BIOGRAPHICAL DATA Name: Baby AC Sex: Female Birthdate: August 02, 2010 Age: 9 months old Address: Dona

Faustina II Machaca Camp Cul, Quezon City Religion: Roman Catholic Nationality: Filipino Fathers Name: Mr. PC Mothers name: Mrs. EC Admission: May 07, 2011 (05:20 AM) Admitting Diagnosis: Infected Varicella Attending Physician: Dr. Rachelle A Grafil

HEALTH HISTORY CURRENT HEALTH PROBLEMS The condition of the patient started 4 days PTA, when the mother noticed vesiculomaculo rash starting from the head going to lower extrimities with accompanying symptoms of fever and vomiting. They went to Barangay Health Center and prescribed with Paracetamol and Immunosin. There was no relief of the symptoms of the patient. One day PTA, persistence of Bullous lesion prompted consult at East Avenue Medical Center then referred to San Lazaro Hospital hence admission.

PAST HEALTH PROBLEMS It was her 2nd hospitalization. Her 1st confinement was due to Sepsis Neonatorum 8 months ago. Her common illness includes cough, colds, and fever. Her mother usually gave her a Paracetamol to relieve her fever. She received all her immunization except for measles. She had no known allergies to drugs, foods, and agents. OBSTETRICAL HISTORY During Mrs. ECs pregnancy, she always go for check- ups in their Barangay Health Center and was completed her Tetanus Toxoid Vaccine. Baby AC delivered in a Normal Spontaneous Delivery without any known complications. Baby AC is a breastfed baby until now but also eats soft foods. FAMILY RISK FACTORS The family is residing at Bucaue, Bulacan. Their common illnesses are cough, colds, headache and fever. They usually take OTC meds to relieve their illness such as Robitusin for cough and colds, Alaxan for headache and Paracetamol for Fever. There is no known diseases noted that runs in their family. There are no known allergies noted in their family.

MEDICATION Paracetamol drops q4hours for fever Zinc Oxide to apply in diaper rash Cloxacillin 250mg/ 5mL QID

PERSON ASSESSMENT PSYCHOSOCIAL Lives at Bucaue, Bulacan with her mother and 2 sisters, ages 5 years old and 3 years old. Her mother and her father separated 5 months ago due to failure to provide the needs of their family. . Her mother is a house wife. She is a Roman Catholic. She was baptized when she was 5 months old. Her mother usually brought her to Barangay Health Center for health consultation. Before hospitalization, she weighs 8.7kgs while during hospitalization, she weighs 7.4kgs. She is active and playful upon assessment. ELIMINATION If there is no stool present in the diaper, she consumed two, one in the morning and one in the night. She defecates once a day, sometimes the color is yellow in color and sometimes green in color. REST AND 1`` ACTIVITY SAFE ENVIRONMENT She has no known allergy in medications and foods. She has dry skin, presence of crust and macules. The mucous membrane is normal in color and there is no presence of dryness. Her present temperature is 37C, on admission her temperature is 39.4C. Medicated with paracetamol, oxacillin and zinc oxide. Medicated at home with paracetamol for her fever. Upon admission her WBC is 17.19 due presence of infection. There is no presence of murmur sound. No accessory muscles being used. Her respiratory rate is 29 cpm. Her cardiac rate is 11O bpm. No presence of edema. ( - ) homans sign. Upon admission her Hb: 10.48, Hct: 37.79, and RBC of 402. Blunch test done; capillary refill immediately back to its normal color. Still on breast feed, but sometimes her mother gives her soft foods e.g. crashed biscuits. She has good appetite. She weighs 7.4, weight loss of 1.3 kgs. over past 4 days. IV: D5 IMB 500cc @ 21 gtts/hour.

OXYGEN

NUTRITION

DRUG STUDY

NAME OF DRUG/GENERIC DRUG CLASIFICATION OXACILLIN (PINICILLIN) BETA-LACTAMASE INHIBITOR DOSAGE: 90 mg/kg/day P.O Q 12 hours for 10 days

ACTION RATIONALE BACKTERICIDAL -INHIBITS THE ENZYME IN CELL WALL SYNTHESIS

SIDE EFFECT

NURSING IMPLICATION

NAUSEA, VOMITING, DIARRHEA, RASH, STOMATITIS, HERPENSENSITIVITY RANGING FROM RASH, UNRTICARIA SUPER INFECTION SIGN/SYNTOMS, BLACK,FURRY TONGUE, THRUSH, AND VIGINAL DISCHARGE

MONITOR V/S MONITOR WBC MONITOR I&O CHECK FOR BLEEDING OF HIGH DOSE OF PENICILLIN. CULTURE & SENSITIVITY REPORTS RENAL FUNCTION TEST

NAME OF DRUG/GENERIC DRUG CLASIFICATION PARACETAMOL (ACETAMINOPHEN) PARA-AMINOPHENNOL DERIVATIVE DOSAGE: 80 mg P.O Q 4 to 6 hours P.R.N

ACTION RATIONALE PRODUCE ANALGESIA BY BLOCKING PAIN IMPULSES BY INHIBITING SYNTHESIS OF PROSTAGLANDIN IN THE CNS

SIDE EFFECT

NURSING IMPLICATION

HEMATOLOGIC: HEMOLYTIC ANEMIA, LEUKOPENIA, NEUTROPENIA, PANCYTOPENIA HEPATIC: JAUNDICE METABOLIC: HYPOGLYCEMIA SKIN: RASH & URTICARIA

MONITOR V/S MONITOR I&O MONITOR WBC,RBC CHECK FOR GLUCOSE AND HEMOGLOBIN

COURSE IN THE WARD DATE AND TIME May 7, 2011 5:15 am PHYSICIANS ORDER -Please admit to PAV -Secure consent for this admission. -Diet for age -V/S every 4 and record please. -I/O every shift and record. -D5 0.3 NaCl x 90 cc/hr for 8 -Diagnostics: -CBC, Fecalysis, U/A, Blood culture -Therapeutics: -Paracetamol drops 0.7 q 4 for temp. of 37.8C -watch out for progression of water stool. -Continue Meds. -Na, K, -IVF @ 30 cc/hr - IVF to 21 cc/hr -IVF T/F D5 IMB 500cc x 21 ugtts/ hr - IVF to run KVO -Daily bath -ff up chest x-ray result -May reinsert I.V -Give warm bath -Shift IV Cloxacillin to oral 250 mg/ml 3.5 ml QID -For possible discharge this am with final chest x-ray result. RATIONALE >

May 8, 2011

May 9, 2011 May 10, 2011 9:30 am May 11, 2011 8:30 am