I.

DEMOGRAPHIC DATA
NAME: Osborn Janos Copero Lacaden AGE: 2 mos. Sex: Male BIRTHDATE: September 15, 2008 BIRTHPLACE: Baguio City ADDRESS: Bineng, La trinidad RELIGION: Anglican NATIONALITY: Filipino DATE ADMITTED: November 23, 2008 TIME ADMITTED: 2:40 pm ADMITTING PHYSICIAN: Dr. Avecilla CHIEF COMPLAINT: Cough, difficulty of breathing, tachypnea and vomiting. DIAGNOSIS: Bronchopneumonia probably bacterial anemia multifactorial.

II. HISTORY OF PRESENT ILLNESS

The patient was apparently healthy until 2 days prior to admission when previously noted occasional cough of 5 days became infuse, productive and was causing irritability to the infant. Patient however still was afebrile, had good intake and was still able to sleep. One day prior to admission, patient was brought to a clinic; x-ray was done and revealed pneumonia. Patient was then advised admission hence went a few hours prior to admission to SLU and was subsequently admitted.

III.

PAST MEDICAL HISTORY

The patient was only an 2 months old and was a history of hospitalization when he was delivered by his mother 3 days prior to delivery, the infant got pneumonia because of meconium aspiration and was advised by the doctor to be confined for a week for further management and observation about the condition last September 2008. The significant other also verbalized that the patient was delivered caesarian and does not have any illness other than what is mentioned previously.

IV: FAMILY HEALTH HISTORY

The patient was only a 2 months old. Due to this condition, the significant other particularly the mother claimed that they have a family history of diabetes, pneumonia and anemia both on the side of the family.

V: COURSE OF CONFINEMENT
The patient was experienced cough last November 8, 2008 but his significant other did not seek for any medical support. One week after the incident the mother of the infant decided to consult a physician because the infant is suffering from productive cough. Due to this condition the physician prescribed antibiotic for the infant. But after 3 days, they decided to seek again for medical support and they decided to x-ray the infant. After the result was given the infant was diagnosed to have bronchopneumonia that made brought them to confine the infant for observation and medication last November 23, 2008.

VI: DIAGNOSTICS
HEMATOLOGY IMPORTANT ELEMENTS Hemoglobin RESULT 103 g/L

Normal value: 120-170 g/L (male) Erythrocytes 0.31 g/L Normal value: 0.40- 0.5 g/L

VII. DRUGS
1. ZINC SULFATE BRAND NAME: ZINCATE Class: Nutritional supplement Mechanism of action: Needed for adequate healing, bone and joint development, taste and smell. Indications: Prevention of zinc deficiency. Contraindications: Hypersensitivity, lactation, seizure disorders. Adverse effects: Dizziness, tremor, anorexia, constipation, nausea and vomiting. Nursing consideration: Monitor zinc levels Monitor vital signs 2. FERLIN BRAND NAME: FERLIN, VITAMIN B-COMPLEX Class: Nutritional supplement Mechanism of action: Needed for adequate growth and development; as a nutritional supplement. Indications: Prevention of delayed growth and development and anemia. Contraindications: Hypersensitivity Adverse effects: Dizziness, tremor, anorexia, constipation, nausea and vomiting. Nursing consideration: Monitor CBC Monitor vital signs Assess for any deficiency

VIII. 13 AREAS OF ASSESSMENT

I. PSYCHOLOGICAL STATUS

A. General Social Status The patient was born in Baguio city at Pines Hospital with a birth weight of 3.4 kg. delivered through caesarian last September 15, 2008. He is only 2 months old and currently residing at Bineng, La Trinidad. Both of his parents are working as a teacher in a public elementary school in La Trinidad. The familys ethnic background is ibaloi but both of his parents can speak tagalong and ilokano. The religious affiliation of the parents of patient was Anglican and they were very active in their religion. Both parents of the patient are government officials. The mother of the patient claimed that they still practiced rituals but they didnt prefer to go to any quack doctors. B. Family or Peer Group Social Status The patient is a 2 months old infant and he was the 2nd child of the family. His father is 31 y/o, currently working as a teacher, a college graduated and his mother is 32 y/o, a teacher, and college graduate. They were 4 in the family including the eldest child which is 9 y/o, grade IV student. The family of the patient live together with their grandmother and a niece in father side at la Trinidad. Primarily caregiver of the patient is the mother. C. Social Developmental Status

The patient is a 2 month old male infant. The mother claimed that the patient can do some social smiles and some eye contact when somebody is talking to him. The patient completed vaccines as follows: DPT, BCG and heap B. In addition, the patient was already undergone newborn screening as verbalized by the mother. There were no unusual discharged observed with the patients genital. There was no previous history of disease or surgery affecting reproductive organs. II. MENTAL AND EMOTIONAL STATUS

A. Mental Status The patient is a 2 month old male infant. He can do social smile and also minimal eye contact. The patient has active flexion and movement of extremities. No abnormalities observed with the patient regarding his mental status basing from his growth and development of his mental status. B. Emotional status The patient often seen cuddled by the mother. Observe good mother and child bonding because the mother always breastfed the patient when he was hungry. The patient have loud and vigorous cry. III. ENVIRONMENTAL STATUS

A. Safety Factors The patient is a 2 month old infant and very prone for falls because motor skills are not full developed yet. His mother always put pillows around the patient to prevent falls and often place in low areas. Due to the patients pneumonia the mother also remove and keep away things which can be considered as allergens that can aggravate the patients pneumonia. B. Infection Control The patient was diagnosed to have bronchopneumonia and anemia. Due to this condition, the patient was given vitamin complex and ferrous sulfate as supplements. The patient also is a 2 months old infant and still his immune system is not yet full develops. The patient had undergone vaccination as follows: DPT, BCG and HEPA b as claimed by the mother. C. Environmental Effects on Illness The patient is a 2 months old infant and has weak immune system because of his age. The patient has history of asthma and pneumonia and has a brother which has asthma. Both of his parents work as a teacher and often seen the infant in the late afternoon. IV. SENSORY STATUS

A. Visual Status The patient does not have a known deficit on her visual acuity. Pupils are equally round and reactive to light and accommodation. No oscillations of the eyeballs when doing cardinal gazes. He can follow gazes. B. Auditory Status

The patient is a 2 months old infant and his hearing was not fully develop and matured. He can notice low pitch sound. No discharges and abnormal findings seen on the auditory status of the patient. C. Olfactory Status The patient cannot discriminate odors and olfactory status because still his body is not yet fully matured. D. Speech formation and perception The patient cant speak because still his brain and body is not fully matured. V. MOTOR STATUS

A. Medical Restrictions on Activity The patient is advised to have rest and be confined for about 1 week for the completion of medications. B. Muscle Skeletal Status The patient has active flexion and movement of both extremities. No musculoskeletal impairment and deformity was observed. C. Mobility The patent is an infant and cannot do ADL all alone. He needs assistance to provide his needs. Mother is the primary caregiver of the patient because still he is at developmental stage of life. VI. NUTRITIONAL STATUS

The patients mother claimed that mixed feeding was done to the patient. Due to hospitalization, the mother claimed that she switch to full breastfeeding until present. Laboratory result particularly hematology reflect that there was a decreased level of hematocrit = 103 g/L. Due to this condition, the patient was given vitamin b complex and other supplement like ferrous sulfate to correct the result. The client was breastfed regularly; vaccination also was done as follows: BCG, DPT and HEPA B. VII. ELIMINATION STATUS

The patient before the illness has a regular once a day elimination pattern but prior to admission she doesnt experienced diarrhea and vomiting. VIII. FLUID AND ELECTROLYTE STATUS The patient prior to admission has adequate intake of fluids. He was breastfed regularly. The patient also urinates for 2-3 times a day prior to hospitalization. IX. CIRCULATORY STATUS

A. Pulse Patients cardiac rate is 140-144 BPM +2. Rhythm is irregular. Patients sometimes experience tachypnea and dyspnea.

X.

TEMPERATURE STATUS

A. Subjective feeling of warmth and cold The patients temperature is ranging from 36.2-36.4 degree Celsius. The skin is warm to touch. No abnormal findings was seen to the patient regarding his temperature status. B. Usual Measures for Temperature Control The patient doesnt have any problem about her temperature because it was in the normal ranges. C. Body Temperature The patient temperature (OTIC) ranges from 36.2- 36.4degree Celsius. XI. INTEGUMENTARY STATUS

A. Skin Condition The patient is 2 months old male infant. Skin is warm to touch and no lesion or any abnormal findings was seen. The patient has good capillary refill and skin turgor of 1-2 seconds. The skin was pinkish and smooth to touch. B. Condition of Nail and Hair The patient is semi bald because he was an infant but the hair is equally distributed. The hair is black and smooth. No clubbing was noted and have good capillary refill of 1-2 seconds. Nails were clean and pinkish in color. XII. COMFORT AND STATUS

A. Sleep The patient claims that she has no problem in her cycles in sleep. B. Comfort The patient does not experience any pain but have productive cough. C. General Appearance The patient is an infant with a present weight of 4.9 kg. Pinkish skin color and skin is warm to touch. No any abnormal findings seen on skin like birth marks and lesions. The patient was chubby and has equally distributed hair (black). Nails were clean and has good odor. As summary, patient was seen generally as a healthy infant. D. Special observation The patients cardiac rate and respiratory rate because the patient sometimes experienced tachypnea and dyspnea because of the retained secretion due to bronchopneumonia.

XIII. RESPIRATORY STATUS The patients respiratory rate is 48 cycles per minute. He experienced productive cough. He has crackles on the right lower lobe of the lungs and doesnt have any palpable nodes. Symmetrical chest wall expansion. Sometimes patient experienced tachypnea.

IX. LIST OF PROBLEMS

1. INEFFECTIVE AIRWAY CLEARANCE related to accumulated secretion of the lungs secondary to bronchopneumonia. ALREADY CHARTED. 2. IMPAIRED GAS EXCHANGE related to alveolar- capillary membrane changes secondary to bronchopneumonia. 3. INEFFECTIVE BREATHING PATTERN related to airway obstruction secondary to bronchopneumonia. 4. RISK IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS related to physiological factors: Anemia. 5. RISK FOR INFECTION related to inadequate primary defenses: Stasis of body fluids. 6. INEFFECTIVE TISSUE PERFUSSION related to decrease HCT concentration secondary to anemia. 7. RISK FOR DELAYED GROWTH AND DEVELOPMENT related to physical illness: bronchopneumonia. 8. KNOWLEDGE DEFICIT related to unfamiliarized information. 9. EFFECTIVE BREASTFEEDING related to basic breastfeeding knowledge. 10. READINESS FOR ENHANCED COPING related to compliance to therapeutic regimen. Prioritization of problems was based in Maslows Hierarchy of needs wherein physiologic needs are prioritized first before problems under safety and security, and social needs. Physiologic needs in the other hand are further subdivided into different priorities, oxygen, fluid, food, temperature, elimination, rest, activity and sex. Acute pain is prioritized first since pain particularly in the flank area was verbalized by the patient in this case and hyperthermia is just only secondary because it was only a symptom of the main problem. Risk problems are prioritized less, and risks are also prioritized according the prior theory presented.

X. PATHOPHYSIOLOGY
S. pneumoniae H. influenza S. aureus Dust and other allergens and factors.

NORMAL FLORA

ALTERED

INVADED

Sterile lower respiratory tract

PNEUMONIA
Produces exudates in alveoli.

Mucosal edema

Inflammatory process
NEUTROPHILS

Fills the alveoli

Interferes with the diffusion of O2 and CO2.

SOURCE: Textbook of medical-surgical Nursing 11th edition by Brunner and Suddarth Pages. 634-635.

Partial occlusion of the bronchi.

Decreased air containing space.

Impaired gas exchange

Ineffective airway clearance

Ineffective breathing pattern

XI. NCP PROPER Problem 1: Bronchopneumonia

ASSESSMENT
S> Minsan nahihirapan siyang himinga.- verbalized by the mother. > Bumibilis din ang pag hinga niya minsan. O> CR- 140 BPM > RR- 48 > T- 36.2 degree Celcius > Crackes in right lower lobe of the lungs. > tachypnea seen > With productive cough. > With x-result of positive for bronchopneumonia. > Hematology result decreased in HCT= 103 g/L. A> IMPAIRED GAS EXHANGE related to alveolar- capillary membrane changes secondary to bronchopneumonia.

EXPLANATION OF THE PROBLEM

Pneumonia arises from normal flora present on patients whose resistance has been altered or from aspiration of flora present in the oropharynx and also result from blood borne oxygen organisms that enter the pulmonary circulation and are trapped in the pulmonary capillary bed. Due to this condition the body must compensate and to inflammatory process which lead by the WBC particularly the neutrophils that fills the alveolar sacs with exudates which interferes the O2 and CO2 exchange because the changes in the capillary membrane brought by the inflammation process. And may later on have mucosal edema and excessive secretion that can occlude the airway passage. SOURCE: Textbook of medicalsurgical nursing eleventh edition by

OBJECTIVES
Goal: At the end of the interaction between the client and student nurse, there will be adequate gas exchange. Objective: At the end of each health teaching, the client would be able to: STO: After 20-30 minutes of health teaching, the mother of the client will enumerate 2-3 interventions when tachypnea arises. LTO: After 2-3 visits to the client, the client will be able to have HCT level greater than 103 g/L.

INTERVENTIONS
Dx: Assess respiratory status.

RATIONALE

EVALUATION
Reassess vital signs and review chart in order to evaluate whether the therapeutic regimen was effective for the client. Also reassess the clients response to interventions. If there are changes and signs of wellness seen in the patient from all of the nursing interventions reinforce the plan of care. If there is partial change in the patient, reorganize or restructure the plan of care for revisions on those ineffective interventions. Reinforce those that are effective.

This will guide the student nurse if what proper interventions should be done. To serve as a baseline data and have knowledge about the current status of the patient for performing appropriate intervention to the client.

Monitor Vital signs (especially blood pressure).

Assess for heart sounds

Tx: Assisted in nebulization

To know the current status of the client and do appropriate intervention for it. This will promote bronchodilation to facilitate for more 02 and CO2 exchange. To decrease the cardiac functioning and to relax the body. The patient is an infant and has

Promote rest

Provide safety by giving pillows.

Promoted ventilation

Problem 2: Bronchopneumonia

ASSESSMENT
S> Minsan nahihirapan siyang himinga.- verbalized by the mother. > Bumibilis din ang pag hinga niya minsan. O> CR- 140 BPM > RR- 48 > T- 36.2 degree Celsius > Crackes in right lower lobe of the lungs. > tachypnea seen > With productive cough. > With x-result of positive for bronchopneumonia. > Hematology result decreased in HCT= 103 g/L. A> INEFFECTIVE BREATHING PATTERN related to airway obstruction secondary to bronchopneumonia.

EXPLANATION OF THE PROBLEM

Pneumonia arises from normal flora present on patients whose resistance has been altered or from aspiration of flora present in the oropharynx and also result from blood borne oxygen organisms that enter the pulmonary circulation and are trapped in the pulmonary capillary bed. Due to this condition the body must compensate and to inflammatory process which lead by the WBC particularly the neutrophils that fills the alveolar sacs with exudates which interferes the O2 and CO2 exchange because the changes in the capillary membrane brought by the inflammation process. And may later on have mucosal edema and excessive secretion that can occlude the airway passage. SOURCE: Textbook of medicalsurgical nursing eleventh edition by

OBJECTIVES
Goal: At the end of the interaction between the client and student nurse, there will be adequate gas exchange. Objective: At the end of each health teaching, the client would be able to: STO: After 20-30 minutes of health teaching, the mother of the client will enumerate 2-3 interventions to improve breathing. LTO: After 2-3 visits to the client, the client will be able to have normal respiratory rate within the normal range of 4060.

INTERVENTIONS
Dx: Assess respiratory status.

RATIONALE

EVALUATION
Reassess vital signs and review chart in order to evaluate whether the therapeutic regimen was effective for the client. Also reassess the clients response to interventions. If there are changes and signs of wellness seen in the patient from all of the nursing interventions reinforce the plan of care. If there is partial change in the patient, reorganize or restructure the plan of care for revisions on those ineffective interventions. Reinforce those that are effective.

This will guide the student nurse if what proper interventions should be done. To serve as a baseline data and have knowledge about the current status of the patient for performing appropriate intervention to the client.

Monitor Vital signs (especially blood pressure).

Assess for heart sounds

Tx: Assisted in nebulization

To know the current status of the client and do appropriate intervention for it. This will promote bronchodilation to facilitate for more 02 and CO2 exchange. To decrease the cardiac functioning and to relax the body. The patient is an infant and has

Promote rest

Provide safety by giving pillows.

Promoted ventilation