Measles(Homer)2.0

8/12/2019 Measles(Homer)2.0

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College of nursing

Submitted by:

Homer D. Elegado

BSN 3A

Submitted to:

Mrs. Maribel Murillo RN. MANClinical Instructor

PATIENT ASSESSMENT DATA BASE


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A. GENERAL DATA1. Patients Name: JA D. C2. Address: Philippines3. Age: 3 months4. Sex: female. !irth date: No"em#er 2$ % 2&13$. 'an( in the )amil*: Da+ghter,. Nationalit*: )ilipino-. Ci"il Stat+s: Single. Data of Admission: )e#r+ar* 2$% 2&141&. /rder of Admission: please admit to 0ard% se+re onsent% monitor S shift% 5) of dlm# && to r+n for 23ho+r.11. Attending ph*siian: Dr. Song+an

B. CHIEF COMPLAINT )e"er and rashes.

C. HISTORY OF PRESENT ILLNESS 3 da*s prior P6A the patient had on and off fe"er 0ith o+gh and olds % +ntil 2 da*s P6A presene of rashes in the fae.

D. PAST HEALTH HISTORY/STATUS

E. FAMILY ASSESSMENT

NA78 '89A65/NS5P A;8 S8< /CC=PA65/N 8D=CA65/NA9A66A5N78N6

JC )ather 32 7ale )ator* 0or(er igh shool ;rad+ate

'D 7other 2- )emale o++se0ife College ;rad+ate

F. HEREDO- FAMILIAL ILLNESS


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G. DEVELOPMENTAL HISTORY

68/'5S6 A;8 S8< PA658N6 D8SC'5P65/N

8ri(son6r+st "s. 7istr+st

5nfan* >#irth to 1-months?

)87A98Children de"elop a sense of tr+st 0hen aregi"ers pro"ide relia#ilt*% are%and affetion. A la( of this 0ill lead to mistr+st.

Piagets theor* ofogniti"e

de"elopment

Sensor*@7otor Stage:Ages !irth thro+gh 60o )87A98

6he Sensory-Motor Stageextends from #irth +ntil approximatel* the ageof t0o. D+ring this stage senses% reflexes% and motor a#ilities de"eloprapidl*. 5ntelligene is first displa*ed 0hen reflex mo"ements #eome

more refined% s+h as 0hen an infant 0ill reah for a preferred to*% and0ill s+( on a nipple and not a paifier 0hen h+ngr*. =nderstanding of the0orld in"ol"es onl* pereptions and o#ets 0ith 0hih the infant hasdiretl* experiened. Ations diso"ered first #* aident are repeatedand applied to ne0 sit+ations to o#tain the same res+lts.

)'8=D /ral Stage >!irth to 1-

months?. )87A98

D+ring the oral stage% the hild if fo+sed on oral pleas+res >s+(ing?. 6oom+h or too little gratifiation an res+lt in an /ral )ixation or /ralPersonalit* 0hih is e"idened #* a preo+pation 0ith oral ati"ities.6his t*pe of personalit* ma* ha"e a stronger tenden* to smo(e% drin(alohol% o"er eat% or #ite his or her nails. Personalit* 0ise% theseindi"id+als ma* #eome o"erl* dependent +pon others% g+lli#le% and

Maternal : Nne Paternal : Nne

Pat!ent : Nne
http://psychology.about.com/od/psychosocialtheories/a/trust-versus-mistrust.htmhttp://psychology.about.com/od/psychosocialtheories/a/trust-versus-mistrust.htm


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perpet+al follo0ers. /n the other hand% the* ma* also fight these +rgesand de"elop pessimism and aggression to0ard others.

H. PHYSICAL ASSESSMENT

A. General S"r#e$!. 6he patient is onsio+s.C. V!tal S!%n& ' t(e Da$ ' P($&!)al E*a+!nat!n

6emperat+re: 3$.4 &C 'espirator* rate: 3$ pmP+lse rate: 1&-#pm

D. Re%!nal E*a+1. ead% air% and )ae: ead is s*mmetrial to the #od*% has rashes on the fae2. 8*es: e*es are s*mmetrial to eah other3. Nose: S*mmetrial% same olor as the fae% 0ith rashes4. 8ars: S*mmetrial and proportion to fae% olor is same as the fae% a+rile le"el are e+al% no lesions% deformities and inflammation.

. 7o+th and 6hroat: Not assess$. Ne( and 9*mph nodes: Proportion to head% presene of arotid p+lse% no inflamed er"ial l*mph nodes% no tenderness +pon palpation%

and no mass noted.,. S(in: 6he s(in is fair in omplexion% 0ith rashes-. Nails: not assess. 6horax and 9+ngs: not assess.1&. Cardio"as+lar: not assess11. !reast and Axilla: not performed12. A#domen: same olor as the other parts of the #od*% 0ith rashes13. 8xtremities: 6he arm of the patient is s*mmetrial to eah otherB the legs are s*mmetrial to eah other

II. PERSONAL/SOCIAL HISTORY

A. Ha,!t&:a. Ca''e!ne: not applia#le,. S+!n%: not applia#le). Al)(l: not applia#le. Tea: not applia#lee. Dr"%&: not applia#le

B. L!'e&t$le: not applia#leC. S)!al A''!l!at!n: not applia#leD. Ran !n t(e 'a+!l$: 1sthildE. Tra#el 0!t(!n 1 +nt(&2: not applia#leF. E")at!nal Atta!n+ent: not applia#le.


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III. ENVIRONMENTAL HISTORY /+r patient is li"ing in it* together 0ith her famil*. 6heir ho+se is made of semi@onrete materials. 6heir 0ater s+ppl* omes from

NAASA. 6he* ha"e their o0n toilet failit* 0hih is 0ater sealed t*pe.

IV. INTRODUCTION

7easles is a #er$ontagio+s >easil* spread? infetion that a+ses a rash all o"er *o+r #od*. 5t is also alled r+#eola. 5t is a+sed #* a "ir+s. 5t isspread 0hen an infeted person o+ghs% sneees% or shares food or drin(s. 6he measles "ir+s an tra"el thro+gh the air. 6his means that *o+ an getmeasles if *o+ are near someone 0ho has the "ir+s e"en if that person doesnEt o+gh or sneee diretl* on *o+.

S!%n& an &$+3t+&

Blotchy rashFeverCoughRunny noseKoplik spots

V. ANATOMY AND PHYSIOLOGY

6he s(in is the largest organ of the #od*% 0ith a total area of a#o+t 2& s+are feet. 6he s(in protets +s from miro#es and the elements% helps reg+late#od* temperat+re% and permits the sensations of to+h% heat% and old.S(in has three la*ers:

6he epidermis% the o+termost la*er of s(in% pro"ides a 0aterproof #arrier and reates o+r s(in tone.

6he dermis% #eneath the epidermis% ontains to+gh onneti"e tiss+e% hair folliles% and s0eat glands.

6he deeper s+#+taneo+s tiss+e >h*podermis? is made of fat and onneti"e tiss+e.


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6he s(ins olor is reated #* speial ells alled melano*tes% 0hih prod+e the pigment melanin. 7elano*tes are loated in the epidermis.6he !nte%"+entar$ &$&te+is the organ s*stemthat protets the #od* from "ario+s (inds of damage% s+h as loss of 0ater or a#rasion from

o+tside. 6he s*stem omprises the s(inand its appendages >inl+ding hair%sales%feathers%hoo"es%andnails?. 6he integ+mentar* s*stem has a "ariet*of f+ntionsB it ma* ser"e to 0aterproof% +shion% and protet the deeper tiss+es% exrete 0astes% and reg+latetemperat+re%and is the attahment sitefor sensor* reeptorsto detet pain% sensation% press+re% and temperat+re. 5n most terrestrial "erte#rates 0ith signifiant expos+re to s+nlight% theinteg+mentar* s*stem also pro"ides for"itamin Ds*nthesis.

VI. PATOPHYSIOLOGY

5nhalation of "ir+s present in respirator* seretion

m+ltipliation in respirator* trat

in"ades #lood stream

spreads to reti+loendolithial s*stem

RISK FACTORS

Exposure to the area

PREDISPOSING FACTORS
http://en.wikipedia.org/wiki/Organ_systemhttp://en.wikipedia.org/wiki/Organ_systemhttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Hairhttp://en.wikipedia.org/wiki/Scale_(zoology)http://en.wikipedia.org/wiki/Scale_(zoology)http://en.wikipedia.org/wiki/Feathershttp://en.wikipedia.org/wiki/Feathershttp://en.wikipedia.org/wiki/Feathershttp://en.wikipedia.org/wiki/Hoofhttp://en.wikipedia.org/wiki/Hoofhttp://en.wikipedia.org/wiki/Nail_(anatomy)http://en.wikipedia.org/wiki/Nail_(anatomy)http://en.wikipedia.org/wiki/Core_temperaturehttp://en.wikipedia.org/wiki/Core_temperaturehttp://en.wikipedia.org/wiki/Core_temperaturehttp://en.wikipedia.org/wiki/Sensory_receptorhttp://en.wikipedia.org/wiki/Sensory_receptorhttp://en.wikipedia.org/wiki/Vitamin_Dhttp://en.wikipedia.org/wiki/Vitamin_Dhttp://en.wikipedia.org/wiki/Organ_systemhttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Hairhttp://en.wikipedia.org/wiki/Scale_(zoology)http://en.wikipedia.org/wiki/Feathershttp://en.wikipedia.org/wiki/Hoofhttp://en.wikipedia.org/wiki/Nail_(anatomy)http://en.wikipedia.org/wiki/Core_temperaturehttp://en.wikipedia.org/wiki/Sensory_receptorhttp://en.wikipedia.org/wiki/Vitamin_D


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m+ltiplies f+rther and "ia #lood transported to s(in% mo+th% respirator* trat and on+nti"a

;eneri Name: Fetorola

!randname: 6oradol

Classifiation: Nonsteroidal anti@inflamator* dr+gs

Dosage: 3&mg. 5P $ '6Cx4doses

5ndiation: short term management to moderatel* to se"ere.

MECHANISM OF

ACTION

SIDE EFFECTS CONTRAINDICATION ADVERSE

REACTION

NURSING CONSIDERATION

=n(no0n. Prod+esanti@inflammator*effet % analgesi andantip*reti effetpossi#l* #* inhi#itingprostaglandins*nthesis

'AS

S8DA65/N

Contraindiate to thepatientsh*persensiti"e to thedr+g and inthose 0ithati"e pepti+lerdisease%reent ;5

Arrh*thmias

Pr+rit+s

P+rp+ra

Stop the mediationimmediatel* and report itto the dotor.

6he patient side rails isal0a*s +p.

fever and chills

cough and colds

rash

kopliks spot

steimsons sign


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#leeding orperforation%ad"anedrenalimpairment%ere#ro"as+lar#leeding%hemorrhagidiathesis

Prolonged#leeding

Gener!) na+e:Paraetamol

Bran na+e:

Cla&&!'!)at!n:Antip*reti and non @ analgesi

D&a%e: mg 5P e"er* 4 ho+rs

In!)at!n:)e"er and a+te pain

Me)(an!&+ ' a)t!n S!e e''e)t& Cntra!n!)at!n& A#er&e e''e)t& N"r&!n% )n&!erat!n&


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5nhi#ition of prostagalandin

s*nthesisB does not possess

anti@inflammator*

propertiesB antip*reti ation

res+lts from inhi#ition of

prostagalndins in the CNS

>h*pothalami heat@

reg+lating enter

Na+sea and

"omiting

*persensiti"it* to the dr+g ;5: hepatotoxiit*

;=: renal fail+re

5nteg: rashes

8ns+re lients safet*.


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ASS8SS78N6 D5A;N/S5S P9ANN5N; 5N68'8N65/N 'A65/NA98 8A9=A65/N

S=!J8C658

/!J8C658

@r*ing

S ta(en as follo0s:6emp: 3$.4&C

'': 3$ pmP': 1&- #pm

5mpaired s(in integrit*related to rashes d+e totra+ma of the tiss+e.

After 3& mins ofn+rsing inter"entionthe patient 0ill stopr*ing.

7onitor "ital signs

5nstr+t the patient to not

srath the area

Position the patient to its

omforta#le position

8no+rage relaxation

tehni+e >Deep !reathing

8xerise?

Ser"es as #aseline data.

6o pre"ent s(in irrita#ilit*

and redness

'ed+es patient irrita#ilit*

6o relie"ed pain

;oal met.

6he patient stopsr*ing.


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S=!J8C658

/!J8C658

@r*ing

@ G o+gh

@ irrita#le

@ pale

@ restlessness

5neffeti"e air0a*learane related to#ronhospasm

After 1. mins ofn+rsing inter"entionthe patient 0illdemonstrate normal

#reathing

7onitor "ital signs

Position the patient to its

omforta#le position

7a(e s+re that the patient

is in semi fo0ler position

Ne#+lier the patient as

ordered

Ser"es as #aseline data.

'ed+es patient irrita#ilit*

6o promote ox*genir+lation

5t helps to loosen the

m+os in nasal area.

;oal met.

6he patientdemonstrate normal

#reathing



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Measles(Homer)2.0