Escolar Documentos
Profissional Documentos
Cultura Documentos
College of Nursing
Submitted to:
CLINICAL INSTRUCTOR
Submitted by:
Group B7 – Cluster 2
I. INTRODUCTION
Most URIs occurs more frequently during the cold winter months, because
of overcrowding. Adults develop an average of two to four colds annually.
Antigenic variation of hundreds of respiratory viruses results in repeated
circulation in the community. A coryza syndrome is by far the most common
cause of physician visits in the United States. Acute pharyngitis accounts for 1%
to 2% of all visits to outpatient and emergency departments, resulting in 7 million
annual visits by adults alone. Acute bacterial sinusitis develops in 0.5% to 2% of
cases of viral URIs. Approximately 20 million cases of acute sinusitis occur
annually in the United States. About 12 million individuals are diagnosed with
acute tracheobronchitis annually, accounting for one third of patients presenting
with acute cough. The estimated economic impact of non–influenza-related URIs
is $40 billion annually.
This individual case study provides goals or objectives which can be used as an
instrument in assessing the patient’s health status and in his present conditions:
1. Use to obtain a complete heath data and can be used in follow up care.
The study includes all the data gathered during the interview and the
observation claimed by the patient as well as the significant others. It also deals
with the several factors observed and gathered during the interview. That
information gathered was the exact answer and the problems of the people in the
community and not just basing in the opinions of the students conducting the
interview of the students.
The limitation of this study is limited in the place of interaction itself which
is in the hospital. This study was completed in 2 days by the interaction of the
student and the patient.
II. HEALTH HISTORY:
A. Profile of the Patient
NAME:
AGE:
SEX:
RELIGION:
BIRTH DATE:
NATIONALITY: Filipino
ADDRESS: tagloan
TEMPERATURE: 36.6
HEIGHT: 94 cm
WEIGTH: 12.7 kg
ALLERGY: No allergy
B. FAMILY AND PERSONAL HEALTH HISTORY
Jurey was born on November 18, 2007. He was delivered NSVD in the
Polymedic General Hospital. He was a healthy and a lovable boy. One month
after birth Jurey experienced diarrhea lasting for two days, her mother panic
and admitted him into the Polymedic General hospital. He was then
diagnosed of having a diarrhea having a watery stool, Jurey stayed in the
hospital for almost a day. A week after, Jurey had a fever due to infection. Her
mother gave him paracetamol and she had performed a tepid sponge both on
him. After giving the medications and performing tipid sponge bath the
temperature of Jurey drop from 38° c to 36.8° c.
D. CHIEF COMPLAINS
Infants enjoy sucking and later biting anything that touches the erogenous
zone of the lips and mouth. Some infants enjoy this oral activity more than the
others. While some may be satisfied by sucking at the breast or bottle, others
require pacifiers, toys or other objects that can be orally manipulated.
MEDICAL ORDERS/RATIONALE/MEDICINE/LABORATORY:
CLASSIFICATION: Cephalosporin
MECHANISM OF ACTION:
SFECIFIC INDICATION: Lower respiratory tract infection, skin and skin structure
infection due to s.aureus
SIDE EFFECTS: Increases in the serum creatine presence of cast in the urine,
alternation of PFs.
NURSING PRECAUTION:
Acute gastroenteritis
Inflammation
1. Teeth
a. Crown projects above the gum, root below. Dentin (bulk of tooth)
surrounds pulp cavity. Enamel covers dentin of crown; cementum
covers dentin of root and anchors tooth to periodontal ligament.
b. Each quadrant of mouth has eight teeth-two incisors, one canine,
two premolars, and three molars.
2. Esophagus
a. Mucous membrane lined with stratified squamous epithelium rather
than simple columnar epithelium, as in stomach and intestine,
b. Muscular layer of upper third, striated; lower third, smooth; middle,
both striated and smooth.
c. Segment above stomach (indistinguishable anatomically from
remainder of esophagus) functions as sphincter, remaining closed
until reflexively relaxed as peristaltic wave approaches,
3. Stomach
a. Consists of upper fundus, central body, and constricted lower pyloric
portion (antrum).
b. Musculature contains an oblique inner layer of smooth muscle in
addition to external longitudinal and underlying circular smooth muscle
layers found elsewhere in digestive tract.
c. Thick circular muscle in pyloric portion forms pyloric sphincter.
d. Openings: cardia, between esophagus and stomach; pylorus, between
stomach and duodenum.
4. Small Intestine
a. Divided into duodenum, jejunum, and ileum.
b. Surface area, serving absorptive function, increased by:
5. Large Intestine
a. Extends from the end of the ileum to the anus and is divisible into the
cecum, colon, rectum, and anal canal. The major part is the colon, which
consists of ascending, transverse, descending, and sigmoid portions.
b. The longitudinal muscle of the cecum and colon forms three
conspicuous bands(taeniae coli).
c. Thickene circular smooth muscle of anal canal forms the internal
anal sphincter. Surrounding skeletal muscle forms the external sphincter.
6.Salivary Glands
a. Three pairs (parotid, submaxillary, and sublingual), with ducts opening into
the mouth.
b. Two types of secretions:
1. Serous containing ptyalin –enzyme initiating digestion of the starch.
2. Mucous – viscous, containing mucus, which facilitates mastication.
7. Pancreas
a. Two types of secretory cells in exocrine pancreas:
1. Enzyme- secreting acinar cells.
2. Bicarbonate-and-water-secreting –intralobular duct cells.
b. Pancreatic duct empties pancreatic juice into duodenum.
1. Swallowing
a. In buccal stage (voluntary) bolus pushed toward pharynx.
b. In pharyngeal and esophageal stages (involuntary) bolus passes
through pharynx into esophagus and through esophagus into
stomach.
c. Reflexes raise soft palate, raise larynx, adduct aryepiglottic folds
and true and false vocal cords, and inhibit respiration. When food
enters the pharynx, reflex contraction of the superior constrictor
muscle initiates peristalsis, propelling the food, and relaxation of the
upper and lower esophageal sphincters allows food to pass first
into the esophagus and then into the stomach.
2. Peristalsis in Stomach
a. Mixes contents and forces chime through pylorus.
b. Three waves each beginning every 20 seconds near midpoint of
stomach, lasting about one minute, and ending with contraction of
pyloric sphincter travel down stomach at one time.
c. Rate of emptying determined largely by strength of contractions.
d. Feedback from duodenum regulates gastric emptying. Two control
mechanisms, one neuronal (enterogastric reflex), the other
hormonal (mediated mainly by enterogastrone), inhibit gastric
motility.
3. Contractions of the Small Intestine
a. Segmenting: rhythmic contractions along a section dividing it into
segments: primarily mixing action.
b. Peristaltic waves superimposed upon segmenting contractions.
c. Ingestion of food increases ileal peristalsis and frequency of
opening of ileocecal valve (gastroileal reflex).
4. Contractions of Large Intestine
a. Simultaneous contraction of circular and longitudinal muscle,
forming haustra,
b. Infrequent usually two or three times daily of most mass
movements transferring contents from proximal to distal colon and
into rectum. Most commonly occur shortly after a meal (gastrocolic
reflex).
5. Defecation reflex
a. Distention of rectum triggers intense peristaltic contractions of colon
and rectum and relaxation of internal anal sphincter.
b. Reflex preceded by voluntary relaxation of external sphincter and
compression of abdominal contents.
Digestion
1. Mouth
a. Enzymatic action: initiation of the digestion of carbohydrate by ptyalin,
which splits starch into the disaccharide maltose. Action in mouth slight,
but continues in stomach until acid medium inactivates ptyalin.
b. Regulation: exclusively nervous- impulses transmitted from center in
medulla activated principally by taste, smell, or sight of food to salivary
glands by parasymphatetic nerve fibers.
2. Stomach
a. Enzymatic action: initiation of protein digestion by pepsin, producing
proteoses, peptones, and polypeptides. Pepsinogen secreted by chief
cells converted to pepsin by autoactivation process in presence of acid
secreted by parietal cells.
b. Regulation
1. Cephalic phase- initiated by taste, sight, or smell of food; secretion
stimulated directly or indirectly by the hormone gastrin. Gastrin, released
from so called G cells in the pyloric region of the stomach, stimulates the
secretion of an acid-rich gastric juice.
2. Gastric phase- initiated by food in stomach; secretion triggered directly or
indirectly, as in cephalic phase.
3. Intestinal phase- initiated by digestive products in upper small intestine;
mediated by hormone released by duodenum acting on stomach.
4. Inhibition- strong acid in antrum inhibits gastrin release. Fat, acid, or
hypertonic salt solutions in duodenum stimulate release of hormones
which inhibit gastric secretion.
3. Intestine
a. Enzymatic action- fat digestion and continuation of carbohydrate and
protein digestion.
1. Pancreatic lipase splits fat into monoglycerides, fatty acids, and glycerol.
2. Pancreatic amylase converts starch and glycogen into maltose. Intestinal
disaccharidases split maltose, sucrose, and lactose into their constituent
monosaccharides,
3. Pancreatic enzymes trypsin and chymotrypsin both endopeptidases split
proteins and the products of pepsin digestion into peptides. Peptidases
split peptides into amino acids.
b.. Regulation of pancreatic secretion: by vagus nerve during cephalic and
gastric phase of gastric secretion and by two duodenal hormones-
cholecystokinin-pancreozymin and sectetin. Vagus stimulation and
cholecystokinin-pancreaozymin stimulate enzyme secretion; secretin
stimulates bicarbonate secretion.
Absorption
1. Occurs almost exclusively in the small intestine.
2. Simple sugars, amino acids, short-chain fatty acids, and glycerol are
absorbed into blood stream via capillary network of villi. Products of lipid
digestion are absorbed as chylomicrons into intestinal lymphatics via
central lacteal of villi.
Digestion process- the digestive system prepares food for consumption by the
cells through five basic activities:
ELIMINATION:
Usual bowel pattern ( ) urinary Comments: “ sahay nlng
frequency Man gasakit akko tiyan.
Loss bowel movement _ 5-7
times a day
( ) urgency Bowel sounds: hyper
Constipation remedy ( ) dysuria active bowel sound
( ) hematuria Present ( ) yes (x) no
Date of last LBM ( ) Incontinence Urine*(color,consistency,
November 18, 2008 Odor)
( ) polyuria
(x ) diarrhea ( ) foly in place If foley is in place?
character ( ) denied
__not present__
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:
(x) dry Comments: “Uga kayo (x) dry () cold () pale
iyang (x ) flushed (x ) warm
( ) itching panit”.as ( ) moist ( ) cyanotic
*
verbalized rashes, ulcers, decubitus (describe size,
( ) denied by her location, drainage) .The patient has a
mother. flushed, warm and dry skin.
ACTIVITY/SAFETY:
( ) convulsion Comments:” Luya kayo ( ) LOC and orientation
ang Gait: ( X) steady ( ) unsteady
() dizziness lawas ni Juey, ________________
dili kaa-
( ) limited motion yo siya ( ) sensory and motor losses in face or
galihok”. As extremities:
of joints verbalized by No sensory and motor loss
the ( ) ROM limitations : patient has the ability to
Limitation in mother. do ROM
ability to
() ambulate
() bathe self
( ) other
(x ) denied
COMFORT/SLEEP/AWAKE:
() pain Comments: “gasakitaay (x) facial grimaces
ako () guarding
(location, iyang tiyan” as () other signs of pain .
verbalized by Pain due to abdominal cramping.
frequency her mother.
remedies)
( ) nocturia
( ) sleep difficulties
( ) denied
COPING:
Observed non-verbal behavior : The patient
3 members of the family___ is rubbing his abdomen portion and has a
Members of household facial grimace due to pain
Diagnostic Examination:
FECALYSIS:
Date: November 19,2008
Macroscopic appearance:
Color: yellow Consistency: Soft
Microscopic appearance:
Pus cells: none seen /hpf
RBC: none seen /hpf
Fat globules: none seen / hpf
Amoeba:
Cyst: 0-2 /hpf
Result: Positive amoeba
URINALYSIS
Date: November 18, 2008
Color: Yellow
Appearance: Clear
Specific gravity: 1.025
Protein (Albumin): Negative
Glucose: Negative
Bacteria: Few
Result: No findings
Hemochrome
Date: November 19,2008
WBC- 13.4 normal range (5-10x103ml3)
Provide prompt diaper change and To avoid skin breakdown and diaper
cleansing gently. rash.
Place the bedpan in the bed of the To provide easy access and to
patient or a commode chair near the reduce the need to wait.
bed.
INTERVENTION RATIONALE
INDEPENDENT
Determine the mother’s perception Establishing knowledge regarding
of disease process. the disease condition of her child .
Emphasize need for long-term Patients with IBD are at risk for
follow-up and periodic colon/rectal cancer, and regular
reevaluation. diagnostic evaluations may be
required..
IDEAL NURSING MANAGEMENT
Dependent:
In the case of Jurey, Immediate intervention was given because Jurey was
admitted to the Sabal Hospital after experiencing loss bowel movement and
vomiting. History was taken to document the onset and frequency of diarrhea.
Exposure to contaminated food or water is initiated with the patient where
drinking water might be contaminated. Physical examination helps the physician
to identify underlying systemic disease. The doctor ordered for some diagnostic
tests to find the cause of diarrhea which include the fecalysis where positively
amoebiasis was detected. Urinalysis and hemochrome was also ordered to
provide more specific data.
XI. REFERRALS:
No one can escape from having this kind of disease Children are very
susceptible to illness that is why I imparted knowledge to Mrs. Tumacas to
continue giving nutritious foods, and vitamins. As much as possible report to the
physician immediately if there are any unusualities may observe because
diarrhea can be dangerous in newborns and infants. Children, especially those
younger than 6 months of age and those with other health risks, need special
attention when they have diarrhea because they can become dehydrated.
Because a child can die from dehydration within a few days, the main treatment
for diarrhea in children is dehydration. Quickly Careful observation of the child's
appearance and how much fluid he or she is drinking can help prevent problems.
And lastly I told her to follow-up the rural health center for his complete
immunization.
XII. BIBLIOGRAPHY:
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