3 nursing diagnosis and their independent and dependent interventions with rationale CASE SCENARIO: Chief Complaints : high grade fever, headache, muscle pains, diarrhea, vomiting Admitting Diagnosis : Typhoid Fever
3 nursing diagnosis and their independent and dependent interventions with rationale
CASE SCENARIO:
Chief Complaints : high grade fever, headache, muscle pains, diarrhea, vomiting
Admitting Diagnosis : Typhoid Fever
Attending physician : Dr. Sanchez
Health History
He is non-smoker, and drink alcohol in moderation. With history of hypertension and cancer on father side and diabetes on mother side. (+) admission 6 months ago due to Acute Gastroenteritis.
History of the present Illness
One day prior to admission, Mr. Salazar arrived from an International Convention that was held in Mumbai, India. He was on a weeklong convention and consumed a variety of dishes/cuisines. Subsequently after his arrival to the Philippines, Mr. Salazar had experienced high grade fever (39.5 C) and body pains. Paracetamol 500mg tablet taken orally with mild relief of symptoms. The next day, he experienced headache, vomiting and diarrhea which prompt him to seek consult, thus admitted.
IV infusions : PNSS 1L at 125cc/hr
Oxygen : None
Diet : DAT, NPO if with vomiting
Special Endorsement : increased fluid intake, monitor V/S Q4 hours, replace GI losses
volume per volume, Strict MIO and record
Medications : Zithromax 1gm loading dose then 500mg 1 tablet p.o. od
Omeprazole 40 mg 1 capsule p.o.od ac
Metoclopramide 10mg q 8 hrs PRN for vomiting
Paracetamol 500 mg I tab PRN for fever
Latest V/S : T-39.3 C, RR-22 cpm, PR-97 bpm, BP-100/70
Laboratories
Complete blood count: WBC (15x1000/ mm2)
Typhidot test: IgM (+) IgG (-)
Stool culture: (+) Salmonella typhi
Serum Sodium: 138 mEq/L
Serum Potassium: 3.4 mEq/L
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