儿科病房护理实习案例分析.pptxVIP

CASE PRESENTATION PEDIATIRC WARD By：Group 3 Peng Sijing (Stone) Li Xiaojing (Cathy) Miao Chunmei (Mango) Nie Fengyan (Zara) CONTENTS Introduction History Physical Examination Neurologic Examination Laboratory Result MIMS Medication Nursing Care PlanIntroduction GENERAL DATA:p.m.e. , 13 years old , female , Filipino , Christian , born on March 23 , 2004 in Manila currently residing in 270 Kalayaan B . St . Batasan Hills Quezon City , admitted for the first time at FEU-NRMF Medical Center on March 3 . 2018 .CHIEF COMPLAINT : Vomiting History HISTORY OF PRESENT ILLNESS: Four hours prior to admission , while swimming in the pool , a container of muriatic acid was noted to be accidentally spilled in the pool , the amount was unknown to the informant . While her cousin moved out of the pool , she submerged herself for a few seconds until she was pulled out of the pool by her uncle . She accidentally ingested approximately 1 cup of pool water . She then experience dizziness , sore throat , chest pain , difficulty of breathing and body weakness. She then washed herself in the shower. Thereafter, she experienced 2 episodes of non-projectile , non-bilous , non-bloody vomit of previously ingested food about cup per bout . She was then brought to a nearby hospital and was hooked to oxygen via nasal cannula . They were advised to transfer hospitals due to lack of a pediatric. History HISTORY OF PRESENT ILLNESS: Few hours prior to admission , upon arrival to the Emergency Department, she had 1 cpisode of non-projectile, non-bilous, non-bloody vomiting of previously ingested food about 1/2 cup. Still with sore throat, chest pain , difficulty of breathing and body weakness. No dizziness noted. On physical examination, she had symmetrical chest expansion; with intercostal, subcostal and supraclavicular retractions, crackles all over, wheezes all over and tight air entry. She had episodes of desaturation with oxygen saturation of 80-90%. Complete blood count with platelet