Post on 26-Feb-2018
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Philippine Christian University
Mary Johnston College of Nursing
415 Morga St., Tondo Manila
TYPHOID FEVER: ENTERIC FEVERCase Study!
Prepared by:Ms. Macapugay, Sheela Mae
Ms. Moleta, Hazel Joyce
Submitted to:Mrs. Rose Marie Lucas
Ms. Xara Dumapat
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DEMOGRAPHIC DATA:
Na"e# Jarett Jethro $o"ero %alang
&ge# ' y(o
%ender# Male
Marital status# Single$eligion# $o"an Catholi)
&ddress# *on +os)o, +rgy. 11, Tondo ManilaNationality# -ilipino
du)ational attain"ent# %rade 1 ele"entary presently studying!
NURSING HISTORY:
Jarett Jethro %alang is ' y(o, "ale /orn in residing in Tondo ad"itted for the 0nd
ti"e in Mary Johnston ospital on July 01,0211 due to fever for several days.
Interviewee:Patient and his "other
Chief Com!"int:-ever
Hi#tor$ of re#ent I!!ne##:
Present illness started 5days prior to ad"ission, patient had fever do)u"ented at 3 Cith asso)iate heada)he /ut still ith good appetite
days prior to ad"ission, patient still had lo grade fever ith rashes and persisten)e of
on and off fever.
P"ttern# of he"!th:*ate of &d"ission# July 01, 0211Ti"e# 5#32 p."
&ttending Physi)ian# *r. Candelaria
&d"itting Physi)ian# *r. Candelaria
Imm%ni&"tion:
+C% 61 dose
*PT 63 doses7P8 63 doses
Measles 63 doses
O'#tetri(# hi#tor$:
+orn to a 04 y(o %5P5
*elivered full ter" via NS*No )o"pli)ations
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F"mi!$ He"!th Hi#tor$:
9! *M :Mother side
9! PN :Mother side9! &sth"a :Mother side
So(i"! Hi#tor$:
e lives ith fa"ily in a ell:lit, ell ventilated house. -ather is 05 servi)e te)hni)ian
hile "other is 32 y(o houseife.Si6:year:old )hildren play in groups, /ut hen they are tired or under added stress, they
prefer one:to:one )onta)t. e doesn;t usually play outside their house instead he ants to play
ith his si/lings.
Growth "n) Deve!oment:
Psy)hose6ual# different shifts
Moral# Pre)onvention level == stages 3 ?4
+elieves in heaven and hell
Type of play# Co"petitive(Cooperation
Play )ontinues to /e rough at age ' years@ hoever, hen )hildren
dis)over reading as an enAoya/le a)tivity that opens the orld, they )an /egin to
spend Buiet ti"e ith /oo>s. e spend hours playing ith laptop and )ell phonega"es, an a)tivity that )an either foster a healthy sense of )o"petition or )reate
isolation fro" others.
&ge:appropriate Toys# %a"es +oo>s
Jigsa pule Ta/le ga"es
%reatest fears#
-ear of repla)e"ent(displa)e"ent
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-ine "otor *evelop"ent#
e )an dra a person ith good detail. e )an print, although he "ayroutinely reverse letters. 7ne of his /iggest dis)overies is that reading and riting
are fun. $eading and riting are a)tivities that )an help a )hild pass the hours of
illness.
*&T# July 04, 0211
GORDON*S FUNCTIONA+ HEA+TH PATTERN
He"!th Per(etion:
Eto >aaala lang ng lagnat niya >aninang hapon.F &s stated EU"a/ot nga ng 3G.GC. ang lagnat niya eh.F &s stated /y the "other.
E Sa/i nga ng do)tor niya "aaaring nahaa da siya sa "ga >asa"a niya sa/ahay >aya nag>alagnat siyaF EMara"i >asi >a"i sa /ahay na nag>atrang>aso tapos siya na yung su"unodF
N%trition,Met"'o!i( P"ttern:
EHu"a>ain din na"an siya ng "ga gulay,o>ra,preo /ihira lang ang "ga dahon,"ahilig din siya sa isda at )hi)>enF as stated
E+ihira lang siya >u"ain ng "ga /a/oy at >arne.F ENung du"ating yung pinsan niya sa>a siya natutong >u"ain ng "ga
titsirya.yung "ga tigpipiso na titsiryaF ENung natuto na siyang >u"ain ng titsirya,lagi na siyang >u"a>ain nun hanggang
na>ahiliga na niya.F -avorite food# )arrots, )hi)>en *isli>es# leafy vegeta/les
S!ee,Re#t P"ttern:
ESapat na"an yung pahinga niya nung nasa /ahay pa >a"i pero nung pu"untana dito sa hospital, din na siya na>a>a hours na tulog >asi panay >uha ng dugo
sa >anyaF
E!imin"tion:
ENung una "edyo "atigas:tigas pero nagging "ala"/ot na rin ng >onti ngayong
ara yung du"i niyaF EMedyo "adila pa rin yung ihi niyaF
A(tivit$,E-er(i#e:
E*i siya gaano lu"ala/as ng /ahay para "a>ipaglaro, ,lala/as lang yan "insanpara "agpaala" na iihi o /i/ili ng paga>ainF
ENag:ee6er)ise po >a"i sa s)hool pag pu"apaso> po a>oF as stated /y thepatient.
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o siya ng papel at lapis para "a>apagli/ang din siyaF
Se-%"!,Rero)%(tive:
EHahit sino na"an >asa"a niya,/a/ae o lala>i,ala siyang pinipiliF
Ro!e,Re!"tion#hi:
EPangli"a siya sa "ga ana> >o, pang:apat siya na lala>iF E&ya niyang na>i>ita na na>i>ipag:aay a>o. %again niya ang gusto niya ag
lang a>o "apa:aayF
Coin.,#tre##/
ENa>a>ayanan na"an niya yung pagtuso> sa >anya ng inAe)tion.F E&ng tapang nga niya eh.hindi siya u"iiya> pag tinuturu>an,"insan tinititigan pa
niya yunF
Se!f,Per(etion:
E sina/i niya sa a>in na antagal tagl na da niyang di pu"apaso> /a>a sa/ihinda sa >anya ng tea)her niya na anga /o/o /o/o na niya >aya nag:reBuest siya na
"agadala a>o ng papel at lapisF
V"!%e,0e!ief:
EHatoli>o yung relihiyon na"inF
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*&T# July 05, 0211
GORDON*S FUNCTIONA+ HEA+TH PATTERN
He"!th Per(etion:
E7>ay lang na"an po a>oF Eayan /a>a pauiin na >a"i /u>as, "ga /ago "ag:10 ng tanghali >asi o>ay
na"an na siya eh, ala ng lagnatF ENung /inigyan siya ng ga"ut,"edyo hu"ila/ yung tiyan niyaF
N%trition"!,Met"'o!i(:
E&yun Magana na"an na siyang >u"ainF ENau/os >o yung paga>ain >o na "ay isdaF E+i/igyan da siya ng reseta n gvita"ins ni do>, in) ata yun tsa>a ii/ahin yung
/rand ng gatas niyaF
EMinsan di siya naghuhugas ng >a"ay /ago >u"ainF
A(tivit$, E-er(i#e:
E&yan pala>ad:la>ad siya dito sa loo/ ng roo", di "apa>aliF
E!imin"tion:
E*alaang /eses siya na>atae, nung una "edyo "atigas pero yung pangalaa"edyo lu"a"/ot naF
Eala po a>ong sa>it na narara"da"an pag u"iihiF
S!ee,Re#t:
ENa>a>atulog na"an siya ng "aayos >aya lang pag "ay "aingay,gala siya nggalaF
Se-%"!,Rero)%(tive:
E+a/ae po "adalas >ong >alaroF
Ro!e,Re!"tion#hi:
E Na"i"iss >o na po yung >uya >o tsa>a yung "ga >apatid >o.Na"i"isss >o poyung paglalaro na"inF
Coin.,#tre##:
Enaglalaro po a>o ng plants vs. o"/ies ts>a yung i/ang laro sa laptopF
V"!%e#,0e!ief:
ENagsisis"/a >a"i lingo linggo.F E=tong si Jethro lang tsa>a yung isa ang isinansa"a >oF
Se!f,er(etion:
EMahal >o po si "a"a..%usto >o na ring /uali> ng s)hoolF
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PHYSICA+ ASSESSMENT
S>in
Dith good s>in turgor, I 0se)s. dry s>in
No lesions on any part of the /ody
Presen)e of s>in rashes all over the /ody /efore ad"ission
S"ooth to tou)h
Dith "ini"al a"ount of perspiration
Dar" to tou)h
air
venly distri/uted thi)> hair
-elt it)hiness for so"eti"e
+la)> hair 7ily s)alp
No infestation of li)e
Nails
Slightly )urved
Dith )apillary refill of !0 se)s.
S"ooth, rounded, and )lean
yes
:! sun>en eye/all
:! eye dis)harge
:! redness, infla""ation or lesions Pale )onAun)tivae
ars
No lesions
No drainage, nodules or redness
S"all a"ount of dry )eru"en
Sy""etri) to the outer )anthus of the eye
Nose
Moist, pin>ish "u)osa
-ree fro" lesions
Mouth Moist /u))al "u)osa
*ry and pale lips
Dith hi))ups
Ne)>
No selling of ly"ph nodes
Supple ne)>
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Chest
Sy""etri)al )hest e6pansion
$$:04/p"
Clear /reath sounds
+reast
No dis)harge S"all, undi"pled. Sa"e )olor as the rest of the s>in
&/do"en
nlarged liver said /y the do)tor
pigastri) pain felt after re)eiving para)eta"ol
$e)tal
:! he"orrhoids
:! diarrhea
*efe)ates fro" hard to soft /ron stool
%enitalia
8oids 4:5 ti"es a day :! *is)harge
:! selling, redness
+ones:Aoints:"us)les
Dell fle6ed
9! $7M
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DIAGNOSTICS AND +A0ORATORIESJuly 04, 0211
$SUe
of high iron foods or supple"ents. -oods ri)h in iron in)lude#
$ed "eat -ish
Poultry
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"olor: yello# $acteria: moderateSpeci%c &ra'ity: (.)() "haracter: *urbid+$": --umerable Protei-: (.ogLR$": ()(/ Reactio-:0.)
1pithelial cells: 2e# Sugar: 34
5ursi-g "o-sideratio-:1-courage to dri-6 ple-ty o7 #ater. Dri-6 at least 8 glasses per day.
COURSE IN THE 1ARD
July 05, 0211
a" asleep on prone position ith L d5i"/ 522)) 6122 level of 352)) left
"eta)arpal vein 52")gtts("in. infusing ell ith soluset for CMC stand /yinitial vital signs ta>en as# T:3'.o), +P:G2(2""hg, P$:120/p", $$:0/p"
#15 a" )onsu"ed half of /rea>fast served@ "a)aroni ith )hi)>en sandi)h
#32 a" present =8- de)reased to 05))(hr as ordered
Eo>ay lang na"an po pa>ira"da" >oF as stated /y the patientEala na siyang rashes at pangangati, din a ri siya nilalagnatF as stated /y the
"other
ith slightly pale )onAun)tivaeith good s>in turgor, 0se)s.
ith )apillary refill of 0se)s.
"oist /u))al "u)osa
readiness to physi)al ellness r(t )o"plian)e to therapeuti) regi"en11 a" a" )are done li>e tooth /rushing and )hanging linen of /ed
en)ouraged to )ontinue in)reasing oral fluid inta>e to 1522"l
en)ouraged to )ontinue drin>ing of "il> as pres)ri/ed /y the do)toren)ouraged to )hange position freBuently
provided diversional a)tivities li>e reading /oo>s and riting
11#32 a" ate O of red apple10 p" )onsu"ed foods served for lun)h@fish and sayote
visited /y dr. )andelaria
10#15p" present =8- shifted to >vo as orderedsleeping in )ri/
0 p" endorsed to N7*
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July 0',0211
'#45 a" asleep on supine position ith L *5=M+ 522)) H87 level of 152))
en as# T:3'oC, +P:G2('2""
NCP PRO0+EM NO23
A##e##ment:
O'4e(tive &sleep on side:lying position
Dith no. *5=M+ 522)) 6 12 the level of 322 )) left "eta)arpal vein inta)t and
infusing ell
Te"p at 3G C
P$:122 /p"@$$:04 /p"
-lushed, ar" s>in noted
Moist oral "u)osa noted
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HEA+TH TEACHINGS
He"!th Per(etion "n) M"n".ement
Taught the "other )ontinuous tepid sponge /ath /e)ause it )an )ause heat loss /y
"eans of )ondu)tion Taught the patient to li"it )onta)t ith the person ho has illness n)ourage the )hild to e6press and rate pain
N%trition "n) Met"'o!i(
=nstru)ted the )lient to avoid eating Aun>foods and avoid drin>ing softdrin>s =nstru)ted the "other to pi)> and ash the foods )arefully =nstru)ted the "other to offer at least 0 glasses of "il> everyday n)ouraged the "other to offer the son nutritious food alays
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E!imin"tion
n)ouraged the )lient to in)rease fluid inta>e to avoid )on)entrated urine and)onstipation
&dvised the "other to )lean their restroo" /e)ause it )an /e the )ause of the illnessof her son
=nstru)ted to ash genitalia after voiding and defe)ating A(tivit$ "n) E-er(i#e
Provided diversional a)tivities li>e reading /oo>s and riting n)ouraged the )lient to so)ialie ith other >ids for hi" not to /e isolated at ho"e
S!ee "n) Re#t
n)ouraged at least hours of sleep to in)rease his i""une syste". &dvise "other to esta/lish )lear rules for rest periods reading or at)hing television
is all right@ playing a ga"e isnot,et).! &dvised "other to "anipulate her house in ter"s of resting ti"e
Co.nitive
n)ouraged the )hild to study his lessons at s)hool
Provided age related "o/ility n)ouraged riting and reading /oo>s
Se!f, er(etion
n)ouraged to /e opti"isti) alays
Se-%"!it$ "n) Rero)%(tive
n)ouraged to so)ialie ith sa"e and opposite se6
Ro!e "n) Re!"tion#hi
&dvised "other to /ring her other )hildren in the hospital t avoid feeling of isolation
Coin. Stre## To!er"n(e
n)ouraged ver/aliation of feelings
n)ouraged to avoid alays playing ith the )o"puter V"!%e# "n) 0e!ief#
Provided spiritual )are /y praying and providing +i/le stories