儿科病房护理实习案例分析(英文版ppt).pptx

By：Group 3 Peng Sijing(Stone)Li Xiaojing(Cathy)Miao Chunmei(Mango)Nie Fengyan(Zara)CASE PRESENTATION PEDIATIRC WARD CONTENTS History Physical Examination Introduction Laboratory Result MIMS Medication Nursing Care Plan Neurologic Examination IntroductionGENERAL DATA:p.m.e.,13yearsold,female,Filipino,Christian,bornonMarch23,2004inManilacurrentlyresidingin270KalayaanB.St.BatasanHillsQuezonCity,admittedforthefirsttimeatFEU-NRMFMedicalCenteronMarch3.2018.CHIEF COMPLAINT:Vomiting HistoryHISTORY OF PRESENT ILLNESS:Fourhourspriortoadmission,whileswimminginthepool,acontainerofmuriaticacidwasnotedtobeaccidentallyspilledinthepool,theamountwasunknowntotheinformant.Whilehercousinmovedoutofthepool,shesubmergedherselfforafewsecondsuntilshewaspulledoutofthepoolbyheruncle.Sheaccidentallyingestedapproximately1cupofpoolwater.She then experience dizziness,sore throat,chest pain,difficulty of breathing and body weakness.Shethenwashedherselfintheshower.Thereafter,sheexperienced2episodesofnon-projectile,non-bilous,non-bloodyvomitofpreviouslyingestedfoodaboutcupperbout.Shewasthenbroughttoanearbyhospitalandwashookedtooxygenvianasalcannula.Theywereadvisedtotransferhospitalsduetolackofapediatric.HistoryHISTORY OF PRESENT ILLNESS:Fewhourspriortoadmission,uponarrivaltotheEmergencyDepartment,she had 1 cpisode of non-projectile,non-bilous,non-bloody vomiting of previously ingested food about 1/2 cup.Still with sore throat,chest pain,difficulty of breathing and body weakness.Nodizzinessnoted.On physical examination,she had symmetrical chest expansion;with intercostal,subcostal and supraclavicular retractions,crackles all over,wheezes all over and tight air entry.She had episodes of desaturation with oxygen saturation of 80-90%.Completebloodcountwithplateletcountwasdonewhichrevealedleukocytosiswithneutrophilicpredominance.BUN,Creatinine,andElectrolytesweredonewhichrevealednormalresults.Electrolytesshowednormalresults.Arterial blood gas showed fully compensated metabolic acidosis.Shewasadvisedadmission,henceadmitted HistoryPAST MEDICAL HISTORY:Patienthadtheusualchildhoodillnesssuchasmeasles,varicella(2011)Patient had the history of Primary Pulmonary Tuberculosis(2011)(6monthstreatment,Competedtreatmentin2013)Nohistoryofseizure,bronchialasthma,dengue,allergiestofoodanddrugs,historyofsurgeryorblood.HistoryFAMILY HISTORY:Fatheris37yearsold,Highschoolundergraduate,Worksasapainter,apparentlywellMotheris39yearsold,Highschoolgraduate,Worksasanailtechnician,apparentlywellGrandmother has Hypertension and in maintenance of Norvasc 5mg and compliantNootherheredo-familialdiseasessuchasdiabetesmellitus,kidneydisease,liverdiseaseandpsychiatricillnesses.HistoryIMMUNIZATION HISTORY:VACCINES Doses Place Given BCG 1Batasan Health Center Hepatitis B 3Batasan Health Center DPT 3Batasan Health Center OPV 1Batasan Health Center MMR 2Batasan Health Center Measles 1Batasan Health Center Dengvaxia 1Batasan Health Center HistoryNUTRITIONAL HISTORY:Thepatientwasexclusivelybreastfeduntil6thmonthofage.ShewasintroducedtocomplimentaryfeedingwithCerelacandGerberonher6thmonthandricewithviandwasgivenat1yearold.Now,sheconsumes4cupsofricewithviandthreetimesdaywithsnacksinbetween.HistoryHEADSSIRST:Home life:patient shares a bedroom and bed with her aunt and grandmotherEducation:sheisan8thgradestudentwithaveragegradesandisapartofthebadmintonclubAbuse:nohistoryofabuseDrugs:with history of alcohol intake,2cupsofunrecalledalcoholmixture;nohistoryofprohibiteddrugintake HistoryHEADSSIRST:Family:nuclearfamily,nohistoryofalcoholnordrugabuseFriends:hasdifferentgroupsoffriendsineverysocialsettingbutiscarefulinwhoshehangsoutwithImage:sees herself as fat,dresses up like the hypebeast cultureSafety:plays volleyball on the streets,no protective gear HistoryHEADSSIRST:Recreation:shelikestoplaysportsandhangsoutwithherfriends,sheisveryaciveonvarioussocialnetworkingsitesSpirituality:sheisaBornAgainChristianwhogoestochurchonmostSundaysThreats and Violence:she had 1 history of selfharmwhenshewas11yearsoldwhenshecutherforearmwithacutterinschool;nohistoryofrunningaway,crueltytoanimals,fightingnorstealing PERSONAL AND SOCIAL HISTORY:HistoryThepatientliveswithhisparentsandsiblingsina1-bedroom2storyhouse,well-litandwellventilatedwith1window.Themotheristheprimaryfinancialprovider.WatersourceisfromMayniladanddrinkingwaterisfromadeepwell.Garbageiscollectedtwiceaweek.Hesleepsforabout10hoursaday.HistoryOBSTETRIC AND GYNECOLOGIC HISTORY:Patienthadhermenarcheat12yearsold,lastingfor5days,consuming3padsperday,moderatelysoaked,with associated dysmenorrhea.Subsequentmenseswereregularwithintervalof28-30days,lastingfor5days,consuming3padsperday,moderatelysoaked,with associated dysmenorrhea.Physical ExaminationGeneral Survey:conscious,coherent,inrespiratorydistresswiththefollowingvitalsignsBP:120/80mmhgCR:100 bpm RR:36 cpm Temp:36,8CO2 Sat:87%Wt:37.7kgHt:155cmBMI:15.71kg/m2IBW:47.63kgz-score:nostuntingnowastingHEENT:pinkpalpebralconjunctiva,whitesclera,intacttympanicmembrane,pinkandboggyturbinates,moistlips,moistbuccalmucosa,pinkpharyngealwallNECK:suppleneck,nopalpablelymphnodes,non-tender Physical ExaminationCHEST/LUNGS:symmetrical chest expansion,with intercostal,subcostal,supraclavicular retractions crackles on all lung fields,wheezes all over,tight air entry.HEART:Adynamicprecordium,normalrate,regularrhythm,nomurmurABDOMEN:flat,soft,nontender,normoactivebowelsounds,non-tenderEXTREMITIES:nogrossdeformities,fullandequalpulses,capillaryrefilltime 12 hr 5-10 ml,7-12 hr 5 ml,2-6 hr 2.5-5 ml.To be taken 6-8 hrly.A:take 1 hr before or 2 hr after meals.CI:B-blockers.PregnancySP:Hyperthyroidism,DM,CV diseaseAR:Fine skeletal muscle tremor,tachycardia,headache.dizziness&arrhythmias(rare)INT:Effects antagonized by propranolol&other B-blockers&enhanced by xanthines.P/P:Syr 2 mg/5 mlx 60 ml Preg Safety(US):CActivates adenyl cyclase.Increased CAMP leads to activation of protein Kinase A,which inhibits phosphorylation of myosin and lowers intracellular Ionic C concentrations resulting in smooth muscle relaxation.Bronchospasm,Uncomplicated premature labor,Prophylaxis of exercise induced bronchospasm,Acute Severe AsthmaHyperthyroidism，myocardial insufficiency,arrhythmias,susceptibility to QT-interval prolongation,Hypertension,Diabetes mellitus,glaucoma,hypokalemia,seizure,disorder.Renal Impairment.Tremor,nervousness,nausea and vomiting,tachycardia,palpitations,chest pain,shakiness,dizziness,headache,sensation,hyperactivity,hypertension,increased sweating,conjunctivitis,UTI,multiforme,SIS.DRUGS MIMSMECHANISM OF ACTION INDICATIONCONTRADICATI0N DAVERSE EFFECTESOmeprazolePRESENTATION:Cap 20ngC:Omeprazole(omexac-40 Na)I:omexac-20 Treatment of reflux esophagitis.acid PUD,zollinger-ellison syndrome.Adjunct in duodenal ulcers associated w/H.pylori combined W/appropriate antibiotics.Prophylaxis of acid aspiration before surgery.Prevention&treatment of NSAID-associated ulcers.Omexac-40 Benign gastric&duodenal ulcers,zollinge rellison syndrome,gastric acid reduction,GERD acid reflux disease,acid-related dyspepsia.D:Relief of acid-related dyspepsia 10-20 mg daily PO for 2-4 wk.GERD 20 mg PO once daily for 4 wk,followed by further 4-8 wk if not fully healed.Refractory esophagitis 40 mg daily Children 1 y,weighing 20 kg PO daily,10-20 kg 10 mg PO daily.Management of PUD 20 mg PO as single daily dose or 40 mg in severe cases.Continue treatment for 4 wk(for duodenal ulcer)&8 wk(for gastric ulcer).H.pylori eradiction in peptic ulceration.Triple therapy return 20 mg bid amoxicillin 500 mgSuppress acid secretion by specific inhibition of the H+/K+ATPase enzyme system at the secretory surface of the gastric parietal cells.Blocks the final step of acid production.Duodenal ulcers(adult),gastric ulcer(adult),GERD,Erosive esophagitis,pathological hypersecretory syndromesKnown hypersensitivity to any component of the formulationAdults:headache,abdominal pain,nausea,diarrhea,vomiting,and flatulence.Pediatric:similar to adults.MIMS Medication MIMS Medication DRUGS MIMSMECHANISM OF ACTIONINDICATIONCONTRADICATION DAVERSE EFFECTESCefuroxime Children(who swallow tab whole)Acute otitis media,acute bacterial maxillary sinusitis 250mg bid for 10 days.Pharyngitis/tonsillitis 20 mg/kg/day bid in divided doses for 10 days,Children Acute otitis media,acute bacterial maxillary sinusitis,impetigomg/kg/day bid in divided doses for 10 daysCl:Hypersensitivity to cephalosporinsSP:History of hypersensitivity w/penicillin or other lactams.AR:Anaphylaxis,angioedema,pruritus,rash serum sickness-like reaction,urticaria,pseudomembranous colitis;hepatic impairmentP/P:Tab 500 mg x 1sPreg Safety(US):BInterferes with peptidoglycan synthesis of the bacterial cell wall by inhibiting the final transpeptidation needed for cross-linkage;bactericidal.For the treatment of bacterial infections such as bronchitis,sinusitis.ear infections,skin infections,gonorrhea,and urinary tract infections.Hypersensitivity Hypersensitivity reactions:rash,nasal congestion,cough,dry throat,eye irritation,or anaphylactic shock.Overdose can cause cerebral irritation leading to convulsions.MIMS Medication DRUGS MIMSMECHANISM OF ACTIONINDICATIONCONTRADICATION DAVERSE EFFECTESHydrocortisone C:Hydrocortisone Na succinateI:Replacement therapy in adrenocortical insufficiency in combination w/more potentmineralocorticoid.May also be used in other conditions for which corticosteroid therapy is indicatedD:MM,Slow/in or infusion Adult 100-500 mg repeated 3 or 4 times in 24 hr.Children 6-12 yr 100 mg,1-5 yr 50 mg,up to 1 yr 25 mgCI:Acute infections.Active or quiescent TBSP:Heart failure.recent MI.HTN.DM epilepsy,glaucoma,hypothyroidism,hepatic&renal failure,osteoporosis,peptic ulceration,psychoses or severe affective disorders renal impairment.Do not give live vaccines for at least 3 min after corticosteroid therapy Monitor fluid intake output.Avoid rapid live in high doses.Children.ElderlyAR:Na water retention w/edema&HTN hypokalemic alkalosis,increased appetiteexcessive metabolic effects resulting in Ca&P mobilization w/osteoporosis spontaneous fractures,nitrogen depletion,hyperglycemia delay wound healing,fetal/neonatal adrenal suppression in high dosage during pregnancyP/P:Powd for inj(vial)100 mg x 10sPreg Safety(US):C,D(in 1st trimester)Glucocorticoids dramatically reduce the manifestations of inflammation.This is due to their profound effects on the concentration,distribution,and function of peripheral leukocytes and to their suppressive effects on the inflammatory cytokines and chemokines and on other mediators of inflammation.For treatment of systemic inflammationimmunosuppressionHeadache,nausea,vomiting,recurrent infection,increase in appetiteNursing Care PlanNursing Problem 1 Impaired gas exchangeChlorine damages the airway.Goal:She can breathe freely without feeling bored.InterventionsPositionpatientwithheadofbedelevated,inasemi-Fowlerspositionastolerated.Regularlycheckthepatientspositionsothatheorshedoesnotslumpdowninbed.Turnthepatientevery2hours.Monitormixedvenousoxygensaturationcloselyafterturning.EncourageslowdeepbreathingusinganincentivespirometerAdministermedicationsasprescribed.Nursing Care PlanNursing Problem 2 Activity intoleranceInsufficientoxygensupply.Goal:Thegoalorexpectedoutcomeofapropercareplanistorestorethepatientsabilitytoperformregularactivitiesinahealthymannerwithoutexperiencinganysignsorsymptomsofactivityintolerance.InterventionsEliminatenonessentialactivitiesorprocedurestoconserveenergyoutput,conservestrengthforimportantactivitiesandensureadequaterest.Assistpatientswithplanningandschedulingactivitiesandprovidedirectfeedbackonperformanceandimprovements.Observeandaddressrestrictiveclothinganditemsthatmayimpactproperbloodflow,oxygenlevelsandphysicalcomfort.Nursing Care PlanNursing Problem 3 Risk for deficient fluid volumeItisrelatedtothelossofbodyfluidscausedbyvomiting.Goal:Toreplenishenoughfluidtomaintainnormalbodyfluidvolume.InterventionsUrgethepatienttodrinkprescribedamountoffluid.Referpatienttohomehealthnurseorprivatenurseinabletoassistpatient,asappropriate.Emphasizetherelevanceofmaintainingpropernutritionandhydration.Identifyanemergencyplan,includingwhentoaskforhelp.Risk for self-mutilationRelatedtopreviousdamagehistoryGoal:Communicatewiththepatient,understandthepatientsthoughts,reducethepatientsanxiety,andavoidself-harm.InterventionsEstablishatherapeuticrelationshipwithclient.Monitor,document,andreportclientspotentialforsuicide.Clientsatriskshouldreceiveevaluationandhelp.Nursing Care PlanNursing Problem 4