ncp muhamad ibnu hasan

1 ENGLISH OF NURSING’S TASK @Coppyright MUHAMAD IBNU HASAN/131411123016/B17/Kelas AJ1

CASE STUDY EIN 2

A three-year-old boy is brought to the emergency room by his parents. The parents report that for the past two days the child has had a fever - the temperature has been as high as

40C - and he has been listless and his oral intake has been well below normal. The child has no prior medical history and does not take any prescription medications. The parents

have been giving the child acetaminophen whenever his temperature was above 38C. The parents are basing this decision on what they read on the internet: 1) that a high fever

can cause permanent brain damage and seizures; 2) that the normal temperature shouldnt be higher than 39. Neither parent can remember how much acetaminophen they give the

child with each dose or how often they have given it and the mother says you can buy acetaminophen at any drug store, and they wouldn’t sell it over-the-counter if it wasn’t safe.

They have also been giving the child ibuprofen every once in a while because again, they had read on the internet that using acetaminophen and ibuprofen was a better way to

lower a fever than using either one alone.

After reviewing the history of the current illness and examining the child, the physician makes the diagnosis of otitis media and prescribes an antibiotic. The physician informs the

parents that a temperature of 40C is not unusual in cases of otitis media, higher fevers are not uncommon, and except for cases of hyperthermia, the seriousness of the illness does

not correlate with the degree of fever. She also tells the parents: 1) a high fever in a child who has a simple infectious process will not cause brain damage; 2) treating a fever will

not prevent febrile seizures; 3) lowering a fever that is caused by a simple, easily treated infectious process will not decrease the time it takes for the illness to resolve, and; 4) a

fever is considered to be a defense mechanism and a fever may decrease the length of an infectious illness. A fever can be treated, she notes, if it is > 38C, but this is an arbitrary

number and lowering the fever is not the goal; the goal is to lower the fever to make the child comfortable and help increase oral intake. Finally, she advises the parents that there

is no evidence that alternating anti-pyretics is more effective than using one alone and that overusing over-the-counter antipyretics, especially acetaminophen and especially in the

context of giving this drug to a child who has a fever, can be dangerous and cause liver damage.

From the given case study, please do the following:

1. Write a table of data analysis

2. Write a nursing diagnosis and intervention based on NIC and NOC


Nursing Care Plan Form

Student Name : Ibnu, M.H Patient Initials / Age : Boy. B / 3 yrs

Medical Diagnose : Otitis Media Dates Caried for : 19/10/2014

Definition Of Medical Diagnose : Otitis Media is an infection of middle ear, caused by eustachian tube dysfunction or infection infection virus and bacteria

Nursing Diagnosis and

Supporting Data

ASSESSMENT AND

DIAGNOSIS

Expected Patient Outcome

PLANNING

Nursing Interventions

INTERVENTION

Rationale

PRINCIPLE

EVALUATION

Expected outcome

Nursing intervention

Deficient knowledge r/t

Information miss

interpretation 2”Miss

perception about fever on

otitis media and febris

management. AEB :

Subjective :

1. “2 days My child

temperature was 400 C,

listless and less oral

intake “

2. “I buy some medicine

on drug store without

medical prescription”

3. “I gave acetaminophen

whenever temperature

above 380 C”

4. “High fever can cause

brain damage and

seizure”

5. “The normal

temperature should not

Short term goals:

1. Pt’s Mom will understand

how to measure the

temperature and febris

range value


characteristic febris on

Otitis Media

3. Pt’s Mom will demonstrate

motivation to learn early

management of febris and

asking question related to

febris management

Long term goals:


disease processes, causes

and factors contributing to

symptoms after dishcarge

2. Pt’s Mom will identify

medications used for

symptom control of each

medical condition as

measured after dishcarge

1. Nurse will demonstrate how

to measure the body

temperature and give some

health education as doctor

prescribed, related to range

value of febris

2. Nurse will repeat to the Pt’s

Mom some information that

doctor has given before

3. Nurse give information

about early febris

management (water

compress)

4. Nurse will evaluate related

to some information that has

given to the Pt’s Mom, and

ask for her, if she has some

unclear information and

wanna give some question

about it

5. Nurse give a leaflet about

febris management to the

Pt’s mom

1. Temperature measurement was

the first line to know, the degree

of febris so according to the

result, we can directly identify

normal, febris or subfebris

2. Pt’s Mom will get easy to

understand and remember If

nurse the information for the

2nd times.

3. Water compress was the

effective first methode on febris

management to reduce

increasing body’s temperature

before some medicine

4. Evaluation will measure how far

Pt’s Mom understand about the

information

5. Leaflet is containing some

information that we have

informed before to the patient

1. Nurse demonstrate

how to measure the

body’s temperature

and Pt’s Mom was

following the ways.

Nurse tells that

temperature degrees

range was :

Hypothermia < 360 C

Normal 36-370 C

Subfebris 37-37.80 C

Febris > 37.80 C

Pt’s Mom was

accepted well

2. Nurse repeat the

information related to

febris on otitis media

usually never more than

380 C and childreen

must be get adequate

oral intake to prevent

increasing of body’s

temperature


higher than 390 C”

Objective data :

1. Mother gave some

medicine, base on some

information that she got

from internet

2. Mother did not bring her

son to the hospital or

heath care provider

when her son got fever

for the first time

3. Pt’s Mom will make a

correct decision what she

has to do, when the basic

management wasnt effectif

(visit dictor/health provider)

after dishcarge

4. Pt’s Mom will not buy

unknown medicine on drug

store without prescription

after dishcarge

and it’s prevent Pt’s Mom forget

the information

(hyperthermia) and Pt’s

Mom take enthusiasm

3. Nurse tells how to give

water compress on

febris Patient and Pt’s

Mom was understand

4. Nurse ask Pt’s Mom

related to information

about early febris

management, and Pt’s

Mom can answer using

her own word

5. Leaflet was giving to

the Pt’s Mom, she keep

it well and take home

ncp muhamad ibnu hasan

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