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this is a case study of S.R from dona rita diaz st. furtuna village sucat
paranaque city. 17 years old. he was admitted at olivarez general
hospital last sept. 05, 2016. with the cheif complaint of fever and
watery stool and vominting .attending physician was Dr. Orteza. his
mother is his companion when he was admitted, prior to admission his
Baseline data was taken. upon admission to the ward, vital sign was
taken. thus has the following report: BP-100/70 PR-72 RR-18 and
temp:38 'c. his physician also prescribed medication to reduce fever,
he given paracetamol 500 mg/tab. he also given cotrimoxazole 800
mg/tab, ercefuryl cap, 1 cap imodium 1 cap, ctoneprazole 40 mg via
(IV) and plasil.his final diagnosis is AGE with moderate Dehydration.
LEARNING OBJECTIVES:
1. to gather comprehensive data through interview and medical chart.
2. to perform physical assessment head to toe approach.
3. to have a review of anatomy ang physiology of the system effected.
4. to trace the pathophysiology of AGE.
5.To determine the different medical and nursing management
employed.
6. to interpret the results of the laboratory and diagnostic procedures.
7. to study the drugs prescribed to the patient and its effect to his
current condition
8.to furmulate and apply nursing care plan utilizing the nursing process
BIOGRAPHIC DATA
NAME: S.R
AGE: 17 Y/O
GENDER: male
STATUS: single
ADDRESS: dona rita diaz st. furtuna village sucat paranaque city
PLACE OF BIRTH: Sucat paranaque
RELIGION: roman catholic
EDUCATIONAL ATTAINMENT: college
OCCUPATION: student
LANGUAGE SPOKEN: filipino
ADMITTING DIAGNOSIS: AGE with moderate dehydration
SOURCE OF INFORMATION: From the patient, hospital record and lab
result
Past History
The client had fever, cough and colds. She had completed all
vaccinations including BCG, DPT, Oral Polio Vaccine, MMR and Hepatitis
B vaccine. The patient had never been any of the childhood disease
such as measles, mumps and chicken pox. The patient had no history
of accident or any injury. She does not have allergy in any food or drug.
She was not hospitalized before and she does not take any medication
or supplements to maintain her health.
Family History
According to the significant others of S.R they have a familial disease
of asthma, on his father side. And an incident of hypertension on his
mother side.
4.Activity-Exercise Pattern:
5.Cognitive-Perception Pattern:
Before his hospitalization, the patient is normal in terms of his
cognitive abilities. He has no problems with his senses.
During his hospitalization, he is able to ask question and he also
cooperative.
6.Sleep-Rest Pattern:
Before his hospitalization, he usually sleeps 8-9 hours. he
wathing NBA and making some homework.
During his hospitalization, the patient sleeps early but has sleep
disturbances when the nurses take his vital signs, administer
medicines and also due to the environment.
8.Role-Relationship Pattern:
The patient has a close relationship with his family, but he is
closer to his father. becouse his father and him is always playing
basketball every sunday.
cousins get his toys, he does not quarrel withthem but instead he
reports it to his parents. During his hospitalization, hefeels
unsafe with people when his mother is not with him. He cries
without thesight of his mother.
10. Value-Belief Pattern:
He is a Roman Catholic. They attend mass regularly with there
family.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE:
The patient is awake, lying on bed, concious and coherent with an IVF
of D5NM 1L.
PHYSICAL ASSESSMENT
1. SKIN:
the patient skin color is light brown, dry skin, rough due to
deviated slight dehydration.
2. head:
hair color is black, no dandruff, no lission and masses palpeted.
3.eyes:
4.ears:
client normaly hears word, ears are symmetrical external pinae.
5.nose:
nose are smooth symmetric with same color as the face. nasal
septum close to midline.
6. mouth
slightly pink, dry lips becouse of dehydration, no tooth decay
precent.
7.neck:
while inpection the trachea is in midline no difficulty of
swallowing.
9. abdomen:
upon inpection skin same at the rest of the body, and when
auscultation there hyperactive sound diviated to diarrhea.
LABORATORY RESULTS
HEMATOLOGY RESULTS
Normal Value
Analysis
WBC
noramal
normal
5.5-10.0
Results
10.0
Lymphocyte
decrease
15-50
GRA
increase
10.5%
35-80%
mid
increase
Hgb
g/dl
81-9%
2-15%
increase
Hct
normal
7.6%
14-18
43.5-53-7
mch
increase
27-32
segmenters
normal
60%-70%
16.7
%
30.20
FECALYSIS
analysis
Results
Physical properties:
Color
Normal
brown
Consistency
d/t profuse secretion
Watery
URINALYSIS
Analysis
50.0%
Results
69%
Color:
Normal
Yellow
Transparency
d/t increased
Slightly turbid
urineconcentration
Reaction
Normal
acidic
Specific gravityDecreased:d/tdehydration
1.020
Sugar
Normal
albumin
few
Negative
negative