Unciano Colleges Antipolo Inc.

Circumferencial road, Antipolo City

A case study of

In partial fulfillment of requirements in

NCM 101
Submitted by:

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 I. TABLE OF CONTENTS

I. Table of contents ………………………………… 2

II. Acknowledgement ………………………………… 3

III. Introduction ………………………………… 4

IV. Background of the study ………………………………… 5

V. Objectives ………………………………… 6

VI. Patients Profile ………………………………… 7

VII. Nursing History ………………………………… 8-10

VIII. Pediatric Assessment ………………………………… 11-18

IX. Anatomy and Physiology ………………………………… 19-21

X. Pathophysiology ………………………………… 22-23

XI. Laboratory Results ………………………………… 24-26

XII. Drug Study ………………………………… 27-29

XIII. Nursing Care Plan ………………………………… 30-34

XIV. Evaluation ………………………………… 35-36

XV. Bibliography ………………………………… 37

XVI. Consent Form ………………………………… 38

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 II. ACKNOWLEDGEMENT

We, the 3rd year Nursing students of, Section D Group 3 of Unciano Colleges

Antipolo, Inc. - Antipolo City would like to thank our clinical instructor , Mrs. Nhina

Sandeep S. De Rosas, RN, for the knowledge that she imparted to us during our duty in

Carlos Medical and Maternity Clinic. Her active supervision has been a guiding light

during the making of our case study.

We would also like to extend our gratitude to the management and staff of Carlos

Medical and Maternity Clinic who accepted us wholeheartedly.

We wish to express our heartfelt gratitude to our client and his family for their

cooperation as we make our assessment and also for giving us information about his

health condition.

Much credit is also given to our dear parents and family for supporting us

emotionally and financially as we conduct this case study.

We also like to thank each other. This case study is a synergetic effort and would

not have been made possible without the cooperation and hard work of every member of

the group.

And above all, we would like to give thanks to our God Almighty for giving us

the wisdom, strength and endurance in making our case study worthy and for giving us

the opportunity to realize the essence of nursing as a profession and as a vocation.

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 III. INTRODUCTION

Nursing is a learned practice discipline with the ultimate goal of contributing as

individuals, collaborative with others and to the promotion of the client’s optimum level

of functioning through health teachings and maximum delivery of case.

Mastering the skills and procedures of nursing practice is essential and is a must.

To survive in nursing practice, one must be able to utilize both hands as well as the head

to be well prepared in dealing with existing and potential problems of the client.

During our exposure in different hospitals we are able to render the proper

attitude towards our client, enhance the knowledge and practice the skills that we have

learned from Unciano Colleges Antipolo.

Our client B.A. is the subject in our case study. We have chosen him to be our

case presentation because our patient is cooperative and easy to talk to. The case

improved our attitudes, skills, and knowledge towards our patient and further gave us

insights on our chosen path. We chose this case to widen our knowledge in Anatomy and

Physiology of the Digestive System and the mechanism and action of Typhoid Fever,

and, to give our best to our clients.

This case study enhanced our knowledge and developed our skills in nursing

process, like assessing the client to come up with the Nursing Diagnosis, formulating

goals and performing interventions with regards to meet our goals.

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 IV. BACGROUND OF THE STUDY

Typhoid fever, also known as enteric fever, Salmonella typhi or commonly just
typhoid, is an illness caused by the bacterium Salmonella enterica serovar typhi.
Common worldwide, it is transmitted by the ingestion of food or water contaminated with
feces from an infected person. The bacteria then perforate through the intestinal wall and
are phagocytosed by macrophages. Salmonella typhi then alters its structure to resist
destruction and allow them to exist within the macrophage. This renders them resistant to
damage by PMN's, complement and the immune response. The organism is then spread
via the lymphatics while inside the macrophages. This gives them access to the
reticuloendothelial system and then to the different organs throughout the body. The
organism is a Gram-negative short bacillus that is motile due to its peritrichous flagella.
The bacteria grows best at 37 °C/99 °F – human body temperature.

S. typhi bacteria are passed into the stool and urine of infected patients. They may
continue to be present in the stool of asymptomatic carriers, who are persons who have
recovered from the symptoms of the disease but continue to carry the bacteria. This
carrier state occurs in about 3% of all individuals recovered from typhoid fever.

Typhoid fever is passed from person to person through poor hygiene, such as incomplete
or no hand washing after using the toilet. Persons who are carriers of the disease and who
handle food can be the source of epidemic spread of typhoid. One such individual gave
her name to the expression "Typhoid Mary," a name given to someone whom others
avoid.

EPIDEMIOLOGY:

With an estimated 16-33 million cases of annually resulting in 500,000 to 600,000

deaths in endemic areas, the World Health Organization identifies typhoid as a serious
public health problem. Its incidence is highest in children and young adults between 5
and 19 years old.

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 V. OBJECTIVES

A. General Objectives

Within 32 hours of exposure Carlos Medical and Maternity Clinic, we, the 3rd

year Nursing students, section D – group 3 of Unciano Colleges Antipolo, aim to convey

our empathy to our patients in the ward and learn and have knowledge trough our skills

that we do all throughout our rotation in providing holistic care to all our patients in the

ward.

B. Specific Objectives

• To be able to establish nurse – patient relationship that would build rapport for the

effective and informative interactions with the patient and the significant others.

• To be able to assess health problem and condition using the Pediatric Assessment.

• To be review the Anatomy and Physiology of the Digestive System and the

pathophysiology of Typhoid Fever.

• To be able to gather necessary data and identify needs in order to formulate

specific nursing care plans.

• To be able to formulate the care for the nursing care plan.

• To be able to impart health teachings relevant to his condition.

• To be able to evaluate the effectiveness of our nursing interventions.

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 VI. PATIENT’S PROFILE

Case Number : 29614

Patient’s Name : S.G

Address : Antipolo City

Date of Birth : June 28, 2006

Age : 3years old

Sex : Female

Status : Single

Religion : Roman Catholic

Chief Complaint : LBM

Final Diagnosis : AGE

Time and Date of Admission : April 25, 2010 / 3:00 pm

Admitted by : Dr. Fabros

Ward : Private Room 315

Date of Assessment : April 26, 2010

Time of Assessment : 5:00 pm

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 VII. NURSING HISTORY

Chief Complaint: “Nagtatae ang anak ko,” as verbalized by the mother of the patient.

History of Present Illness

According to her mother, 2 days prior to admission, April 24, 2010, she noticed

that her daughter S.G defecated more often. From her usual 2 times a day, S.G defecated

about 4-5 times. But she just ignored it and has not taken any actions

April 25, 2010 at around 1:00pm her mother noticed that S.G is warm to touch.

She then gave her Tempra 125mg. 5ml for one time. But the fever did not cease. She then

decided to bring her to the nearest hospital, Unciano Medical Hospital

On arriving at the hospital she was taken to the emergency room. Her vital

signs were taken and recorded at;

Pulse rate - 97 bpm

Respiratory Rate - 23 cpm

Temperature - 38.1oC

She was given Paracetamol 125mg 5ml STAT for her fever. The doctor on duty

examined her and ordered for admission. She was given Intravenous fluid of D50.3NaCl

½ L X 75cc/hr at 470cc level inserted at her right metacarpal vein. The doctor ordered the

following medications; Diazepam 5 mg 0.5 ml TIV PRN for active seizures,

Met6ronidazole125/9mL q 80, and Tempra 2.5 ml PO q 4o. The attending physician, Dr.

Fabros made request for Hematology, fecalysis and urinalysis.

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 At about 3:00 pm she was brought to Private room 315 with the diagnosis of

Acute Gastroenteritis.

History of Past Illness

According to her mother, our client has not been hospitalized 5 years ago. But

only experienced common cough and colds and took OTC medicines such as

Carbocisteine and Paracetamol to relief illness.

Heredo – familial History

According to her mother she cannot recall that there is notable disease in the

family.

Socio – Economic Status

Her mother is as Pharmacist at mercury Drug Corporation for 7 years in Antipolo.

She will take charge for her daughter’s hospital bills and other expenses. She did not

mention the occupation of her husband and their salary as well.

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 Immunization:

Vaccine No. of Shots 1st/2nd/3rd Dose

BCG 1 1st Month

DPT 3 2nd/3rd/4th Month

OPV 3 2nd/3rd/4th Month

Hepatitis B 3 2nd/3rd/4th Month

Measles 1 9th Month

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 VIII. PEDIATRIC ASSESSMENT

A. Physical Growth and Development

Weight: 13 kg

Normal Value: 13-18 kg

Remarks: within appropriate range

Height: 97 cm

Normal Value: 87-104 cm

Remarks: within appropriate range

Our client, S.G looks kempt. She has round face and body build. Her body is

symmetrical. Her look is appropriate to her age.

During our assessment S.G is smiling to us and does the activities I asked her to

do but she does not respond to all our questions because of being shy.

B. Motor Development

i. Gross Motor Adaptive

According to her mother SG can go upstairs on her own. She loves to play Barbie

dolls with her cousin. We asked SG to perform activities to test her gross motor skills. I

asked her to sit and walk on will. While lying she turns from side to side. She can stand

erect. She was able to walk, sit and stand when we asked her to.

During our assessment SG is sometimes moving bed from one place to the other

to get her toys. We also saw her playing with her mother her favorite Barbie doll.

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 ii. Fine Motor Adoptive

According to her mother SG can eat on her own. Her mother also observed that

SG loves to draw. Her mother said that SG always looks for pen and paper where she can

write and draw. She can also wear her clothes by herself.

C. Language and Learning

During our assessment, we observed that SG can already express her feelings and

demands. She responds to our questions when she feels like to answer. Like when she

first answered our question that what is her favorite food, she quickly responded by

saying “adobo at sinigang.” She can speak and understand using tagalong words. She is

able to communicate her wants and rejections by saying “gusto ko ng…” at “ayaw.”

According to the studies she should have been speaking at most 2000 words. Her words

are not clearly stated but we are still able to understand what she is trying to say.

We asked her to answer 1+1 she just smiled to us and didn’t answer.

D. Playing

SG loves to play at home together with her friends and her cousin. She loves to

play like Barbie Doll. She also loves to play bahay-bahayan. She also loves to show her

friends her favorite Doll. At her stage she is currently on the bridge of the parallel play of

toddlerhood and the competitive play of the pre-schooler. Her plays are more of

competitive as she loves to play with others wanting to be the center of the play.

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E. Nutritional Assessment

We asked her mother about SG’s appetite. According to her mother SG eats a lot

before hospitalization. She really likes to eat “adobo” and “sinigang.” She especially likes

“sabaw” for her food. She also loves to eat fruit but not very likely to vegetables.

According to her mother she likes to “samalamig” from the store beside their

house. She also likes to eat junkfoods, stick-O and candies. She also likes to eat fish-ball

that passess trough their house during the afternoon. According to her mother she uses

the fish-ball as reward to encourage SG to sleep.

During our assessment when she ate her merienda, she ate on her own using

spoon but we haven’t seen that her hands we’re washed.

On observing, the color of her buccal mucosa is pinkish. Her tongue and gums is

also pink. She doesn’t want us to observe her teeth but we have seen it and observed that

it is color white and has no tooth decay observed. Her lips are observably dry.

During her infancy, according to her mother, SG is bottle fed starting from birth

up to 2 ½ years old. Her mother uses 1:1 formula – a scoop of milk to 1 ounce of water.

She has IVF of D50.3NaCl ½ L X 75cc/hr at 470cc level inserted at her right

metacarpal vein.

_______________________________________________________________________

F. Stages of Growth and Development

i. Developmental (Robert Havighurst)

According to this developmental theory, learning is basic to life and that people

continue to learn throughout life. A certain task arises at a certain time of life of an

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individual, successes achievement of which leads to happiness and to success with later

tasks, while failure leads to unhappiness in the individual and difficulty with later task.

These are the tasks that CR was able to perform with regards to Havighurst’s Age

period and Developmental Task

• Learned to walk

• Learned to take solid foods

• Learned to talk

• Learned to control the elimination of body wastes but he is not yet fully toilet

trained.

• Learned to distinguish right and wrong

ii. Psychosexual (Sigmund Freud)

According to this theory, the personality develops in five overlapping stages from

birth to adulthood. If the individual does not achieve a satisfactory progression at each

stage, the personality becomes fixated at that stage.

According to Sigmund Freud’s CR is on Anal stage where his center of pleasure

is his anus and bladder. He is already trained of toileting. He informs his mother when

he feels like voiding or defecating.

iii. Psychosocial (Erik Erikson)

This theory envisions life as a sequence of levels of achievements. Each stage

signals a task that must be achieved. The resolution of the task can be complete, partial or

unsuccessful. The greater the task achievement, the healthier the personality of the

person; failure to achieve a task influences the person’s ability to achieve the next task.

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 According to Erik Erikson’s Stages of Development CR is under Early Childhood

stage and his central task is Autonomy vs. Shame and Doubt. He shows indicators

positive resolution as he is able to cooperate and to express himself. He has control over

himself of what he wants and what he does not want.

He also is showing partial resolution on late childhood stage where his central

task is Initiative versus Guilt. According to his mother, he loves to do things on his own.

iv. Cognitive (Jean Piaget)

This theory refers to the manner in which people learn to think, reason, and use of

language. It involves a person’s intelligence, perceptual ability, and ability to process

information. According to this theory, cognitive development is an orderly, sequential

process in which a variety of new experiences must exist before intellectual abilities can

develop.

According to Piaget’s Phase of Cognitive Development, he is under

Preconceptual Phase. He tells us story of how he plays with his friends and how are they

amazed of his robot toy. He often expresses his wants. He also likes to tell story that he is

a superhero and he will fly and defeat bad guys.

v. Moral (Lawrence Kohlberg)

According to this theory, moral development progresses through three levels and

six stages. Levels and stages are not always linked to a certain development stages,

because some people progresses to a higher level of moral development than others.

According to Kohlberg’s Stages of Moral Development CR is under Punishment

and Obedient Orientation Stage. According to his mother he obeys commands when he is

told to be punished of disobedience.

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G. Vital Signs

i. Body Temperature

During our assessment his temperature is 36.1oC using a digital thermometer on

his right axilla for 1 minute.

ii. Respiratory Status

His respiratory rate is 26 cpm. We observed that his respiration is rapid and deep.

We auscultated his chest using a stethoscope and asked him to inhale and exhale deeply

and softly. Soft intensity, low pitch and gentle sound were heard.

iii. Circulatory Status

The radial pulse rate of CR is 116 bpm. Each beat is strong and can be felt easily.

We got his apical pulse and recorded 120 bpm. His pulse deficit is 4bpm.

We used the blanch test to test his Capillary Refill Time. We applied pressure on

the patient’s right finger of his right hand and released it. His fingertips returned to its

usual color after 2 seconds, the result was normal. We also did the same to his left arm

finger and his lower extremities and obtained the same result.

H. Elimination Pattern

i. Bowel

Before hospitalization, according to his mother CR usually defecates 2 times a

day. With the stool usually soft, brown and foul odor.

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 Three days before hospitalization, CR defecated 4-5 times a day. According to his

mother the stool is yellowish in color, watery and foul in odor.

We have auscultated a hyperactive bowel sound. The sound is loud and frequent

at about every 3 seconds. There are 20 sounds per minute in each of the four quadrants.

ii. Bladder

Before hospitalization he voids about 6-7 times a day. His mother told us that it is

approximately 90-100ml per voiding. 7 X 100 = 700 ml/day.

During hospitalization, according to his mother, CR urinates about 7-9 times.

Each urination is 70 ml. X 9 = 630 ml/day.

According to his mother, CR has urinated 3 times until our assessment at 11:00

am. Each urination is about 70 ml.

Approximation is used using the empty vessels of IV fluids.

I. Reproductive Assessment

According to his mother, CR is not yet circumcised. We are not able to assess his

penis because CR is shy and does not allow us to. But we saw him void and his penile

length is approximately 2 ½ inches long.

According to his mother, his penis is smooth and proportioned, and his testes are

normal.

J. State of Skin and Appendages

i. Skin: His skin is brown and intact. There is not presence of lesions observed.

His skin is dry, and he has fair skin turgor.

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 ii. Hair: His hair is black, soft and well-trimmed. The strands of his hair is thin/

He has intact scalp. There are no signs of infections or infestations seen. He has evenly

distributed hair.

iii. Nails: CR’s nails have a convex curvature. His nails are noticeably long and

there is presence of dirt on finger and toe nails. The epidermis around the nails is intact.

K. State of Rest and Comfort

According to his mother, CR usually sleeps at about 1:00 – 3:00 pm during

daytime and 8:00pm – 6:00am during the night.

During hospitalization, according to his mother, CR sleeps at about 8:00pm. His

sleep is usually disturbed because of his medications but he manages to sleep again with

ease.

He is usually, reporting to his mother pain in the abdomen. We asked him where

he usually feels the pain – he pointed on the right upper quadrant of his abdomen.

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 IX. ANATOMY AND PHYSIOLOGY

The Digestive System

1. Ingestion – is the process of taking food into the mouth.
2. Secretion – is the liberation of water, acid buffers and enzymes into the lumen of
GI tract. Within the walls of GI tract are cells that secrete a total of about 9 liters
per day of these substances in the lumen of GI tract.
3. Mixing and Propulsion – is the churning and passage of food through the GI tract.
It is usually brought about by the alternate contraction and relaxation of smooth
muscle in the walls of GI tract.
4. Digestion – is the mechanical and chemical breakdown of food.
5. Absorption – is the passage of food from the GI tract into the blood and lymph.
6. Defecation – is the elimination of indigestible substances from the GI tract to the
anus.
Important Facts of Small Intestine
1. This is where the major events of digestion and absorption occur.
2. It begins at the pyloric sphincter of the stomach, coils through the central and
inferior parts of the abdominal cavity and eventually opens into the large
intestine.
3. It averages 21/2cm in diameter and the length is about 3meters or 10 feet in a
living person and about 6 ½ meters or 21 ft in a cadaver due to loss of smooth
muscle tone after death.
4. It is divided into three segments: the duodenum, jejunum and ileum.
5. The ileocical sphincter connects the ileum to the large intestine.
6. There are many projections called circular folds or plicae circulars that
enhance absorption by increasing surface area and causing the chyme to spiral
as it passes through the small intestine
7. The wall of the small intestine is composed of the same four coats that make
up the GI tract
8. The mucosa forms a series of fingerlike villi that give the intestinal mucosa a
velvetly appearance.

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 The Important Facts About Large Intestine
1. Its overall functions are completion of absorption, manufacture of certain
vitamins, formation of feces and expulsion of feces from the body
2. It is about 1 ½ m long and 6 ½ cm in diameter that extends from the ileum
to the anus, and is attached to the posterior abdominal wall by its
mesocolon.
3. Structurally the large intgestine is divided into four principal regions, the
cecum, colon, rectum and the anal canal.
4. The wall of the large intestine differs from that of the small intestine since
there are no villi or permanent circular folds are found in the mucosa
5. The mucosa is consist of simple columnar epithelium, lamina propria and
muscularis mucosae
6. The submucosa is similar to that found in the rest of the GI tract
7. The muscularis is consist of an external layer of longitudinal muscles and
an internal layer of circular muscles
8. There are epicloic appendages, which are small pouches of visceral
peritoneum filled with fats.

PHYSIOLOGY OF DIGESTION IN THE SMALL INTESTINES

1. The first step occurs trough segmentation where major movement of the small
intestine occurs.
(1) It begins with the circular muscle fibers in the small intestines contract, an
action that constricts the intestines into segments.
(2) Next, the muscle fibers that encircle the middle of each segment contract
that further divides the segments into smaller segments.
(3) Finally, the muscle fibers that contract first will relax and each smaller
segment unite to form a large segment.
These segment occur 12-16 times a minute, pushing the chime back and forth.
2) The second process is called Peristalsis that propels the chyme onward trough the
intestinal tract to be absorbed.

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 ABSORPTION AND FECES FORMATION IN THE LARGE INTESTINE
1. By the time the chyme has remained in the large intestine 3-10 hours and then
become solid or semisolid as a result of water absorption and feces will be
formed.
2. Feces are consisting of water, inorganic salts, and sloughed-off epithelial cells
from the mucosa of GI tract, bacteria and undigested parts of food.

Peyer’s Patches is an oval masses of lymphoid tissue on the mucous membrane

lining the small intestine.

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 X. PATHOPHYSIOLOGY OF TYPHOID FEVER

The pathophysiology of typhoid fever is a complex process which proceeds

through several stages. The disease begins with an asymptomatic incubation period of 7-

14 days, during which bacteria invade macrophages and spread throughout the

reticuloendothelial system. The first week of symptomatic disease is characterized by

progressive elevation of the temperature followed by bacteremia. The second week

begins with the development of rose spots, abdominal pain and splenomegaly. The third

week is marked by a more intense intestinal inflammatory response particularly in the

Peyer’s patches with associated necrosis which can result in perforation and hemorrhage.

These clinical stages are associated with complex cellular events just now being

understood.

Invading organisms pass through the intestinal epithelial cells and come into

contact with phagocytic cells in the Peyer’s patches of the intestinal wall. However the

macrophages do not kill the bacteria. Thence, bacterial replication is primarily

intracellular. Salmonella avoids encapsulation in lysosomes by diverting normal cellular

mechanisms. Bacteria inject effector proteins into the cells of the innate immune system

(macrophages and natural killer cells) though a type III protein secretion system (TTSS)

which stimulate both pro and anti-inflammatory responses.

Over the asymptomatic incubation period of 7-14 days the bacteria proliferate and spread

through the blood stream to other cells in the reticuloendothelial system in the liver,

spleen, bone marrow and gall bladder. As replication inside phagocytic cells continues,

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bacteria are shed into the blood stream in sustained but low concentrations and the

clinical syndrome of fever, headache and abdominal pain begins. The gallbladder is felt

to be a significant site for ongoing exposure of intestinal epithelial cells to the pathogen.

The inflammatory response to this process of repeated exposure is felt to give rise to the

necrosis which is a prominent feature of the disease. This occurs in areas of greatest

macrophage concentration such as the Peyer’s patches and explains why intestinal

bleeding and perforation are the most frequent complications. Elsewhere typhoid nodules,

foci of macrophages and lymphocytes proliferate. As the infection progresses the typical

changes of sepsis accumulate in the heart, brain and kidneys. If not interrupted this

process may lead to circulatory failure and death from overwhelming sepsis.

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 XII. Laboratory Results

Hematology Date: September 1, 2009

Parameters Result Reference Significance

WBC 7.0X109 5.0-10.0 X 106 u/l Primarily protects the body
against infection and tissue
integrity.
Neutrophils 0.72 0.45-0.73 Phagocytosis (ingestion and
digestion of bacteria and
particles)
Lymphocytes 0.27 0.2-0.4 Integral component of immune
system
Monocytes 0.01 0.02-0.08 Enters tissue as macrophage;
highly phagocytic, especially
against fungus; immune
surveillance
RBC 4.55X1012 4.0-6.0X1012 Carries Hemoglobin to provide
oxygen to tissues; average life
span
Hemoglobin 130gm/dL 13-18gm/dL Iron-containing protein of
RBCs; delivers oxygen to
tissues
Hematocrit 0.39 0.42-0.52 Percentage of total blood
volume consisting of RBCs

Acela G. Tantiongco, MD

Pathologist

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Fecalysis Date: July 10, 2009

Parameters Result Reference Significance

Apearance Brown Brown Normal

Consistency Soft formed Soft Normal

PUS Negative Negative Normal

No ova and/or parasite seen

Serology

Ig M – Positive
Ig G – Positive

Acela G. Tantiongco, MD

Pathologist

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URINALYSIS July 7, 2009

TEST RESULT NORMAL VALUES SIGNIFICANCE

Color Yellow Yellow Normal
Transparency Clear Clear Normal
PH (reaction) Neutral Acidic A pH below 7 indicates acidity

and a pH in excess of 7

indicates alkalinity
Specific Gravity 1.020 1.015-1.025 Normal
Glucose (-1) Negative Normal
Protein (albumin) (-1) Negative Nrmal

Acela G. Tantiongco, MD

Pathologist

XIII. DRUG STUDY

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 DRUG CLASSIFICATIO ACTION ADVERSE NURSING RESPONSIBILITY
NAME N& REACTION
INDICATION

DIAZEPAM C: A benzodiazepine No adverse reaction >Warn the patient’s SO to

benzodiazepine that probably seen on the patient. avoid activities that require
5 mg 0.5 ml potentiates the alertness and good
TIV PRN effects of GABA, Possible adverse coordination until effects of
For active I: Status depresses the CNS reaction: drugs are known.
siezure epelepticus, and suppresses the Drowsiness,
severe recurrent spread of seizure dysarthria, slurred >Warn patient not to
seizures activity speech, fatigue, abruptly stop drug because
headache and withdrawal symptoms may
insomnia. occur.

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 DRUG CLASSIFICATIO ACTION ADVERSE NURSING RESPONSIBILITY
NAME N& REACTION
INDICATION

Ceftriaxone C: Third generation Inhibits cell wall No adverse reaction  If large doses are given. Therapy
Sodium cephalosporin synthesis, promoting noted in the patient is prolonged, or patient is at high
1 gm, TIV od osmotic instability; usually risk, monitor patient for signs f super
(-) ANST I: Acute Bacterial bactericidal Possible adverse infection
infection reactions:
 Tell patient’s SO to report
Fever, headache, adverse reaction promptly.
dizziness, chills.
Tell patient’s SO to notify
prescriber about loose stool or
diarrhea.

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 DRUG CLASSIFICATIO ACTION ADVERSE NURSING RESPONSIBILITY
NAME N& REACTION
INDICATION

Tempra C: Thought to Adverse reaction:  May decrease glucose and

Paraaminophenol produce analgesia by No adverse reaction hemoglobin levels and hematocrit.
2.5 ml, 125 mg blocking pain impulses noted in the patient
q 4o PO I: Mild pain or fever by inhibiting synthesis  Warn patient’s SO that high
of prostaglandin in the doses or unsupervised long term
CNS or of other use can cause liver damage.
substances that Possible adverse
synthesizes pain reaction:  Contraindicated with patients
receptors to stimulation. Hemolytic anemia, hypersensitive to drug.
The drug may relieve jaundice, hypoglycemia,
fever trough central rash
action in the
hypothalamic heat-
regulating center.

XIII. NURSING CARE PLAN

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 CUES / DATA NURSING GOALS OF NURSING INTERVENTIONS EVALUATION
DIAGNOSIS CARE

Subjective: Acute pain Within 1 Independent After 1 hour of

“masakit ang tiyan ng related to hour of nursing  Provided Comfort measures nursing interventions
anak ko” as verbalized biological injuring interventions the such as back rubbing and the client has
by the mother of the agents specifically client will change in position demonstrated behavior
patient infections as demonstrate > To provide non- that shows alleviation
evidenced by behavior that shows pharmacologic pain pain.
Objective: expressive and alleviation pain. management.
• Expressive destruction  Encouraged divisional Goal met.
behavior such as behavior and facial activities such as toys, plays
moaning, crying grimace and facial and others.
and irritability pain scale of > To divert attention from
• Distraction pain.
behavior such as  Re-check for the vital signs.
pacing and > Usually altered in acute
repetitive pain
activities
• Facial grimace Dependent
• Facial pain scale  Administered analgesics as
of indicated to maximal dosage
as needed (Tempra)
> to maintain acceptable level of
pain.

CUES / DATA NURSING GOALS OF NURSING INTERVENTIONS EVALUATION

DIAGNOSIS CARE

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Subjective: Isotonic fluid Within 30 Independent After 30
“madaming beses na volume deficit minutes of nursing  Kept fluids within client minutes of nursing
siyang dumudumi” as related to active intervention the reached and encouraged the intervention the
verbalized by the mother fluid volume lost client’s mother will SO to increase the fluid intake client’s mother has
of the patient specifically verbalize of the client. verbalized
diarrhea. understanding of understanding of
Objective: causative factors  Discussed the effects of causative factors and
 Decrease urine and purpose of humidity and ambient air purpose of individual
output individual temperature. therapeutic
 Dry lips therapeutic interventions and
 Dry skin interventions and  Reduced beddings clothes, medications.
 Weakness medications. provide TSB
> Reduced metabolic rate
Goal met.
 Encouraged to change
position frequently.
>To promote comfort and
safety

 Encouraged the mother to

provide frequent oral care
>to prevent injury from
dryness

 Discussed factors related to

occurrence of dehydration

CUES / DATA NURSING GOALS OF NURSING INTERVENTIONS EVALUATION

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 DIAGNOSIS CARE

Subjective: Deficient Within 30 Independent After 30

“Binibigyan ko siya ng knowledge minutes of nursing  Provided information relevant minutes of nursing
fishball para makatulog regarding lifestyle intervention the to situation intervention the
siya sa hapon” as related to client’s SO will client’s SO has
verbalized by the mother unfamiliarity with verbalize  Provided positive verbalized
of the patient information. understanding of reinforcements. Avoid understanding of
conditions and negative reinforcements. conditions and
Objective: individual risk individual risk factors.
 Verbalization of factors.  Provided information for
wrong actions. client’s SO Goal met.
 Inadequate >Reinforces learning
performance process

 Begin with information the

client already knows and
move to what the client does
not know, progressing from
simple to complex.
>Limits sense of
overwhelmed.

 Provided information about

additional learning resources.
>May assist in further
learning/promote learning
at own pace.

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 CUES / DATA NURSING GOALS OF CARE NURSING INTERVENTIONS EVALUATION
DIAGNOSIS

Subjective: Readiness for Within 30 Independent After 30

“Paano kaya nakukuha enhance minutes of nursing  Verified client’s SO level of minutes of nursing
ng anak ko ang sakit knowledge on intervention the knowledge about specific intervention the
niya?” as verbalized by health. client’s SO will topic. client’s SO has
the mother of the patient verbalize >Provides opportunity to verbalized
understanding of assure accuracy and understanding of
information gain. completeness of knowledge information gain.
base for future learning.
Goal met.
 Determined
motivation/expectations for
learning.
>Provides insight useful in
developing goals and
identifying information
needs.

 Assisted client’s SO to
identify learning goals.
>Helps to frame or focus
content to be learned and
provides measure to
evaluate learning process.

 Identified/provided
information in valid formats
appropriate to client’s

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 learning style.

CUES / DATA NURSING GOALS OF CARE NURSING INTERVENTIONS EVALUATION

DIAGNOSIS

34
Objective: Risk for infection Within 30 Independent After 30
related to minutes of nursing  Note risk factors for minutes of nursing
 Salmonella insufficient intervention the occurrence of infection. intervention the
Typhi infection knowledge to client’s SO will client’s SO has
avoid exposure to verbalize Health Teachings: verbalize
pathogens. understanding of understanding of
individual • Ensuring proper individual
causative/risk environmental sanitation causative/risk factors.
factors. • Hygienic sewage
disposal systems in a
community as well as Goal met.
proper personal hygiene
are the most important
factors in preventing
typhoid fever.
• Proper handling and
cooking of foods
specially on meats
• Avoid the foods that are
not properly cooked
• Safe source of water

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 XIV. EVALUATION

A. General Objectives

After 32 hours of exposure Carlos Medical and Maternity Clinic, we, the 3rd year

Nursing students, section D – group 3 of Unciano Colleges Antipolo, was able to convey

our empathy to our patients in the ward and learned and had knowledge trough our skills

that we do all throughout our rotation in providing holistic care to all our patients in the

ward.

B. Specific Objectives

• We were able to establish nurse – patient relationship that would build rapport for

the effective and informative interactions with the patient and the significant

others.

• We were able to assess health problem and condition using the Pediatric

Assessment.

• We were able to review the Anatomy and Physiology of the Digestive System and

the pathophysiology of Typhoid Fever.

• We were able to gather necessary data and identify needs in order to formulate

specific nursing care plans.

• We were able to formulate the care for the nursing care plan.

• We were to impart health teachings relevant to his condition.

• We were able to evaluate the effectiveness of our nursing interventions.

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 Health Teaching

• Ensuring proper environmental sanitation

• Hygienic sewage disposal systems in a community as well as proper personal

hygiene are the most important factors in preventing typhoid fever.

• Proper handling and cooking of foods specially on meats

• Avoid the foods that are not properly cooked

• Safe source of water

Discharge Plan

• Advised patient to follow medication regimen properly.

• Advised the patient to take adequate rest

Prognosis

Our patient chance is recovery is high. During our rotation in Carlos Medical and

Maternity Clinic, our client CR was able to recover and got home on September 4, 2009.

He is expected to resume his ADL’s as soon as he had enough of rest. The mother is

advised to watch out for possible re-infection of salmonella typhi virus and to be carefull

of possible seizures.

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 XV. BIBLIOGRAPHY

1. Marieb, Elaine RN; Essentials of Human Anatomy and Physiology 6th Edition

2005

2. Kozier, Barbara RN et al; Fundamentals of Nursing7th Edition2004

3. Smeltzer Suzanne EdD, RN, FAAN et al; Textbook of Medical-Surgical Nursing

11th Edition 2008

4. Doenges, Marilyn RN, BSN, MA; Nurse’s Pocket Guide 9th Edition 2004

5. Palma, Gregory Navarro; G&A Notes 2nd Edition2009

6. Divinagracia, Carmelita; PDD’s Nursing Drug Guide 2nd Edition 2008

7. Wiley, John; The Bantam Medical Dictionary 5th Edition 2004

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