De La Salle Health Sciences Institute College of Nursing and School of Midwifery Dasmarinas, Cavite

Case Analysis
Submitted by: Jose Rebecco P. Adao Bon Kervin V. Argel Submitted to: Maam Damian

DE LA SALLE HEALTH SCIENCES INSTITUTE College of Nursing and School of Midwifery Dasmarinas City, Cavite I. DEMOGRAPHIC DATA Clients Initials: .J.A. Age: 12 y.o. Gender: Female Civil Status: Single Address: Sampaloc, Manila Religion: Catholic Educational Attainment: Elementary Undergraduate Occupation: None CHIEF COMPLAINT/ MEDICAL DIAGNOSIS Cough and Fever HISTORY OF PRESENT ILLNESS 2 weeks PTC, the patient had cough productive greenish to whitish phlegm. No fever noted, consulated at Sta. Ana Hospital and was given Coamoxiclav 312.5 ml but with no relief 1 week PTC, the patient had a persistent of cough now accompanied with fever and thus they prompted to consult at Ospital ng Sampaloc and cefuroxime 250mg/5ml was given. Chest x-ray was also done and the result was the lateral view reveals a cavity with air filled at right upper lobe of the lungs. No changes noted hence the consultation at San Lazaro Hospital. OTHER RELEVANT INFORMATION The client had no serious illness or disease in the past. This was the first time that the client was hospitalized in a long term basis. Wheezes were heard at both lung fields as well as crackles. At present the client dont show signs of abnormality regarding her vital signs and lab tests were still being done to rule out the definitive diagnosis. The client also shows hyponatremia and decrease serum chloride in the body. ANALYSIS OF CARE ANALYSIS OF CARE Age: Clients age plays a very important role in her diagnosis. At her young age her immune system is still not that definite compared to adults. Added by her immobility the client is at high risk of

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FOCUS Demographic Data

acquiring illnesses and diseases from the environment Gender: Residence: Developmental Task

Other Relevant Information

Intervention/ Action Done/ Rationale/ Patients Response (Medical/ Surgical/ Diagnostics/ Procedures/ Nursing Care)

DATE/ TIME February 21, 2011 2:30 PM

INTERVENTION/ ACTION DONE

3Nurse-Patient Interaction established

RATIONALE
3To build rapport with the client

PATIENTS RESPONSE
3Client displayed hemodynamic

stability by on 3To administer manifesting replacement stable vital fluids in right signs and amounts consistent 3Determined vital 3Provides peripheral signs and cognitive baseline for pulses status comparison to follow trends 3Client 3IVF regulated desired rate and evaluate response to interventions; and if infection to the incision site is already happening as manifested by the clients temperature reported increase in confidence in doing breasfeeding 3Client demonstrated an increase in activity 3Encouraged rest and 3For assisted in physical energy lesser tolerance

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expenditure 3Client and easy body participated in restoration activities that 3Psychological rest helps reduce emotional stress 3Can cause changes in cardiac pressures and impede blood flow reduce the workload and rested for the remaining hours

3Provided quiet environment conducive for patients rest and relaxation

3Instructed client to avoid/limit activities that may stimulate Valsalva response

together with the baby in a safe quiet environment.

3To reduce 3Encouraged deep anxiety and for breathing and better gas relaxation techniques exchange 3To prevent 3Turned client side to pressure ulcers side q2 3Clears airway 3Instructed in and facilitates effective coughing and oxygen delivery deep breathing 3To prevent 3Provided safety injury and falls measures by staying at clients side and babys, ensuring side rails up 3 Provided opportunities to rest and sleep during hospital stay 3 Provided 3Prevents and reduces fatigue

3 Encouraged and demonstrated to do chest clapping and postural drainage to the significant others 3Provided health teachings about the following to the significant others: A. Diet B. Compliance to medications C. Relaxation Techniques D. Safety measures and precautions E. Active and passive ROM exercises F. Disease Process G. Diseases Management

opportunities to rest and sleep during hospital stay

3To provide information and promote fast recuperation