儿科病房护理实习案例分析PPT课件.ppt

By Group3PengSijing Stone LiXiaojing Cathy MiaoChunmei Mango NieFengyan Zara CASEPRESENTATIONPEDIATIRCWARD CONTENTS History PhysicalExamination Introduction LaboratoryResult MIMSMedication NursingCarePlan NeurologicExamination Introduction GENERALDATA p m e 13yearsold female Filipino Christian bornonMarch23 2004inManilacurrentlyresidingin270KalayaanB St BatasanHillsQuezonCity admittedforthefirsttimeatFEU NRMFMedicalCenteronMarch3 2018 CHIEFCOMPLAINT Vomiting History HISTORYOFPRESENTILLNESS Fourhourspriortoadmission whileswimminginthepool acontainerofmuriaticacidwasnotedtobeaccidentallyspilledinthepool theamountwasunknowntotheinformant Whilehercousinmovedoutofthepool shesubmergedherselfforafewsecondsuntilshewaspulledoutofthepoolbyheruncle Sheaccidentallyingestedapproximately1cupofpoolwater Shethenexperiencedizziness sorethroat chestpain difficultyofbreathingandbodyweakness Shethenwashedherselfintheshower Thereafter sheexperienced2episodesofnon projectile non bilous non bloodyvomitofpreviouslyingestedfoodaboutcupperbout Shewasthenbroughttoanearbyhospitalandwashookedtooxygenvianasalcannula Theywereadvisedtotransferhospitalsduetolackofapediatric History HISTORYOFPRESENTILLNESS Fewhourspriortoadmission uponarrivaltotheEmergencyDepartment shehad1cpisodeofnon projectile non bilous non bloodyvomitingofpreviouslyingestedfoodabout1 2cup Stillwithsorethroat chestpain difficultyofbreathingandbodyweakness Nodizzinessnoted Onphysicalexamination shehadsymmetricalchestexpansion withintercostal subcostalandsupraclavicularretractions cracklesallover wheezesalloverandtightairentry Shehadepisodesofdesaturationwithoxygensaturationof80 90 Completebloodcountwithplateletcountwasdonewhichrevealedleukocytosiswithneutrophilicpredominance BUN Creatinine andElectrolytesweredonewhichrevealednormalresults Electrolytesshowednormalresults Arterialbloodgasshowedfullycompensatedmetabolicacidosis Shewasadvisedadmission henceadmitted History PASTMEDICALHISTORY Patienthadtheusualchildhoodillnesssuchasmeasles varicella 2011 PatienthadthehistoryofPrimaryPulmonaryTuberculosis 2011 6monthstreatment Competedtreatmentin2013 Nohistoryofseizure bronchialasthma dengue allergiestofoodanddrugs historyofsurgeryorblood History FAMILYHISTORY Fatheris37yearsold Highschoolundergraduate Worksasapainter apparentlywellMotheris39yearsold Highschoolgraduate Worksasanailtechnician apparentlywellGrandmotherhasHypertensionandinmaintenanceofNorvasc5mgandcompliantNootherheredo familialdiseasessuchasdiabetesmellitus kidneydisease liverdiseaseandpsychiatricillnesses History IMMUNIZATIONHISTORY History NUTRITIONALHISTORY Thepatientwasexclusivelybreastfeduntil6thmonthofage ShewasintroducedtocomplimentaryfeedingwithCerelacandGerberonher6thmonthandricewithviandwasgivenat1yearold Now sheconsumes4cupsofricewithviandthreetimesdaywithsnacksinbetween History HEADSSIRST Homelife patientsharesabedroomandbedwithherauntandgrandmotherEducation sheisan8thgradestudentwithaveragegradesandisapartofthebadmintonclubAbuse nohistoryofabuseDrugs withhistoryofalcoholintake 2cupsofunrecalledalcoholmixture nohistoryofprohibiteddrugintake History HEADSSIRST Family nuclearfamily nohistoryofalcoholnordrugabuseFriends hasdifferentgroupsoffriendsineverysocialsettingbutiscarefulinwhoshehangsoutwithImage seesherselfasfat dressesuplikethe hypebeast cultureSafety playsvolleyballonthestreets noprotectivegear History HEADSSIRST Recreation shelikestoplaysportsandhangsoutwithherfriends sheisveryaciveonvarioussocialnetworkingsitesSpirituality sheisaBornAgainChristianwhogoestochurchonmostSundaysThreatsandViolence shehad1historyofselfharmwhenshewas11yearsoldwhenshecutherforearmwithacutterinschool nohistoryofrunningaway crueltytoanimals fightingnorstealing PERSONALANDSOCIALHISTORY History Thepatientliveswithhisparentsandsiblingsina1 bedroom2storyhouse well litandwellventilatedwith1window Themotheristheprimaryfinancialprovider WatersourceisfromMayniladanddrinkingwaterisfromadeepwell Garbageiscollectedtwiceaweek Hesleepsforabout10hoursaday History OBSTETRICANDGYNECOLOGICHISTORY Patienthadhermenarcheat12yearsold lastingfor5days consuming3padsperday moderatelysoaked withassociateddysmenorrhea Subsequentmenseswereregularwithintervalof28 30days lastingfor5days consuming3padsperday moderatelysoaked withassociateddysmenorrhea PhysicalExamination GeneralSurvey conscious coherent inrespiratorydistresswiththefollowingvitalsignsBP 120 80mmhgCR 100bpmRR 36cpmTemp 36 8CO2Sat 87 Wt 37 7kgHt 155cmBMI 15 71kg m2IBW 47 63kgz score nostuntingnowastingHEENT pinkpalpebralconjunctiva whitesclera intacttympanicmembrane pinkandboggyturbinates moistlips moistbuccalmucosa pinkpharyngealwallNECK suppleneck nopalpablelymphnodes non tender PhysicalExamination CHEST LUNGS symmetricalchestexpansion withintercostal subcostal supraclavicularretractionscracklesonalllungfields wheezesallover tightairentry HEART Adynamicprecordium normalrate regularrhythm nomurmurABDOMEN flat soft nontender normoactivebowelsounds non tenderEXTREMITIES nogrossdeformities fullandequalpulses capillaryrefilltime 2secondsSKIN noactivedermatoses NeurologicExamination Cerebrum GCS15 E4V5M6Cerebellum Nonystagmus NotremorsCranialNerves I Cansmellcoffeell 2 3mmequallyreactivetolightIll IV VI Intactextra ocularmusclesV Equalsensationsonbothsidesoftheface abletoclenchjawVIL NofacialasymmetryVIll Canhearsoundsbilaterally NeurologicExamination IX X Uvulaatthemidline canswallow intactgagreflexXl Abletoelevateshoulders canshrugbothshouldersequallyXII TongueinmidlineuponprotrusionREFLEXES Noprimitivereflexes negativeBabinskiSIGNSMENINGEALIRRITATION Nonuchalrigidity nokernig s noBrudzinski LaboratoryResult LaboratoryResult LaboratoryResult LaboratoryResult ADMITTINGDIAGNOSIS Substanceingestion inhalation Chlorine MIMSMedication MIMSMedication MIMSMedication MIMSMedication NursingCarePlan NursingProblem1 ImpairedgasexchangeChlorinedamagestheairway Goal Shecanbreathefreelywithoutfeelingbored InterventionsPositionpatientwithheadofbedelevated inasemi Fowler spositionastolerated Regularlycheckthepatient spositionsothatheorshedoesnotslumpdowninbed Turnthepatientevery2hours Monitormixedvenousoxygensaturationcloselyafterturning EncourageslowdeepbreathingusinganincentivespirometerAdministermedicationsasprescribed NursingCarePlan NursingProblem2 ActivityintoleranceInsufficientoxygensupply Goal Thegoalorexpectedoutcomeofapropercareplanistorestorethepatientsabilitytoperformregularactivitiesinahealthymannerwithoutexperiencinganysignsorsymptomsofactivityintolerance InterventionsEliminatenonessentialactivitiesorprocedurestoconserveenergyoutput conservestrengthforimportantactivitiesandensureadequaterest Assistpatientswithplanningandschedulingactivitiesandprovidedirectfeedbackonperformanceandimprovements Observeandaddressrestrictiveclothinganditemsthatmayimpactproperbloodflow oxygenlevelsandphysicalcomfort Nursin