Grand Case Ee

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    CLEFT LIP AND PALATE

    A Case StudyPresented to the College of Nursing

    In Partial Fulfillment of

    the requirements for

    Related Learning ExperienceIn Medicine Ward of DMDH

    Shirley May De Gracia RN, MSNClinical Instructor

    John Carlo T. Chico

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    FOREWORD/PREFACE

    In creating this study, theauthors share to life the experiencesand differences theyve made withinthese pages, by describing what they

    have studied and learned during theirclinical exposure in the ObstetricsWardof Dona Marta Medical District

    Hospital.

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    FOREWORD/PREFACE

    And thus, not only did they becomeimproved nursing students but also theybecome more aware, open minded,found responsibility, help others and

    have move forward together, ready toface whats coming next for them.

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    FOREWORD/PREFACE

    Their knowledge was enhanced as they

    encountered different cases and proceduresin the Medicine Ward. These form importantlearning experiences, creating much newlight for them from pre-conferences andpost-conferences, medications, patients andsignificant others, assessments and a wholelot more vital to their nursing careers.

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    DEDICATION

    This study is dedicated to our

    loved ones whom never failed in givingus support financially, spiritually andmorally, for guiding us through and for

    showing us that even a big task can beaccomplished as long as there isteamwork and dedication. We alsodedicate this to ourselves because of thehard work and dedication we haveshowed in making this study and toMrs. Shirley May De Graciafor guiding

    us and believing in us.

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    DEDICATION

    Lastly, we dedicate this to thehealthcare team of Dona Marta MemorialDistrict Hospital because without them,there will be no basis for this study. Theyhave opened up their doors for us toattain and broaden our knowledge in thehealth care industry.

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    OBJECTIVES

    For this case study, we aim that:

    We will have better understanding ofTyphoid fever by reading books, articlesand journals that are related with thetyphoid fever;

    understand clearly the pathophysiology ofthe disease, risk factors, manifestationsand treatment and modalities of the

    typhoid fever; and equip ourselves with skills and health

    teachings that are appropriate for the careof patients with typhoid fever.

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    CASE INTRODUCTION

    A 21 years old male patientadmitted on June 27, 2013with diagnosis of Typhoid

    fever and experiencingrelapsing abdominal pain.

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    Typhoid fever, also known simplyas typhoid, is a common worldwide bacterialdisease transmitted by the ingestion of food

    or water contaminated with the feces of aninfected person, which contain thebacterium Salmonella entericaenterica, serovarTyphi.

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    PATIENTS DATA (BABY)

    NAME: Miss X

    GENDER: Female

    BIRTHDAY: May 23 ,1967

    Children: 4

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    Pathophysiology Typhoid fever is termed as an acute illness

    accompanied by fever caused by a gram negativebacilli called as Salmonella typhi. It is transmittedvia fecal- oral route through contaminatedwater supply or food. Clients who had harboured thisinfection may become asymptomatic for a long timeand could be called as carrier. Those carriers can

    then be a cause for future outbreaks of typhoid feverespecially if there is improper sanitation andhandling of food and poor hygiene.

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    Nursing Care Plan

    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Subjective:Pabalik balik angpagsakit ng tiyanng ko, madali langito nawawalangunit masakitas verbalized by

    the patientObjective>FacialGrimmase>Restlessness>BP 140/80mmHg>Temp 37.2 c>RR 26 cpm>Pulse 88 bpm>Pain scale of8/10

    Acute Pain After 8 hours ofnon-stop caringto the patient. Thepatient will beable to:>Minimized orease the pain

    >avoid theoccurrence ofpain

    >Regulate hisnormal V/S

    > Reduces thepain scale

    > Identify/Locatethe site of pain

    Identify thecausative factorsthat causing pain

    Administeredanalgesics orpainkiller ifneeded

    Demonstrateactivities that maydivert and relievethe pain

    Treat thecausative factorsof pain by givingmedications andusage of different

    techniques

    To localized thepain site

    To identify thecausitive agentand to providebaseline

    knowledge

    To relieve/lessen the pain

    To divert thepain and ease andrelieve the pain

    To avoid theoccurrence ofpain and treat themain source ofthe pain

    After 8 hours ofnon-stop caringto the patient. Thepatient will beable to:Minimized andeased the pain

    Avoid theoccurrence ofpain

    Regulated hisVital Signs

    Reduced thepain scale from8/10 to 4/10.

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    Drug Study

    TherapeuticClassification

    Action Contraindicaiton Toxicity/ SideEffects

    Safe Doze

    Metrinidazole

    Anti-Bacterial

    Bactericidal Contraindicated withhypersensitivity tometronidazoke;pregnancy

    Use cautiosly with

    CNS diseases, hepaticdisease, candidiases,blood dyscrasias,lactation

    HeadacheDizzinessInsomiaNausea andVomittingDiarrhea

    DysuriaThrombophlebitis dryness and skinirritation

    250mg-650mg

    Paracetamol

    Anti-pyreticand Anti-Analgesic

    Anti-pyretic and Anti-Analgesic

    Contraindicated withthe hypersensitivity tothe drug

    Hemolytic anemiaRashesLiver damage

    225mg- 650mg

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    Treatment

    Administer anti-pyretics drugs and antibacterialdrugs

    Infused d5lr or PNSS to reflenish the fluid loss and

    electrolyte imbalanced

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    DISCHARGE PLAN

    CA O O S

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    IMPLICATION OF THE STUDY

    The implication of this study in thepractice of nursing serves as a guide or atool for the fellow nursing students and

    staff nurses. It provides a detailedbackground, management, interpretationsand documentations for patients who havetyphoid fever. It will help broaden the

    knowledge and skills of the healthcareteam.