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PAMANTASAN NG CABUYAO

COLLEGE OF HEALTH ALLIED SCIENCES


COLLEGE OF NURSING
CASE ABSTRACT:
•This is a case of patient a 5 yr. old female residing at Mercedes Vill, Sala, Cabuyao Laguna., the patient was received at
St.James Hospital last Sept 30, 2009 at 7:50 pm with a chief complaint of fever. Initial vital signs were taken T-
38.5˚C, RR- 40bpm, PR- 130bpm. Initial diagnosis was Pediatric Community Acquired Pneumonia-C. The patient was
subjected for Urinalysis, Blood Chemistry, Hematology and Radiologic exam and was given Cefaclor, Salbutamol,
Erdostien, Polynerv syrup b1+b6+b12 as prescribed. Upon further history taking we found out that both of her parents were
active-smokers.
LEARNING OBJECTIVE:
•The study aims to impart knowledge
regarding community acquired pneumonia and means to restore or maintain patient’s health status utilizing
a holistic approach of promoting and rehabilitative process of nursing managements.
1. Identify nursing problems and the corresponding nursing considerations and managements involved for
promotion and maintenance of patient’s health.
2. Enumerate therapeutic nursing interventions through formulation of NCP.
3. Specify the appropriate laboratory
and diagnostic procedures / examinations and correlate them with the case
presented.
4. Discuss simple pathophysiology of
case presented, its predisposing factors, signs / symptoms, complications and
treatments.
REVIEW OF ANATOMY AND PHYSIOLOGY: RESPIRATORY SYSTEM

•The respiratory system consists of all the organs involved in breathing. These include the
nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important
things: it brings oxygen into our bodies, which we need for our cells to live and function properly;
and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose,
pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is
funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the
bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes
wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder
for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common
respiratory symptoms include breathlessness, cough, and chest pain.
The Upper Airway and Trachea
• When you breathe in, air enters your body through your nose or mouth. From there, it
travels down your throat through the larynx (or voice box) and into the trachea (or
windpipe) before entering your lungs. All these structures act to funnel fresh air down
from the outside world into your body. The upper airway is important because it must
always stay open for you to be able to breathe. It also helps to moisten and warm the
air before it reaches your lungs.

The Lungs
Structure
• The lungs are paired, cone-shaped organs which take up most of the space in our
chests, along with the heart. Their role is to take oxygen into the body, which we need
for our cells to live and function properly, and to help us get rid of carbon dioxide,
which is a waste product. We each have two lungs, a left lung and a right lung. These
are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers.
The right lung has three lobes but the left lung has only two, because the heart takes up
some of the space in the left side of our chest. The lungs can also be divided up into
even smaller portions, called 'bronchopulmonary segments'.
• These are pyramidal-shaped areas which are also separated from each other by
membranes. There are about 10 of them in each lung. Each segment receives its own
blood supply and air supply.
How they work
• Air enters your lungs through a system of pipes called the bronchi. These pipes start
from the bottom of the trachea as the left and right bronchi and branch many times
throughout the lungs, until they eventually form little thin-walled air sacs or bubbles,
known as the alveoli. The alveoli are where the important work of gas exchange takes
place between the air and your blood. Covering each alveolus is a whole network of little
blood vessel called capillaries, which are very small branches of the pulmonary arteries.
It is important that the air in the alveoli and the blood in the capillaries are very close
together, so that oxygen and carbon dioxide can move (or diffuse) between them. So,
when you breathe in, air comes down the trachea and through the bronchi into the
alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across
the walls of the alveoli into your bloodstream. Traveling in the opposite direction is
carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli
and is then breathed out. In this way, you bring in to your body the oxygen that you need
to live, and get rid of the waste product carbon dioxide.
Blood Supply
• The lungs are very vascular organs, meaning they
receive a very large blood supply. This is because the
pulmonary arteries, which supply the lungs, come
directly from the right side of your heart. They carry
blood which is low in oxygen and high in carbon
dioxide into your lungs so that the carbon dioxide can
be blown off, and more oxygen can be absorbed into the
bloodstream. The newly oxygen-rich blood then travels
back through the paired pulmonary veins into the left
side of your heart. From there, it is pumped all around
your body to supply oxygen to cells and organs.
Precipitating Factor:
Predisposing Factor: age Environment

Streptococcal Pneumoniae

Enters through nose or mouth


by inhalation

Passes to the pharynx, larynx


and trachea

Microorganism enters and affects


both airway and lung parenchyma Lung invasion
Airway damage
Activates macrophages
Macrophages destroys RBC
and leukocytes
Decreased RBC count
Infiltration of bronchi Mucus and Phlegm Production

Coughing Productive or non- Bilirubin Production


Infectious organism lodges
Productive
stimulation in bronchioles
jaundice
Alveolar wall Collapse Narrowing of air passage

Increase pyrogens in the


body
Difficulty of Breathing

Fever
Health History

Patient Name: Patient A


Age: 5 Yrs. Old
Sex: Female
Nationality: Filipino
Civil Status: Single
Religion: Roman Catholic
Highest Educational
Attainment: Preparatory
Rank in the
Family: Second Child of Three siblings
Address: Mercedes Vill. Sala Cabuyao, Laguna
Inclusive Date
of Confinement: Four Days
Admission Date
and Time: Sept. 30, 2009 at 7:50 PM
Discharge Date: Oct. 4, 2009 at 1:36 PM
Attending
Physician: Mariano M. Carteciano M.D.
Initial Diagnosis: PCAP – C
Final Diagnosis: PCAP – C
Source of
History: Mother
Chief Complaint: Fever
I. Health Perception – Health Management Pattern

•Before hospitalization, the patient perceives health in a way that


she is not suffering from a disease.
During hospitalization, the patient feels unhealthy and is
obedient in taking her medications.

II. Nutrition-Metabolic Pattern


A. Height: 3 ft., 5 in. tall
B. Weight: 19.1 kg.
C. Appetite: Good
D. Usual Eating
E. Pattern: 3 meals a day
Usual Daily Menu
a. Breakfast: Chocolate Drink / Milk
b. Lunch: Usually hotdog with rice
c. Dinner: Typical viand (meat, vegetable, etc.) with rice
d. Snacks: Chocolate Cookies
F. Diet: usual diet
G. Has good skin turgor
III. Elimination Pattern

A. Bowel:
a. Usually no problem with elimination
b. Last bowel movement yesterday, formed, normal
B. Bladder:
a. Decreased urinary frequency

IV. Activity – Exercise Pattern

A. Self Care Ability:


Feeding: 0 Toileting: 0 Dressing: 0 Bathing: 0 Bed Mobility: 0 Grooming: 2

*Legend:
Functional Levels Code:
0 – Full self-care
1 – Requires use of equipment or device
2 – Requires assistance or supervision from another person
3 - Requires assistance or supervision from another person and
equipment
or device
4 – Dependent and does not participate
B. Past Health Status:
b.1. Prophylactic Medical/Dental Care: None
b.2. Childhood Illness: Measles
b.3. Immunizations: Complete
b.5. Major Illnesses/Hospitalizations: None before this current
admission
b.6. Current Medications: Paracetamol (Prescribed)
b.7. Allergies: None
V. Sleep- Rest Pattern
A. Sleep Habits:
a. 8-9 hours of sleep/night
b. Occasionally takes afternoon naps
B. Has no difficulty going to sleep

VI. Cognitive-Perception Pattern


>No sensory deficits
>Pupils 3mm, equal
>Oriented to time, place and person
>Responsive, but fatigued
>Responds appropriately to verbal and physical stimuli
>Recent and remote memory intact

VII. Self-Perception – Self Concept Pattern


>Patient states, “Marami po akong mga kalaro sa School.”
>Does not feel good about herself since illness started.

VIII. Role-Relationship Pattern


>Patient lives with her father, mother, and two other siblings
>Family members are supportive towards patient’s hospitalization
>Patient states good relationship with friends
IX. Coping-Stress Tolerance Pattern
>Anxious and Irritable
>Mother helps with coping with stress

X. Sexuality – Reproductive Pattern


>Patient is aware of her own gender and
sexuality

XI. Value-Belief Pattern


>Roman Catholic
>No wish to see priest at present
I. GENERAL SURVEY 5 year old female child admitted to ER
Appears normally on her age
Mild irritability but cooperative
Mild weakness
Good posture
(+) cough; productive
(+) difficulty of breathing
(-) retraction
19.1kg in weight
3ft 5 in height

II. VITAL SIGNS DAY 1 DAY 2 DAY 3 DAY 4


Temperature 38.5 37.5 36.9 36.1
Pulse/cardiac rate 130 124 104 88
Respiratory rate 40 36 38 32
Blood pressure

III. INTEGUMENTARY

•Skin: >with slight jaundice on facial area, mild dryness,


good skin turgor
•Mucous membrane: >pink oral mucosa
•Nails: >no clubbing, smooth in texture, capillary refill
at 2-3 seconds
•Hair: >evenly distributed, mild thinning of hair,
no infestation
IV. HEENT
• Head
> Size: 52 cm
> Shape: Well rounded; smooth skull contour;
symmetric facial movement
• Eyes
> Color: Dark-Brown
> Pupil Response: PERRLA
• Ears
> Symmetrically equal; no tenderness
> Discharge/Growth: no discharge: able to response on questions

• Nose
> Mucosal Condition: pinkish in color
> Discharge/Growth: no discharge noted

• Mouth/Throat/Pharynx/Teeth:
> pink moist lips; pinkish tongue; no cavities; no missing teeth ; tonsils are not
reddened
• Face
>Symmetry: Symmetrically equal
>Facial Musculature: has the ability to frown and smile
IV. NECK/LYMPH
a. Symmetry: equally symmetrical muscles
b. Growth: inflamed lymph node
c. Location: right and left anterior cervical areas

V. PULMONARY (Breath Sounds)


>Normal: diminished bronchial sounds; equal chest expansion
>Abnormal: fine crackles at both lung fields

VI. BREAST ABD AXILLARY AREAS


a. Symmetry: equal in size and symmetry for her age
Growth: normal for age
b. Retraction: no retraction noted
c. Discharges: No Discharge Lymph Nodes: No lymph inflammation

VII. CARDIVASCULAR
• Normal: normal rhythm Abnormal: no murmurs
• Rhythm: regular rhythm
• Rate: 120-150 beats per minute
VIII. PERIPHERAL/VASCULAR
Peripheral Pulses (state if equal-bilaterally)

Grade:4 Temporal: equally bilateral Legend:


Peripheral Pulse Scale
Grade: 4 Carotid: equally bilateral 0>Absent
Grade: 4 Brachial: equally bilateral 1>Markedly
diminished
Grade: 3 Radial: equally bilateral 2>Moderately
Grade: N/A Femoral: N/A diminished
3>Slightly
Grade:2 Popliteal: equally bilateral diminished
Grade: 2 Posterior Tibialis equally bilateral 4>Normal

Grade: 3 Dorsalis Pedis equally bilateral


IX. ABDOMEN
a. General Contour: rounded abdomen Legend:
Reflex Scale
Tenderness: rated 6 on pain scale at LUQ 0> no response
b. Bowel Sounds: normal bowel sounds 1> low normal
c. Abdominal Sounds: N/A 2> normal
3> brisk Legend: Glascow coma
4> hyperactivescale
A. Eyes open
X. MUSCOLO-SKELETAL spontaneous
A. STRENGTH: decrease muscle strength -4
B. ROM: within normal limits on command
-3

XI.NEUROLOGICAL to pain -2
A. Mental Status (LOC): 15 pts.
no response - 1
B. Pupils Size: 3-4 mm
C. Cranial Nerves: N/A B. Best Verbal
D. Sensory: N/A Response
Alert and oriented
E. Deep Tendon Reflex (grade the dotted areas) -5
Confuse -4
XI. RECTAL/ANUS Inappropriate -3
Incomprehensive -2
>N/A No response
-1
XII. GENETALIA
C. Best Motor
>Growth: N/A Response
>Discharge: No abnormalities as stated by the mother Follows direction -6
Localizes pain
-5
Withdraws from pain
Urinalysis Result Normal value Significance
MACROSCOPIC      
       
COLOR Color Clear Change of
      appearance of the
TRANCEPARENCY Slightly Hazy Clear urine is an indication
      of renal or urinary
Ph 6.5 4.6- 6.5  track infection.
 
Disturbance of  Ph
indicates acid-based
disorder.
MICROSCOPIC      
      -Alteration of Specific
Specific gravity 1.010 1.015-1.030 gravity inidactes
      level of consentration
Albumin Negative Negative of urine.
      -Presense of albumin
Sugar Negative Negative may indicate
      glomerular disease
Pus cells 8-10/hpf 0-1/Hpf -Presence of sugar in
      the urine may
RBC 0-2/hpf 0-1/hpf indicates
      complications.
Bacteria None none -Presence of pus cells
in urine indicated
urinary tract
infection.
-Alteration of RBC in
urine indicated
Urinary tract
infection.
-Presence of bacteria
indicates infection.
 
Blood chemistry Result Normal value significance
Sodium Test 129 mmol/L 137-145 mmol/L Low level of
      sodium in the
Potassium test 3-7 mmol/L 3.5-5.1 mmol/L blood may cause
      convolsions.
      High potassoum
Calcuim 9-6mg/dL 8.4-10.2mg/dL level indicates
alteration to
electrical activity
on the heart.
Essesial for
maintaining a
regular heart beat,
neuro muscular
impulses.
 

Hematology Result Normal value significance


Hemoglobin 12.2 11-16q/dL Normal
Hematocrit 36% 38-47% Normal
RBC 4.00 4.5-4.8 Loss of RBC
indicates bleeding
TOTAL WBC 9.9 5-10/uL Alteration of WBC
indicates infecton
Platelets 335,000 150000-450000/uL Alteration of
platelet counts
will affect
coagulation,hemos
tasis,and clothing
formation.
• X-ray
• Roentgen logical findings:
• There are steaky densities in both lung
field
• The vascular marking are not
accentuated
• The heart is not enlarge
• Diaphragm & sulci are intact

• Impression: “pneumonitis bilateral”


A. DIET:
• Diet appropriate for age (5 yr. old)
• High caloric food such as rice
• Increased Fluid intake
• Low fiber diet
B.1 STANDING ORDER

NAME OF THERAPEUTIC INDICATION CONTRAINDICATION DOSAGE ADVERSE EFFECT NURSING


DRUGS ACTION /CAUTIONS CONSIDERATI
ON

>assess for the


GENERIC Bactericidal Treatment of >patient with allergy to Children: CNS: history of drug
NAME: Inhibits otitis media, cephalosporin Suspen- Headache, allergy,
Cefaclor synthesis of phryngitis, sion dizziness, pregnancy and
Bacterial tonsillitis, 5ml per lethargy lactation
BRAND NAME: wall Acute >hypersensitivity to beta 8hrs GI: >assess patient for
Cecavil causing cell Bacterial lactam antibiotics three times Nausea, signs and
Cefaclor Death. Exacerbation a vomiting, symptoms of
Apo-Cefaclor of chronic day for 5 diarrhea, infection
bronchitis, >may induce days anorexia, before and
CLASSIFICATION: pneumonia, anaphylactic shock Adult: Abdominal during therapy
Anti Biotic Uncomplica-ted 500mg per pain, >assess for renal
d skin and 8hrs flatulence function test,
Skin Hematologic: respiratory
structure, bone marrow status, culture
lower UTI depression and sensitivity
Hypersensitivit to test of
y: infected area
ranging from >take the drugs with
rash to fever meal or food to
prevent the GI
discomfort..
NAME OF THERAPEUTIC INDICATION CONTRAINDICATION DOSAGE ADVERSE NURSING
DRUGS ACTION CAUTIONS EFFECT CONSIDERATIO
N

Relief of >Hypersensitivity to Adults and Headache; The drug should be


Generic Stimulates beta 2 Bronchospasm Salbutamol, also to children over tremor; avoided during
name: receptors of in bronchial atropine and its 12 years: The tachycardia; pregnancy,
Salbutamol or bronchioles by asthma chronic derivatives. Recommend hypertension; particularly
albuterol increasing levels Bronchitis d dose is 2 – anxiety. during the first
of camp which Emphysema >Threatened abortion 4 Rarely trimester and during
Brand name: relaxes smooth and other during 1st and 2nd mg (5 - 10 ml nausea, labor, because it is
Ventolin muscles to Reversible trimester. syrup) 3 – 4 vomiting, and established that the
Combivent Produce Obstructive times daily. skin rash can high doses can
Salbutamol Bronchodilata-tion. Pulmonary >cardiac arrhythmia The maximal be observed suppress the
diseases. associated w/ daily dose contractions of the
Classification: tachycardia caused should not uterus. There are no
Respiratory by digitalis exceed 32 mg data for risks related
drugs intoxication. (divided in 3 with the
Anti or 4 doses). administration
asthmatic >prevention of premature Children: of the drug in breast
labor associated w/ between 2 feeding women..
toxemia of pregnancy and 6 years, Because of the
or ante partum the dose is possibility for
hemorrhage. 0.1 - 0.2 induction of tremor,
mg/kg body dizziness, and
Weight weakness, the drug
given 3 should be used
times daily. cautiously in drivers
The and people working
Maximal with machines.
daily dose
must not
exceed 4 mg,
3 times
daily, and
the daily dose for
6 - 12 years-old
children is
to 24 mg daily,
divided in 3 or 4
doses.
NAME OF DRUGS THERAPEUTIC INDICATION CONTRAINDICATION DOSAGE ADVERSE NURSING
ACTION /CAUTIONS EFFECT CONSIDERATION

GENERIC NAME: Erdostien is an Treatment of Hepatic disorders & Adult 1 cap Gastric burning, >assess for the
Erdostien original acute & abnormalities, renal bid. Susp 8.5 nausea; ageusia history of drug
derivative of chronic insufficiency, mL bid. or dysgeusia. allergy, pregnancy
BRAND NAME: natural bronchopulmo homocystinuria, Childn 2-6 yr and lactation
Zertin mercapto- nary diseases, phenylketonuria (10-20 kg) 2.5
aminoacid in rhino sinusitis, mL bid, 7-12 >assess for renal
CLASSIFICATION: thiolactonic laryngopharyn yr (21-30 kg) 5 function test,
For respiratory form. Following gitis or mL bid, 5 mL respiratory status,
Drugs oral exacerbations tid or 7.5 mL culture and
administration of these bid. sensitivity to test of
Erdostien is chronic infected area
rapidly diseases in
metabolized in association w/ >take the drugs
the liver. The mucus with meal or food
product acts as a production & to prevent the GI
prod rug and its transport. discomfort
metabolites are
mainly >do not give to the
responsible for patient 2yrs old
mucolytic below
activity, due to
the presence of
free thiol groups
which cause the
splitting up of
the intra- and
intermolecular
disulfide bridges
of several
proteins and
mucoproteins
present in the
expectoration,
resulting in a
reduction of the
mucus elasticity
and viscosity.
NAME OF DRUGS THERAPEUTIC ACTION INDICATION DOSAGE NURSING
CONSIDERATION

GENERIC NAME: VITAMINS B1, B6 & B12 VITAMINS B1, B6 & 1-2 years old : 2.5 >assess for the nutritional
Polynerv syrup b1+b6+b12 (POLYNERV™ Syrup) is B12 (POLYNERV™ mL (1/2 teaspoon) status of the patients
0 valuable in conditions where Syrup) is indicated daily >assess for the drug
BRAND NAME: the requirements for B for the prevention reaction to the patients
Polynerv b1+b6+b12 vitamins are increased (as in and treatment of 3-6 years old : 5.0 >give the vitamins with
growth, physiologic stress, deficiency disorders mL (1 teaspoonful) meals or food to prevent
CLASSIFICATION: decreased resistance to arising from poor daily gastrointestinal discomfort
vitamins infection and chronic dietary intake,
illnesses, metabolic disorders impaired B vitamins 7-12 years old :
and in certain diseases of the absorption (as in 10.0 mL (2
digestive tract and nervous prolonged diarrhea, teaspoonfuls) daily
system). It can also be given excessive vomiting
before and after surgical and antibiotic
procedures. therapy) intake of
drugs which interfere
with the utilization of
the B vitamins (i.e.
isoniazid).
As a nutritional
supplement to
promote appetite,
weight gain and
height increase.
NAME OF DRUGS THERAPEUTIC INDICATION DOSAGE NURSING
ACTION CONSIDERATION

Generic name: Decreases fever by Relief of mild to children's Asses pt. fever or
Paracetamol or inhibiting the effects moderate pain dosages are pain
Acetaminophen of pyrogens on the and treatment based on a
hypothalamic action of fever single dose of Assess allergic
Brand Name: leading to sweating 10mg reaction
Calpol and vasodilation. Paracetamol
Relieves pain by per kilogram Assess
Classification: inhibiting the bodyweight, hepatotoxicity
Anti-pyretic prostaglandin which can be Monitor liver and
analgesic synthesis at the CNS repeated 4-6 renal function
but does not have anti- hourly, not
inflammatory action exceeding four Inform pts. That
because of its minimal doses per 24 urine may dark
effect on peripheral hours. brown as a result of
prostaglandin phenacetin (a
synthesis. metabolite of
acetaminophen)

Verify the doctor’s


order
C. INTRAVENOUS THERAPY

IV Classification INDICATION Actions Side Effect NURSING


Fluid Precaution

5% dextrose and Hypertonic Fluid Challenges Replenish fluid >hypernatrem Don’t use in
0.3% sodium Fluid nutrient ia patient with heart
chloride replacement in Carbohydrates failure
D50.3%NaCl patient with and electrolytes Edema or
DKA, hypernatremia
hyponatremia because it can
shock lead to overload
IV Classification INDICATION Actions Side Effect NURSING
Fluid Precaution

5% dextrose with Isotonic For dehydration Replaces fluid and Increase Do not use to the
multiple balance For patient with electrolyte of the secretion of anti patient without case
solution respiratory problems body diuretics of dehydration
ION multiple balance
D5IMB All IONs either hormone
positive or negative
are present.
D. THERAPEUTIC MEASURES
PROCEDURE INDICATIONS NURSING PRECAUTIONS
1. Positioning (High back When the client is in this position, > The nurse should not place an overly large pillow or more than one
rest or Fowler’s gravity pulls the diaphragm pillow behind the client’s head. This error promotes the
position) downward, allowing greater development of neck flexion contractures. If the client desires
chest expansion and lung several head pillows, the nurse should encourage the client to
ventilation. Client’s confines to rest w/out a pillow for several hours each day to extend the neck
bed but capable of eating, fully and counteract the effects of poor neck alignment.
watching television or visiting >Put pillows under forearms to eliminate pull on shoulder and assist
find this procedure venous blood flow from hands and lower extremities.
comfortable. > Keep side rails securely up. For patient’s falls prevention.

>Ensure the patency of the patient’s nostrils.

> Never administer O2 by nasal cannula at more than 2L/min to a


patient w/ chronic lung disease unless you have a specific order
to do so.
2. Oxygen Administration
>Used when patient will need
oxygen need oxygen therapy
when hypoxia results from a
respiratory or cardiac
emergency or an increase in
metabolic function( offensive
for low of concentrations)

>Supplies the body w/ enough


oxygen to meet its cellular
needs.
Cont…
PROCEDURE INDICATIONS NURSING PRECAUTIONS

3. Nebulizer Therapy >Nebulization is a process of > Be alert for signs of


adding moisture or medication over dehydration
to inspired air by mixing exhibited by
particles of varying sizes w/ the unexplained weight
air. The moisture added to the occurring over several
resp. system through days after the
Nebulization improves beginning of therapy)
clearances of pulmonary when using high
secretions. output nebulizers.

>Aids bronchial hygiene by


restoring and maintaining
mucous blanket continuity,
hydrating dried, retained
secretions, promoting
expectoration of secretions;
humidifying inspired O2;
delivering medication.

> Used for administration of


bronchodilators and mucolytic
agents
D. REFERRALS

Respiratory Therapist:
-Noel A. Co, RN

Pediatrician:
-Dr. Estillore

Pulmonologist:
-Dr. Alonzo

Attending physician:
-Dr. Carteciano
E. Prognosis/Current Status of Patient

• The patient experiencing CAP manifest signs and symptoms of productive cough,
difficulty of breathing, fever and jaundice. CAP is caused by streptococcus
Pneumoniae which is normally acquired by inhalation of respiratory secretion
through droplets, direct and contact, contact with contaminated hands and
fomites. The child must be guided by SO’s to facilitate health care process not to
aggreviate the child’s health status.

CONDITION OF THE PATIENT UPON DISCHARGE:


• (+) intermittent productive cough
• (-) colds
• (-) retraction
• A febrile

HOME MEDICATION:
• Combivent Nebule 1 nebule every 6 hours for 5 days
• Cefaclor Suspension 250mg/5ml 5ml every 8 hours for 5 days
• Zertin syrup 5ml twice a day for 5 days
• Polynerv syrup 5ml once a day

EXERCISE:
• Encourage patient with deep breathing exercise with the help of the SO’ to facilitate
expectoration of sputum or discharge.

TREATMENT:
• The patient must cooperate with the maintenance of medication and Nebulization
therapy for the continuity of treatment.
HEALTH TEACHING:
• The patient who has PCAP should practice deep breathing exercise and
coughing exercise, at the same she should always cover her nose to avoid
allergens such as smoky places that might precipitate the current status.
• The Significant other especially the mother should guide her daughter in
practicing the above guidelines
• The mother or the other SO’s must ensure the patient will follow the discharge
orders required for the patient especially the intake of home meds.
• Teach the patient and SO’s to encourage patient to increase oral intake and how
it helps the patient in her condition.

FOLLOW UP CHECK-UP:
• October 16, 2009, for patient’s health status evaluation.

DIET:
• Diet for age (DFA)
• Patient must follow the diet required for the patient because other food
contents might aggreviate her condition.
PATHOPHYSIOLO NURSING PLANNING INTERVENTION RATIONALE EVALUATION
CUES GIC BASIS DIAGNOSIS

Subjective: Microorganism • Thermo • After 3 hours of • Provide tepid • to decrease • After 3 hours of
“ Mainit at enters the regulation nursing sponge bath temperature by Nursing
masakit ang ulo airway passages Ineffective intervention, means of intervention, the
niya”, as related to the patient’s • Change dress into evaporation and patient’s body
verbalized by the Disease body loose clothing conduction Temperature
mother.. Triggers the immune Process temperature • Ensure proper room• to reduce body alleviated at
system to fight (presence of will alleviate at ventilation temperature normal/desirable
Objective: the foreign Bacterial normal/desira • Advised patient oral • to provide cool level.
• flushed skin objects infection) as ble level. fluid intake environment • Goal met.
• febrile 38.9 manifested by • Administer
• skin warm to elevated body analgesics as • to release heat from
touch Neutrophils kills the temperature. ordered by the he body
• not in bacteria physician
Respiratory As a result of fever, • Ambulate the • to facilitate fast
distress chills and patient recovery
• conscious, ineffective
coherent, and thermoregulation
ambulatory • Maintain bed rest • to facilitate
• (-) dehydration blood circulation
• irritable turn side by side)
• to metabolic
demands/
Oxygen
consumption
CUES PATHOPHYSIOLOGIC NURSING PLANNING INTERVENTION RATIONALE EVALUATION
BASIS DIAGNOSIS

Subjective: Microorganism enters the • Ineffective • After 4 hours • Advise increase • To liquefy secretion • After 4 hours
“Hirap huminga airway passages Breathing of nursing fluid intake of nursing
ang anak ko related to intervention, • Perform Chest • To facilitate Intervention
dahil sa ubo.” As Retained the patient will Physio therapy expectorations the patient’s
verbalized by small blood vessels in the secretions in Loosen (Back Tapping) of retained secretion has
the patient’s lungs (capillaries) the bronchi. secretions in secretions been loosen
mother. become leaky, and the lungs. • Administer • to facilitate fast and she has
protein-rich fluid medications as recovery been able
Objective: seeps into the ordered to breath
• (+) productive alveoli • Check the • As baseline data for At tolerable level.
cough consistency of medication
• afebrile 37.4 secretions administration
• dyspnic in • To prevent further Goal partially met
appearance results in a less functional • Instruct patient to retention of
• no cyanosis area for oxygen- expectorate the secretions
noted carbon dioxide mucus •
• conscious, exchange secretion
coherent, and •Provide health
ambulatory teaching
• GCS – 15 patient becomes regarding the
• (+) crackles relatively oxygen importance of
Upon deprived, while personal
auscultation retaining potentially hygiene
damaging carbon
dioxide

Mucus production is
increased through
the leaky densities
CUES PATHOPHYSIOLOGIC NURSING PLANNING INTERVENTION RATIONALE EVALUATION
BASIS DIAGNOSIS

Subjective: • Ineffective • After 3-4 hours • Assess patient’s • To know and • After 3-4 hours of
“ Nahihirapan siya Microorganism enters Airway of nursing condition determine nursing
huminga dahil sa the airway passages Clearance intervention, the • Monitor and record patient’s needs intervention,
plema”, related to patient’s vital signs • to established the patient’s
as verbalized by presence of respiration will •Auscultate lung fields, baseline data respiration
her mother. Secretions improve and noting areas of • To determine has been
small blood vessels in the secondary to difficulty of decreased or possible improved
Objective: lungs (capillaries) pneumonia breathing will absent airflow bronchospasm and difficulty
• (+) productive become leaky, and relieved. and adventitious or obstruction of breathing
cough protein-rich fluid breath sounds has bbeen
• (+) crackles seeps into the • Assist patient to relieved.
• (+) DOB alveoli change position • Goal met.
• afebrile 37.3 every 30 minutes
• Elevate head of bed • To mobilize
distress and align head in secretions
• restlessness results in a less the middle
• irritability functional area for • Provide health
oxygen-carbon teachings • To facilitate
dioxide exchange regarding breathing
effective
coughing and
patient becomes deep breathing • To expel the mucous
relatively oxygen exercise.
deprived, while • Encourage increase
retaining fluid intake • To liquefy
potentially • Encourage steam secretions
damaging carbon inhalation
dioxide • To moisten
secretions and
• Administer alleviate
Mucus production medications as congestion
is increased, and ordered • To reduce
the leaky capillaries bronchospasm
and mobilize
secretions
ARRIETA, MA. PAMELA GUTIERREZ, FROILAN
CABINTOY, AGNES PENALBA, CYRON
CASTRILLO, JENELYNN LUNAS, JUDITH
DELOS REYES, RENIER SABALLO, JEFFREY
FERNANDEZ, BARBARA YUDELMO, RYAN
“The beginning of knowledge is the
discovery of
something we do not
understand “

- FRANK HERBERT