Arnel Biel Delcano Yna Moira m.

Ibrahim CASE ANALYSIS

06-18-13

1. Based on the given situation identify the subjective and objective data. SUBJECTIVE: Masaki tang tiyan ko dalawang araw na ngayon OBJECTIVE: Vomiting Temp = 39C (+) Rovings sign WBC

2. Formulate and develop 2 NCPs for the patient. HRP NSG DIAGNOSIS F E E L I N G Objective: Temp = 39C (+) Rovings sign WBC Pain r/t Subjective: AMB PATHOPHYSIOLO GY The appendix of the patient is inflamed and increase the production of histamine and prostaglandins making the patient feel pain CLIENT OUTCOME After intervention s the patient will be able to demonstrate use of relaxation skills, and other methods of comfort Maintain semifowlers position. NURSING INTERVENTION Assess pain noting location, duration, intensity (0-10 scale), and characteristics Changes in location or intensity are not uncommon but may reflect developing complications. Reduces abdominal distention, thereby reduces tension. RATIONALE EVALUA TION

Inflammation Masakit ang of tissue tiyan ko dalawang araw na ngayon

 Move patient slowly and deliberately.

Reduces muscle tension or guarding, which may help minimize pain of movement.

Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises.

Provide diversional activities.

HRP

NSG DIAGNOSIS

AMB

PATHOPHYSIOLOGY

CLIENT OUTCOME

NURSING INTERVENTION Monitor client temperature. Note shaking, chills or profuse diaphoresis. Advised to wear light

RATIONALE

EVALUA TION

E X C H A N G I N

Hyperthermia r/t metabolic rate Temp= 39C

Fever is the bodies response to infection, Therefore there will be increase metabolic rate resulting to fever

After interventions the patient will be able to have a body temperature within normal range

To note for any alteration in her temp.

So she will be comfortable

and be free of chills.

and non constrictive clothing. Provide tepid sponge baths.

and will the circulation will not impede. To decrease body surface temp.

Administer antipyretics as ordered OFI

To decrease core temp.

To replace water loss.

Our priority nursing care is pain r/t inflammation of tissues because if the patient is in pain, she will not cooperate to the intervention that the nurse will implement and also the patient will not able to get enough rest.

3. Make 2 drug study. GN B N CLASS MOA INDICAT ION CONTRAINDI USUAL CATION DOSE ACTUA L DOSE SIDE EFFECT S C E F U R O X I M E C E F T I N Cephalos -porin (second generatio n) Cefuroxime binds to one or more of the penicillinbinding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting Appendici tis Hypersensitivit y to cephalosporins . 750 mg IVTT q 6-8 hrs 750 mg IVTT q 8 hrs cerebral irritation and convulsio 2. Perform skin test ns; nausea, vomiting, diarrhea, GI disturban ces; erythema 3. Avoid alcohol while taking this drug and for 3 days after because severe reactions often occur. prior to administration 1. Observe 10s of drug administration NSG RESPONSIBILTY

biosynthesis and arresting cell wall assembly resulting in bacterial cell death.

multifor me

4. Report severe diarrhea, difficulty breathing, unusual tiredness or fatigue.

5.check renal function test result.

GN

B N

CLASS

MOA

INDICATIO N

CONTRAIN DICATION hypersensitivity to nalbuphine, sulfites

USUAL DOSE 10 -20

ACTUAL DOSE 10 mg IM

SIDE EFFECTS Sedation.

NSG RESPONSIBILTY

NALB UPHIN E HYDR OCHL ORIDE

N U B A I N E

Narcotic agonist-

acts as an agonist at

1. Relief of moderate to severe pain

1. Observe 10s of drug

mg/ml IM pre-op q 3-6h

Clamminess administration , sweating headache, 2.have a narcotic antagonist and equipment

antagonis specific t opioid

analgesic receptors in the CNS to

2. Preoperative analgesia, as a supplement to

nervousness, for assisted ventilation restlessness, depression, crying, confusion, faintness, hostility, unusual dreams, 4. institute safety and 3. monitor respiratory status readily available when administering the drug IV.

producean surgical algesia, sedation but also acts to cause hallucinati anesthesia, and for obstetric analgesia during labor and delivery

hallucination comfort measures.

ons and is an antagonist at recepto rs

s,euphoria, dysphoria, unreality, dizziness, vertigo, floating feeling, feeling of heaviness,nu mbness, tingling, flushing, warmth, blurred vision

5.Monitor response to the drug.

4. Make 2 diagnostic/laboratory studies CBC Determinants Actual values Normal values Interpretation Significance Nursing Responsibilities WBC 18.4 x 104/L 4.0 10.0 Increased It is increased because the patient has appendicitis RBC 4.58 x 1012/L 4.20 5.40 Normal 1. administer antibiotics as ordered 2. monitor intake and output HGB 120g/L 115 155 Normal 3. monitor and HCT 0.40 0.36 0.47 Normal regulate the IVF of the patient PLT MCV MCH 171 x 109/L 88.2 Fl 30.2 pg 150 400 85 - 95 28 32 Normal Normal Normal 4. increase OFI

MCHC RDW-SD NEUTRO

343 g/L 41.1 fL 85.2%

320 350 37 46 40 70

Normal Normal Increased It is increased because patient has appendicitis

LYMPHO

6.5

19 48

Decreased

It is decreased because patient has appendicitis

EOSINO

0.0

28

Decreased

It is decreased because patient has appendicitis

MONOCYTES BASOPHILS

8.2 0.1

39 0-5

Normal Normal

CXR IMPRESSION: There are no lung infiltrates Heart is not enlared Both lung fileds are remarkable