CASE STUDY on Typhoid

7/25/2019 CASE STUDY on Typhoid

1/13

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


2/13

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


3/13

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


4/13

-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.


5/13

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


6/13

*&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


7/13

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)>


8/13

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


9/13

DIAGNOSTICS AND +A0ORATORIESJuly 04, 0211

$SUe

of high iron foods or supple"ents. -oods ri)h in iron in)lude#

$ed "eat -ish

Poultry


10/13

"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*


11/13

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


12/13

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


13/13

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

CASE STUDY on Typhoid

Documents

Transcript of CASE STUDY on Typhoid