Professional Documents
Culture Documents
I.
Introduction......2
II.
Objectives....4
III.
Patients Data..7
IV.
Health History..9
a. Genogram
b. Past Health History
c. Present Health History
d. Medication Reconciliation
V.
Development Data....13
VI.
VII.
VIII.
Physical Assessment...26
IX.
Etiology30
X.
Symptomatology...33
XI.
Pathophysiology35
XII.
Doctors Order.66
XIII.
Nursing Theory..64
XVI.
Drug Study...51
XXI.
Recommendation...77
a.
b.
Nursing Education
c.
Nursing Practice
d.
Nursing Research
Bibliography.80
Chapter 1
Introduction
Paediatric Community Acquired Pneumonia (PCAP) refers to pneumonia in a
previously healthy person who acquired the infection outside a hospital. PCAP is a
common illness that affects infants and children. In children, the majority of deaths
occur in the newborn period, with over two million worldwide deaths a year. In fact, the
WHO estimates that one in a three newborn infant deaths are due to pneumonia. It
occurs because the areas of the lung which absorb oxygen (alveoli) from the
atmosphere become filled with fluid and cannot work effectively. (Smeltzer, et. al.
Medical-Surgical Nursing: 11th Edition. Lippincott Williams and Wilkins. 2008)
Children are very susceptible to acquire this illness especially when their immune
systems are low. They can get it anywhere like in school, for example,one of the
classmates has a cough. Then in house, if there is a poor environment. Then in
playground, wherein there are lots of other children playing.
PCAP is classified into four types. First is, PCAP A, which has a minimal risk, there is
no dehydration, with a respiratory rate of greater than 30-50/min.Second is, PCAP B,
which has a low risk, there is mild dehydration, with a respiratory rate of greater than
30-50/min. Third is, PCAP C, which has a moderate risk, with moderate dehydration,
with a respiratory rate of greater than35-60/min. Fourth is, PCAP D, which has a high
risk, with severe dehydration,with a respiratory rate of greater than 35-70/min.
The United Nations Children's Fund (UNICEF) estimates that 3 million children die
worldwide from pneumonia each year; these deaths almost exclusively occur in children
with underlying conditions, such as chronic lung disease of prematurity, congenital heart
disease, and immunosuppression. According to the WHOs Global Burden of Disease
2000 Project, lower respiratory infections were the second leading cause of death in
children younger than 5 years (about 2.1 million [19.6%]).
The chronology we have came from the Department of Healths Health statistics
which have been updated sometime last January 2014, documented that one of the
leading causes of mortality in the Philippines is Pneumonia either community acquired
or hospital acquired, Pneumonia is considered the 3rd leading cause of death and the
4th leading cause of morbidity in children (Department of Health, 2015 Health
Statistics). For the adults, this occurs mainly as a complication of other chronic diseases
like lung cancer, COPD, tuberculosis, and other debilitating illnesses that leave them
bedridden most of the time and for the children, this remains to be a major killer. In the
year 2004 it was recorded that in every 100,000 total population in the Philippines over
15,822 males died this year and 16,276 for the females. In the Philippines, there are
more than 40,000 cases of PCAP annually. More than 50% are admitted in the hospital.
In the statistics in Davao City on 2011 PCAP was rank second in the top common
disease in all age groups in the 16 health districts of Davao City between January and
February last three year based on statistics prepared by the City Health Office (CHO).
Since January that year , PCAP is also the most common disease among admitted
patients at the Community Health and Development Cooperative Hospital, Anda
Riverside, Davao City.
The group chose the case of PCAP C which is Paediatrics Community Acquired
Pneumonia C primarily because of having a prior knowledge on this type of paediatric
illness, thus requiring to apply this knowledge in the actual setting.This would serve as a
good avenue for the group to develop skills in relation to the facts and information that
have already learned in the university.
As student nurses and future registered nurses, the proponents want to understand
and appreciate more on what is happening to a patient with PCAP C, being one of the
most common illnesses affecting children, the group are in a pursuit for knowledge to be
able to impart it to others. Through this, the group are hoping that we will be able to find
the right plan of care and interventions, not forgetting the patients rights as a person. All
in all, these will help them become efficient and effective nurses in the future.
Chapter 2
Objectives
General Objective
Within the 4 days of duty in the Davao Medical School Foundation
Hospital. Our fundamental goal for the study is to be able to select a patient for
our case study and conduct a comprehensive case study of the illness, and most
especially, to provide a holistic and effective nursing care to the client by relating
and putting to use the knowledge that we have acquired.
Specific Objectives:
Cognitive:
Define the complete diagnosis of the patient
Conduct a cephalocaudal assessment of the patient and Identify
any abnormalities within the physical assessment.
Psychomotor
gather data and comprehend the patients data, family
background, health history and present health condition
Select a pediatric patient who will be the main subject of the
case presentation.
Affective
establish good rapport with the patient to gain their trust
and cooperation
show respect, genuine concern, and empathy to the
patient by giving care and attention
provide the best quality of care along with the
principles of nurse-patient relationship
Give the best quality of care with integrity, honesty, love and
compassion by doing bedside care and regular visit.
Allow patient to express their feelings and thoughts through active
listening and have a good and open communication.
CHAPTER 3
Patients Data
Name: C. V. B. B.
Sex: Female
Age: 2Y 9M 20D
Address: Iron Street, Mineral Village, Brgy 19-B Bajada, Davao City
Nationality: Filipino
Occupation: none
Status: Single
Name of Father: A. B. Jr
Name of Mother: C. M. B.
Clinical/Admission Data
Date of Admission: September 14, 2016
Chief Complaint: Fever and cough
Presenting Symptoms:
2 days PTA
- Onset of fever
-Productive cough (yellow phlegm around 10x a day)
-Runny nose
1 day PTA
-Fever
-Productive cough
-Onset of abdominal pain (bilateral lower abdomen; lasts for 2secs)
-Fever
-Cough
-Abdominal pain (1ep)
CHAPTER 4
Health History
A. Genogram
BCG 1x
DPT 3x
OPV 3x
Measles 1x
Hib 1x
Hepatitis 3x
3. Feeding History
Breastfeeding: 7 months
4. Natal History
AOG: 38 weeks
G3P3
BW: 3.2kg
10
Anomalies: None
Complications: None
5. Past Illness
None
Ht 87cm
Wt 10.3kg
HC 49cm
P 130 bpm
R 45 cpm
1 week PTA, patient had onset of non-productive cough associated with colds.
This was not associated with fever, LBM or vomiting. No consult and no meds taken.
Cough gradually progressed to be productive with yellowish sputum until 2 days
PTA. Patient developed fever at 38.7 degrees Celsius, still with productive cough
and colds. Until the day of admission, symptoms persisted now with decrease in
appetite prompting consult hence admission.
2 days PTA, patient had onset of fever, undocumented hot to touch; intermittent,
given paracetamol syrup 250mg/5ml, 2.5ml (12MKD) associated with productive cough
yellow phlegm around 10x a day, rpm quantity; running nose, no consult done.
1 day PTA, patient had persistence of fever and productive cough. Patient had
new onset of abdominal pain, bilateral lower abdomen, 2-3x lasts for 2 seconds. No
medications given for pain.
11
b. Laboratories
CBC
UA
12
Chapter 5
Development Data
Development is an increase in the complexity of function and skill progression.
Development is the behavioural aspect of growth. Growth and development are
continuous, orderly, sequential processes influenced by maturational, environmental
and genetic factors. Components of growth and development are generally categorised
as physiologic, psychosocial, cognitive, moral and spiritual. Normally, an individual
cannot have growth without development.
Many factors can influence growth and development. An example of which is,
genetic inheritance, which is already established at conception. Characteristics such as
gender and physical can be determined. Temperament refers to the way how individuals
respond to their external and internal environment. The role of the family is to provide
support and safety for the each member of the family. Since family is involved in an
individuals growth and development. Not only the family, but also environmental factors
such as socioeconomic status, climate and community, health and cultural customs.
Adequate nutrition can also affect an individuals growth and development. Different
nutritional practices may influence the rate of growth for infants.
Most importantly, only the person himself can contribute a lot in his own growth
and development. This highly includes the way how an individuals lifestyle, the way he
handles different life situations and also the way he manages life difficulties.
Psychosocial Theory of Development by Erik Erikson
Erikson enumerate eight stages though which healthily developing human should
pass from infancy to late adulthood. At each stage, there is a crisis to be resolved and a
virtue to be gained. According to the theory, failure to properly master each step leads to
problems in the future.
13
Stage
Description.
EARLY
CHILDHOOD
(1 to3)
Result
the process
Autonomy vs.
Shame
Justification
assistance of the
mother.
14
DEVELOPMEN RESULT
TAL TASK
JUSTIFICATION
Learning to walk
Achieved
Learning to take
solid foods
Achieved
Learning to talk
Achieved
RESULT
JUSTIFICATION
15
Chapter 6
Patients Diagnosis
Final Diagnosis: Paediatric Acquired Pneumonia Type C
Diagnosis
Rationale
Pediatric
Pneumonia
Type C
16
Chapter 7
Anatomy and Physiology
RESPIRATORY SYSTEM
The Respiratory system consists of the external nose, the nasal cavity, the pharynx, the
larynx, the trachea, the bronchi and the lungs. Although air frequently passes through
the oral cavity, it is considered to be part of the digestive system instead of the
respiratory system. The upper respiratory tract refers to the external nose, nasal cavity,
pharynx, and associated structures; and the lower respiratory tract includes the larynx,
trachea, bronchi, and lungs.
17
"
Nose
The nose consists of the external nose and the nasal cavity. The external nose is
the visible structure that forms a prominent feature of the face. Most of the external
nose is composed of hyaline cartilage, although the bridge of the external nose consists
of bone. The bone and cartilage are covered by connective tissue and skin.
The nasal cavity extends from the nares to the choane. The nares or nostrils, are
the external openings of the nose and the choane are the openings into the pharynx.
The
nasal septum is a partition dividing the nasal cavity into left and right parts. A
deviated nasal septum occurs when the septum bulges to one side or the other. The
hard palate forms the floor of the nasal cavity, separating the nasal cavity from the oral
cavity. Air can flow through the nasal cavity when the mouth is closed or when the oral
cavity is full of food. Three prominent bony ridges called conchae are present on the
lateral walls on each side of the nasal cavity. The conchae increase the surface of the
nasal cavity.
Paranasal sinuses are air-filled spaces within bone. The maxillary, frontal,
ethmoidal and sphenoidal sinuses are named after the bones in which they are located.
The paranasal sinuses open into the nasal cavity and are lined with a mucous
membrane. They reduce the weight of the skull, produce mucus, and influence the
quality of the voice by acting as resonating chambers. The nasolacrimal ducts, which
18
carry tears from the eyes, also open into the nasal cavity. Sensory receptors for the
sense of smell are found in the superior part of the nasal cavity. Air enters the nasal
cavity through the nares. Just inside the nares the epithelial lining is composed of
stratified squamous epithelium containing coarse hairs. The hairs trap some of the large
particles of dust suspended in the air. The rest of the nasal cavity is lined with
pseudostratified columnar epithelial cells containing cilia and many mucus-producing
goblet cells. Mucus produced by the goblet cells also traps debris in the air. The cilia
sweep the mucus posteriorly to the pharynx, where it is swallowed. As air flows through
the nasal cavities, it is humidified by moisture from the mucous epithelium and is
warmed by blood flowing through the superficial capillary networks underlying the
mucous epithelium.
"
19
Pharynx
The pharynx is the common passageway of both respiratory and digestive
systems. It receives air from the nasal cavity and air, food, and water from the mouth.
Inferiorly, the pharynx leads to the rest of the respiratory system through the opening
into the larynx and to the digestive system through the opening into the larynx and to
the digestive system through the esophagus. The pharynx can be divided into three
regions: the nasopharynx, the oropharynx, and the laryngopharynx.
The nasopharynx is the superior part of the pharynx. It is located posterior to the
choaneae and superior to the soft palate, which is an incomplete muscle and connective
tissue partition separating the nasopharynx from the oropharynx. The uvula is the
posterior extension of the soft palate. The soft palate forms the floor of the
nasopharynx. The nasopharynx is lined with pseudostratified ciliated columnar
epithelium that is continuous with the nasal cavity. The auditory tubes extend form the
middle ears open into the nasopharynx. The posterior part of the nasopharynx contains
the pharyngeal tonsil, which aids in defending the body against infection.
The soft
palate is elevated during swallowing, this movement results in the closure of the
nasopharynx, which prevents food from passing from the oral cavity into the
nasopharynx.
The oropharynx extends from the uvula to the epiglottis, and the oral cavity
opens into the oropharynx. Food and drink all passes in the oropharynx. The
laryngopharynx passes posterior to the larynx and extends from the tip of the epiglottis
to the esophagus.The larynx (plural larynges), colloquially known as the voicebox, is an
organ in the neck of mammals involved in protection of the trachea and sound
production. The larynx houses the vocal folds, and is situated just below where the tract
of the pharynx splits into the trachea and the esophagus. Sound is generated in the
larynx, and that is where pitch and volume are manipulated. The strength of expiration
from the lungs also contributes to loudness.The trachea, or windpipe, is the bony tube
that connects the nose and mouth to the lungs, and is an important part of the
vertebrate respiratory system. When an individual breathes in, air flows into the lungs
for respiration through the windpipe. Because of its primary function, any damage
incurred to the trachea is potentially life-threatening.The bony skeletal trachea is
20
comprised of cartilage and ligaments, and is located at the front of the neck. The
trachea begins at the lower part of the larynx and continues to the lungs, where it
branches into the right and left bronchi. It measures 3.9 to 4.7 inches (10-12 cm) in
length, and .62 to .7 inches (16-18 mm) in diameter. The trachea is composed of 16 to
20 c shaped rings of cartilage connected by ligaments, with a ciliated-lined mucus
membrane. It is this structure that helps push objects out of the airway should
something become lodged.
Larynx
The larynx is the portion of the breathing, or respiratory, tract containing the
vocal cords which produce vocal sound. It is located between the pharynx and the
trachea. The larynx, also called the voice box, is a 2-inch-long, tube-shaped organ in
the neck.
We use the larynx when we breathe, talk, or swallow. Its outer wall of cartilage
forms the area of the front of the neck referred to as the "Adams apple". The vocal
cords, two bands of muscle, form a "V" inside the larynx.
Each time we inhale (breathe in), air goes into our nose or mouth, then through
the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air
goes the other way. When we breathe, the vocal cords are relaxed, and air moves
through the space between them without making any sound.
When we talk, the vocal cords tighten up and move closer together. Air from the
lungs is forced between them and makes them vibrate, producing the sound of our
voice. The tongue, lips, and teeth form this sound into words.
The esophagus, a tube that carries food from the mouth to the stomach, is just
behind the trachea and the larynx. The openings of the esophagus and the larynx are
very close together in the throat. When we swallow, a flap called the epiglottis moves
down over the larynx to keep food out of the windpipe.
Trachea
A tube-like portion of the breathing or "respiratory" tract that connects the "voice
box" (larynx) with the bronchial parts of the lungs.
21
Each time we inhale (breathe in), air goes into our nose or mouth, then through
the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air
goes out the other way.
The esophagus, the tube that carries food from the mouth to the stomach, is just
behind the trachea and the larynx. The openings of the esophagus and the larynx are
very close together in the throat. When we swallow, a flap called the epiglottis moves
down over the larynx to keep food out of the windpipe.
The trachea is also called the windpipe, weasand (sometimes written wesand or
wezand) or wesil. "Cut his weasand with thy knife." The Tempest, Shakespeare.
"
Bronchi
The trachea divides into left and right main (primary) bronchi. Each of which
connects to a lung. The left main bronchus is more horizontal than the right main
bronchus because of it is displaced by the heart. Foreign objects that enter the trachea
22
usually lodge in the right main bronchus, because it is more vertical than the left main
bronchus and threfore more in direct line with the trachea. The main bronchi extend
from the trachea to the lungs. Like the trachea, the main bronchi are lined with
pseudostratified ciliated columnar epithelium and are supported by C- shaped pieces of
cartilage.
The large air tubes leading from the trachea to the lungs that convey air to and
from the lungs. The bronchi have cartilage as part of their supporting wall structure. The
trachea divides to form the right and left main bronchi which, in turn, divide to form the
lobar, segmental, and finally the subsegmental bronchi.
Bronchi is the plural of bronchus from the Greek word bronchos, a conduit to the lungs.
23
Lungs
The lungs are the principal organs of respiration. Each lung is cone-shaped, with
its base resting on the diaphragm and its apex extending superiorly to a point about 2.5
cm above the clavicle. The right lung has three lobes called the superior, middle and
inferior lobes. The left lung has two lobes called the superior and inferior lobes. The
lobes of the lungs are separated by deep, prominent fissures on the surface of the lung.
Each lobe is divided into broncho-pulmonary segments separated from one another by
connective tissue septa, but these separations are not visible as surface fissures. There
are 9 broncho-pulmonary segments in the left lung and 10 in the right lung. The main
bronchi branch many times to form the tracheobronchial tree. Each main bronchus
divides into lobar bronchi as they enter their respective lungs. The lobar (secondary)
bronchi, two in the left and three in the right lung, conduct air to each lobe. The lobar
bronchi in turn give rise to segmental (tertiary) bronchi, which extends to the bronchopulmonary segments of the lungs. The bronchi continue to branch many times, finally
giving rise to bronchioles. The bronchioles also subdivide numerous times to give rise to
terminal bronchioles, which then subdivide into respiratory bronchioles. Each respiratory
bronchiole subdivides to form alveolar ducts, which are like long, branching hallways
with many open doorways. The doorways open into alveoli which are small air sacs
become so numerous that the alveolar duct wall is little more than a succession of
alveoli. The alveolar ducts end as two or three alveolar sacs, which are chambers
connected to two or more alveoli. There are about 300 million alveoli in the lungs. As the
air passageways of the lungs becomes smaller, the structure of their walls changes. The
amount of cartilage decreases and the amount of smooth muscle increases, until at the
terminal bronchioles, the walls have a prominent smooth muscle layer, but no cartilage.
Relaxation and contraction of the smooth muscle within the bronchi and bronchioles can
change the diameter of the air passageways. For example, during exercise the diameter
can increase, thus increasing the volume of air moved. During an asthma attack,
however, contraction of the smooth muscle in the terminal bronchioles can result in
greatly reduced air flow. In severe cases, air movement can be so restricted that death
results. As the air passageways of the lungs become smaller, the lining of their walls
also changes. The trachea and bronchi have pseudo stratified ciliated columnar
epithelium, the bronchioles have ciliated simple cuboidal epithelium. The ciliated
24
epithelium of the air passageways functions as mucus-cilia escalator, which traps debris
in the air and removes it from the respiratory system. The respiratory membrane of the
lungs is where gas exchange between the air and blood takes place. It is mainly of the
alveoli and surrounding capillaries but theres some contribution by the alveolar ducts
and respiratory bronchioles it is very thin to facilitate the diffusion of gases.
Pleural cavity
In human anatomy, the pleural cavity is the body cavity that surrounds the lungs.
The pleura are a serous membrane which folds back upon itself to form a two-layered,
membrane structure. The thin space between the two pleural layers is known as the
pleural cavity; it normally contains a small amount of pleural fluid. The outer pleura
(parietal pleura) is attached to the chest wall. The inner pleura (visceral pleura) covers
the lungs and adjoining structures, viz. blood vessels, bronchi and nerves.
The pleural cavity, with its associated pleurae, aids optimal functioning of the
lungs during respiration. The pleural cavity also contains pleural fluid, which allows the
pleurae to slide effortlessly against each other during ventilation. Surface tension of the
pleural fluid also leads to close apposition of the lung surfaces with the chest wall. This
physical relationship allows for optimal inflation of the alveoli during respiration. The
pleural cavity transmits movements of the chest wall to the lungs, particularly during
heavy breathing. This occurs because the closely opposed chest wall transmits
pressures to the visceral pleural surface and hence to the lung itself.
25
Chapter 9
Physical Assessment
General Assessment
Physical assessment done at Davao Medical School Foundation 3A Pediatric
Ward at around 9:30 AM of September 16, 2016 while patient was lying on bed, awake
and responsive. The patient is 2 years old, Female. Received patient with an IVF of
D5IMB 500mL at 480mL, infusing well at 60cc/hr at her left metacarpal vein. The stated
age is congruent with the apparent age. No physical deformities noted. Arms and legs
are proportionate to the body. Mobility and gait is normal for age. Patient is not yet
capable to walk. Patient appears neat and clean. She is wearing a sando and a pair of
shorts, which are appropriate for the environment. Crying and babbling noted for
speech.
Vital Signs
Temperature 37.1oC
Cardiac Rate 132 bpm
Respiratory Rate 30 cpm
Blood Pressure 70/40 mmHg
Pulse Rate 132 cpm
Skin, Hair and Nails Assessment
Skin color is fair. Lip membrane is pink. Nails are properly trimmed and clean.
Nail beds and palms are pink. Skin is warm to touch and sweating with temperature of
37.1oC. Normal skin turgor noted. Thin, smooth, black, minimal hair on head is noted
which is normal for age. Terminal hair is found in the eyebrows, eyelashes, and scalp.
Hair is evenly distributed throughout the body. No lesions, scars, tenderness, masses,
and infestations noted upon inspection and palpation. Capillary refill of 2 seconds noted.
Head, Neck and Regional Lymphatics Assessment
26
Lip and membranes are pink, moist, and smooth with no evidence of lesions or
inflammation. Tongue is in the midline of the mouth. No swelling or bleeding found. No
teeth noted which is normal for her age. Gums are pink, moist, and firm with no signs of
bleeding or swelling. No tenderness, masses, or lesions noted. Uvula is at midline.
Tonsils are present and pink in color. No inflammation noted.
Thorax and Lungs Assessment
Patients shoulders are of the same height. The scapulae are at the same height
bilaterally. No masses, tenderness. Respiratory rate is 30 breaths per minute. Slightly
deep and irregular respirations noted. Patient inhales and exhales through the nose. No
chest indrawing noted. Wheezing is noted upon auscultation. Minimal crackling sounds
noted. Productive cough noted.
Abdomen Assessment
Abdomen contour is rounded and clean. Slight protruding appearance noted
which is normal. Diaphragm rises with inspiration and falls with expiration. Umbilicus is
depressed and beneath the abdominal surface. Skin immediately returns to normal
shape when slightly pinched, results to normal skin turgor. Bowel sounds are active with
10 per minute.
Musculoskeletal System Assessment
Patients head is at midline and is perpendicular to the shoulders and pelvis. The
shoulder and hips are at level, and the arms hand freely from the shoulders. Right and
left shoulders are of the same level. Ankle, hip, shoulder, and hand mobility is normal.
No pain, stiffness, masses, and inflammation noted. Patient is not able to fully ambulate
which is normal due to underdeveloped muscles. Babinski reflex is present which is
normal.
Mental Status
Patient is aware of her surroundings. She is responsive to the external stimuli
and irritable.
28
Genito-Urinary Assessment
Patient is wearing a diaper. Her labias are clean and smooth. No masses, and
tenderness noted upon palpation. Patient is able to urinate efficiently. Minimal rashes
noted around anus.
29
Chapter 10
Etiology
PRECIPITATING FACTORS
Factor
Pres
Rationale
Justification
ence
Environment
Lifestyle
Smoking damages fragile lung tissue, making lungs The patient is only 2
more vulnerable to infection.
Source:http://www.knowpneumonia.com/causes-pneumococcal-
pneumonia
30
PREDISPOSING FACTORS
Factor
Pres
Rationale
Justification
enc
e
Age
31
Genetic
s/Family
History
has
is
pneumonia.
Source:http://www.webmd.com/asthma/guide/asthma-riskfactors
32
Chapter 11
Symptomatology
SYMPTOMS
ACTUAL
RATIONALE
JUSTIFICATION
COUGH
Present
CHEST PAIN
Absent
FEVER
Present
FATIGUE
Present
SHORTNESS
OF BREATH
Present
33
RAPID
BREATHING
Present
CRACKLES
Present
WHEEZING
Present
CHEST
RETRACTIO
NS:
Absent
>SUBCOSTA
L
Absent
>SUBSTERN
AL
Present
>INTERCOST
AL
Absent
>SUPRACLA
VICULAR
HYPOXIA
Absent
34
Chapter 12
Pathophysiology
35
Chapter 13
Doctors Order
DATE &
DOCTORS ORDER
RATIONALE /
TIME
JUSTIFICATION
ORDERED
9-14-16
5:00 pm
> Please admit under the service of Admission is required to assess and
Dr. Dahinog
To avoid aspiration.
40 cpm.
> VS q 4 and record please
> Labs
CBC
U/A
Chest X-ray
36
> Meds
(1) Paracetamol 250, 3ml q 4
PRN
(2) Cefuroxime 375 mg IVTT
q8 ANST
#1) @ 45cc/hr
>Hydration rounds q4
nebulization
>Add meds:
-Zinc sulfate syrup 5mL OD 37
9-14-16
RATIONALE /
DOCTORS ORDER
JUSTIFICATION
6:30 pm
> IVF TF: (bottle #2) D5 IMB 500 -For maintenance of fluid and electrolytes
@ 55cc/hr once with urine output. especially to patients who need calories
and hydration.
9-15-16
>Meds:
(1) Cefuroxime
(2) Salbutamol neb q6
(3) Zinc
6 am
>Refer accordingly
38
Chapter 14
Diagnostic/ Laboratory Test
1) Chest X-ray
Chest x-rays (CXR) are
among the most frequently
performed radiologic studies and
yield a great deal of information
about the pulmonary and cardiac
systems. The lung fields, the
clavicle and ribs, the cardiac
border, the mediastinum, the
diaphragm, and the thoracic spine
can all be studied using CXRs.
Although only a single view is
obtained, critical problems such as
pneumonia, atelectasis,
pneumothorax, pulmonary edema, and pleural effusion can be identified. (Cavanaugh,
2003)
In the posterior-anterior (PA) view, the x- ray beam passes through the client from
back to front. This is a preferred view because it results in less magnification of the
heart than does the anterior-posterior (AP) view.13 The farther away from the x-ray film
an object is situated, such as the heart in the AP view, the more magnified and less
distinct will be its image. (Cavanaugh, 2003)
Patient was ordered to have a chest x-ray since her diagnosis was a pulmonary
infectious disorder, which is Pediatric Community-Acquired Pneumonia Type C
40
TEST
CLINICAL SIGNIFICANCE
NORMAL VALUE
PATIENTS
RESULT
41
Hemoglobin
L 99
0.36 0.45
L 0.30
42
Red Blood
Cells
43
4.00 6.00
x10^12/L
4.28
White Blood
Cells
5.00 10.00
6.89
x10^9/L
L 70.1
27.0 31.0 pg
L 23.1
330
Corpuscular
Hemoglobin
Concentration
81.0 99.0 fL
44
DIFFERENTIAL COUNT
Neutrophil
0.45 0.65
L 0.41
Lympochyte
0.20 0.35
H 0.50
0.02 0.06
H 0.08
0.00 0.04
0.01
0.00 0.01
0.00
150 - 450
326
Monocyte
Eosinophil
Basophil
Platelet Count
Nursing Responsibilities
Explain to the client:
45
3) Urinalysis
Routine urinalysis, one of the most widely ordered laboratory procedures, is used
for basic screening purposes. It is a group of tests that evaluate the kidneys ability to
selectively excrete and reabsorb substances while maintaining proper water balance.
The results can provide valuable information regarding the overall health of the patient
and the patients response to disease and treatment. The urine dipstick has a number of
pads on it to indicate various biochemical markers. Urine pH is an indication of the
kidneys ability to help maintain balanced hydrogen ion concentration in the blood.
Specific gravity is a reflection of the concentration ability of the kidneys. (Cavanaugh,
2003)
The routine urinalysis is a screening technique that is an essential component of a
complete physical examination, especially when performed on admission to a healthcare facility or before surgery. It may also be performed when renal or systemic disease
is suspected. Note that the components of a UA may be performed separately, if
necessary. (Cavanaugh, 2003)
Patient needs urinalysis because its one of the initial protocols of the institution
and to check the acid-base balance status of her body or system. Since the patients
respiratory system is affected and it is one of the buffer systems of the body, her
condition might progress to metabolic acidosis.
46
PARAMETER
S
RESULTS
REFERENCE
SIGNIFICANCE
RANGE
PHYSICAL EXAMINATION
Light Yellow
Clarity
Clear
47
CHEMICAL ANALYSIS
The pH of urine reflects the kidneys
ability to regulate the acidbase
balance of the body. In general, when
too much acid is present in the body
pH
6.0
5.0 9.0
Specific
Gravity
1.001 1.029
Glucose
Negative
Negative
Protein
Negative
Negative
48
amounts of low-molecular-weight
serum proteins such as albumin.
URINE FLOWCYTOMETRY
Normally, only a few white blood cells are found in urine.
Increased numbers of leukocytes in the urine generally indicate
either renal or genitourinary tract disease. As with red blood cells,
WBC
10
0-17/
uL
white blood cells may enter the urine either through the
glomerulus or through damaged genitourinary tissues. In addition,
white blood cells may migrate through undam- aged tissues to
sites of infection or inflammation. An excessive amount of white
blood cells in the urine is termed pyuria.
Red blood cells are too large to pass through the glomerulus; thus,
the finding of red blood cells in the urine (hematuria) is
considered abnormal. If red blood cells are present, damage to the
RBC
0-11/
uL
Epith
Cells
0-17/
uL
49
Casts are gel-like substances that form in the renal tubules and
collecting ducts. Healthy individuals may normally excrete a few
casts, especially if there is a low urinary pH, increased protein in
Cast
0-1/uL the urine, increased excretion of solutes, and decreased urine flow
rate. Otherwise, excretion of an excessive number of casts is
usually associated with wide-spread kidney disease that involves
the renal tubules.
Bacteria are not normally present but may be seen if UTI is
present or if the sample was contaminated externally. The number
Bacter
ia
28
0-278/
uL
Nursing Responsibilities:
Explain to the client:
That results are most reliable if the specimen is obtained upon arising in the
morning, after urine has accumulated overnight in the bladder (Exception: Serial
urine samples for glucose should consist of fresh urine.)
The proper way to collect the sample, if the client is to do this independently.
The importance of the sample being received in the laboratory within 1 hour of
collection.
Prepare for the procedure:
The client should be provided with the proper specimen container.
For women, a clean-catch midstream kit should be provided.
For catheterized specimens, a catheterization tray is needed if an indwelling
catheter is not already present.
50
Chapter 15
Drug Study
Generic Name
Cefuroxime axetil
"
Brand Name
Classification
Dosage and
Frequency
51
Mechanism of
action
Indications
Contraindication
s & Cautions
52
Drug to Drug
Interactions
Side effects
Hypersensitivity reactions
Nausea
Vomiting
Diarrhea
Vaginitis
Adverse effects
53
Nursing
Considerations
54
"
Brand Name:
Classification:
Dosages
1 neb q6
Mechanism Of Action
Indications
55
Contraindications&
Cautions
56
Adverse effect
57
Nursing Considerations
Assessment
Monitor therapeutic effectiveness which is
indicated by significant subjective improvement in
pulmonary function within 6090 min after drug
administration.
Monitor for: S&S of fine tremor in fingers, which
may interfere with precision handwork; CNS
stimulation, particularly in children 26 y,
(hyperactivity, excitement, nervousness,
insomnia), tachycardia, GI symptoms. Report
promptly to physician.
Lab tests: Periodic ABGs, pulmonary functions,
and pulse oximetry.
Consult physician about giving last albuterol dose
several hours before bedtime, if drug-induced
insomnia is a problem.
Patient & Family Education
Review directions for correct use of medication
and inhaler (see ADMINISTRATION).
Avoid contact of inhalation drug with eyes.
Do not increase number or frequency of
inhalations without advice of physician.
Notify physician if albuterol fails to provide relief
because this can signify worsening of pulmonary
function and a reevaluation of condition/therapy
may be indicated.
Note: Albuterol can cause dizziness or vertigo;
take necessary precautions.
Do not use OTC drugs without physician
approval. Many medications (e.g., cold remedies)
contain drugs that may intensify albuterol action.
Do not breast feed while taking this drug without
consulting physician.
58
Generic Name
Paracetamol,
Acetaminophen
"
Brand Name:
Classification:
Dosages
Mechanism Of Action
59
Indications
Contraindications&
Cautions
Adverse effect
Nursing Considerations
61
Zinc Sulfate
Generic name
"
Brand Names
Classification
Indication
Contraindication
Side effects
Adverse effects
62
Nursing responsibilities
63
Chapter 16
Nursing Theories
64
the right theory to be taught and given importance by the client due to its relevance in
the development and personal health of the client.
Orems Self Care Deficit Theory
Orems self care deficit theory is based on the idea that people have the innate
ability, right, and responsibility to care for themselves. It reflects a concept of human
development that maturation is accompanied by self-reliance, a desire to be selfdirecting, and to encourage others to be so. Self-care is seen as a behavior learned
throughout a persons lifetime from childhood where it is learned and in adulthood
where it is maintained or perpetuated in the succeeding years. It contains those
activities one does and performs to maintain the optimum well being. The nurse role is
therefore, to assist the client with self-care activities and to maximize ones capability to
care for themselves. It specifies when nursing care is needed too. Nursing is needed
when the client cannot continuously maintain ones daily living pattern and activities to
sustain ones own life and health, to recover from a condition, or to cope with its effects.
There are instances wherein patients are encouraged to bring out the best in them
despite being ill for a period of time. This is very particular in rehabilitation settings, in
which patients are entitled to be more independent after being cared for by physicians
and nurses. Therefore the theory is used to identify when patients should receive help
to meet their heath care needs, to what degree the client needs help, and to allow the
patient to care for themselves.
Prevention is better than cure. Although there is already a presenting problem, it
may complicate and worsen into a more sophisticated and severe problem. In terms of
knowledge regarding the problem, the healthcare team or the nurses and doctors know
more about what is best for the client. Simple intervention and ways can decrease the
chance of complications arising. Cooperating with the parents of the client may very well
improve the overall health of the client. To also maximize the time in teaching the family
they will be taught the importance of caring oneself to open their minds and thus be
more aware of themselves for the betternment of their life. Orems theory can very well
be related to the problem as it identifies and is able to give guide to the care that should
be given to the client.
65
66
Chapter 17
Nursing Care Plan
1.
2.
3.
4.
67
Cues
Need
Diagnosis
Objectives
Intervention
Evaluation
Time
1.) Monitor and record vital
Goal Partially
signs
Met
Septemb Objective:
Ineffective
er 16,
airway
of nursing
Productiv
clearance
interventions,
e cough
related to
with
presence of
2016
phlegm
nursing
interventions,
secondary to
ons
effort
inflammatory
upon
process in
no
the alveoli
and difficulty of
breathing was
slightly not
Have
R: This is to mobilize
secretions
improved
respirations
Crackles
R: The
heard
inflammation
and
noted;
upon
auscultati
increased
Able to
moderate high
clearance
Nasal
repositioned in
secretions
expecto
brought
rate
about by
not able to
Maintai
phlegm.
flaring
minutes
After 3 hours of
Exertional T
on
reference
respirati
secretions
expectora E
tion
R: This is to establish
noted
pneumonia
Mild
make it
chest
difficult to
na
indrawing
maintain a
patent
noted
patent
airway
Shortnes
airway. This
symptoms of infection
s of
is due to the
R: To identify infectious
breath
decreased
noted
ability to
Wheezing
expel the
noted
excessive
R: Strict compliance of
Rapid
mucus
breathing
produced that
chances of complications.
noted
will lead to
interventions
8.) Administer medications
as prescribed
extensive
R: to clear secretions.
obstruction of
the airway.
68
the patient is
expectorate
Date/
Cues
Nee
Diagno
sis
Time
Objectives
Intervention
Evaluation
Septemb
Objective:
Impaire
Within the 2
Goal Met.
er 15-16,
-Dyspnea,
d gas
day nursing
After the 2-
intervention
Manifestations of respiratory
day nursing
2016
-Tachycardia
exchan
ge
Restlessness
related
be able to:
to
-Demonstrate
alveolar
improved
status.
improved
capillar
ventilation
tissues by
membr
ABGs within
E
R
C
ane
change
s
patients
acceptable
range and
intervention
the patient
was able to
demonstrate
and
oxygenation
of tissues by
(circumoral). R: Cyanosis of
ABGs within
patients
absence of
symptoms of
respiratory
earlobes, mucous
distress.
symptoms of
respiratory
membranes) is indicative of
distress and
systemic hypoxemia.
participate in
participate in
actions to
Restlessness, irritation,
actions to
maximize
maximize
oxygenation.
decreased cerebral
P
A
T
T
E
R
N
-Patients care
giver will be
able to
oxygenation.
4. Monitor heart rate and
rhythm. R: Tachycardia is
usually present as a result of
fever and/or dehydration but
may represent a response to
hypoxemia.
69
acceptable
range and
absence of
oxygenation.
70
Cues
Nee
Time
Diagnosis
Objectives
Intervention
1.Establish rapport
Evaluation
Septem Objective:
Ineffective
Within the 2
ber
-Increase in
breathing
day nursing
15-16,
respiratory
pattern
intervention
2016
rate of 30
related to
the patient
cooperation.
cpm
presence of
will be able
-Shortness
tracheo-
to:
of
bronchial
-Be free of
breath(orth Y
secretions
opnea)
and nasal
-Dyspnea
secretions
normal
-Use of
breathing
increased water
accessory
pattern
breathing
muscles
dissolve secretions.
pattern.
intake to
8-10glasses. R:
can lead to
dehydration;
3. Instruct patient to
inbreathing C
do deep breathing
-Increased
anterior-
demonstrating proper
posterior
technique. R: Deep
exercise after
breathing exercise
diameter
-Chest
increases oxygen
Retractions A
alleviate dyspnea.
T
T
E
R
N
71
After the
nursing
intervention:
Goal partially
-Patient was
free of
which is an
abnormal
4. Keep environment
allergen free (dust,
feather pillows,
smoke, pollen). R:
Presence may trigger
allergic response that
may cause further
increase in mucus
secretion5. Take vital
signs. R: To get baseline
data.
6. Suction naso, tracheal/
oral PRN. R: These may
compromise airway. A
distended abdomen can
interfere with normal
diaphragm expansion
7. Educate proper
hand washing. R: To
prevent infections such
as nosocomial
infections
8. Position the patient in
Semi-fowlers position.
R: To enable the body to
recuperate and repair.
9. Encourage patient
to eat nutritious foods
such as green leafy
vegetables and lean meat
10. Review clients chest
x-ray for severity
of acute/ chronic
condition. R: To prevent
allergic reactions that
can cause respiratory
distress
72
Cues
Nee
Diagno
sis
e/
Objectives
Intervention
Evaluation
Tim
e
Se
Objective:
pte -
Intoler
mb Weakness, T
er
1516,
20
16
fatigue,
exhaustion
-Exertional
dyspnea,
tachypnea
Tachycardi
day nursing
ance
to
will be able
2. Provide a quiet
imbala
to:
nce
Report/
betwee demonstrat
n
ea
of interventions.
environment and limit visitors
Goal
Partially
Met. After
the 2-day
nursing
intervention
the patient
was able to
report/
a,
increases
oxygen measurable
activities as appropriate. R:
supply increase in Reduces stress and excess
on activity
and
Temperatur C
e 37.1oC
-Cardiac S
Rate
132 bpm
tolerance to
dyspnea
and
Respirator P
vital signs
y Rate 30 A
within
- B l o o d T
Pressure
7 0 / 4 0
mmHg
measurable
rest. R: Bedrest is
activity but
without the
excessive
cpm
stimulation.
demonstrate
absence of
dyspnea
and
determined by individual
excessive
fatigue, and
patients
acceptable
insufficiency.
unusual vital
range.
- P u l s e N
Rate
132 cpm
73
patients
age.
74
Chapter 18
Prognosis
Good Fair
Onset of
illness
"
Duration of
ilness
"
Poor Justification
Precipitating
Factors
Willingness
to take the
medication
"
"
75
Environment
al Factors
"
Family
Support
"
Total
Poor: 2*3/6 = 1
Fair: 1*3/6 = 0.5
Good: 3*3/6 = 1.5
Total: 3
General Prognosis:
1-1.6 = Poor
1.7-2.3 = Fair
2.4-3.0 = Good
As shown in the calculated prognosis, it shows a good prognosis. This means that the
patient, through medical treatment has able to attain a good recovery. The factors
related to the prognosis shows that the patient is capable on therapeutic management
on her illness and was cooperating based on the data.
76
Chapter 20
Recommendations
Through the rationalisation of the information in this case presentation, the student
nurses would like to recommend the following:
Patient and Family
To patient C. B. and to her parents, we recommend continuing taking care of
patient C.B. To support her with her needs, to always have time for her. We recommend
the parents to help the patient comply with her medications.
Nursing Education
We recommend the nursing education to support us throughout our college life
as nursing students. May they provide us more knowledge and good skills in taking care
of our patients in the future. May they encourage us to be more studious so that we can
learn in our own ways through their guidance. May they continue to educate us with the
updated medical trends. Furthermore, may the nursing education help us in
disseminating and educating our patients, the community and the society regarding
health education. In this way, it would help not only us student nurses but also the
people around us.
Nursing Practice
We, the nursing students of the Ateneo de Davao University, make sure to
provide equal nursing quality care to all the people we encounter everyday, may they be
ill or not. We should be more flexible in learning and should fully understand the things
we deliver to our patients such us the health teachings, nursing interventions and such.
We should not limit ourselves in acquiring new information regarding health education.
To our clinical instructors, may they guide us in each and every clinical exposure, that
they may be able to fulfil our shortcomings. May they continue to educate us with more
knowledge and skills to prepare us in whatever examinations we will encounter in the
77
future. Furthermore, may they also be able to guide us not only in our studies, but also
in the different aspects of life.
Nursing Research
In this case study, we discovered and learned a lot of things from our patient
through analysing her case. In this way, it would improve our critical thinking, it would
give us more knowledge, it would enhance our learning, and so, we can make our future
case studies better through acquiring new knowledge. And through rationalisation of the
information of this case presentation, we will know what nursing quality care should we
deliver to our patient. Not only knowing and giving care to our patient but we also know
the rationale behind these interventions. Furthermore, this study taught us that being
flexible in finding sources helps us learn more.
78
Chapter 21
Bibliography
Lewis, S. (2014). Pneumonia. Medical-Surgical Nursing, Assessment and
Management of Clinical. Retrieve September 26, 2016. pp. 522-528
Bauman, R. (2015). Bacterial Pneumonia. Microbiology with Diseases by Body
System. Retrieve September 26, 2016. pp. 686-687
Cavanaugh, B. (2003). Nurses's Manual of Laboratory and Diagnostic Tests.
Retrieve September 26, 2016Tidy, C. (September 25, 2014) Mild-to-Moderate
Chronic Kidney Disease. Patient.info. Retrieve August 1, 2016. [Web Page] URL:
http://patient.info/health/mild-to-moderate-chronic-kidney-disease
Fundamentals of Nursing Concepts, Process and Practice 7thEdition
Authors: Barbaras Kozier, Glenora Erb, Aubrey Berman and Shirlee
SryderPublished by: Oearson Education Inc., Copyright 2004
Medical-Surgical Nursing 7th edition Authors: Brunner & Suddarth
2007 Lippincotts Nursing Drug Guide by Amy M. Karch Copyright Lippincot Williams
and Willkins
Nurses Pocket Guide Diagnoses, Prioritized Intervention and Rationales,10thEdtion
Authors: Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Murr
Published by: F.A. Davis Company, Philadephia, Pennsylvania Copyright
2006
Nursing Care Plans Guidelines for Individualizing Patient Care, 6th EditionAuthors:
Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. MurrPublisher: F.A.
Davis Company, Philadephia, Pennsylvania Copyright 2002
79
80
"