A Group Case Study 2nd Sem 1

lOMoARcPSD|34293632
lOMoARcPSD|34293632
PSYCHOSOCIAL
ASSESSMENT/FINDINGS
PRE ASSESSMENT POST ASSESSMENT PHYSIOLOGICAL BASIS

(3/30/22023) (3/31/2023)
Significant Others Ms. SK (Aunt)
Religion Catholic
Primary Language Iloko
Financial Resources Related to Health RHU

Care
Occupation Student
Education Grade 6, Elementary Student
General Appearance Well groomed and neat looking. Looks tired and stressed
During the assessment, the patient was
The patient appears to be the age provided. able to follow proper grooming. Since the
The patient is dressed accordingly. whether is hot, the patient wore a thin
fabriced shirt and a slightly loose short.
However the patient looks tired and
drained after the surgery due to the effects
of anesthesia.
Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

lOMoARcPSD|34293632
Affect Mr. JP shows signs of pain and discomfort. Mr. JP shows signs of pain, irritable and
uncomfortable The patient shows suitable facial
expressions in relation to emotions, since
pain is present before and after surgery.
Orientation Alert and oriented x4 (person, time, place, The patient needs to avoid speaking for The patient is well-oriented since he is
and situation). atleast 2 nights as ordered paying attention to the details and
answered the questions appropriately, also
Q: Pwede po bang malaman ang pangalan
the patient was able to comply with the
niyo?
doctor's order.
A: JP po
Q:Alam mo po ba kung anong date
ngayon?
A: March 30 po
Q: alam niyo po ba kung nasaan ka
ngayon and kung bakit ka andito? A:
Hospital po may tonsillitis po kasi ako

lOMoARcPSD|34293632
Memory We asked the patient to recite the letters The patient needs to avoid speaking for Immediate memory is good since, he was
Immediate Memory that we said. atleast 2 nights as ordered. able to repeat the letters correctly.
Q: Pwede po bang paki ulit ang mga
Immediate memory was not assessed
letrang Q, J, K, R? A: Q, J, K, R. during the post-assessment because the
patient was adviced to avoid speaking for
at least 2 nights.
We asked the patient to recall events from
months or weeks ago. Recent memory is good because he can
The patient needs to avoid speaking for remember the food he ate the night before
Recent Memory Q:Ano po kinain niyo kagabi? atleast 2 nights as ordered the assessment.
A: “Kumain po ako ng adobo at tilapiang
prito ng gabihan, nag miryenda rin po ako
ng tinapay at gatas bago matulog.”
We asked the patient to recall events that Remote memory is good, since he can
happened years ago. The patient needs to avoid speaking for remember the first time he experienced
Q: Ilang taon ka po unang nagka atleast 2 nights as ordered tosilitis
Remote Memory
tonsillitis ka?
Remote memory was not assessed since
A: 8 yrs old po the patient was asked to refrain form
speaking for atleast 2 days.
Speech Pateint’s speech is vague, with a low The patient needs to avoid speaking for
The patient cannot verbalize properly
volume and tone, stuttering, and slurring. atleast 2 nights as ordered
during the pre assessment due to tonsil
pain.
Patient was refrained from speaking during
the post assessment.

lOMoARcPSD|34293632
Nonverbal Behavior Mr. JP shows signs of pain and fear. Mr. JP shows postoperative pain
Signs of pain and discomfort was observed
in patient’ s nonverbal behavior.
Elimination
PRE ASSESSMENT POST ASSESSMENT PATHOPHYSIOLOGICAL

(3//30/2023) (3/31/2023)
Stool operation
The patient didn’t poop since No abnormalities found in the stool of the
● Color His feces is brown (light and dark depends the patient during the pre-assessment.
on the food that he eats) Stool was not assessed during the post-
● Consistency assessment because the patient did not
Stated that his feces appears to be soft in N/A
consistency defecate that time due to lack of apetite
after surgery.
● Frequency He poops once a day N/A
● Amount Minimal N/A

Urine The patient since the
● Frequency Ms. SK stated that he voided 4 times operation Urinary retention is a common
didn't urinate
during the day and thrice during the night. complication that arises after a patient has
anesthesia or surgery. The analgesic drugs
often disrupt the neural circuitry that
● Color Yellow controls the nerves and muscles in the
N/A

lOMoARcPSD|34293632
● Odor None N/A urination process.
● Specific Gravity 1.015 N/A
● With difficulty or with pain upon Absence of pain N/A

urination
Toilet Activity The patient doesn't need assistance i The client can ambulate slowly and can go
going to the toilet. n to the toilet with assistance. The patient was able to defecate and
urinate alone during the pre-assessment.
The patient needed assistance when

walking and going to the toilet after the
surgery.
REST AND ACTIVITY

(3//30/2023) (3/31/2023)
Current Activity Level The client can sit, stand, and walk slowly Body movements are limited.
without assisstance. The patient can tolerate the pain and move
alone during the pre-assessment.
Activities are limited during the post

assessment due to recovery from surgery.
Activity of Daily Living:

lOMoARcPSD|34293632
● Dressing Mr. JP can dress himself independently but Patient JP was able to independently
Mr. JP can dress himself independently. with minimal assistance handle his daily living activities during the
pre-assessment.
Patient JP needed minimal assistance after

Mr. JP can feed himself with minimal his surgery.
● Eating assistance
Mr. JP can feed himself without the any
assistance
● Brushing Mr. JP can brush his teeth with assistance

Mr. JP can brush his teeth routinely
● Bathing Mr. JP cannot take a bath

without assistance
Mr. JP can take a bath without assistance
and he takes a bath daily
Sleep Pattern Sleep history: Sleeps without disturbance Sleep history: Sleeps with disturbance due Tonsillectomy causes difficulty and
but tonsils are slightly irritated. to post-operation pain. disturbance when sleeping since it can be
uncomfortable to breathe through your
Duration: 7 hours of sleep Duration: 6 hours of sleep mouth right after surgery
Quality: Below Normal Quality: Below Normal

lOMoARcPSD|34293632
Body Pattern Weight: 55.5 kg Weight: 55.5 kg Based on the height and weight entered, the
BMI is 28.4, placing the BMI-for-age at the
Height: 145cm Height: 145cm 98th percentile for 12 year and 9 month-old
boys. This falls in the Obesity BMI category.
BMI: 28.4 (overweight) BMI: 28.4 (overweight) Having excess weight can increase a child or
teen’s risk for type 2 diabetes, high blood
pressure, or other chronic conditions.
Posture Normal Spinal Curvature Normal Spinal Curvature
Gait The patient can walk normally without the The client can walk slowly with assistance.
assistance of significant other.
Coordination Fine: Able to hold the hands of his mother. Fine: Able to hold the hands of his mother.
Gross: Able to flex and extend his upper Gross: Able to flex and extend his upper
extremities. extremities.
Muscle Strength No involuntary movements. No involuntary movements.
Strength: 4/5 Strength: 3/5
SAFE ENVIRONMENT

lOMoARcPSD|34293632

(3//30/2023) (3/31/2023)
Allergies/ Reaction
Medication: Mr. JP doesn’t have any allergies and reactions to medications
Food: Mr. JP doesn’t have allergies/reaction to foods
Environment: Mr. JP doesn’t have allergies/reaction to environment
Eyes/Vision
PERLLA all assessed as normal
Pupils contract when light enters the client’s eye.
Equal. Pupils are around the same size- 4 mm
Round. Pupils are perfectly round spheres
Reaction to. Pupils responds to its environment
Light. Pupils contracts when exposed to light
Accommodation. The client can see objects near and far distance (until 4-5 meters
away)
Hearing/ Hearing Aid There were no lesions, or unusual There were no lesions, or unusual
secretion noted on both ears. secretion noted on both ears.
The patient doesn't use any hearing The patient doesn't use any hearing
devices devices

lOMoARcPSD|34293632
Skin Skin: slightly cold and pale Skin: not-so-warm to touch

Lips: pink Lips: pink
Nail beds: pink Nail beds: pink
Palm: slightly cold to touch Palm: not-so-warm to touch
Mucous Membrane Patient experiences sore throat, burning Patient experiences pain and slight In very rare cases, tonsillitis can cause
sensation over the tongue and friable bleeding in the tonsils due to surgery. tonsils to bleed. This is more likely with
white/ gray patch on the oral mucosa. certain viruses that cause ulcers or sores
on the tonsils.Tonsils are next to many
major blood vessels, so severe bleeding
can quickly become life-threatening.
TEMPERATURE 36.3 degrees Celsius, right axillary 36.6 degrees Celsius, right axillary If there is a risk of infection after a
tonsillectomy, it is more likely that the
temperature would increase rather than
decrease. However, it's important to note
that not all infections will result in a fever,
and other symptoms such as pain, redness,
swelling, or discharge at the surgical site
may also indicate an infection
OXYGENATION

(3//30/2023) (3/31/2023)
Patient is able to perform his daily Limited body movements Feeling of tiredness and limited body
Activity Tolerance activities. movements are normal after tonsillectomy.

lOMoARcPSD|34293632
Airway Clearance Due to the tonsillitis, the patient is snoring Patients airway is clear and patents The enlarged tonsils during post
which means that there is an airway assessment was cause by airway
obstruction/narrowing obstruction that led to difficulty in
swallowing, difficulty speaking, and
snoring.
Respiration Rate: 22 cpm Rate: 21cpm

Rhythm: Rapid breathing Rhythm: Regular Rapid breathing during pre-assessment
was caused by swelling of tonsils and
airway blockage.
98% 99%
Oxygen Saturation
Pulse rate Rate: 88 beats per minute Rate : 74 beats per minute
Location: Apical pulse Location: Apical pulse
Rhythm: regular Rhythm: regular
Strength: normal Strength: normal
120/80 mmHg 120/60 mmHg

Blood pressure
Lung Sounds No adventitious sounds such as crackles or wheezes auscultated.

Capillary Refill -less than 3 seconds -less than 3 seconds
-pink tone has returned immediately when -pink tone has returned immediately when
pressure is released pressure is released
Brownish Brownish
Skin Color
lOMoARcPSD|34293632
0 0
Edema
NUTRITION

(3//30/2023) (3/31/2023)
Hospital Diet Restrictions NPO
DAT
Avoid acidic foods
Cold, soft, and blonde foods.
Fluid Intake 8-10 glassess of cold water The patient didn't drink water since the During the pre-assessment, the patient was
operation well hydrated, but was unable to drink
after the surgery (post-assessment).
Tonsillectomy, or removal of the tonsils,
causes pain and discomfort in the patient,

making it difficult for the patient to drink
and eat.
IVF D5LR D5LR
Skin Turgor
Snaps rapidly back to its Snaps rapidly back to its
normal position normal position
Patient is able to chew, swallow, and feed Patient is able to chew, hard to swallow,
Ability to CHEW, himself. and feed himself.
SWALLOW, FEED
HIMSELF

lOMoARcPSD|34293632
DRUG STUDY
Mechanism of Side/Adverse Nursing

Date and Time Drug Indication Contraindication
Action Effects Responsibility
Pre-op: Generic Name: Decreases Used to treat Contraindicated to CNS: Monitor patient’s
March 30, 2023 Dexamethasone inflammation, mainly inflammatory patients euphoria, insomnia, weight, blood
Sodium Phosphate by stabilizing conditions hypersensitive to psychotic behavior, pressure, and
6:00PM leukocytes lysosomal drug or its pseudotumor electrolyte levels.
Therapeutic membranes. ingredients. cerebri, vertigo,
March 31, 2023 Classification: headache, Inspect patient’s skin
Corticosteroid paresthesia, seizures, for patechiae.
2:00AM depression
Don’t confuse
Pharmacological CV: dexamethasone with
Classification: Heart Failure, desoximetasone.
Glucocosteroid hypertension, edema,
arrhythmias, PATIENT
Doctor’s Order: thrombophlebitis, TEACHING:
Dexamethasone 4mg thromboembolism
IV q 8 Teach patient signs
EENT: and symptoms of
Cataracts, glaucoma early adrenal
insufficiency:
GI: fatigue, muscle
Peptic ulcerations, weakness, joint pain,
GI irritation, fever, anorexia,
increased appetite, nausea, shortness of
pancreatitis, nausea, breath, dizziness,
vomiting fainting

lOMoARcPSD|34293632
GU: Warn patient about

Increased urine easy bruising
glucose and calcium
levels
Metabolic:
Hypokalemia,
sodium retention,
weight gain
Musculoskeletal:
Growth suppression
in children, muscle
weakness,
osteoporosis, tendon
rupture, myopathy
Skin:
Hirsutism, delayed
wound healing, acne,
various skin
eruptions, thin fragile
skin
Other:
Cushingoid state,
susceptibility to
infection, acute
adrenal, insufficiency
after increased stress,
Angioedema

lOMoARcPSD|34293632
Pre-op: Generic Name: Inhibits cell-wall Indicated as a Contraindicated CV: Monitor patient for
March 30, 2023 Cefuroxime sodium synthesis, promoting treatment for hypersensitive to Phlebitis, signs and symptoms
osmotic instability; pharyngitis and drug or other thrombophlebitis of superinfection and
6:00PM Therapeutic usually bactericidal. tonsillitis cephalosporins. diarrhea and treat
Classification: GI: appropriately.
Antibiotics Diarrhea,
pseudomembranous Patient is at risk for
Post-op: colitis, nausea, bleeding, monitor
March 31, 2023 Pharmacological anorexia, vomiting patient.
Classification:
5:40PM Second-generation Hematologic: Do not confuse
cephalosporins Hemolytic anemia, cefuroxime with
thrombocytopenia, other cephalosporins
Doctor’s Order: eosinophilia that sounds alike.
Cefuroxime 750 mg
IV q 12 Skin: PATIENT
Maculopapular and TEACHING
erythematous rashes,
urticaria, pain, Instruct patient to
induration, sterile notify prescriber
abscesses, about rash, loose
temperature stools, diarrhea, or
elevation evidence of
superinfection.
Other:
Anaphylaxis, Advice patient
hypersensitivity receiving drug IV to
reactions, serum report discomfort at

sickness IV insertion site.

lOMoARcPSD|34293632

Pre-op: Generic Name: Ipratropium Management of Hypersensitivity to CNS: Take care to prevent
March 30, 2023 Combivent UDV bromide: reversible atropine or its Headache leakage around the
(Ipratropium bromide - Inhibits vagally bronchospasm derivatives. mask for patients
7:00PM and Albuterol sulfate) mediated reflexes by associated with EENT: using nebulizer since
antagonizing obstructive airway Throat irritation, eye pain or
March 31, 2023 Therapeutic acetylcholine at cough temporary blurring
diseases.
Classification: muscarinic receptors of vision may occur.
5:00AM ● Ipratropium on bronchial smooth GI:
muscle. GI motility disorders Monitor patient for
bromide:
(constipation, effectiveness.
bronchodilator
diarrhea, vomiting),
● Albuterol Albuterol sulfate: - nausea, dizziness
sulfate: relaxes bronchial,
Bronchodilators uterine, and Others:
vascular smooth Dry mouth
Pharmacologic muscle by
Classification: stimulating beta 2
● Ipratropium receptors.
bromide:
Anticholinergic
● Albuterol
Sulfate:
Adrenergic
beta-2 agonist
Doctor’s Order:
1 vial q 8
Date and Time Drug Mechanism of Indication Contraindication Side/Adverse Nursing

lOMoARcPSD|34293632
Pre-op: Generic Name: Thought to produce Indicated for the Contraindicated to CNS: Use cautiously when
March 31, 2023 Acetaminophen analgesia by relief of mild to patients with known Agitation, preparing and
(Paracetamol) inhibiting moderate pain and sensitivity to administering IV
7:15PM prostaglandin and the reduction of acetaminophen. CV: acetaminophen to
Therapeutic other substances that fever. Tachycardia avoid dosing errors
Classification: sanitize pain leading to accidental
Analgesic receptors. GI: overdose and death
Post-op: Constipation
April 1, 2023
GU:
1:00AM Pharmacological Oliguria
Classification:
Para-aminophenol Hematologic:
derivatives Leukopenia,
neutropenia,
pancytopenia,
Doctor’s Order: anemia
Paracetamol 600mg
q 6 TIV x pain x 4 Hepatic:
doses Jaundice
Metabolic:
Hypoalbuminemia,
Hypoglycemia,
hypokalemia,
hypomagnesemia,
hypophosphatemia

lOMoARcPSD|34293632
Musculoskeletal:
Extremity pain
Respiratory:
Wheezing, hypoxia,
pulmonary edema,
stridor
Skin:
Infusion-site pain

lOMoARcPSD|34293632

Pre-op: Generic Name: Competitively and Given intravenously, Contraindicated in CNS: Be alert for unusual
March 31, 2023 Tranexamic Acid reversibly inhibits tranexamic acid is patients with a Dizziness bleeding or bruising
the activation of indicated for short- known or bruising. Report to
1:00AM Therapeutic plasminogens via term use in patients hypersensitivity to EENT: physician
Classification: binding at several with hemophilia to tranexamic acid or Visual abnormalities immediately.
Hemostatic agents distinct sites, prevent or reduce any of the
ingredients. Severe CV: Check blood pressure
including four or five bleeding.
Post-op: Pharmacological Hypotension, especially if patient
low-affinity sites and allergic reactions
March 31, 2023 Classification: thromboembolism, develops dizziness or
one high-affinity have been reported.
Antifibrinolytic thrombosis syncope.
10:00AM site, the latter of
which involved in its GI: Instruct patient to
Doctor’s Order: binding to fibrin. The Diarrhea, nausea, report other side
Tranexamic acid binding of vomiting effects such as severe
500g IV q 8 x 2 plasminogen to fibrin or prolonged vision
doses induces fibrinolysis – abnormalities or GI
by occupying the problems (nausea,
necessary binding vomiting, diarrhea).
sites tranexamic acid
prevents this
dissolution of fibrin,
thereby stabilizing
the clot and
preventing
hemorrhage.
Date and Time Drug Side/Adverse Nursing

Effects Responsibility
lOMoARcPSD|34293632
Mechanism of
Indication Contraindication
Action
Pre-op Generic Name: Inhibits proton pump Indicated as a Contraindicated in CNS: Monitor patient for
March 31, 2023 Omeprazole activity by binding management to patients Asthenia, dizziness, signs and symptoms
to hydrogen- improve the gastric hypersensitive to headache of acute interstitial
6:00 AM Therapeutic potassium adenosine environment. drug or its nephritis.
Classification: triphosphate, located components. GI:
Antiulcer drugs at secretory surface Abdominal pain, Prolonged use of
Post-op: Use cautiously in constipation, PPIs may cause low
of gastric parietal
April 1, 2023 patients with diarrhea, flatulence, magnesium levels.
cells, to suppress hypokalemia and
Pharmacological nausea, vomiting Monitor magnesium
gastric acid respiratory alkalosis levels before starting
6:00AM Classification:
PPIs secretion. Musculoskeletal: treatment and
Back pain, weakness periodically
thereafter.
Doctor’s Order: Respiratory:
Omeprazole 20 mg Cough, upper Do not confuse
IV OD respiratory infection omeprazole with
aripiprazole,
Skin: esomeprazole, or
Rash fomepizole.
PATIENT
TEACHING
Teach patient to
recognize and report
signs and symptoms
of low magnesium
levels.


lOMoARcPSD|34293632
Post-op: Generic Name: Hexetidine is a For disinfection and Contraindicated in GI: Caution patient that
March 31, 2023 Hexetidine bactericidal and prevention of patients taste disturbances, the solution may be
fungicidal antiseptic bacterial, fungal, and hypersensitive to irritation, too harsh to taste.
8:00 AM with a broad yeast infection of the solution of tingling/numbness of
Therapeutic spectrum oral mucosa. hexetidine and the tongue or inside Assess patient for
Classification: antimicrobial activity components of the the mouth, any lesions in the
Antiseptic against gm +ve and drug. sensitization mouth.
gm –ve bacteria,
yeast and fungi Not recommended PATIENT
Pharmacological under six years of TEACHING:
Classification: Anti- age without doctor’s Instruct patient not to
infective advice. swallow the
medication.
Doctor’s Order:
Bactidol mouthwash
after meal
DOCTOR’S NOTES NURSE’S NOTES .

lOMoARcPSD|34293632
NURSING DATA, ACTION, AND RESPONSE
DATE/TIME DOCTOR’S ORDER FOCUS
April 30, 2023 Admission D: A 12-year-old boy arrived at Nueva Vizcaya Provincial Hospital with a presenting symptom of snoring
3:00 PM and dysplasia
Please submit to ROC

Vital signs were taken with data of;
Diagnostics:
- Antigen Swab test
● Body Temperature: 36.3°C (afebrile)
- Complete Blood
● Heart rate: 88 beats per minute
Count
● Respiratory rate: 22 counts per minute
- Blood Typing
● Blood pressure: 120/80 mmHg
- Partial ● O2 sat: 98%
Thromboplastin
Time (PTT)
A: Seen and examined by Dra. Ayahao with order made and carried out
- Electroencephal ● consent for admission and laboratory request or diagnostic procedure secured.
ogram (EEG)
- Electrocardiogra m
(ECG) 4:50 PM R: Request forwarded, endorsed
Pediatric Evaluation
(-) fever
(-) cough

lOMoARcPSD|34293632
(-) neurologic
deficiency
(-) airway difficulty
and with clear breath sound
(-) cardiac pathology
(+) history of seizure
(+) Recurrent
tonsillitis
5: 00 pm D: Inform ER per wheelchair
Post- transfer
March 30, 2023 For Tonsillectomy and 5:00 pm D: For tonsillectomy at 6: 00 am on Friday
Adenoidectomy tomorrow Pre- operative care
Pre- op orders at 6 am- first case under
general anesthesia A: Notified OR team
5: 10 PM
● consent secured
Pre- operation clearance to ● informed Dr. Apostol for anesthesia and Dr. Manaois for pediatric clearance ● IV
Dr. Hazel Manaois inserted and hooked D5LRS II regulated at KVO rate
D5LRS IL regulated at R: For further care

KVO rate
6:00 pm A: Administered Cefuroxime and Dexamethasone as ordered

➢ Skin test cefuroxime and
Diclofenac. If negative,

lOMoARcPSD|34293632
may start,
Dexamethasone IV q8
➢ Administer Cefuroxime
750 mg IV q12 ANST
➢ Administer
Dexamethasone 4 mg IV
q8
D: the available room at private ward

7: 00 pm
A: Instructed S.O. regarding transfer
Trans out
● hospital policy reiterated
● informed nurse on duty regarding transfer
R: Transferred via wheelchair
8: 45 pm
9:00 pm
D: For tonsillectomy as scheduled
Pre operative care
A: Oral hygiene advised,
● IV patency ensured
Vital signs taken and recorded with a data of:
T: 36. 5
BP: 120/ 70 mmHg
RR: 22 cpm
PR: 88 bpm

lOMoARcPSD|34293632
10:00 pm ➢ Strictly NPO at 10 pm A: Instructed NPO at 10: 00 pm
12: 00 am ➢ Fluid D5LR 1L 12 hours

A: Hooked D5LRS IL regulated at
KVO rate
➢ Combivent ncb and 5 am,1 A: Administered Combivent as ordered, 1 hour prior to surgery
March 31. 2023 hr. before OR
5:00 am
5:55 am R: Endorsed to OR
6: 00 am A: Administered Omeprazole as ordered.

Omeprazole 20 mg IV
OD
D: General anesthesia inducted by Dr. Apostol

6:00 am
A: antisepsis done; sterile draping applied
Induction of
anesthesia
➢ Endorse patient to the 6: 30 am D: operation started by Dra. Ayahao

Operating Room
Surgery A: Received by the OR nurses endorsed by the nurse via wheelchair, antisepsis done; sterile draping
applied

lOMoARcPSD|34293632
R: Patient was cooperative.
March 31, 2023 Endorse patient to the 6: 57 am D: In to RR per stretcher S/P tonsillectomy and adenoidectomy
Post-op orders PACU Trans-in A: Received at PACU endorsed by the OR nurse via wheelchair
6:57 am To RR, VS q15 until · Place the patient in a high fowler position.
stable for 2 hours
● O2 administered via facial mask at 2 to 3 pm
● V/S monitored and recorded every 15 minutes for 2 hours.
Diet cold soft, diet with ● Monitored for any untoward signs and symptoms, due meds given as ordered.
aspiration precaution ● IVF regulated at the same rate
● Transferred to RR per stretcher
Regulate IVF to 35
ugtts/min
IVF to follow D5LR same

rate
Continue cefuroxime
q12
Nalbuphine 5 mg q4 x
severe pain

lOMoARcPSD|34293632
Continue omeprazole
Continue
dexamethasone 4 mg 98
IV x 3 dose more
Please refer
Monitor vital signs 7: 00 am

Patient’s vital sign has been monitored with a data of;
BP: 120/60
SPO2: 99
RR: 21
PR: 79
Ø Monitor vital signs 7: 15 am A: Patient’s vital sign has been monitored with a data of;
BP: 130/80
Ø Paracetamol 600 mg
q6 TIV x pain x 4 doses SPO2: 99
RR: 22
PR: 80
· Paracetamol administered as per doctor’s order

lOMoARcPSD|34293632
Monitor vital signs 7: 30 am A: Patient’s vital sign has been monitored with a data of;
BP: 130/70
SPO2: 99
RR: 22
PR: 81
BP: 120/80
SPO2: 99
RR: 21
PR: 75

lOMoARcPSD|34293632
Ø Monitor vital signs 8: 00 am

A: Patient’s vital sign has been monitored with a data of;
BP: 130/70
SPO2: 99
RR: 22
PR: 81
Ø Monitor vital signs 8:15 am

A: Patient’s vital sign has been monitored with a data of;
BP: 130/70
SPO2: 100
RR: 20
PR: 84

lOMoARcPSD|34293632
BP: 130/70
SPO2: 99
RR: 20
PR: 80
Ø Monitor vital signs 8:45 am A: Patient’s vital sign has been monitored with a data of;
BP: 130/70
SPO2: 99
RR: 21
PR: 78

lOMoARcPSD|34293632
Ø Diet cold soft blonde 9: 00 am D: Status tonsillectomy

diet Trans out
A: Medications given, IVF regulated accordingly, Cold soft blonde diet, monitor for untoward signs and
Ø Bactidol mouthwash
symptoms
after meal
Patient’s vital sign has been monitored with a data of;
Ø Ice-cream or ice
cubes to prevent BP: 140/90
bleeding
SPO2: 99
Ø Avoid speaking for at
least 2 nights RR: 21
Ø Please refer PR: 78
R: Endorsed patient with stable vital sign and bearable post- op pain
A: Administered Tranexamic as ordered by the Doctor

Ø Tranexamic acid 500 mg IV
q8 x 2 doses
Ø Continue A: Continued to administer Dexamethasone as ordered

dexamethasone 4
mg 98 IV x 3 dose
more
5:00 pm D: “Medyo masakit ato”y karabukob ku,” as stated by the client
Altered comfort With a pain scale of 8/10

lOMoARcPSD|34293632
A: monitored pattern of comfort
● diverted activities advise

● comfort measure rendered
● kept rested, secured safety
R: “Haan unay nasakiten,” as stated by the client
With a pain scale of 6/10
5:40 pm ➢ Continue cefuroxime q12 A: Continued to administer Cefuroxime as ordered.
A: Administered Paracetamol as ordered.

➢ Administer Paracetamol
April 1, 2023 600 mg q6 TIV x pain x 4
doses
1: 00 am
6: 00 am ➢ Administer Omeprazole A: Administered Omeprazole and Cefuroxime as ordered
20 mg IV OD
➢ May go home with 1:00 pm

hospital clearance D: may go home order by Dra. Ayahao
➢ Home medications Discharge
planning A: Health teaching instructed
- Clindamycin 300
mg 2x a ● proper hygiene and daily wound care emphasized ●
day Home meds and follow up advised.
R: discharged with good condition.

lOMoARcPSD|34293632
- Etoricoxib 200 mg
bid for pain
➢ Follow -up on Monday

4/10/23 at 10: 00 in the
morning, Solano
NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING INTERVENTION
RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Surgery Short term: Independent: GOAL MET
Within 2 hours of Perform pain ●
investigate, or Short Term:
nursing intervention, monitor changes
After 2 hours of
assessment
Tissue the patient will: from the previous
nursing
Injury/Inflammatory ● Verbalize each time pains reports
intervention, goal
Cell methods occur was met as
that provide evidence by the relief ● Pain may
result in patient able to:
Sense by fatigue, which
● Verbalize
Nociceptor may result in
methods
● Demonstrate exaggerated pain. that provide use of A peaceful and relief
Converted to relaxation Provide quiet quiet electro chemical skills and environment
may ● Demonstrate
signals diversional Environment facilitate rest.

use of
lOMoARcPSD|34293632
Subjective Cues: Acute pain “Medyo

masakit related to ato”y karabukob postku,” as verbalized operative by the client incision
secondary to
Objective Cues: tonsillectomy
● Pain Scale of 8/10
● Presence of facial grimace
Vital Signs
T: 36.6 °C

lOMoARcPSD|34293632
P: 75 bpm Transmitted to activities as ● Exercises were relaxation

R: 21 cpm spinal cord by indicated for effective in skills and
BP: 120/60 Dorsal Root individual reducing the pain diversional
mmHg Ganglia situation experienced due activities as
to various factors indicated for
on the first individual
Brain ● Absence of
and second situation
facial
postoperative
grimace
days
Acute Pain ● Absence of
facial
Long Term:
To divert focus grimace
Within 1 days of Instruct, or ● from pain
nursing interventions
encourage use
patient will: Long Term:
● Report a of breathing
After 1 days of
distinctive relaxation
nursing
reduction exercise interventions, goal
Ice causes your
in severity ● blood vessels to was met as evidenced
of pain narrow, by the patient able to:
>3 decreasing blood ● Patient reported
flow to the area. 3/10 using the
In turn, this helps numerical pain
reduce the scale
Encourage inflammation that
causes swelling
diversional
Reduces pain
activities (watching TV,
reading)
●
Give ice cubes
or ice cream

lOMoARcPSD|34293632
Dependent:
Use of
analgesic
medications:
Paracetamol
600 mg q6 TIV
x pain x 4 doses
Etoricoxib 200
mg bid for pain
Nalbuphine 5
mg q4 x severe
pain
ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING INTERVENTION RATIONALE EVALUATION
Subjective Cues: Risk for Post tonsillectomy Short term: Independent: GOAL MET
“Panu po pag ineffective Within 1 hour of ● Encourage to increase Short Term: After
nahirapan po ako airway nursing intervention, fluid intake ● Adequate 1 hour of nursing
huminga” as clearance Retained secretion the patient will: hydration keeps intervention, goal
evidenced by and blood secretions moist
verbalized by the collection of Increase the work ● Maintain a ● and easier to was met as
Position patient in semi ●
lOMoARcPSD|34293632
patient secretion of bre athing patent airway or high fowlers expectorate evidence by the
and blood in Inability as patient able to:
Objective the demonstrated ● Maintain a
Cues: oropharynx to cough To take advantage patent airway
by normal
● (-) sign of of gravity as
respiratory
DOB decreasing demonstrated
rate and
● (-) Difficulty ve airway pressure on the by normal
rhythm and
swallowing Ineffecti ance diaphragm and respiratory
clear breath
● (-) Child clear enhancing rate and
sound.
breathe via drainage rhythm and
mouth only of/ventilation to clear breath
● Expectorate different lung sound.
Place the child prone or
Secretions segments
Vital Signs ● side-lying position.
readily. ● Expectorate
T: 36.6 °C
Secretions
P: 75 bpm ● Demonstrate
Promotes readily.
R: 21 cpm absence or
BP: 120/60 drainage of blood
reduction of ● ● Demonstrate
mmHg and unswallowed
congestion with absence or
saliva from the
breath sounds reduction of
Discourage the intake mouth that can
clear, respiration congestion
● of milk, ice cream, and potentially be
noiseless, with breath
pudding. aspirated.
improved oxygen sounds clear,
exchange. respiration
These dairy
noiseless,
products may coat
Long Term: improved
● the throat causing
Within 1 day of Advise to have oxygen
the child to cough
nursing interventions ● adequate rest periods exchange.
out and clear the
patient will:
throat.
● Demonstrate
Long Term:
breathing
After 1 day of
Rest conserves nursing
energy and interventions, goal
●

lOMoARcPSD|34293632
● pattern with no ● reduces degree of was met as evidenced

shortness of dyspnea by the patient able to:
● Teach and ● Demonstrate
breath and
demonstrate breathing breathing
acute distress
exercises. Promotes lung pattern with no
expansion, shortness of
Practice deep
enhanced air breath and
breathing and
exchange and acute distress
coughing
● prevents the risk
exercises
of pneumonia.
● Administer ● Practice deep
oxygen breathing and
This will correct
coughing
impaired gas
exercises
exchange
Dependent:
● Use of Reduces
analgesic inflammation
medications:
IV
Prevent an
Corticosteroids
infection
caused by
bacteria.
Antibiotics (e.g.,
penicillin, Reduce
amoxicillin, or pharyngea
erythromycin) l edema.


lOMoARcPSD|34293632
Subjective Cues: Risk for Surgery Short term: Independent: GOAL MET
“Ano po gagawin infection Within 1 hour of ● Assess vital signs with ● Signs of septic Short Term: After
namin para di po related to nursing intervention, frequent, noted no shock, endotoxin 1 hour of nursing
mainfect ung impaired oral Immune system the patient will: improvement or circulation causes intervention, goal
sugat nya” as mucousa ● Verbalize continuing vasodilation, loss was met as
verbalized by the secondary to understanding hypotension, of fluid from the evidence by the
SO Tissue Injury of individual patient able to:
tonsillectomy decreased pulse circulation, and
causative/risk ● Verbalize
pressure, tachycardia, low cardiac output
Objective factors. understanding
Exposure to fever, tachypnea. status.
Cues: of individual
● (-) signs of opportunistic causative/risk
infection pathogens ● Identify ● Warm, redness,
factors.
noted preventions to dry skin is an
prevent/reduce early sign of
Invasion of infection. septicemia. ● Identify
Vital Signs Further preventions to
● Note the color,
T: 36.6 °C ● Demonstrate manifestations prevent/reduce
temperature, humidity.
P: 75 bpm Infection technique, include cold, pale of infection.
R: 21 cpm lifestyle skin moist and
BP: 120/60 changes to cyanosis as a sign ● Demonstrate
mmHg promote safe of shock. technique,
environment. lifestyle
changes to
● Prevent the
promote safe
Long Term: spread and limit
environment.
Within 1 day of the spread of
nursing interventions infectious
patient will: organisms / cross Long Term:
● Achieve timely contamination. After 1 day of
● Maintain strict aseptic
wound nursing
technique in the interventions, goal
healing; be treatment of wound
free purulent was met as evidenced
incision / open, and the ● Reduces infection
drainage or by the patient able to:
invasive side.

lOMoARcPSD|34293632
erythema; be Dependent: ● Achieve timely

afebrile ● Use of wound
analgesic healing; be
medications: free purulent
drainage or
Cefuroxime 750
erythema; be
mg IV q12 afebrile
ANST
Clindamycin
300 mg 2x a
day
Dexamethasone
4 mg IV q8
Bactidol
mouthwash

lOMoARcPSD|34293632

Subjective Cues: Risk for fluid Short term: Independent: ● Replaces losses GOAL MET
“Ano po gagawin volume Cells Within 1 hour of ● Administer IV fluids via from surgery Short Term: After
pag ayaw nya po deficit Diverting nursing intervention, infusion pump as and maintains 1 hour of nursing
kumain kasi po related to energy from the patient will: ordered. Monitor IV site hydration if the intervention,
masakit daw po decreased food away ● Plan an eating hourly. child is unable to goal
ung lalamunan fluid intake from normal Diary/list that drink. was met as
niya” as metabolic includes evidence by the
secondary
verbalized by the highcalorie, patient able to:
to pain on ● Small quantities
SO processes highprotein ● Plan an eating
swallowing may be more
Due to foods and Diary/list that
Objective easily tolerated.
abnormal supplements ● Provide clear cool non- includes
Cues: Red, purple, or
cell growth and reflects citrus fluids in small highcalorie,
● (-) Lack of brown may
his food amounts (e.g., crushed highprotein
appetite stimulate the
preferences. ice, popsicles); Avoid foods and
Lack of appearance of
red, purple, or brown supplements
appetite blood if the child
Vital Signs liquids. and reflects
● Verbally vomits.
T: 36.6 °C his food
P: 75 bpm demonstrates preferences.
Decreased the ● Refraining from
R: 21 cpm food intake
BP: 120/60 understanding drinking through
in selection of ● Verbally
mmHg a straw lessens
foods and demonstrates
Intake the risk of
meals suitable ● Discourage the use of the
insufficient physical trauma
for acquisition straws or any sharp understanding
to meet in the operative
of appropriate object inside the in selection of
metabolic site and suction
weight. mouth. foods and
produced
meals

lOMoARcPSD|34293632
needs ● Understand ● in sucking may suitable for

the cause bleeding. acquisition of
importance of appropriate
Pain when taking an weight.
swallowing Excessive
adequate
coughing, nose
amount of ● Understand
blowing, clearing
nutrition. the
fluid volume deficit the throat, or
importance of
vomiting may
taking an
Long Term: ● Discourage excessive promote bleeding
● adequate
Within 1 day of coughing, nose in the operative
amount of
nursing interventions blowing, or clearing of site.
patient will: nutrition.
throat. Administer
● Report antiemetics as Teaching ensures
improved prescribed to prevent that parents will Long Term:
sense of vomiting. continue to After 1 day of
energy. ● monitor fluid nursing
● Regain balance. interventions, goal
interest in was met as
food. ● Provide parents with evidenced by the
Nutritional support patient able to:
discharge instructions
may be ● Report
on diet, fluid intake,
recommended for improved
activity, and when to
patients who are sense of
notify medical team.
unable to energy.
maintain
Dependent: nutritional intake ● Regain
● Consider the possible by interest in
need for enteral or the oral route. If food.
parenteral nutritional gastrointestinal
support with the tract is functioning
patient, family, and well, enteral tube
caregiver, as feedings are
appropriate indicated.

lOMoARcPSD|34293632

lOMoARcPSD|34293632
CHAPTER X REFERENCES
Deitrick, K., Adams, J., & Davis, J. S. (2020). Emergency Nursing Care of Patients With
NovelCoronavirus Disease 2019. Journal of Emergency Nursing, 46(6), 748–759.
https://doi.org/10.1016/j.jen.2020.07.010
Is your sore throat strep? (2023, May 10). Centers for Disease Control and Prevention.
https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html
Pediatric Tonsillitis - Children’s Health. (n.d.).

https://www.childrens.com/specialties-services/conditions/tonsillitis
Rheumatic Fever: All You Need to Know | CDC. (n.d.).

https://www.cdc.gov/groupastrep/diseases-public/rheumatic-fever.htmlRheuma
ticfeverisacondition,importantinfightingoffinfections.
Rheumatic fever - Diagnosis and treatment - Mayo Clinic. (2022, April 19).
https://www.mayoclinic.org/diseases-conditions/rheumatic-fever/diagnosis-treatment/drc-2035
4594 Sahin, M. Ö.,
Streptococcus pyogenes (Group A β-hemolytic Streptococcus). (n.d.).

http://www.antimicrobe.org/b239.asp
VanPutte, Regan, & Russo. (2019). SEELEY’S ESSENTIALS OF ANATOMY &

PHYSIOLOGY (10th ed.). Mc-graw Hill Education.
https://drive.google.com/file/d/1dUOb9HRNWW9iajKUIGZ54nnn4j6lS7dM/view
Yalcin, M., & Kocyigit, D. (2016). Prevalence of rheumatic heart disease in patients with
recurrent tonsillitis and elevated anti-streptolysin O titers. International Journal of
Pediatric Otorhinolaryngology, 89, 133–135. https://doi.org/10.1016/j.ijporl.2016.08.0
lOMoARcPSD|34293632

A Group Case Study 2nd Sem 1

Uploaded by

Copyright:

Available Formats

You might also like

A Group Case Study 2nd Sem 1

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

A Group Case Study 2nd Sem 1

Uploaded by

Copyright:

Available Formats

lOMoARcPSD|34293632

PRE ASSESSMENT POST ASSESSMENT PHYSIOLOGICAL BASIS

Significant Others Ms. SK (Aunt)

Primary Language Iloko

Financial Resources Related to Health RHU

Education Grade 6, Elementary Student

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

Patient was refrained from speaking during

the post assessment.

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

PRE ASSESSMENT POST ASSESSMENT PATHOPHYSIOLOGICAL

● Amount Minimal N/A

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

● Odor None N/A urination process.

● Specific Gravity 1.015 N/A

● With difficulty or with pain upon Absence of pain N/A

The patient needed assistance when

REST AND ACTIVITY

PRE ASSESSMENT POST ASSESSMENT PATHOPHYSIOLOGICAL

Activities are limited during the post

Activity of Daily Living:

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

Patient JP needed minimal assistance after

● Brushing Mr. JP can brush his teeth with assistance

● Bathing Mr. JP cannot take a bath

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

Posture Normal Spinal Curvature Normal Spinal Curvature

Muscle Strength No involuntary movements. No involuntary movements.

Strength: 4/5 Strength: 3/5

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

PRE ASSESSMENT POST ASSESSMENT PATHOPHYSIOLOGICAL

Food: Mr. JP doesn’t have allergies/reaction to foods

Environment: Mr. JP doesn’t have allergies/reaction to environment

Pupils contract when light enters the client’s eye.

Equal. Pupils are around the same size- 4 mm

Round. Pupils are perfectly round spheres

Reaction to. Pupils responds to its environment

Light. Pupils contracts when exposed to light

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

Skin Skin: slightly cold and pale Skin: not-so-warm to touch

PRE ASSESSMENT POST ASSESSMENT PATHOPHYSIOLOGICAL

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

Respiration Rate: 22 cpm Rate: 21cpm

120/80 mmHg 120/60 mmHg

Lung Sounds No adventitious sounds such as crackles or wheezes auscultated.

PRE ASSESSMENT POST ASSESSMENT PATHOPHYSIOLOGICAL

causes pain and discomfort in the patient,

IVF D5LR D5LR

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

Mechanism of Side/Adverse Nursing

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

GU: Warn patient about

Date and Time Drug Indication Contraindication

Action Effects Responsibility

reactions, serum report discomfort at

Downloaded by Shermaigne Buya (buyashermaigne@gmail.com)

Mechanism of Side/Adverse Nursing