I.

Nursing Assessment

A. PERSONAL DATA

Name: R.D.C.

Address: Ubihan, Meycauyan, Bulacan

Age: 1 1/2 y/o

Birthday: December 10, 2008

Place of Birth: Ubihan, Meycauyan, Bulacan

Sex: Female

Nationality: Filipino

Religion: Catholic

Date/Time of Admission: July 2, 2010, 8:12 am

B. CHIEF COMPLAINT

The client has a fever for 2 days.

C. HISTORY OF PRESENT ILLNESS

The client had a fever on Thursday at 5 pm the temperature of Ryza was 38.5 °C. The client is warm to touch. Her fever lasted on Friday
morning at 4 am. The patient is noted for enlarge, palpable lymph node (posterior cervical at left side of neck). She has a guarding behavior. The
client is exposed to hot environment due to extreme weather.

D. HISTORY OF PAST ILLNESS

The client had a cough and colds oftentimes she has remaining 1 dose of Diptheria Pertussis Tetanus vaccine and 1 dose of Hepatitis Vaccine.
She doesn’t experienced any injuries or hospitalization. She experienced “hinihingal” for 1 day last year.

E. Family Health Illness History

The family of Ryza’s father side has a history of lung disease. Other than that there are no illnesses from her mother’s side.
 GENOGRAM

M.C. (D)
L.D. M.D. T.C. (LD) (+)
55 yrs (+)
57 yrs 64 yrs

M.C

34 yrs
A.D.

25 yrs
L.C.

29 yrs

J.D.C. 20
R.D.C
yrs
26 yrs

LEGEND: R.D.C. R.D.C.

Male (+) Died 3 yrs 1 ½ yrs
Female
client

LD- Lung disease

D- Deceased
F. Functional Health Patterns

1. Health Perception/ Health Management

Oftentimes, the client is only experiencing cough and colds. Her mother gives her paracetamol and sponge bath when she has a fever. They also
consult to the health center near their baranggay.

2. Nutritional Metabolic Pattern

The mother starts to introduce solid food to the client like bread, rice, fish and vegetable. Breast milk is primary source of her nutrition. Her mother
doesn’t use feeding bottle. The client has inadequate nutrition because of poverty. They seldom eat meats.

3. Elimination Pattern

The client’s urine is color light yellow and clear transparency. Her stool is color brown and semi formed.

4. Activity/ Exercise Pattern

The client is always playing inside their house with her brother.

5. Sleep Rest Pattern

She usually sleeps at night from 7:30 pm – 6:00 am. The client also takes a nap in the afternoon from 12 noon – 2:00 pm.
6. Cognitive Perceptual Pattern

The client doesn’t have defects in her visual, hearing, taste, smell, and touch.

7. Self Perception/ Self Concept Pattern

Not applicable.

8. Role Relationship Pattern

The client is the youngest daughter in the family.

9. Sexual Reproductive Pattern

Not applicable.

10. Coping Stress Pattern

Not applicable.

11. Values Belief Pattern

Her family’s religion is Catholic, they seldom go to church.

 PHYSICAL ASSESSMENT

NAME: Ryza Diamante Condecido DATE: July 2, 2010

Age: 1 ½ y/o

Vital Signs

Weight: 8 kg
Height: 77 cm
BMI: 13.36
Temperature: 38.5 °C

General Appearance

- Clean, Neat appearance, no obvious physical deformities, small body frame

Mental Signs

- Crying, irritable, obvious signs of fear to strangers

Skin and Nails

- Convex curvature of nails, light pink nail beds, prompt return of usual color, brown complexion

Head and Face

- Rounded shape head, smooth, absence of nodules, symmetric facial movements

Eyes

- Eyebrows evenly distributed skin intact, no discharge on eyelids, symmetric movements of eyes, transparent bulbar conjunctiva, pink palpebral conjunctiva,
white sclera, black color of pupils.
Ears

- Mobile, firm pinna, not tender, dry cerumen, voice tone are audible

Nose

- No obstruction, no lesion, not tender, clear nares

Mouth

- Pale color of lips, moist buccal mucosa, no lesion on tongue

Neck

- Head centered has tenderness on left side of neck, enlarged palpable lymph nodes (posterior cervical)

Abdomen

- Unblemished skin, rounded, no tenderness

Upper and Lower Extremities

- No lesion, deformities, tenderness

Generic Name Route of Indication / Purpose Adverse Effect Nursing Responsibilities
administration,
dosage, frequency

Acetaminophen • Pediatric • Analgesic – anti • CNS: headache • Do not exceed the recommended dosage.
patient – 4 to 5 pyretic in patients • CV: chest pain, dyspnea, • Consult physician if needed for children less
times per day with aspirin myocardial damage, when doses of than 3 yrs., if needed longer than 10 days: if
per orem allergy, hemostatic 5-8 grams per day are ingested continued fever, severe or recurrent pains
• 12 – 23 months disturbances, daily for several weeks or when occur
– 120 mg bleeding, upper GI doses of 4 grams per day are • Avoid multiple preparation containing
recommended disease, gouty ingested for 1 year acetaminophen
dosage arthritis • GI: hepatic toxicity, and failure, • Give drug with food, if GI upset occurs
• Common could, flu, jaundice • Discontinue drug if hypersensitivity reaction
other viral and • GU: acute renal failure, renal occur
bacterial infection tubular necrosis
with pain and fever • Hypersensitivity: rash, fever
• Prophylactic for
Brand Name children receiving
Tempra DPT vaccination to
reduce incidence of
fever and pain.
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
S> “Nilagnat ang anak Hyperthermia r/t After 1-2 hrs. of nursing • Promote surface • Heat loss by After 2 hrs. of nursing
ko kahapon” as exposure to hot intervention the client cooling by means of radiation and intervention the client
verbalized by the mother environment as evidence will be able to maintain undressing conduction was able to maintain core
of the client by increased body core temperature within • Cool environment or • Heat loss by temperature within
temperature normal range. fans convention normal range.
O> • Tepid sponge bath • Heat loss by
- Increased in or immersion evaporation
body temperature • Local ice packs • Areas of high blood
above normal specially in groin or flow
range axilla
- Temperature: • Administer • To reduce fever by
38.5 °C antipyretic orally as lowering pain
- Warm to touch needed
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
S> “May bukol siya sa Risk for infection r/t After 1-2 hrs. of nursing • Encourage parent of • To avoid spreading After 2 hrs. of nursing
may kaliwang leeg niya” enlarge palpable lymph intervention the client sick children to keep of microbial intervention the client
as verbalized by the node as evidence by will be able to identify them away from pathogens was able to identify
mother of the client fever and inadequate interventions to child care settings interventions to
acquired immunity prevent/reduce risk of and school until prevent/reduce risk of
O> infection. afebrile for 24 hrs. infection.
- Enlarge, palpable • Administer • To prevent infection
lymph nodes prophylactic
(posterior antibiotics and
cervical left side) immunization as
- Fever: 38.5 °C indicated.
- Inadequate • Promote childhood • For complete
acquired immunization immunization
immunity program. Encourage
parent of sick
patient to
obtain/update
immunization as
appropriate.
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
S> “hindi kami Imbalance nutrition: less After 1-2 hrs. of nursing • Identify client for at • Risk factor for After 2 hrs. of nursing
nakakakain ng sapat”, as than body requirements intervention the client risk for malnutrition inadequate nutrition intervention the client
verbalized by the mother r/t economic factors as will be able to verbalize • Note for • Identify health care was able to verbalize
of the client evidenced by understanding of availability/use of source understanding of
underweight, BMI 13.56, causative factors when financial resources causative factors when
O> and small body frame known necessary and support system known necessary
- Body weight 20% intervention • Ascertain • To determine intervention
or more under understanding of informational needs
ideal weight individual of client
- Small body frame nutritional needs.
- BMI: 13.56
- Underweight
Study of the disease
Lymph nodes (also called lymph glands) are small oval structures scattered all over the body. Lymph nodes contain lymph cells (called lymphocytes).
Lymphocytes grow and mature inside a lymph node. These cells are a type of white blood cell (WBC) that helps the body fight against infections. Lymph nodes are
a part of the lymph system of the body.

Lymph nodes are connected to each other by lymph channels called the lymphatics –- small tubes (like blood vessels)-– through which lymph nodes as well
as proteins and other substances move from one part of the body to another.

Lymph nodes in different parts of the body are named differently

• Cervical lymph nodes – lymph nodes in the neck

• Axillary lymph nodes – lymph nodes in the armpits
• Mediastinal lymph nodes – nodes inside the chest
• Inguinal lymph nodes – those in the groin
• Retroperitoneal and Mesenteric lymph nodes – lymph nodes in different parts of the abdomen.
• Pelvic lymph nodes – nodes in the pelvis.

When lymph nodes increase in size, they are called enlarged lymph nodes. When enlarged nodes can be felt by the doctor (in areas like the neck, armpits and
groin) they are called palpable lymph nodes.

Lymph nodes can increase in size in a number of conditions. Infections, cancer and many immune diseases can affect lymph cells and cause an enlargement of
lymph nodes. Enlarged lymph nodes are often the first sign of lymphoma, a cancer of lymph cells. But all enlarged nodes are not lymphoma. Any enlarged node
should be brought to the notice of a physician and investigated for the correct diagnosis.

Lymphoma is a cancer of the lymph system.

What is cancer?:

A cancer is a condition when some of the body's own cells start behaving abnormally. Our body is made of different types of cells in different organs eg.
nerves or blood. Sometimes a normal cell stops listening to the signals that ask it to stop growing. The cell continues to grow and multiply. This is a cancer cell. As
the cancer grows, the organ cannot work normally. Some of these cells also break off from their original site and spread to other parts of the body and affect other
organs.
What is the lymph system?:

The lymph system is an interconnected network of thin tubes and nodes that carries white blood cells. These cells fight infections and are vitally important
for our well-being. So when a lymphocyte (a type of white blood cell) that is a part of the lymph system becomes cancerous, it may grow and multiply to form a
lymphoma.

Which part of my body is affected?:

Lymphoma may affect any of the parts of the lymph system. Most commonly, patients first notice an enlargement of lymph nodes - usually in the neck,
groin or armpits. But lymphomas can occur in other organs as well. This is because small amounts of lymph and lymph tissue pass through practically all organs in
the body in order that white blood cells can reach them to control infections.

One disease or many?:

Lymphoma is not a single cancer but a group of many related cancers. In fact, there are nearly 30 different types of lymphoma. Broadly, they are grouped
under two categories: Hodgkin Disease and Non-Hodgkin Lymphoma. These two broad groups may be similar in their symptoms and the tests that are required, but
they behave differently when they affect a person.

Hodgkin's lymphoma, previously known as Hodgkin's disease, is a type of lymphoma, which is a cancer originating from white blood cells called
lymphocytes. Hodgkin's lymphoma is characterized by the orderly spread of disease from one lymph node group to another and by the development of systemic
symptoms with advanced disease.

Non-Hodgkin's lymphoma is cancer of the lymphoid tissue, which includes the lymph nodes, spleen, and other organs of the immune system.

Top 8 Warning Signs of Lymphoma

Lymphoma occurs innocuously, often so harmlessly that it takes some time before you may realize that there is anything seriously wrong. Here is a list of the
common symptoms of lymphoma. But you must remember that most of these symptoms are common with many harmless conditions. You should not panic if you
have any of these symptoms. Consult your doctor, and he will be able to address most of your fears and doubts.
1. Painless lumps in your neck, armpits or groin
This is the most common symptom and often the only one. These are enlarged lymph nodes. Most people first notice these lumps while bathing or changing,
or they may be first felt by your partner. All of the other symptoms that are given below should be present along with these enlarged nodes to be specific as a
warning for lymphoma. Only an enlargement of nodes may not be specific for lymphoma.

2. Weight loss
Weight loss usually occurs rapidly over a period of a few months for no known reason. Often an individual can lose ten to fifteen pounds over a couple of
months.

3. Fever
Fever that is continuous or occurs intermittently over a period of time and doesn't seem related to a chest or urinary infection should be a cause for you to
consult a doctor. Fever that is related to node swellings occurs commonly with infections and many lymphomas are often mistaken as infections at the early stage.
Occasionally, in those affected by Hodgkin lymphoma, a characteristic fever called Pel-Ebstein fever occurs.

4. Excessive sweating at night

This unique situation may be quite bothersome. You may wake up at night drenched in sweat without any apparent reason.

5. Itchiness all over your body

Another unique situation that is related to the secretion of some special chemicals from the lymphoma cells.

6. Loss of appetite
As lymphomas spread within your body and grow in size, many individuals feel a considerable loss in their appetite. Weight loss of more than 10% can be a
matter of concern as it is a poor prognostic factor for lymphomas.

7. A feeling of weakness
As cancer cells are always growing, they use up more of the body's nutrients, leaving the body with less. This makes you feel weaker.

8. Breathlessness along with swelling of the face and neck

Rarely, when a lymphoma in the neck or chest grows very large, it may block the flow of some vessels and lead to a swelling of the face and neck along with a
feeling of breathlessness. As lymphomas can occur in any organ, may give rise to some unusual symptoms as well. A lymphoma in the stomach can cause pain in
the abdomen, and a lymphoma in the brain can cause a headache or leg weakness.
Lymph nodes play an important part in the body's defense against infection. Swelling might occur even if the infection is trivial or not apparent.

Lymphadenitis is an infection and inflammation of one or more of the lymph nodes and usually results from an infection that begins near a lymph node. Often
caused by Staphylococcus aureus bacteria, this condition affects the nodes in the neck, groin and armpit. It sometimes strikes individuals who have had coronary
artery bypasses using a saphenous vein from the leg: The removal of this vein is accompanied by removal of related structures of the lymphatic system, lowering
immunity to infection.

Acute lymphangitis is a bacterial infection in the lymphatic vessels which is characterized by painful, red streaks below the skin surface. This is a potentially serious
infection which can rapidly spread to the bloodstream and be fatal.

Lymph nodes are filters that can catch malignant tumor cells or infectious organisms. When they do, lymph nodes increase in size and are easily felt.

While lymph nodes are the most common cause of a lump or a bump in the neck, there are other, much less common causes, e.g., cysts from abnormalities of fetal
development or thyroid gland enlargement. Usually, your doctor can tell the difference on a physical examination.

Causes & Development

When lymph nodes are active in fighting infection, they may become swollen and painful. Usually, the pain is mild, and the lymph node does not get much bigger
than 2 centimeters (slightly under 1 inch) in size.

Swelling of lymph nodes generally results from localized or systemic infection, abscess formation, or malignancy; other causes of enlarged lymph nodes are
extremely rare. By far the most common cause of lymph node enlargement is infection. As a rule, when swelling appears suddenly and is painful, it is usually
caused by injury or an infection. Enlargement that comes on gradually and painlessly may result from malignancy or tumor.

Common causes of enlarged lymph nodes:

• Infectious mononucleosis (behind the ears or neck)

• Rubella, also known as German measles (behind the ears)
• Tuberculosis (above the collar bone)
• Mumps (salivary glands)
• Ear infections or sore throat (neck glands, sometimes)
• Infection in the scalp (behind the ears or in back of the head)
• Impacted tooth (swollen gums)
Treatment & Prevention

Generally, if you have symptoms of a cold or other minor infection, give the glands about 2 weeks to go back to normal. No specific treatment for them is needed. If
the glands are small (less than 2cm or 3/4 inch across), are in your groin or under the chin, and you are a young adult, this is considered normal. Children tend to
have a more active lymphatic system, so their glands may feel enlarged.

In general, always check with your health care provider to determine the nature of the lump. Do not try to diagnose lumps without professional help.

For a lump in the armpit caused by an infected, painful gland, follow the instructions about the proper treatment for the underlying infection.
BULACAN STATE UNIVERSITY

COLLEGE OF NURSING

S.Y. 2010-2011

OUTPUT
IN
CASE STUDY

Submitted by:

Pineda, Yasmin M.

BSN-3A Group 1

Submitted to:

Mr. Rogie Abalos, RN

Clinical Instructor