Reyes JM Requirements

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NORTHERN LUZON ADVENTIST COLLEGE

Artacho, Sison, Pangasinan
A SEVENTH -DAY ADVENTIST INSTITUTION
Accredited by ACSCU -AAI & IBE -AA
SCHOOL OF NURSING
Tel. No. 075 -632 -2290 http://www.nlac.edu.p h e -mail address: Info@nlac.edu.ph ; dean.nursing.nlac@gmail.com
Name: JM Reyes
CASE STUDY
Patient's profile
I. Identification Data
Client Name: Caranay, Daniel D.
Age/Sex: 7/M
Father/Spouse name: Jameson Caranay
Ward: Room III
Hospital No.: 506048608210
Address: Sampaloc Bolinao, Pangasinan
Civil Status: Child
Religion: Roman Catholic
Date of Admission: January 22, 2023
Date of Discharge:
Diagnosis: Hospital Acquired Infection: Osteomylitis
Surgery (if any): none
Date of Surgery: none
Doctor In-charge:
II. Diagnosis
Hospital Acquired Infection: Osteomyelitis
Introduction:
Bone infection is called osteomyelitis. It is an acute or chronic inflammatory process involving the bone and its
structures secondary to infection with pyogenic organisms, including bacteria, fungi, and mycobacteria.
III. History
• Chief Complaints: 1month & 12 days PTA, the pt. feel from guava tree, had (+) fever 38.5 oC. Consultation done at Bolinao
Com. Center: unrecalled antibiotics, paracetamol and vit were given with temporary relief. 1month & 10days, pt. had pain and
Swelling on his left ear area and admitted at Eastern Alaminos. Antibiotics are given and stayed there for 6 days. Transferred to
R1MC (Dec 22) for facial nerve palsy sec to AOM. 2 day PTA, (+) body weakness, (+) headache, (+) ear pain, (+) fever, given
PCT. FHPTA, (+) body weakness, (+) vomiting.
• Past Medical History: Dec 14 - Eastern Alaminos
Dec 22 – R1MC – Facial nerve palsy
• Family History: none
IV. Physical Examination

• Skin: brown completion, dry skin, good skin, (-) pallor
• Head Eent: AS, PPC, patent nares, (+) inflammation r/t ear (tender)
• Lymph Nodes: no CLAP
• Chest and Lungs: SCE, CBS, NR
• Cardiovascular: AP, no murmur, NRRR
• Breast: grossly (n)
• Abdomen: soft, flat, non-tender
• Rectum: patent
• Genetalia: grossly (n)
System Review
• General:(+) loss of appetite
• Skin: (-) rash
• Eent: (-) eye discharge (+) ear pain
• Musculoskeletal: (-) tremors
• Respiratory: (-) colds
• Cardiovascular: (-) chest pain
• Gastrointestinal: (-) loose stool
• Genitourinary: (-) hematuria
• Female-Reproductive: (-) bleeding
• Nervous: (-) seizure
V. Laboratory
• Immuno-Hematology (CBC typing, Agglutination Reaction and ESR)
• Serum Electrolytes
• Clinical Chemistry (Creatinine)
• Creative Protein
• Blood Culture and Sensitivity (Initial and final)
• Clinal Microscopy (Urinalysis)
• CT scan (Cranial, Cranial with contrast and Temporal Bone)
• Chest X-ray (AP supine and lateral view)
Nursing Care Plan
Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Activity intolerance After 3 days of 1. Evaluate the level 1. This will serve as Goal partially met.
“Hindi niya po related to nursing of physical activity baseline data in
maigalaw pakanan osteomyelitis of right intervention, the and mobility of the devising and After 3 days of
ang ulo niya” as temporal bone as patient will patient. identifying nursing nursing intervention,
verbalizes by the evidence by difficulty demonstrate a goals during goal the patient
setting and treatment
mother. to turn the head in the measurable planning.
demonstrated a
right side. elevation in activity 2. Evaluate the measurable elevation
Objective: tolerance and will patient’s nutritional 2. Certain nutritional in activity tolerance
T: 36.8 oC employ methods status. requirements must be and will employ
PR: 107 bpm that can help met to efficiently methods that can
RR: 24 bpm alleviate activity perform physical help alleviate
O2Sat: 96% intolerance as activities. activity intolerance
evidence by able to 3. Promote active as evidence by able
move his head on range of motion 3. Physical activity to move his head on
-uneasiness the right side and exercises as well as through exercise can the right side and
help maintain muscle
-muscle atrophy relaxed movement participation in relaxed movement of
strength, exercise
-limitation of of the head. planning activities tolerance, and joint
the head.
movements that progressively range of motion.
establish the patient’s
endurance. 4. Physical exertion
through exercise can
4. Assist and teach help in promoting free
the patient on how to joint mobility and
perform isometric, circulation. It can also
and active and help in improving
passive range of muscle tone and
coordination and
motion exercises
preventing non-
applicable to all functional contracture.
extremities.
5. Performing
activities of daily
living promote general
5. Encourage the well-being.
patient to participate Encouraging physical
in ADLs within the activity at home can
physical limitations. help the patient
transition to perform
tasks independently.
6. Immobilize the 6.Immobilization of
affected part. the affected part with a
splint can help reduce
pain and muscle
spasms.
7. Allow rest periods
in between physical 7. Rest periods will
activities. allow the patient to
restore his/ her
baseline energy.
Collaboration 1. Physical therapists
1. Collaborate with are movement experts
physical therapist. who improve quality
of life through
prescribed exercise,
hands-on care, and
patient education.
DRUG STUDY
Name of Student: Reyes, JM I. Subject/Area of Exposure: R1MC Pedia Ward
Name of CI: Ervin Gelido, RN
Name of Drug Classification Mechanism of Nursing

Indication Contraindication Adverse Effect
Action Responsibilities
Generic Name It belongs to the Ceftazidime is a Ceftazidime Ceftazidime is Common side Nursing
class of medicines bactericidal agent injection is used to contraindicated in effects may considerations:
Ceftazidime known as that inhibits treat bacterial patients include: -Observe site
cephalosporin bacterial cell wall infections in many with known allergy • allergic closely for
Brand Name: antibiotics. synthesis different parts of to the reaction. extravasation
following the body. cephalosporin • numbness, during
Fortaz attachment to However, this group of tingling, administration.
penicillin binding medicine will not antibiotics. burning -Observe for signs
Dosage: proteins (PBPs). work for colds, flu, pain. of adverse effects.
This results in the or other virus • headache, -Observe for signs
700mg interruption of cell infections. dizziness. of renal, hepatic,
wall • nausea, or hematological
Route: (peptidoglycan) vomiting, dysfunction during
biosynthesis, diarrhea, prolonged therapy.
IV which leads to stomach -Monitor for signs
bacterial cell lysis pain. of super-infection.
Frequency: and death.
8o

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NORTHERN LUZON ADVENTIST COLLEGE

IV. Physical Examination

Assessment Diagnosis Planning Interventions Rationale Evaluation

Name of Drug Classification Mechanism of Nursing

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