Simple case study for Semester 1 student...

1. SRN Noorhazamin Hamid
Nursing Education Services

4.  Mr L
 Male
 36 years old
 Technician
 Malay
 10/10/11 @ 1635H
 Wheeled in to ward

5. Mr L was admitted to 4XX-1 with
complaint of :
Fever & cough
Sorethroat
Rhinorrhoea
Headache
Muscle & joint pain
His wife had fever before.

6. Doctor = Dato’ I
Diagnosis
= URTI (upper respiratory
tract infection)
= Acute Bronchitis

7. Medical history - Nil
Family history - Nil
Surgical history - Nil
Allergic - Nil

8. Smoking – 12 sticks / day
Cough with whitish sputum
Mild shortness of breath
Loss of appetite
Other ADL normal

9. SUNKEN EYES
DRY LIPS

10. Temp = 38.5˚C
Pulse = 72 bpm
Resp = 22 bpm
B/P = 130/80 mmHg
Weight = 99 kg

17. Inflammation of the upper
respiratory tract cause by
viral or bacterial
infection.

25. An inflammation of
bronchi (medium-size airways)
in the lungs that is usually
caused by viruses or bacteria
and may last several days or
weeks

35. Smoking
Old age & children
Low immune system
Poor hygiene habit
Close contact with sick people
Pregnant

37. Pneumonia
Sinusitis
Ear infection
Meningitis

39. White blood cell count
- 10.7 (4.3 – 10.5 10³/UL)
Monocyte
- 11.7% (1-11%)
Sodium
- 134 mmol/L (135 – 155)

40. Bacteria
- Occasional (Nil)

41. CXR - Normal
CT SINUS - Pansinusitis

42. AFB - Not seen
C&S - No growth seen

43. Influenza A antigen
- Not detected
Influenza B antigen
- Detected

45. Group : Anti
inflammatory, analgesic,
antirheumatic
I : Reduce pain & fever

46. Group : Corticosteroid
hormones
I : Anti inflammatory, anti-
allergic & antitoxic

47. Group : Penicillin
I : Antibiotic

48. Group : Anti viral
I : Halt the spread of virus in
body, reduce symptom &
complication

49. Group : Cough & cold
remedies
I : Relief of congestion & dry
irritating cough e.g. those
associated with common
cold, upper resp tract
infection & allergic rhinitis

51. NCP 1
Alteration in body
temperature :
hyperthermia
related to infection

52. Date / Time : 10/10/11 @ 1635H
Goal : Patient’s body temperature will
reduce to normal range (36.2 – 37.5˚C)
after 1 hour nursing intervention given
& during hospitalization.

53. Supporting data :
Non verbal : T˚ = 38.5˚C, shivering, skin is
warm to touch & having flushing face.
Verbal : C/O chills & rigor.

54. 1. Assess pt gen condition e.g. flushing
face, skin warm to touch, lethargic,
temperature etc.
R – As a baseline data for further action.
2. Monitor T˚ every 4 hourly.
R – To detect any elevation in body T˚.

55. 3. Provide conducive environment such
as switch on aircond or fan.
R – To promote heat loss via evaporation.
4. Encourage patient to rest in bed.
R – To reduce activity which can increase
body metabolism & raise temperature.

56. 5. Provide cold compress if T˚ < 38.5˚C
R – To reduce temperature by radiation.
6. Do tepid sponge if T˚ > 38.5˚C
R – To promote heat loss by evaporation.
7. Advise pt to wear thin cloth.
R – To reduce heat by radiation &
evaporation.

57. 8. Encourage pt to drink > 2L of water per
day.
R – To replace fluid loss.
9. Administer medication e.g Voren Supp
50mg STAT/PRN as ordered by doctor.
R – To help reduce the T˚.

58. 10. Administer IVD as ordered by doctor.
R – To replace body fluid loss.
11. Monitor IX as ordered e.g. med profile,
dengue serology, sputum AFB etc.
R – To rule out source of infection.

59. 12. Record patient’s improvement or
deterioration.
R – To indicates progress or
abnormalities.
10. Inform doctor if condition
deteriorating or not improving.
R – For review of changing of treatment
or further intervention.

60. Date / Time : 10/10/11 @ 1730H
Evaluation :
Patient body temperature has reduce to
normal range.
Evidence :
Non Verbal – Skin not warm to touch, no
more flushing face, T˚ = 36.8˚C
Verbal – Patient verbalized no more

61. Re – evaluation :
Date / Time : 10/10/11 @ 2000H
Patient temperature is normal = 36.8˚C

62. Alteration in
breathing pattern
related to cough.

63. Alteration in comfort
related to cough.

64. Alteration in comfort
related to headache
and joint / muscle pain.

65. Ineffective airway
clearance related to
hypersecretion.

66. Alteration in nutritional
status related to loss of
appetite.