Professional Documents
Culture Documents
CASE STUDY
BY: GROUP I
FACULTY OF NURSING
AIRLANGGA UNIVERSITY
2009
2
PREFACE
Author
3
CONTENTS
Cover.........................................................................................................i
Preface.....................................................................................................ii
Contents..................................................................................................iii
I. Case .................................................................................................1
CASE STUDY
II
A. ASSESSMENT
1. Patient Identity
Name : “B”
Age : 2,5 years old
Race : Java
Religion : Moslem
Education :-
Address : Mulyorejo, Surabaya
– Vital Sign :
Temperature: 38,80 C P : 135 x/minute RR : 30 x/menit
6
– Psycho-social
Client’s mother said that he is jealous of his new baby
sister because he has occasional tantrums when she holds the
baby. Client’s mother is concerned about client’s development
because he recently started to refuse using potty, a skill that is
newly acquired. Client crying and seems irritable.
– Endocrine System
Complain : None
1. Laboratorium
Blood
• Hb : 11,9
• PLT : 160
• WBC : 13,2
• RBC : 3,00
• PCV : 37,4
Urine : Leukosit : 1-3
1. Radiologi :
2. Therapy :
A. DATA ANALYSIS
Objective Data
Temperature of
1020 F
Tympanic
membranes red
and bulging
bilaterally
Pharynx slightly
red without
exudates
Lab test WBC :
13,2 K/UL
Client’s mother
said that Billy
tension in medial ear
has been irritable
and feverish
9
Objective:
Pharynx slightly
red without
exudates
Objective
Nasal congestion
with clear
discharge
The client’s can’t
perform effective
cough
Difficulty
vocalizing
A. NURSING DIAGNOSTIC
C. PLANNING
Expected
Dx Nursing Orders Rationale
Outcomes
at-rest or
compromised
individual, such
6. inform client or as one with sleep
care giver to apnea
maintain 6. Cold water or
adequate fluid fluid can lower
intake especially the verge limit of
warm fluid. allergic and
7. Administer make nasal
prescribed congestion worse
expectorant,
decongestant or 7. Expectorant
anti histamine helps loosen
secretions so
they can be
coughed up an
wxpelled.
Decongestant
and or anti
histamine can
8. Discuss
helps reduce
important of
mucous edema
following the
and nasal
therapeu-tic
congestion
procedure as its
8. Discipline in
schedule
following the
9. Inform client/
therapeutic
caregiver about
procedure deter-
the medication
mine the success
procedure (e.g.,
of therapy
the use of
9. Knowledge about
medicine, side
medication can
effect, schedule,
14
dosage) increase
client/care-giver
discipline, avoid
anxiety related to
side effect of
medicine and
also determine
the success of
therapy
(e.g.,
inflammation,
4. assessment pain
trauma,
scale helps to
infection
plan the suitable
process)
way to relieve
4. Use pain rating
pain
scale
appropriate for
age/ cognition
(e.g., facial
expression/Wo
ng-Baker faces
pain scale for
pediatric or
nonverbal,
5. identify behaviors
behavior pain
that may indicate
scale)
pain in persons
5. Observe
who cannot
nonverbal
communicate
cues (e.g.,
verbally. Helpful
how client
in recognizing
walks, holds
presence of pain
body, guarding
behaviors, gri-
macing facial,
narrowed
6. Blood pressure,
focus; crying,
respiratory and
lethargy in
heart rate are
infant)
usually altered in
6. Monitor vital
acute pain
signs during
7. The type of
episodes of
medication
pain
ordered depends
16
pressure in ear
(e.g., promote
swallowing or
yawning)
enhances
immune system
3. Teach parents
functioning in
how to measure
presence of
child’s
infection and is
temperature, at
not harmful as
what body
long as individual
tempe-rature to
is not dehydrated
give antipyretic
or susceptible to
medica-tions,
febrile seizures.
and what
Fever may be
symptoms to
treated at home
report to
to relieve the
physician
general
discomfort and
lethargy
associated with
fever. Fever is
reportable,
however,
especially if it is
unresponsive to
antipyretics and
fluids, because it
often
accompanies a
treatable infec-
tion (viral or
bacterial)
4. Adequate fluid
intake needs to
replace fluids lost
through perspira-
19
4 Demonstrate un-
1. Assess 1. Identifies
derstanding in
client/care- teaching needs
avoid altered nutri-
giver and/or helps
tion; risk for less
knowledge of guide choice of
than body require-
nutritional intervention.
ments. As eviden-
needs and
ce by:
ways client is
a. Client/
meeting these
caregiver
needs. 2. Increase appetite
verbalizing
2. Teach can increase the
understandi
client/care- nutrition intake.
ng how to
giver way to in- a. To promote
keep
crease sense of control
adequate
appetite: and give client
nutrition
a. Determine when opportunity to eat
intake for
client prefers/ when feeling
client
tolerates largest more rested, less
b. Client
meal of the day. pain or nausea
finished all
Maintain flexi- b. Reduce feeling of
of his meal
bility in timing of fullness that can
c. Present
food intake accompany
weight in
b. Provide nume- larger meals, and
control
rous small feed- to improve
22
possible
withheld before
2. Suggest
meals or with
client/care-
meals if
giver to
interfering with
promote
food intake
adequate/timel
y fluid intake
5 1. Expectation of
Client/caregiver 1. Discuss family
client and family
Demonstrate perceptions of
members
effective family situation
may/may not be
coping
realistic and may
Outcome criteria: interfere with
ability to deal
a. Client/ family 2. Identify current be-
with situation
can verbalize haviors of the
2. Indicators of
the way to cope family members
extent of
the situation (e.g., ig-noring/
problems existing
caring client at
b. Family/parents with-in family.
home; anger and
verbalizing their Relation-ships
ways of touching
understanding among family
between family
of growth members before
members, care
process in and after current
expressions)
toddler new born affect
3. Suggest family to ability to deal
involve client in with problems of
taking care of the caretaking
new baby 3. Getting involve in
24
5. Helping family/
parents to take
6. Explain family/ pa-
care of client
rents about the
appropriate to
importance of
client growth.
deve-loping good
6. Good
com-munication
communication
between parents
make it easier for
and child
family to teach
client skill that is
appropriate to his
growth (e.g.,
using potty)
C. IMPLEMENTING
1. Ineffective 1. Monitoring
1. Respiration rate
air-way respiratory
35x/ minute.
clearance status; rate,
Difficulty in
related to re- depth
respiration
tained secret
because of nasal
and edema
congestion with
of nasal
clear discharge.
mucous
Client has runny
nose
2. RR: 35x/minute,
2. Monitoring vital pulse:
sign 100x/minute,
temperature: 1020
F
3. Clear discharge
from nasal. Client
3. Evaluating
cannot expel the
amount and type
secretion by
of secretions
coughing it up
being produce.
4. Client’s parents
said that they
really concern
4. Assessing
about client
client/care-giver
condition and don’t
knowledge of
know about the
contributing
medication
causes,
treatment plan,
specific
medication and
therapeutic 5. Client’s parents
procedures said that they
26
9. Informing
client/care-giver
about the
medication
procedure (e.g.,
27
the use of
medicine, side
effect, schedule,
dosage)
3. Observing
nonverbal cues
(e.g., how client
walks, holds
body, guarding
behaviors,
grimacing facial,
4. RR: 35x/minute,
narrowed focus;
pulse 100x/minute,
crying, lethargy in
temperature 1020F
infant)
28
blood flow)
4. Client’s verbalizing
their willingness to
promote adequate/
timely fluid intake
for their child
C. EVALUATION
Nursing
Evaluation
Diagnosis
1
S:
O:
2 S:
– Client’s parents said that they understand and know
how to helps their child to demonstrate the way to
maintain same pressure in ear
35
O:
3
S:
O:
4
S:
36
O:
5
S:
O:
A : Goal meet
P : Intervention stopped