ENGLISH TASK

NURSING PROCESS BASED ON A CASE STUDY

Name : Alifiatul Oza Hamanu

NIM : 131411123070

Class : AJ2 – B17

FACULTY OF NURSING AIRLANGGA UNIVERSITY

SURABAYA

2014
 NURSING PROCESS BASED ON A CASE STUDY

Case:

A three-year-old boy is brought to the emergency room by his parents. The parents report that for
the past two days the child has had a fever - the temperature has been as high as 40C - and he
has been listless and his oral intake has been well below normal. The child has no prior medical
history and does not take any prescription medications. The parents have been giving the child
acetaminophen whenever his temperature was above 38C. The parents are basing this decision
on what they read on the internet: 1) that a high fever can cause permanent brain damage and
seizures; 2) that the normal temperature shouldnt be higher than 39. Neither parent can
remember how much acetaminophen they give the child with each dose or how often they have
given it and the mother says you can buy acetaminophen at any drug store, and they wouldn’t
sell it over-the-counter if it wasn’t safe. They have also been giving the child ibuprofen every
once in a while because again, they had read on the internet that using acetaminophen and
ibuprofen was a better way to lower a fever than using either one alone.

After reviewing the history of the current illness and examining the child, the physician makes
the diagnosis of otitis media and prescribes an antibiotic. The physician informs the parents that
a temperature of 40C is not unusual in cases of otitis media, higher fevers are not uncommon,
and except for cases of hyperthermia, the seriousness of the illness does not correlate with the
degree of fever. She also tells the parents: 1) a high fever in a child who has a simple infectious
process will not cause brain damage; 2) treating a fever will not prevent febrile seizures; 3)
lowering a fever that is caused by a simple, easily treated infectious process will not decrease the
time it takes for the illness to resolve, and; 4) a fever is considered to be a defense mechanism
and a fever may decrease the length of an infectious illness. A fever can be treated, she notes, if
it is >38C, but this is an arbitrary number and lowering the fever is not the goal; the goal is to
lower the fever to make the child comfortable and help increase oral intake. Finally, she advises
the parents that there is no evidence that alternating anti-pyretics is more effective than using one
alone and that overusing over-the-counter antipyretics, especially acetaminophen and especially
in the context of giving this drug to a child who has a fever, can be dangerous and cause liver
damage.

From the given case study, please do the following:

1. Write a table of data analysis

2. Write a nursing diagnosis and intervention based on NIC and NOC
 Nursing Expected patient Nursing Rational/ Evaluation
Diagnosis Outcome Intervention principles
& supporting Planning (NOC) (NIC)
data
(NANDA)
Hyperthermia Thermoregulation Temperature
related to with expected regulation
desease outcomes:
process. - Body - Monitor the - To obstain - Body
Subjectives: temperature temperature at an accurate temperature
- The within normal least every 2 core within normal
parents range hours temperature range
report that
for the - Pulse and - Pulse and
past two Respiratory Respiratory
days the Rate in the - Monitor blood - To evaluated Rate in the
child has normal range pressure, of normal range
had a pulse, and RR. effectiveness
fever - the - No skin Also Monitor of - No skin
temperatu discoloration skin color and intervention discoloration and
re has and no temperature and monitor no dizziness,
been as dizziness, by feeling
high as feeling complication comfortable
40C. comfortable
- Increase fluid - To prevent
Objectives: intake and the
- Patient’s nutrition dehidration
temperatu
re is as
high as
40oC - Cover the - To prevent
patient with the loss of
blankets and body warmth
most clothing

- Give anti - Antipyretic

pyretic if act to
necessary hypotalamus
to regulated
temperature
Source :

Herdman, T.H. (2012). NANDA International. Nursing Diagnoses: Definition and

Classification, 2012-2014. Oxford: Willey-Blackwell.

Wilkinson, Judith M. (2012). Buku Saku Diagnosis Keperawatan: Diagnosis NANDA,

Intervensi NIC, Kriteria Hasil NOC. Alih bahasa: Esty Wahyuningsih, editor edisi
bahasa Indonesia: Dwi Widiarti. Edisi 9. Jakarta: EGC.