Grand Case Ee
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Transcript of 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.