Indirect Inguinal

Hernia
Hernia
Indirect
Inguinal
IN

3D
 Demographic Data

 
Patient Name : H.M.
Age : 10 years old
Sex : Female
Birthday : December 2,2000
Civil Status : child
Address : Indang Cavite
Religion : Roman Catholic
Nationality : Filipino
Educational Background : Elementary Level
Date of Admission : September 9,2010
Chief Complaint : Fever and abdominal pain
Final Diagnose : Dengue Fever Syndrome
Attending Physician : Dr. Reyes
Hospital : Korean Philippines Friendship
Hospital
SOURCES AND RELIABILITY OF THE INFORMATION

• The data presented in the case was taken

from the hospital chart as well as from
the patient mother through nursing
patient interaction.
 
III. Chief Complaint

According to the mother she

brought her son the hospital because of
high fever with abdominal pain.
• IV. History of Present Illness

• Two days prior to admission the patient

experience cough, colds and fever
• V. Past Medical History

• According to the mother all vaccination of his

son is completed since at birth and this is the
first time she brought her son to the hospital.
Family History
 Health Perception and Health Maintenance
 
 

According to the patient’s mother she always consulted with the health center whenever her children got sick or not feeling well.
• Self-esteem, Self Concept and Self Perception
Pattern
•  
• According to the mother her child always
telling her everything that happen to her
especially what is happening in the school.
• Sleep / Rest Pattern

• According to the mother her child always

sleep early during weekdays and even though
during weekends.
•  
• Activity and Exercise
• As verbalize by the mother, her child is not
really interested in any kind of activities at
home but participated activities at school.
• Nutrition and Elimination Pattern
• According to the mother her child eat any
kind of food she prepared and consume junk
food also.
• Sexuality
• According to segmund freud (psychosocial
theory). He belong in the school age child in the
latent phase (children libido appears to be
diverted into concrete thingking.)
•  
•  
• EnterPersonal Relationship
• As verbalize by the mother, her child is a loving
daughter and always has fun with their neighbor.
•  
• Stress Management / Tolerance Pattern
• According to the patient’s mother her child way of handling
pressure especially at school is talking to her and to his father.
•  
•  
• Personal Habit
• As verbalize by the mother she always reminds her child
on good hygiene and she always follow her instruction.
•  
• Environmental Hazard
• The patient live besides the highway, and their place is prone
to accident.
Review of systems
Sept. 12, 2010 Sept. 13, 2010

Pale looking, with Pale looking, with

Abdominal pain scale of 4, Abdominal pain scale of 4,
Limited movement Limited movement
Febrile- 38.7*C Afebrile- 36.9*C
(+) petichae. (+) petichae.
(+) petichae, warm skin to (+) petichae, warm skin to
touch, flush skin touch, flush skin

RR= 29cpm, with RR= 26cpm, with

productive cough productive cough
CR= 66bpm, CR= 72bpm
Bp=80/60mmHg Bp=90/60mmHg
No abnormal Normal heart
sound sound

Normal bowel and Normal bowel and

urine output. urine movement.
Limited range of Limited range of
movement movement

Scalp intact, no Teary eyes, pale

lesions, pale conjunctiva, normal
conjunctiva vision
Anatomy and Physiology
Blood

Whole blood has two components:

(1) blood plasma, a watery liquid matrix
that contains dissolved substances, and

(2) formed elements, which are cells and

cell fragments.
Blood is about 45% formed
elements and 55% plasma. Normally
more than 99% of the formed
elements are red-colored red blood cells.
Pale colorless white blood cells and
platelets occupy less than 1% of total
blood volume.
 Bite from Infected
Aedes Aegypti

Dengue Virus Type I(Chikungunya Virus)

IgG adheres to the platelet

(initiates destruction of the platelet)

inflammatory response

petechial rash, high fever, headache

abdominal pain)
 Normal Results Significance Nursing
implimentat
ion

WBC 4.1- 10.9 6.4 Normal Within the

WBC 4.1- 10.9 5.0 Normal normal range
Within the
normal range
Lympocytes 0.6-4.1 1.5 Normal Within the
normal range

Lympocytes 0.6-4.1 .71 Normal Within the

normal range

Segmenters 0.45-.65 .29 Decrease Infection

Segmenters 0.45-0.65 .31 Decrease Infection

RBC
RBC 4.20-6.30
4.20-6.30 4.4
4.2 Normal
Normal Within
Within the
the
normal
normal range
range

HGB 12.0-18.0 13.2 Normal Within the

HGB 12.0-18.0 12.9 Normal Within
normal the
range
normal range

Hct 37-51 39 Normal Within the

normal range
Hct 37-51 38 Normal Within the
normal range
Platelet 140-440 135 Decreased Risk for
count bleeding

Platelet 140-440 139 Decreased Risk for

count bleeding
Dosage,
Side Effects
Nursing
Drug Indication &&
Mechanism
Responsibilities
Name Classification
Frequency and Contraindication
Action
Route

Generic
275mg Name:
IV q 4 Honohoid
>I- analgesicsof
Treatment and
Paracetamol
Anemia, hepatitis, antipyretics
Reduce fever
-Brand
assessName: mild
patient for history of liver diseaseby
to moderate or
analgesic
alcohol acting
Tempra abuse (acetaminophen
pain and onexcessive
and the
fever
nephropathy,
alcohol may have adverse hypothalamus
livernot
does have to
effects)
-monitor vital signs and cause
nephrotoxicity signs of adverse
reaction at beginning of antirheumatic
therapy and at regular
with chronic vasodilatation and
intervals with long term effects
use.
overdose, sterile
-take with food or milk. sweating.
(analgesics)
pyuria. (limited to >C-
important of life hypersensitivity to
threatening acetaminophen or
symptoms. any component of
the formulation:
patients with
known G6PD
deficiency.
Side
Drug
Dosage,
Effects
Name
NursingFrequency Classification
Indication
Mechanism
Responsibilities &&
and Route Contraindication
Action

>Headache,
Generic
7.5 ml TID
>Obtain Name:
nausea,
patients historyMucolytic
>I-
>Reduces
ofAcute
coughand
the
agents
chronic
before
Ambrozol
vomiting
therapy and, HDI
anoresia, disorders
viscosity
reassess after givingofof
thebronchial
the
drugs.
Brand
gastric discomfort, respiratory
secretions
> Instruct patient to follow exactly the and
tract
diarrhea,
Name:
directionGI onbleeding
medication. associated
facilitates
Stress thewith
Ambrolex
and disturbances,
importance of notskin pathologically
expectoration.
taking more drug than
rash. Bronchospasm,
directed. thickened mucus and
stomatitis, and
> Advice medical impairedfor
consultation mucus
rhinorrhea. Chills, of than
persistent cought transport.
more than 7 days.
fever.
> AdiseHemoptysis.
patient to avoid>C- Hypersensitivity
smoking, smoke
Other
filled isolated reports todust
rooms, perfumes, ambroxol
and or any
including dizziness,
environmental ingredient
pollutants, these canof
insomia,palpitation
increase cough. ambrolex.
and mild sugarless loznges to decrease
> Suggest
hypoglycemia.
throat irritation and cough. Hard candy
orgum can be used to prevent dry mouth.
Nursing
Dosage,
SideDrug
Effects
Name
Responsibilities
Indication
Mechanism
Classification
&&
Frequency and Action Contraindicatio
Route n
750mg
-CV:
Generic
before
phlebitis,
IVgiving
Name:
q 8 drug>I- serious
Second
2nd
askgeneration
if he is
respiratory tract in
thrombophlebiti
allergic
Cefuroxime
to penicillins
generation
cephalosporin
or
fection, UTI, skin
s
cephalosporins.
sodium cephalosporin
structure infection,
Brand bone
that or joint
inhibits cell
GI: diarrhea,
-obtain specimensinfection,
for culture and
nauseaName:
sensitivity wall
andtest before synthesis
giving
septicaemia, first
zinacef
vomiting,
dose. Therapy may promoting
meningitis,
begin while
gonorrhoea
anorexia.results. osmotic
awaiting
instability;
preoperative
prevention.
usually
>C
bactericidal.
- contraindicated in
pts hypersensitive to
drug or other
cephalosporins.
Nursing
Drug Name
Dosage, Responsibilities
Frequency
Side Effects Classification
Indication
Mechanism&&
and Route Contraindication
Action

-Assess
1 ampule
Generic
CNS: qpatient
8
Name:
headache for>I-
H2 abdominal
active duodenal
receptor
Competitively
pain.
Ranitidine
malaise, vertigo gastric
inhibitsulcer.
antagonist action of
Hydro-chloride
EENT: -maitenance
-Noteblurred
presence ofhistamine
blood
therapy
on the H2
in
for duodenal
vision
Brand and the receptors site
emesis, stool,
Hepatic: Jaundice
Name:
or gastric
or gastric aspirate.
ulcer
of parietal cells,
- drug
Others: may be added
Anaphylaxis, -gastro-
to total
decreasing gastric
Zantac esophageal reflux
angioedema,
parenteralburning acidsolutions.
nutrition secretion.
and itching at the -erosive
-instruct patient toesopahagitis
injection site. which or
without regard to>C- mealsin patients
because
hypersensitivity to
absorption isn’t affected
drugs and by
thosefood
with
acute porphyria
  
ACTUAL PROBLEM

PROBLEM DATE IDENTIFIED DATE RESOLVED

1 Fever September 12, 2010 Resolved

2 Ineffective airway clearance September 12, 2010 Resolved

3 Abdominal pain September 12, 2010 Resolved

4 Ineffective tissue perfusion September 12, 2010 Ongoing

 
POTENTIAL PROBLEM
PROBLEM NO PROBLEM

1 Risk for bleeding

PLANNING
ASSESSMENT DIAGNOSIS
EXPECTED OUTCOME
 
Actual Problem “Fever “

S> “Mainit ang

The
Short ptTerm
shallnya”
pakiramdam haveasa decreased bodyrelated
Hyperthermia
temperature from 39.8 to 37
At the end by
verbalized of the
the shift the
to patient
increasetemperature
metabolic
The pt shall have identified
will decrease from 38.7 rate
mother to 37. underlying
in the body as
factors
O> and importance of treatment
evidence by as
well as s/sx requiringtemperature
Long Term further evaluation
of 38.7
>
orTemp of 38.7 the patient will identify
intervention
Prior to dismissal
underlying factors & importance of
> Flushed skin
treatment as well as s/sx requiring further
evaluation or intervention
> Skin warm to touch
 Expected outcomes Diagnosis
Assessment
Intervention Planning
Rationale
ineffective airway clearance

>Establish Rapport >To gain patient trust

>Monitor
S>”Nahihirapan
The patient Vital Signs
will >Totoobtain
Ineffective
be able baseline
Airway
maintain
siyang
airway huminga”
patency. as data
Clearance related to
>Encourage deep
Short
verbalized
breathing
Term
by the increased mucous
At the end and
mother. >To
of the shift the incision
production
patient in to
willthe
be
coughing exercises. maximize
able to maintain airwaybronchial
O>reproductive effort.
patency tree as
>Elevate the head of evidence
cough >To takebyadvantage
Long
the bed
>with
Term
or change
wheezes of gravity decreasing
productive coughwill
At the end
position. of hospitalization the patient
pressure on the
>with
be ablecrackles upon behaviors
demonstrate to improve or
>Increase fluid
auscultation on intake diaphragm
both and
maintain
leastclear
to atfields. airway. enhancing drainage
2000ml/
lung
day.
>RR=29 of ventilation to
>Auscultate breath different lung
sounds and assess air segment.
movement. >To help liquefy
>Encourage secretion.
opportunities for rest > To acertain status
and limit activities to and note progress.
level of respiratory >To promote
tolerance. wellness.
Expected outcome Diagnosis
Assessment
Planning Knowledge Deficient

S> “Nasakit
The patient ang
willtiyan
able toAcute pain alteration
decrease the pain
niya”
from as 6 toverbalized
4. in comfort related to
Short
by Term
the mother. asmanifested by
O>facial grimace facial grimace and
*>Pain
At thescale
end of
of 6the shift the pain
with verbal will be
report able
of pain.
to decrease pain
is moderate the pain from 6 to 4, which is
mild pain.
>Irritable

Long term
*At the end of the hospitalization the patient
will be able to free from pain
 INTERVENTION Planning
RATIONALE
ineffective tissue perfusion EXPECTED OUTCOME
ASSESSMENT DIAGNOSIS

Independent To gain patient trust

Establish Rapport To obtain baseline data
Monitor Vital Signs
To assess contributing factors
Subjective:
Assess patient’s condition
The pt shall have
“nanghihina sya” demonstrated
Ineffective
For comparison with tissue
current p
behaviours
Short
Note to improve
Termby the erfusion
customary baseline data circulation
findings
as
The
At verbalized
pt shall
the end of the haveshiftdemonstrated
the patient will from
mother
Determine presence of
increased perfusion
demonstrate related
To to
identify alterations
behaviorsasnormal
toappropriate
improve
dysrhythmias
Objective:
circulation. decreased HgB
Perform blanch test concentration
To in the
identify / determine adequate
Long
-decreased
Check
Term
for Homan’sWBC sign
perfusion
blood secondary to
  To determine presence of
At the end of DHF 1formation
-decreased
Note platelet thrombusthe
hospitalization
presence of bleeding pt will
demonstrate increased perfusion as
Elevate HOB To determine risk of anemia
-decreased HgB
appropriate
Encourage quiet & restful To promote circulation
atmosphere
-decreased To promote comfort & decrease
capillary
Instruct to avoidrefill time
tiring activities tissue O2 demand

Encourage light ambulation To decrease cardiac workload

Encourage use of relaxation To enhance venous return

techniques
To decrease tension and anxiety
Dependent  level
Administer medications
To treat underlying cause
At the end of the shift the

INTERVENTION
Planning
patient mother will able to
RATIONALE
EXPECTED OUTCOME
demonstrate safety precaution Risk for Skin Integrity
to avoid potential injury

At the end of the shift the patient

mother will able to demonstrate
Independent To have
Patient will demonstrate
safety precaution to avoid baseline data
safety
Short Term
To monitor
potential
precaution
injury vital sign.
and evaluate
to avoid potential injury.
Apply pressure on the efficiency of
injection
At the endsite. intervention.
of the shift the patient mother
Instruct to avoid Prevent bleeding on
will able to demonstrate safety precaution to
injury from sharp the site
avoid potential injury
objects Provide precautionary
Provide safe measure
environment (pad Minimizes fall and
Long Term
side rails to prevent injury if falls occurs.
Prior
fall) to dismissal the patient
Detectwill able
early to
evidence
decreasestool
Observe and injury
potential of bleeding
emesis for occult Reduces the side
blood. effect secondary to
Dependent damage liver in
Administer meds care ability to detoxify.
fully, monitor for side
effect.