intervention is more likely to be successful in alleviating pain - to provide nonpharmacological pain management - to rule out worsening of underlying conditions/ development of complication - to prevent fatigue - pain is subjective experience and cannot be felt by others - to release endorphins, enhancing sense of well-being Evaluation Goal met. After 30 of nursing interventions, the patient was able to demonstrate of relaxation skills and diversional activities as indicated for individual situation.

NURSING CARE PLAN

Date Identified: Date Evaluated:
Cues O: periorbital edema noted edema on both feet noted difficulty of breathing exclaimed oliguria, urinates 3 times a day restlessness I&O input 210 ml output 50 ml Nursing Diagnosis Excess fluid volume related to compromised regulatory mechanism Objectives/ Evaluating Criteria Within 40 of nursing interventions, the patient will be able to stabilize fluid volume as evidenced by balanced I&O, vital signs within clients normal limits and free of signs of edema. Nursing Intervention 1) Assess appetite, note presence of nausea/vomiting 2) Monitor vital signs 3) Auscultate breath sounds 4) Measure abdominal girth 5) Evaluate edematous extremities, change position frequently 6) Place in semi-fowlers position as appropriate 7) Stress need for mobility and frequent position changes 8) Instruct patient to limit fluid intake 800 ml/day 9) Provide adequate rest periods 10) Record I&O accurately Rationale - to prevent dehydration and for early intervention - serves as baseline data - for presence of crackles/congestion - girth for changes that may indicate increasing fluid retention/edema - to reduce tissue pressure and risk of skin breakdown - to facilitate movement of diaphragm improving respiratory effort - to prevent statis and reduce risk of tissue injury - to prevent further complications and prevent edematous - to limit fatigue - for further evaluation Evaluation Goal met. After 40 of nursing interventions, the patient was able to stabilize fluid volume as evidenced by imbalanced I&O, vital signs within clients normal limits and unfree of signs of edema.

NURSING HEALTH HISTORY

It is a complete medical history of the client basic information by asking specific questions either objective or subjective data from the client and of the people who knew the client and can give suitable information. The purpose of this is to established a data about the client level of wellness, health practices, past illness, and related experiences and health care goals. Basic information data gathered through the clients chart last Feb. 22, 2011 at 7:30 in the evening. To maintain clients dignity and privacy, I will call him Pt. A. Mr. and Mrs. E got 12 siblings, 6 boys and 6 girls. Patient A was the youngest among all the siblings, he was born on Sept. 9, 1994 through home delivery at Quarry, Tungao, Butuan City. According to his mother, Patient A and his brothers and sisters were completely immunized since there birth and never had a problem since they were born. They recently living at P-20 Quarry Tungao, Butuan City. Patient A stop in school at the age of 14 due to financial problem. Patient A loves to eat nutritious foods such as green leafy vegetables and fruits. Patient A upon eating doesnt wash his hands promptly. Basta magdali na siya ug labi na pag-gutomon dili matarong iyang paghugas sa iyang kamot, as verbalized by his mother. Patient A often play cards with his friends and sometimes online games. Mrs. E said kini siya usahay man gud magpataka-taka ug pamalit-palit ug mga pagkaon sa amoa lugar labi na pag magdula na siya og online games bisan unsa na siguro pangan-on. Patient A got sick only fever and chickenpox and normal illnesses like colds and cough, aide for it Mrs. E only know about her familys hereditary illnesses were only high blood and rheumatism.

On January 30, 2011, Patient A had a fever associated with productive cough for 2 weeks until he admitted on February 11, 2011 around 8:20 am with a chief complain of 2 weeks unattended fever associated with anorexia and body malaise, numbness on both lower extremities, cough and 2 weeks at the age of 16 y. o. accompanied by his mother Mrs. E. Vital signs taken; BP 180/90 mmHg, Temp. 36.90C, HR-118 bpm. Seen and examined by Dr. De Vera with orders as follows: admit to accommodation of choice; problem: fever, CBC and U/A requested; IVF D5.3 NaCl 1L regulate @ 20 gtts/min; medication prescribed: Ciprofloxacin 500mg tab BID PO, Paracetamol 500mg tab every 6h PRN; I&O every 6h; v/s every 6H; refer accordingly; DAT, CBC results done on, the same date around 8:18 pm, results are HGB-65 g/L, HCT-021; with the requesting physician doctor De Vera. On Feb. 12, 2011, at 11:25 am, the doctors order ceftriaxone 1pm IVTT, 8h med; for blood typing STAT, blood type O+; Ranitidine 50mg IVTT every 8h; HAMA; 4pm secure 3 units PRBC, at 10:50 pm give calciblock 5mg now by Dr. Dacera. On Feb. 13, 2011, the doctors order were for serum creatinine 19.4; Catopril 20mg/neb 1 tab every 6 hours prn for BP > 100 mmHg by Dr. Burigga. On Feb. 14, 2011, the doctors order were catopril, hold, calciblock 5mg; Ranitidine 50mg IVTT every 12 h, Hydrocortisone 80mg IVTT; please facilitate creatinine determination; Furosemide 20mg IVTT now then OD; IVF to 10 gtt/min;

limit oral fluid 800ml/day, repeat U/A proteinuria for chest x-ray PA; K+ deterioration STA, NaHCO3, 650g 2 tabs TID, advised hemodialysis. On Feb. 15, 2011, the doctors order were D/C Ceftriaxone IVTT, refer meds to D5W/PCSO for assistance. I received patient A sitting on bed, awake with IVF #4 PNSS 1L 800cc level regulated at 10 gtts/min hooked at right metacarpal vein; infusing well. Initial vital signs as ff: Temp-36.80C, Pulse-73 bpm, R-86 bpm, OP140/120 mmHg, afebrile with O2 inhalation at 2 LPM. He had edema on both feet and a periorbital edema noted; productive cough noted; difficulty of breathing claimed. On February 16, 2011 at 9am, the doctors order was flourosemide 40mg IVTT noted results as WBC-15.7 g/L dec.; HCT-32.1. On February 17, 2011 the doctors order were for repeat CBC, creatinine today, flourosemide 40mg IV today, informed reading dialysis to seek assistance for PCSO BT of 2 units done, and 9:30 pm, IVF to follow D5.3 NaCl 1L @ SR by Dr. Dacera. On February 18, 2011 at 5pm, the doctors order is for referral to hospital of choice for hemodialysis. And around 5:50 pm, Patient A was discharged with a admitting diagnosis of typhoid fever.

DRUG STUDY

Ceprofloxacin: Proseloc Classification: Anti-bacterial Action: Interferes with conversion of intermediate DNA fragments into high molecular weight DNA in bacteria, DNA grayse inihibtor, bactericidal action. Route/Dosage: 500mg BID, PO Adverse Effect: Headache, dizziness, fatigue, restlessness, nausea, vomiting, diarrhea. Uses: Adult urinary tract infections, chronic bacterial prostatitis, acute sinusitis, lower resp. Contraindications: Hypersensitivity to quinolones Precautions: Frequency C, lactation, children, renal disease Nursing Consideration: Patient Educ: Teach patient to report sore throat, bruising, bleeding, joint pain may indicate blood dyscariasis. Teach patient to contact prescriber if adverse reaction occurs. Advise to rinse mouth frequently. Assess patient for previous sensitivity reaction Assess patient for s/sx of infection including sputum, urine, stool

COMPLETE BLOOD COUNT

Test HBG

Normal Value Non containing 117-140 g/L oxygen transport in the RBC Definition

Result Result

Interpretation

Significance

Feb. 11, 2011

65

Decrease

May indicate anemia, fluid retention

Feb. 17, 2011 HCT

109 The important determinant proportion of blood volume occupied by RBC 0.34-0.44

Decrease

Feb. 11, 2011 Feb. 17, 2011 WBC

0.21 32.1 Cells of immune system. It defends the body against infection and from foreign material 5.0-15.0 Hx10 g/L

Decrease Decrease

Low HCT suggest anemia

Feb. 11, 2011

12.90 Hx10^ g/L 15.71 Hx10^ g/L Produces antibiotics and other chemicals responsible for destroying microorganism, contributes to allergic reaction, graft rejection, tumor control, and regulation of the immune system 0.20-0.80

Normal

Feb. 17, 2011 Lymphocytes

Increase

Leukocytosis commonly signals infection.

Feb. 11, 2011 Feb. 17, 2011

0.24 0.27

Normal Normal

Occur in conditions such as anemia and bone marrow suppression

Monocyte

Phagocytic cell in the blood, leaves the blood and becomes a macrophage which phagocytizes bacteria, dead cells, cell fragments, and other debris within tissues

0.08-014L

Feb. 11, 2011 Feb. 17, 2011 Platelet Count Forms platelet plugs, release chemicals necessary for blood clotting 150-390 Hx10 g/L

0.13L

Normal

Feb. 17, 2011 Feb. 17, 2011

342 g/L 325 g/L

Normal Normal

Blood Typing

Blood type: O+

February 12, 2011

Creatinine February 13, 2011 Result 19.4mg/dl N0 value 0.7-1.34 mg/dl

Potassium February 14, 2011 Result 4-6 mmol N0 value 3.6-5 mmol

Urinalysis Color: Pale Yellow pH: 6.0 Albumin: 4 Pus cells: 10-15 Transparency: Hazy Sp. gravity: 1.1055 Sugar: Negative

PROBLEM LIST

DATE STARTED February 15, 2011

PROBLEM Ineffective airway clearance related to retained secretions in the bronchi

DATE ENDED February 15, 2011

February 15, 2011

Acute pain related to underlying disease process

February 15, 2011

February 15, 2011

Excess fluid volume related to compromised regulatory mechanism

February 15, 2011

February 15, 2011

Risk for aspiration related to depressed cough and gag reflexes

February 15, 2011

February 15, 2011

Risks for injury related to restlessness 20 to typhoid fever

February 15, 2011

PHYSICAL ASSESSMENT
Physical assessment or nursing assessment is a method of gathering information about a patient physiological, psychological, sociological and spiritual status. A physical examination is the observation or measurement on the patient. It included inspection, auscultation, percussion and palpation techniques. Vital signs will be taken also to obtain a baseline data. The process of physical assessment includes 3 phases: The interview, the physical examination, and documentation. Instruments were: thermometer, stethoscope, paper and pen. The assessment was done on February 15, 2011 at the Medical Ward, Butuan Medical Center, Butuan City. A. General Survey Received Patient A sitting on bed, awake at the Medical Ward. He was restlessness. He was afebrile, weak looking, difficulty of breathing claimed, fairly groomed. Patient As vital signs were as follows: Temp: 36.80C, P-73 bpm, R-26 bpm, BP-140-120 mmHg. Body Parts Head Inspection No dandruff and lice noted. Scars are noted at right temporal area. Head and facial skin are smooth. No presence of wound or any lesions noted. Eyes and Visual The eyebrows have Acuity five hairs and are aligned. Eyelids from left and right closed at the same time. Periorbital edema noted. No presence of swelling, lesions or discoloration. The sclera is white and both pupils are symmetrical. Dry eyes noted. Ears and Ears are symmetrical, Hearing firm and hard. No swelling noted skin color of external ears are fair same as facial color. Cerumen are noted upon infection. Palpation Free of tenderness upon palpation Percussion Auscultations

Free of tenderness upon palpation

Nose

Oropharynx

Tongue

Neck

Breast and Axilla

Abdomen

Can hear upon interaction External structure of nose is well formed, without lesions or abrasions, presence of discharges noted on both nares. No unusual sounds heard at the time of inhalation and exhalation activity. Patient As lips are pale. No lip laceration. Dry lips observed. The teeth are complete. Tonsil is intact and uninflammed Pale in color, regular size intact, w/o laceration or sore throat. It moves freely and involuntarily Neck is no in size. Evenly distributed skin tone. Edema, prickles, warts, abrasions and other lesions are not found. Jugular veins are observable. Normal breast structure as inspected with round nipple, brown in color, equal in size and everted. NO presence of hair in the axilla noted. Axillary temp. 36.80C during assessment. Flat abdomen upon inspection, no lesions, abrasions noted. Umbilicus is midline with the body. Pain at the left upper epigastric exclaimed

No lymph nodes upon palpation

No masses upon palpation

No tender upon palpation

Normal Audible bowel sound upon sound is heard percussion upon auscultation

Heart

Lub dub heard upon auscultation.

Chest and lungs

Difficulty of breathing Non noted. NO presence of tenderness or bruises noted. masses upon palpation Skin color of upper No masses or extremities are fair. tenderness Well flexed upon palpation extremities. Skin is free lesions and deformities. Finger nails are untrimmed, presence of dirt underneath the nails noted. Nail beds are pale in appearance. Presence of scars on both arms noted. Capillary refill of 2-3 sec. Skin color is fair, well flexed extremities, untrimmed nails noted. Presence of dirt underneath the nails noted. No abrasions or lesions noted scars noted on both legs. Pedal edema on both legs are noted. Were not inspected due to rights and privacy of the patient.

HR-73 bpm Retained Crackles are secretions in heard upon the bronchi auscultation upon RR-26 bpm percussion

Upper Extremities

Lower Extremities

Genitalia and Rectum

DEFINITION OF TERMS
Salmonella enterica (formerly Salmonella choleraesuis) is a rod shaped, flagellated, aerobic, Gram-negative bacterium, and a member of the genus Salmonella. Eosinopenia is a form of agranulocytosis where the number of eosinophil granulocyte is lower than expected. Leukocytosis with eosinopenia can be a predictor of bacterial infection.[ It can be induced by the use of steroids. Pathological causes include burns and acute infections. Leukocytosis is a raised white blood cell count (the leukocyte count) above the normal range in the blood. The Widal test is a presumptive serological test for enteric fever or undulant fever. In case of Salmonella infections, it is a demonstration of agglutinating antibodies against antigens O-somatic and H-flagellar in the blood. For brucellosis, only O-somatic antigen is used. A dicrotic pulse is a type of pulse characterized by a percusion wave in systole and a prominent dicrotic wave in diastole. Physiologically, the dicrotic wave is the result of reflected waves from the lower extremities and aorta Borborygmus (plural borborygmi,) also known as stomach growling, rumbling, or wambling, is the rumbling sound produced by the contraction of muscles in the stomach and intestines of animals, including humans, platypodes and ants. The word borborygmus refers to this rumbling.

INTRODUCTION
Typhoid fever, also known as typhoid, is a common worldwide illness, transmitted by the ingestion of food or water contaminated with the feces of an infected person, which contain the bacterium Salmonella enterica enterica, serovar Typhi. The bacteria then perforate through the intestinal wall and are phagocytosed by macrophages. The organism is a Gram-negative short bacillus that is motile due to its peritrichous flagella. The bacterium grows best at 37C / 98.6F human body temperature.This fever received various names, such as gastric fever, abdominal typhus, infantile remittant fever, slow fever, nervous fever, pythogenic fever, etc. The name of "typhoid" was given by Louis in 1829, as a derivative from typhus. CAUSE: Flying insects feeding on feces may occasionally transfer the bacteria through poor hygiene habits and public sanitation conditions. SIGNS AND SYMPTOMS: Typhoid fever is characterized by a slowly progressive fever as high as 40 C (104 F), profuse sweating and gastroenteritis. Less commonly, a rash of flat, rose-colored spots may appear. A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms, but capable of infecting others. According to the CDC approximately 5% of people who contract typhoid continue to carry the disease after they recover. The most famous asymptomatic carrier was Mary Mallon (commonly known as "Typhoid Mary"), a young cook who was responsible for infecting at least 53 people with typhoid, three of whom died from the disease. Mallon was the first apparently perfectly healthy person known to be responsible for an "epidemic". Many carriers of typhoid were locked into an isolation ward never to be released in order to prevent further typhoid cases. These people often deteriorated mentally, driven mad by the conditions they lived in. Typhoid fever is characterized by a slowly progressive fever as high as 40 C (104 F), profuse sweating and gastroenteritis. Less commonly, a rash of flat, rose-colored spots may appear. Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache and cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in the number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a positive diazo reaction and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal test is negative in the first week. In the second week of the infection, the patient lies prostrate with high fever in plateau around 40 C (104 F) and bradycardia (sphygmothermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and abdomen in around a third of patients. There are rhonchi in lung bases. The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to pea soup. However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly) and tender, and there is elevation of liver transaminases. The Widal reaction is strongly positive with antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage. (The major symptom of this fever is the fever usually rises in the afternoon up to the first and second week.) DIAGNOSIS: Diagnosis is made by any blood, bone marrow or stool cultures and with the Widal test (demonstration of salmonella antibodies against antigens O-somatic and H-flagellar). In epidemics and less wealthy countries, after excluding malaria, dysentery or pneumonia, a therapeutic trial time with chloramphenicol is generally undertaken while awaiting the results of Widal test and cultures of the blood and stool. The Widal test is time consuming and often times when diagnosis is reached it is too late to

start an antibiotic regimen. The term "enteric fever" is a collective term that refers to typhoid and paratyphoid When untreated, typhoid fever persists for three weeks to a month. Death occurs in between 10% and 30% of untreated cases. In some communities, however, case-fatality rates may reach as high as 47%. TREATMENT: The rediscovery of oral rehydration therapy in the 1960s provided a simple way to prevent many of the deaths of diarrheal diseases in general. Where resistance is uncommon, the treatment of choice is a fluoroquinolone such as ciprofloxacin[9][11] otherwise, a third-generation cephalosporin such as ceftriaxone or cefotaxime is the first choice. Cefixime is a suitable oral alternative. Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, Amoxicillin and ciprofloxacin, have been commonly used to treat typhoid fever in developed countries. Prompt treatment of the disease with antibiotics reduces the case-fatality rate to approximately 1%. WHEN UNTREATED, typhoid fever persists for three weeks to a month. Death occurs in between 10% and 30% of untreated cases. In some communities, however, casefatality rates may reach as high as 47%.