CLEFT LIP AND PALATE

A Case Study Presented to the College of Nursing In Partial Fulfillment of the requirements for Related Learning Experience In Medicine Ward of DMDH

Shirley May De Gracia RN, MSN Clinical Instructor

John Carlo T. Chico

FOREWORD/PREFACE In creating this study, the authors share to life the experiences and differences theyve made within these pages, by describing what they have studied and learned during their clinical exposure in the Obstetrics Wardof Dona Marta Medical District Hospital.

FOREWORD/PREFACE And thus, not only did they become improved nursing students but also they become more aware, open minded, found responsibility, help others and have move forward together, ready to face whats coming next for them.

FOREWORD/PREFACE
Their knowledge was enhanced as they encountered different cases and procedures in the Medicine Ward. These form important learning experiences, creating much new light for them from pre-conferences and post-conferences, medications, patients and significant others, assessments and a whole lot more vital to their nursing careers.

DEDICATION

This study is dedicated to our loved ones whom never failed in giving us support financially, spiritually and morally, for guiding us through and for showing us that even a big task can be accomplished as long as there is teamwork and dedication. We also dedicate this to ourselves because of the hard work and dedication we have showed in making this study and to Mrs. Shirley May De Graciafor guiding us and believing in us.

DEDICATION Lastly, we dedicate this to the healthcare team of Dona Marta Memorial District Hospital because without them, there will be no basis for this study. They have opened up their doors for us to attain and broaden our knowledge in the health care industry.

OBJECTIVES
For this case study, we aim that: We will have better understanding of Typhoid fever by reading books, articles and journals that are related with the typhoid fever; understand clearly the pathophysiology of the disease, risk factors, manifestations and treatment and modalities of the typhoid fever; and equip ourselves with skills and health teachings that are appropriate for the care of patients with typhoid fever.

CASE INTRODUCTION

A 21 years old male patient admitted on June 27, 2013 with diagnosis of Typhoid fever and experiencing relapsing abdominal pain.

Typhoid fever, also known simply as typhoid, is a common worldwide bacterial disease transmitted by the ingestion of food or water contaminated with the feces of an infected person, which contain the bacterium Salmonella enterica enterica, serovarTyphi.

PATIENTS DATA (BABY)

NAME: Miss X GENDER: Female BIRTHDAY: May 23 ,1967 Children: 4

Pathophysiology
Typhoid fever is termed as an acute illness

accompanied by fever caused by a gram negative bacilli called as Salmonella typhi. It is transmitted via fecal- oral route through contaminated water supply or food. Clients who had harboured this infection may become asymptomatic for a long time and could be called as carrier. Those carriers can then be a cause for future outbreaks of typhoid fever especially if there is improper sanitation and handling of food and poor hygiene.

Nursing Care Plan

Assessment
Subjective: Pabalik balik ang pagsakit ng tiyan ng ko, madali lang ito nawawala ngunit masakit as verbalized by the patient Objective >Facial Grimmase >Restlessness >BP 140/80 mmHg >Temp 37.2 c >RR 26 cpm >Pulse 88 bpm >Pain scale of 8/10
Diagnosis Planning Intervention Rationale Evaluation

Acute Pain

After 8 hours of non-stop caring to the patient. The patient will be able to: >Minimized or ease the pain >avoid the occurrence of pain
>Regulate his normal V/S > Reduces the pain scale

> Identify/Locate the site of pain

Identify the causative factors that causing pain

To localized the pain site

To identify the causitive agent and to provide baseline knowledge To relieve/ lessen the pain

After 8 hours of non-stop caring to the patient. The patient will be able to: Minimized and eased the pain Avoid the occurrence of pain
Regulated his Vital Signs

Administered analgesics or painkiller if needed Demonstrate activities that may divert and relieve the pain Treat the causative factors of pain by giving medications and usage of different techniques

To divert the pain and ease and relieve the pain To avoid the occurrence of pain and treat the main source of the pain

Reduced the pain scale from 8/10 to 4/10.

Drug Study
Therapeutic Classification Metrinidazole Anti-Bacterial Action Bactericidal Contraindicaiton Contraindicated with hypersensitivity to metronidazoke; pregnancy Toxicity/ Side Effects Headache Dizziness Insomia Nausea and Vomitting Diarrhea Dysuria Thrombophlebitis dryness and skin irritation Hemolytic anemia Rashes Liver damage Safe Doze 250mg-650mg

Use cautiosly with CNS diseases, hepatic disease, candidiases, blood dyscrasias, lactation
Paracetamol Anti-pyretic and Anti-Analgesic Anti-pyretic and AntiAnalgesic Contraindicated with the hypersensitivity to the drug

225mg- 650mg

Treatment
Administer anti-pyretics drugs and antibacterial

drugs Infused d5lr or PNSS to reflenish the fluid loss and electrolyte imbalanced

DISCHARGE PLAN

IMPLICATION OF THE STUDY

The implication of this study in the practice of nursing serves as a guide or a tool for the fellow nursing students and staff nurses. It provides a detailed background, management, interpretations and documentations for patients who have typhoid fever. It will help broaden the knowledge and skills of the healthcare team.