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ABSTRACT

The study shows the analysis of the disease condition and health status of a 6 year old male from Capitol University Medical Center at the medical ward station 3. This study aims to draw a conclusion and find appropriate nursing interventions to improve patient condition and thus, facilitates promotion of optimal wellness. The author of this study focuses on the management of Facial /Periorbital cellulitis .

The researcher is interested on this health problem for it entails a thorough study and assessment for it to be fully understood. The researcher also wants to know the appropriate care that she has to provide for a patient having this situation. The study and results are just based on the actual rendering of care to the patient which lasted for three days including a thorough assessment of the patient’s past and present hospitalization and health problem.

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ACKNOWLEDGEMENT

I would like to take this opportunity to express my gratitude and deep regard to my guide and mentor, Mr. Leo Hamed Fabre RN,MAN, our Clinical Instructor, for his exemplary guidance, monitoring and constant encouragement throughout the rotation duty and especially this case study. The help, guidance and education given by him shall carry me a long way in the journey of my life on which I am about to embark.

I am also very thankful to our God Almighty, to my parents, and friends for their constant encouragement. Without them, this assignment would not be possible.

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INTRODUCTION

“When you are a nurse you know that every day you will touch a life

or a life will touch yours.” – Anonymous

We, as health care practitioners, called to the responsibility of

promoting health through providing strategic care to patients and to

actively involve of the development of the nursing profession. In addition

to the conventional nursing duties of observing, assessing and recording

symptoms and treatments, they also provide emotional support to patients

and their families. In each patient we care, we tend to provide quality of

care as if we are taking our own family member and at the end of the day

we are bound to touch a person’s life or their life will touch ours.

The chosen patient has a case of Facial Periorbital cellulitis

What is a Cellulitis? Is a common, potentially serious bacterial skin infection. Cellulitis appears as a swollen, red area of skin that feels hot and tender. It can spread rapidly to other parts of the body. Cellulitis isn't usually spread from person to person.

Skin on lower legs is most commonly affected, though cellulitis can occur anywhere on your body or face. Cellulitis might affect only your skin's surface. Or it might also affect tissues underlying your skin and can spread to your lymph nodes and bloodstream.

Left untreated, the spreading infection can rapidly turn life-threatening. It's important to seek immediate medical attention if cellulitis symptoms occur.

Periorbital cellulitis, also known as preseptal cellulitis. Is an inflammation and infection of the eyelid and portions of skin around the eye, anterior to the orbital septum. It may be caused by breaks in the skin around the eye, and subsequent spread to the eyelid; infection of the sinuses around the nose (sinusitis) or from spread of an infection elsewhere through the blood.

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NURSING PROCESS

The researcher used the nursing process for appropriate nursing interventions. During Assessment, collecting patient health data’s through physical assessment, patient’s chart and by asking the patient and significant other necessary questions, this help the researcher clearly identify specific patient problem. Nursing diagnoses, analyzing assessment data’s and determine priority nursing diagnosis. Planning, developing plan of care and prescribe intervention to attain expected outcomes. Implementation, initiating the intervention identified in the plan of care and integrates evidence with clinical expertise and patient’s unique needs. Evaluation, evaluating attainment of patient’s outcome.

Scope and Limitations of the Study

The researcher has chosen this particular case to associate and incorporate the concept of a nurse.

This case study focuses on medical condition of Patient Cabanday MC French Laurence, a 6 year-old Male, who was admitted last July 02, 2015 at around 2:35 pm at Capitol University Medical Center- Medical ward. This covers the patient’s medical history, present condition, disease process, diagnostic tests, prognosis and evaluation. Data were collected via physical assessment, observations, and interviews with the patient.

However, this study is limited to the time when the patient was assigned, seen and assessed by the researcher last July 07,2015 and to the information the researcher was able to obtain from the patient and significant others.

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SIGNIFICANCE OF THE STUDY

Nursing Education

This study can be a useful learning guide in nursing education as this can be used by students as a reference for future studies regarding Heart failure and related cases. This case study will enable the students to learn how to assess patients with any complications and be able to provide appropriate nursing care and management.

Furthermore, the students will learn about the nursing interventions and have an idea of the rationale behind its actions. They can apply this intervention in the real setting when they encounter the same or similar condition. In this way, they are acquiring more knowledge about the complication that they can use to further develop their skills as student nurses and future nurses. It may open a new door, in the practice of getting quality care. This study might also inspire other individuals to come up with their own research about this complication or any similar conditions.

Nursing Practice

This case study can be used as a tool in nursing practice because it provides nursing interventions for patients with Heart failure. This study can give a good introduction to the complication so that an established nursing action can be quickly utilized. And through discovering and rediscovering, and trial after trial of innovative interventions and facilitation of this condition, a more advanced using management may be developed. Through this study, important information regarding this complication has been gathered which will be helpful on the researcher to have an in-depth understanding on the said condition.

Nursing Research

This case can be used as a baseline data for further research of the current management of patients with Heart failure. There might be some information in this study that can be of good use for future research. It is important to do research every now and then to gain new information, better interventions and techniques to provide to the patients. Aside from being beneficial as a simple academic informative material, this study might serve as a guide for orienting people about the substance of the condition, and how this affects the person. Therefore through this study, the researcher should have introduced the condition, treatment (for information), and management.

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OBJECTIVES OF THE STUDY

General ObjectiveAfter 16 hours hospital exposure at Capitol University Medical

center @ medical ward, the researcher aims to develop the cognitive, affective and psychomotor skills effectively in dealing with periorbital cellulitis patient. The researcher also aims to show and demonstrate how the nursing process was utilized in the care of a Periorbital cellulitis by presenting a thorough assessment, identifying nursing diagnoses, prioritizing nursing care plans, implementing nursing interventions and honestly evaluating their outcomes.

Specific ObjectivesThis study aims to:

Describe the patient’s condition properly. To gain knowledge about the disease process, pre-disposing

factors, clinical manifestation and the disease management. To gain skills and appropriate attitudes needed to function as a

student-nurse in the caring patient in the hospital. To be able to use the nursing process as framework for care of the

patient. To develop and establish therapeutic nurse-patient relationship, as

well as to the significant others effectively. Render proper nursing interventions to the patient effectively. Promote wellness through health teachings to the patient and

significant others who are unfamiliar with Facial Cellulitis.

PATIENT’S PROFILE

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Nursing Health History

BIOGRAPHICAL DATA

Patient is a 6 year old Filipino male, and born on September 6, 2008 and presently residing at Tagoloan, Misamis Oriental. He is a Member of Aglipay religion. He was admitted in Capitol Univirsity Medical Center on July 2, 2015 around 2:35 pm.

CHIEF COMPLAINT

Patient was brought to Capitol University Medical Center July 2, 2015 due to Facial swelling.

HISTORY OF PRESENT ILLNESS

4 days prior to admission, patient experience to have low grade fever and swelling, erythema on the left nares. Self-medicated by his mother with paracetamol syrup.

3 days prior to admission, symptoms persisted associated with circumoral swelling. Sought consult with a private doctor, advised admission however patient’s mother refused and given with cloxacillin.

On July 2, 2015, Afternoon patient’s swelling in the face spread to the Left eye sought admission.

PAST HISTORY

Patient family history has no known Hypertension on his mother side and

no known diabetes in both sides’ families. No previous admissions

Patient’s General Appearance

During assessment patient appeared conscious, coherent, and

awake. Pale, weak in appearance.

FUNCTIONAL HEALTH PATTERN

NUTRITIONAL AND METABOLIC PATTERN

The patient eats everything before he was been admitted. He drinks 5-7 glasses a day. After diagnosed with Facial periorbital he was been in hypoallergenic diet.

ELIMINATION PATTERN

According to the patient he usually defecated for at least once a day with yellowish brown in color, soft formed with no discomfort. During his illness he defecated once a day.

He urinated with an average of 350ml each day, clear urine.

ACTIVITY -EXERCISE PATTERN

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For his leisure activity he plays with his friends in their house.

SLEEP-REST PATTERN

Pre-hospitalization: Patient usually sleeps at night around 9:00 pm to 6:00 am. He has no history of sleep disturbances and his place was so conducive for sleeping which makes him well-rested at night.During hospitalization: Patient is having a hard time sleeping.

COGNITIVE-PERCEPTUAL PATTERN

Patient is conscious and oriented.

ROLE-RELATIONSHIP PATTERN

Patient Lives with his family. He knows his family members and can easily familiarize the people around him.

COPING-STRESS TOLERANCE PATTERN

The patient is sometimes stressed with the pain he feels. To manage this his mother is there to give medication self-medicated.

VALUES/BELIEF PATTERN

Patient is a member of Aglipay and he put his faithful in GOD that he will be somehow help through his faith.

PHYSICAL ASSESSMENT

Vital SignsDay 1 of Assessment (July 5, 2015)The Patient’s temperature is 36.3°C, Pulse rate is 94 bpm, Respiratory rate is 23 cpm, and Blood Pressure of110/70mmHg.Day 2 of Assessment (July 6, 2015)The Patient’s temperature is 36.5°C, Pulse rate 90 bpm, Respiratory rate is 25 cpm, and Blood Pressure of 110/80 mmHg. Day 3 of Assessment (July 7, 2015)The Patient’s temperature is 36.3°C, Pulse rate 95 bpm, Respiratory rate is 26 cpm, and Blood Pressure of 110/80 mmHg.

HeadHead is normocephalic, with symmetrical facial movements. Hair is fine in distribution with no dandruffs nor wounds and scars noted.

EyeWith anicteric sclerae and pale palpebral conjunctiva.

NoseSeptum was in midline with pinkish mucosa. Both patent with no obstruction masses and lesions noted. With no discharges noted. Gross smell normal and no tenderness noted.

EarsExternal pinnae are symmetrical in alignment, with no tenderness and lesions noted. No discharges noted and no hearing difficulties.

Mouth

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His lip was dry and pallor in color. Mucosa is moist, tongue is in midline and pale gums.

NeckTrachea is in midline upon palpation. Thyroids were non-palpable. No tenderness noted upon palpation of the cervical lymph nodes.

PharynxUvula is in midline. Tonsils and posterior pharynx are not inflamed.

AbdomenUpon auscultation of the abdomen, hypooactive bowel sounds of less than 5-30 clicks per minute.Upon palpation, abdomen is soft and non-tender. And +fluid wave

CardiovascularThe point of maximal impulse was located at 5 th intercostal space at midclavicular line.

RespiratoryUpon inspection, respiratory rate was 24 cycles per minute, with deep inspiration and shallow expiration.Upon Palpation, trachea is in midline.

ExtremitiesFaint pulses and cold extremities.

ANATOMY AND PHYSIOLOGY

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He has wound at the left side of the nostril

Facial swelling

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PATHOPHYSIOLOGY

Redness warmth swelling of lymph nodes

Erythematous inside the Left nares

(+) neck lymph nodes

PREDISPOSING FACTORS

- Male

PRESIPITATING FACTOR

- Viral agent

Cellulitis

Entry of pathogen through impaired skin integrity:

commonly S. Aureus and S. Pneumoniae

Tissues of the skin are colonized

Infection

Inflammation

Vasodilation

Increased blood flow

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DIAGNOSTIC TESTS AND LABORATORY RESULTS

Hematology Report

A complete blood count is used to determine the number of

leukocytes, erythrocytes, and platelets; a white blood cell differential count

to indicate the relative percentages of the different leukocytes; coagulation

studies such as prothrombin time (PT), partial thromboplastin time (PTT),

and bleeding time; and morphology to differentiate various anemias and

blood dyscrasias.

Lab result: 07/02/15 Time: 03:51:38PM

TEST RESULT UNIT REFERENCE

WHITE BLOOD CELLS 19,500 Cell/mm3 5,000-10,000

RED BLOOD CELLS 5.2 10^6/Ul 4.2 – 5.4

HEMOGLOBIN 14.60 g/dL 12.0 - 16.0

HEMATOCRIT 40.50 % 37.0 - 47.0

MCV 87.4 fL 82.0 – 98.0

MCH 27.80 Pg 27.0 – 31.0

MCHC 31.5 g/dL 31.5 – 35.0

RDW-CV 12.7 % 12.0 - 17.0

PDW 10.50 fL 9.0 -16.0

MPV 09.80 fL 8.0 – 12.0

DIFFERENTIAL COUNT

Lymphocyte (%) 20 % 17.4 – 48.2

Neutrophil (%) 52 % 43.4 – 76.2

Monocyte (%) 5 % 4.5 – 10.5

Eosinophils (%) 2 % 1.0 – 3.0

Basophils (%) 0.20 % 0.0 – 2.0

Bands/Stabs (%) % 1.0 – 3.0

PLATELET 527,000 Cell/mm3 144,000-372,000

INTERPRETATIONS:

1. WBC – High white blood cells indicates infection.

Medical Management

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Generic Name: cetirizine hydrochloride

Brand Name: -Reactine (CAN)-Zytec

Classification: AntihistaminePregnancy Category B

Dosage: 5-10 mg Adult 6-11yrs 5 or 10mg

Route: p.o.

Frequency: q8 3times a day

Mechanism of Action: Potent histamine (H1) receptor antagonist; inhibits histamine release and eosinophil chemotaxis during inflammation, leading to reduced swelling and decreased inflammatory response

Indication: Management of seasonal and perennial allergic rhinitis

Treatment of chronic, idiopathic urticaria

Treatment of year-round allergic rhinitis and

chronic idiopathic urticaria in infants > 6 mo

Contraindication: Contraindicated with allergy to any antihistamines,

hydroxyzine.

Use cautiously with narrow-angle glaucoma, stenosing peptic

ulcer, symptomatic prostatic hypertrophy, asthmatic attack,

bladder neck obstruction, pyloroduodenal obstruction (avoid use

or use with caution as condition may be exacerbated by drug

effects); lactation.

Adverse effect: CNS: Somnolence, sedation

CV: Palpitation, edema

GI: Nausea, diarrhea, abdominal pain, constipation

Respiratory: Bronchospasm, pharyngitis

Other: Fever, photosensitivity,

rash, myalgia, arthralgia, angioedema

Nursing Responsibilities: Give without regard to meals.

Provide syrup form or chewable tablets for pediatric use if

needed.

Arrange for use of humidifier if thickening of secretions, nasal

dryness become bothersome; encourage adequate intake of

fluids.

Provide skin care for urticaria.

Generic Name: clindamycin

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Brand Name: Cleocin, Cleocin Suppository, Dalacin C

Classification: -Lincosamide Antibiotic

Dosage: 200mg

Route: IVTT

Frequency: q8 3times a day

Mechanism of Action: Inhibits protein synthesis in susceptible bacteria, causing cell death.

Indication: Systemic administration: Serious infections caused by

susceptible strains of anaerobes, streptococci,

staphylococci, pneumococci; reserve use for penicillin-allergic patients or

when penicillin is inappropriate; less toxic antibiotics (erythromycin) should

be considered

Parenteral: Treatment of septicemia caused by staphylococci,

streptococci; acute hematogenous osteomyelitis; adjunct to surgical

treatment of chronic bone and joint infections due to susceptible

organisms; do not use to treat meningitis; does not cross the blood–brain

barrier.

Topical dermatologic solution: Treatment of acne vulgaris

Contraindication: Contraindicated with allergy to clindamycin, history of

asthma or other allergies, tartrazine (in 75- and 150-mg capsules); hepatic

or renal dysfunction; lactation.

Use cautiously in newborns and infants due to benzyl alcohol content;

associated with gasping syndrome.

Adverse effect: CNS: Fatigue, headache

Dermatologic: Contact dermatitis, dryness, gram-

negative folliculitis

GI: Pseudomembranous colitis, diarrhea, bloody diarrhea;

abdominal pain, sore throat

GU: Urinary frequency

Nursing Responsibilities: Keep solution away from eyes, mouth and

abraded skin or mucous membranes; alcohol base will cause stinging.

Shake well before use.

Keep cool tap water available to bathe eye, mucous membranes, abraded

skin inadvertently contacted by drug solution.

Nursing Management:

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Assessment DataSubjective: “Gangulngol akong samad” as verbalized by the patient.

Objective Data: facial grimace (+)IrritabilityRestlessness

Nursing Diagnosis: Acute pain related to disruption of the skin

Goals and Objectives:Goal:

After effective nursing interventions, the clients’s pain will decrease from 5/10 to 2/10.

Objectives:

After 1 hour of nursing interventions, the client will be able to:

1. Perform non-pharmacological management for pain.

2. Demonstrate increased comfortability.

Nursing Interventions and Rationale:- administer pain medication as ordered by the doctor to relief pain.- encouraged to support the affected area upon movement to lessen

the pain.- advised non-pharmacological management like focus imaging and

other activities to divert attention from pain.- performed wound cleaning and dressing to diminish the irritability of

the patient.- provided clean environment to lessen the risk for worsening of the

wound.- encouraged adequate rest to aid and put on a normal body result.

Evaluation:After 1 hour of nursing intervention, the pain felt by the client wass

decreased from 5/10 to 2/10.

Assessment DataSubjective: “Iya gakaluton pirme iya samad” as verbalized by his mother.

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Objective Data:

Nursing Diagnosis: Risk for infection related to breakage of superficial skin

Goals and Objective:After 8 hours of nursing intervention, the patient will gain knowledge in

infection control.

Nursing Interventions and Rationale:- encouraged patient to avoid touching the woundto prevent

contamination and prevent infections.- encouraged intake of protein and calorie-rich food, this maintains

optimum nutritional status.- encouraged to maintain good hygiene, this reduces the risk of having

infection.- teach the mother to wash hands of her child especially before and

after meals and before and after administering self care, hand washing reduces the risks for infection.

- discuss the mother the following signs of infections: redness, swelling, pain, fever and purulent drainage in the site to impart the mother when the wound become infected and when to sought medical care.

Evaluation:After 8 hours of intevention, the mother of the patient gained

knowledge in infection control as evidenced by discussing the wound care.

Assessment DataSubjective: “Dili na sya sakit” as verbalized by the patient

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Objective Data:AmbulatoryNormal vital signs

Nursing Diagnosis:Readiness for enhanced home maintenance management

related to improving health status

Goals and Objectives:After 2 hours of nursing intervention, the patient’s mother will

verbalize the understanding of importance of continued heealth maintenance and supervision

Nursing Interventions and Rationale:- assessed patient’s vital signs to monitor changes in patient’s

health status.

- allowed patient to rest and stay in bed, as children his age are usually highly active physically especially as his condition improves.

- discussed with mother discharge needs and home care, continued monitoring necessarry to prevent possible development of complications.

- emphasized importance of home adults supervision, supervision is necessary to direct children’s curiosity in the proper direction.

Evaluation:Goal met.As evidenced by patient’s mother verbalized and understood

discharge needs of the patient.

DISCHARGE PLAN/ HEALTH TEACHINGS

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Medications

Should be taken regularly as prescribed, on exact dosage, time, &

frequency, making sure that the purpose of medications is fully

disclosed by the health care provider.

Encourage the client to report or inform the physician if any of these

side effects occur. Inform and explain to the client in simple terms

that other drugs, such as over the counter drugs that he is taking,

will probably have other effects with the medication given.

Moreover, emphasize the right timing or taking or the right time

intervals of these drugs to maximize its effects and avoid further

complications.

Provide information for better understanding regarding therapeutic

regimen.

Rationale: To be able to provide a list of take home medications for

patient X. This would also help his in the on-time and proper

compliance of maintenance medications.

Exercise

The patient is permitted to resume his former activities and

responsibilities completely once recovered from illness. Until then,

bed rest is recommended.

Treatment

After discharge is expected for patients and watcher with Septic

Shock to fully participate in continuous treatment.

Discuss to the patient the complication of the condition.

Rationale: To be able to suggest alternative measures if medical

treatment is not effective. This may also lead to the development of a

new problem or if not, a threat to health.

Health teachings

Regarding the importance of proper hygiene and hand washing,

food and water.

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Preparation, intake of adequate vitamins especially vitamin C-rich

foods to strengthen the immune response and increasing of oral

fluid intake should be conveyed.

OPD

Encourage patient and family members to consider regular check-

ups as ordered by the physician to ensure the continuing

management and treatment.

Diet

Inform family if there is specific diet ordered by the physician.

Rationale: To be able to present information regarding the types of foods

patient X must include this on his diet. Diet is one of the most vital parts

on patient’s recovery. This will help in reminding the patient on what food

they shall eat or avoid. For the patient’s condition, he must be reminded

so as to help alleviate his condition.

RELATED LEARNING EXPERIENCE

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Related learning experience subject is one of the most important

subject in the field of Nursing. It is because in this subject, we are able to

gain knowledge and skills in the real hospital setting. Thus, it is in this

subject matter that we will be able to perform all the procedures that we

acquired from school up to the real situation. Furthermore, it serves as our

foundation and training ground towards becoming a proficient nurse.

My exposure at Capitol University Medical Center, Intensive care

unit was the most astonishing and in fact the most unforgettable moment

that I will never forget for my entire nursing profession. I was amazed by

the learning experience. Our clinical instructor Mr. Hamed Leo B. Fabre,

RN, MN who served as a teacher who guided and assisted us on what I’m

going to do prior to the care of my patient.

Having been exposed to the hospital area was not that easy

because we were dealing with the lives of the patients. It is in this rotation

that I felt that I was now moving on towards a more challenging event in

my career. My skills have enhanced due to our day to day duties, I was

introduced to new skills and procedures and how to use and perform

them. I learned how to become responsible and effective nurse when it

comes to giving quality care to patients.

The experience I had was fruitful because I was able to acquire

new knowledge and skills that I need and it was very beneficial in my part

because my capabilities have reach its peak level.

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BIBLIOGRAPHY

A. Books

Doenges, Marilynn E., Moorhouse, Mary Frances. Murr, Alice C.

(2006). Nurse’s PocketGuide. Philadelphia, Pennsylvania.

Delgin, Judith H., Vallerand, April H. (2007). Davi’s Drug Guide for

Nurses Tenth Edition. 1915 Arch Street Philadelphia, PA 19103.

Marieb, Elain. (2006). Essentials of Human Anatomy and

Physiology.8th Edition. Pearson Education.Jurong, Singapore.

B. Internet

http://en.wikipedia.org/wiki/Hemothorax

http://emedicine.medscape.com/article/2047916-overview

http://www.nlm.nih.gov/medlineplus/ency/article/000126.htm

http://www.teleflex.com/en/usa/ucd/thoracic_system_pathology.php

http://www.sciencedirect.com/science/article/pii/

S0272523104001030