Nursing Case Study: University of Perpetual Help System-Molino Campus

University of Perpetual Help System-Molino Campus
COLLEGE OF NURSING Molino III, Bacoor, Cavite
NURSING CASE STUDY

I. HEALTH HISTORY A. DEMOGRAPHIC (BIOGRAPHICAL DATA) Clients Initial : Z. A Gender: Female Age: 1 year old Religion: Catholic Occupation: N/A Usual Source of Care: Hospital Date of Admission: February 24, 2012 (10:25 pm) Initial Diagnosis: Dengue Febrile Syndrome Final Diagnosis: Acute Tonsillopharyngitis B. SOURCE AND RELIABILITY OF INFORMATION Since the patient is an infant, the gathered information came from the mother of the patient who was with her (patient). The mother was reliable enough to answer all the questions asked. Patients mother was also coherent enough and actively participated during the interview. Patients chart was also utilized for some additional information C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINT The Following symptoms prompted the patients parents for hospital admission. On and off fever for 2 days with 38-39C Irritability
D. HISTORY OF PRESENT ILLNESS 2 days prior to admission the patient was experiencing an on and off fever with the temperature ranging from 38-39C. The patient was given Tempra and temporary relief was achieved. There was no consultation done. But still the patients fever goes back. The patient doesnt have any diarrhea and no vomiting at all. But the patient seems weak and irritable due to the fever. So patients parents d ecided to bring her to the hospital.
E. PAST MEDICAL HISTORY It was the patient first time to be hospitalized. Patient didnt experience any disease except for cough, fever and colds. According to patients mother her daughters immunization was not yet complete. As far as they know, patient dont have existing food or drug allergies.

F. DEVELOPMENTAL MILESTONE
Trust vs. Mistrust (Infants, Birth to 12-18 Months)

Psychosocial Crisis: Trust vs. Mistrust Virtue: Hope The first stage of Erik Erikson's theory centers around the infant's basic needs being met by the parents. The infant depends on the parents, especially the mother, for food, sustenance, and comfort. The child's relative understanding of world and society come from the parents and their interaction with the child. If the parents expose the child to warmth, regularity, and dependable affection, the infant's view of the world will be one of trust. Should the parents fail to provide a secure environment and to meet the child's basic needs a sense of mistrust will result. According to Erik Erikson, the major developmental task in infancy is to learn whether or not other people, especially primary caregivers, regularly satisfy basic needs. If caregivers are consistent sources of food, comfort, and affection, an infant learns trust- that others are dependable and reliable. If they are neglectful, or perhaps even abusive, the infant instead learns mistrust- that the world is in an undependable, unpredictable, and possibly a dangerous place. While negative, having some experience with mistrust allows the infant to gain an understanding of what constitutes dangerous situations later in life.
G. FAMILY HISTORY
LEGEND:

COLLEGE OF NURSING Molino III, Bacoor, Cavite Patients mother and father are still alive and well. The patient is an only child. Patients mother is 32 y/o and a housewife. While his father, 33 y/o works as a caregiver.
H. REVIEW OF SYSTEMS Date of Assessment: February 27, 2012 System a. General/ Over All Health Status Review of System Physical Exam >weakness >fever (temperature of 37.8) >response of the body to an infection. After the body detected infection there will be an immune response release of pyrogens that will stimulate the hypothalamus to release prostaglandin that is responsible to release temperature to set point causing death of certain opportunistic organism. > due to fever Significance
> Warm to touch 1. LABORATORYSTUDIES DIAGNOSTICS
Procedure
Indication
Normal findings
Actual findings
Implication
Nursing Responsibilities Pre - Positively identify the client Inform pt that this test can assist in evaluating the
Hematology February 25, 2012
>It assesses the general status of the patient. This helps
RBC 4.50-6.00 X10^12/L
4.69
Normal

COLLEGE OF NURSING Molino III, Bacoor, Cavite determine if the Hemoglobin component 120 160 g of the blood /L is adequate to sustain the Hematocrit needs of the (Hct) body. 0.40-0.54 L It is an important WBC measurement 4.50 in the 10x10^9/L evaluation of Segmenters anemia, 0.50-0.70 oxygen and Platelet carbon 150 dioxide 400X10^9/L carried by the blood as Monocytes well as the 0.00-0.07 acidity, to determine the presence Lymphocyte 0.20-0.40 of infection and allergy MCV 80-100 fL MCH 26-34 pg amount of hemoglobin in the blood Obtain hx of the pt compliant Note any recent procedure that can infere the result Obtain list of current medication No fluid or food restriction unless by medical direction.
128
Normal -
0.40
Normal -
7.8 0.59 204
Normal Normal Normal Increased presence of bacterial infection Normal Normal Normal -
0.08
0.33 85 27.3
MCHC 320-360 g/l
322
Normal
Intra - Observed standard precautions - Maintain asepsis - Assess pt vital sign - Cubital vein commonly used for venipuncture - Assist medical technologist Post - Monitor for sign and symptoms of vlooding - Direct preassure - Observe for bleeding - Label vial - Proper documentation.
IV. PROBLEM LISTS A. Actual or Active Problem No. Problem Date Identified

COLLEGE OF NURSING Molino III, Bacoor, Cavite 1. 2.
Hypothermia Ineffective breathing pattern
February 27, 2012 February 27, 2012
B. High Risk or Potential Problem No. 1. 2. Problem Risk for fall Risk for Imbalanced nutrition Date Identified February 27, 2012 February 27, 2012

NCP
Submitted by: Shayne Marie Apon BSN 4A
Submitted to: Ms. Jovy Reano, RN, MAN

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COLLEGE OF NURSING Molino III, Bacoor, Cavite