DE LA SALLE HEALTH SCIENCES INSTITUTE

Dasmarias City, Cavite

College of Nursing and School of Midwifery

NURSING CASE STUDY

Submitted by: Julius C. Bustamante, SN13 BSN 3-3 August 2011

Submitted to: Mrs. Regiebe G. Vicencio, R.N., M.A.N. (Clinical Instructor)

I.

HEALTH HISTORY A. DEMOGRAPHIC DATA 1. Clients initial: F.C.B. 2. Gender: Female 3. Age: 2 y/o 4. Birthdate: January 21, 2009 5. Birthplace: General Trias, Cavite 6. Marital status: Single 7. Race and Nationality: Filipino, Asian 8. Religion: Roman Catholic 9. Address: Manggahan, General Trias, Cavite 10. Telephone Number: N/A 11. Occupation: N/A 12. Usual Source of medical care: Barangay Clinic 13. Diagnosis: Pediatric community acquired pneumonia B. SOURCE AND RELIABILITY OF INFORMATION y Clients mother who seems reliable y Patients chart from the Nurses station C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS y Fever y Cough and colds D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH 3 days prior to admission, patient experienced fever which is 39 oC. She also had cough and colds and her mother gave her carbocisteine as a remedy. Patient also manifested loose watery stool. 2 days prior to admission, fever still persisted with combination of cough and colds too. They seek consultation at wellcare clinic and they were given cefuroxime, cetirizine, and salbutamol. Few hours prior to admission, persistence of signs and symptoms continued and the patients parents were unable to fed the patient properly.

E. PAST MEDICAL HISTORY OR PAST HEALTH y Pediatric/childhood/adult illnesses The patient did not experienced serious illnesses during childhood except for those seasonal illnesses which are cured by OTC medicines. y Injuries or accidents The patient did not experience any types of injuries and accidents before since her parents are taking good care of her. y Hospitalization This time was the patients first time to be hospitalized since she was born by her mother. y Operation The patient did not undergo any surgery before. y Immunization Patient had completed all the vaccinations needed since she was given birth. y Allergies The patient has no known allergy to any foods or environmental allergens y Medications The patient was not taking any medications except for supplements like vitamin C for her immunity.

F. FAMILY HISTORY MATERNAL PATERNAL

HPN, age unrecalled

HPN, age unrecalled

62, w&a

CA, 49

36, HPN

42, w&a

34, W&A

13, W&A

40, w&a

10, W&A 32, W&A

38, w&a

9, W&A 30, W&A 36, w&a

46, W&A

2, W&A 30, w&a

LEGEND:

Patient

Deceased

Male

Female

Synthesis: The above diagram shows the family tree of patient FCB. Together with the diagram are the ages and diseases that the patients family has. And also, the diagram show the relatives of the patient and about on how they are connected and interrelated. As we can see, the patients family does not have much of diseases or disorders that the patient may inherit. There are only two: hypertension and cardiac arrest, which of both are disorders of the heart. No other inheritable disorders from other vital organs of the body were traced. The maternal side of the patient is not that accurate because the mother of the patient, who served as the source of information, was not able to recall everything from her family because they were not living in one place for a long period of time.

G. SOCIO-ECONOMIC The source of information, or the patients mother did not disclose any data with regards to their socio economic status. What they have stated was that what they earn from their work is enough to sustain their needs. It was very evident because they could even afford to choose private room for their daughter which is costly compared to other public rooms in the hospital. H. DEVELOPMENTAL HISTORY The patient, age 2, is under the stage of early childhood with accordance to Erik Ericksons developmental theory. In this stage of development, we learn to master skills for ourselves. Not only do we learn to walk, talk and feed ourselves, we are learning finer motor development as well as the much appreciated toilet training. Here we have the opportunity to build self-esteem and autonomy as we gain more control over our bodies and acquire new skills, learning right from wrong. It is also during this stage, however, that we can be very vulnerable. If we're shamed in the process of toilet training or in learning other important skills, we may feel great shame and doubt of our capabilities and suffer low selfesteem as a result. The most significant relationships are with parents. The patient manifested a well-developed personality. She was able to talk and communicate just like any other ordinary child. She seemed to be very bonded with her mom. She could also perform tasks without manifestations of any hesitations or fears. Skills that should be learned at her age were already attained by the patient.

I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. R.O.S. and P.E. SYSTEM 1. General R.O.S. P.E.  Awake, conscious, slight coherent  Temp= 37.8oC N/A  RR= 52 cpm  AP= 144 bpm  (+) mild general weakness  (+) irritability  (+) crying  (+) ambulatory 2. Integument Skin  Skin is dark, dry, N/A smooth and evenly fair  Good skin turgor  Warm to touch  (-) skin lesions  (-) abnormal discoloration Hair  Hair is black, long, and fine  (+) Normal hair distribution  (-) lice and dandruff

Nails  Fingernails are clean  Round, hard nails with partial whiteness on the nail beds  (-) nail clubbing  Capillary refill <3 seconds 3. Head  Head is round and organs are symmetrically N/A distributed  (-) lesions on the scalp  Proportional to body  temporomandibuilar joint felt bilaterally within  (-) involuntary facial movements  (-) abnormal masses found all over the face 4. Eyes  Symmetrical and simultaneous blinking  PERRLA N/A  round and equal iris  (-) protrusions  (-) inflammation

 (-) unusual discharges  (-) discoloration of sclera  (+) teary eyed 5. Ears  Ears are soft and symmetrical  Ears are aligned with N/A the outer cantus of the eyes  (+) recoils when folded  (+) firm cartilages  (-) discharges on external ear  (+) small amount of cerumen in the ear canal without foul odor  (-) tenderness and abnormal masses  (-) lesions and abrasions  (+) pierce on both sides 6. Nose and Sinuses  Located at the midline of the face  Symmetrical in N/A shape  Pink and moist mucosa with no lesions  (+) nasal secretion:

clear, slightly thick, small amount  (-) tenderness and masses upon palpation 7. Mouth and throat  Lips are slightly dry  Lips are pinkish in color N/A  (-) lesions and inflammation  (+) sweet tooth  Pharyngeal tonsils not inflamed  (-) bad breath  (-) tenderness and masses upon palpation  (-) mouth ulcers or stomatitis 8. Neck  (+) ROM  Smooth, firm, nontendered thyroid N/A  (-) lymph node enlargements  (-) abnormal prominence of bones 9. Breast and Axilla  (-) axillary lymph nodes enlargement  (-) abnormal secretions

N/A

 (-) skin damage or abrasions  Chest expands symmetrically while breathing

10. Respiratory

N/A

 RR 52 cpm  AP 144 bpm  Effortless respiration  (+) productive cough  (+) crackles

11. Cardiac

 (+) apical pulse felt at 5th ICS LMC line  AP 144 bpm N/A  (-) hypertension  (-) distension of jugular vein  (-) edematus  (-) bruit upon auscultation

12. Gastrointestinal

 Stomach is round and distended  (-) protrusion of the N/A umbilicus  (-) rashes  (-) mass and tenderness

13. Urinary

 Urine is slightly clear and yellowish in color

N/A

 Changes diapers at least 7 times per day.

14. Genitalia 15. Peripheral vascular

N/A

 No P.E.  (-) any abnormalities of

N/A

blood vessels  (-) edematus on any extremeties  (-) paresthesia

16. Musculoskeletal

 Patient stands erect  (+) ROM and muscle strength of upper and N/A lower muscle  Muscle is proportionally and equally distributed  (-) muscle pain and weakness

17. Neurologic

 (+) oriented to place and person  (+) conscious, N/A coherent and communicative  (-) problems to nerve reflexes

18. Hematologic N/A 19. Endocrine N/A

 (-) unusual bleeding  (-) bruising  (-) rashes  (+) heat and cold tolerance

2. Laboratory Studies/Diagnostics Date Indication Normal values Actual findings 09/18/2011 Hgb 118 Monitor of the 140-175 g/L Blood components of Chemistry the blood to Hct 0.36 check for 0.36-0.45 infection, deficiency, loss WBC 3.4 of electrolytes, 5-10 x 109/L etc..

Differential count: Segmenters 0.36 0.66 Lymphocytes 0.22 0.40 0.63

0.36

PC 150-450 x 109/L

286

Nursing responsibilities y Explain to the patient the rationale and the interpretation of the result of the exam. y Monitor vital signs and signs and symptoms relating to increase or decrease in RBC. y Maintain adequate hydration. y Assist with medical interventions. y Instruct the client to eat foods rich in iron like liver, green veggies, etc. y Instruct patient to prevent to the exposure of chemical elements like lead to avoid ingestion and poisoning.

09/18/2011 Check for UTI Urinalysis

Color Characteristic Specific gravity pH

Yellow Clear 1.015 6.0

y Explain to the patient the rationale and the interpretation of the result of the exam. y Maintain

Albumin Sugar WBC RBC Epithelial cells

negative trace 0-1/hpf 0-1/hpf rare

adequate hydration y Assist with medical interventions y Monitor UO

3. Other assessment tools Date taken Comprehensive actual content/Legend ---

Actual result --

J. FUNCTIONAL ASSESSMENT 1. Health perception/Health management pattern The patient seems to be healthy but not that well because she find difficulty in performing activities due to occasional difficulty of breathing due to lung secretions. 2. Self-esteem, self concept/self perception pattern The patient is too young to state her self-perception. 3. Activity/exercise pattern The patient used to play and playing served as her exercise. When she was still not admitted, she used to have playmates in the neighbor, but on her current stay at the hospital, only her mother who takes care of her is the only one who serves as her playmate 4. Sleep/rest pattern The patients mother told that her daughter does not possess any sleeping disorder. She could sleep any time she wants without any difficulties. She was able to attain enough hours of sleep during night and even at afternoons even at the hospital. 5. Nutrition/elimination The patient with the aid of her parents was able to attain enough nutrients she needs to sustain body requirements. She was able to take healthy meals to make herself strong. 6. Sexuality/reproductive The patient is yet too young to have sexual or reproductive assessment

7. Interpersonal relationships/resources The patient is obviously strong bonded with her family. She was able to communicate effectively with them. They do not have any family issues that could affect the child. 8. Coping and stress management/tolerance pattern Whenever the patient is stressed, sleeping and playing is the only solution used to manage these stressors. 9. Environmental hazards Patients parents were able to provide safe and conducive environment for the patient to live. They try to give the safest environment for their children to keep them away from accidents. II. PROBLEM LIST A. ACTUAL OR ACTIVE Problem No. Problem 1 Sleep disturbance

Date identified August 18, 2011

Date resolved August 18, 2011

B. HIGH RISK OR POTENTIAL Problem No. Problem Date Identified 1 Risk for infection August 4, 2011 related to presence of an open site secondary to intravenous infusion

III. Cues

NURSING CARE PLAN Nursing Background Long diagnosis knowledge term Sleep deprivation related to frequent awakenings secondary to cough Due to ineffective pattern of lung mucus secretions elimination, stasis of mucus in the lung field occurs. As a normal body mechanism, the patient would tend to cough. These unstoppable cough caused the patient frequent awakenings during sleep hours during night time and so the patient was sleep deprived. After a week, the patient will be able to sleep without interruptio ns in case that she will still stay at the hospital.

Short term Intervention

Rationale

Evalua tion

S: N/A O: y Received pt lying on bed currently breastfed by her mother, awake and conscious with IVF of D5IMB 500cc with remaining level of 475cc regulated and infusing well at right metacarpal vein at the rate of 45-46 gtts/min y with diagnosis of PCAP-B y on diet of DAT with SAP y (+) crying y (+) nonproductive dry cough y (+) irritability y (+) crackles y v/s taken q4,

Within the 8 hours shift, the patient will be able to attain rest/sleep for at least 3 hours without disturbanc es

y NPI established

y For the patient to be comfortable while communicating with the nurse y To attain baseline information about the patient y To determine if patient is getting enough hydration

y Monitored v/s q4

y Monitored

I&O

y Assessed cough of the patient

y To know the characteristics, color, amount and consistency of the mucus secretions for further assessment y To acquire information about the patients comfort while staying in the hospital for further

y Assessed recent sleeping pattern

@8am: y T 37.8 oC y AP 144 bpm y RR 52 cpm

assessment y Performed health teaching about attaining proper sleep and rest: 1. Assume comfort able position 2. Limit visitors 3. Decrea se noise within the room y Discussed the disadvanta ges of not having enough sleep/rest: 1. Fatigue 2. Palenes s 3. Body y To resolve sleeping disturbance problem of the patient

y For the patient to acquire knowledge about the effects that he may experience when sleep insufficiency is not resolved y To treat and prevent recurrence of the disease

weaknes s

y For the patient to find ease in doing self hygiene as a part of the treatment

y Due meds given

IV.

ANATOMY AND PHYSIOLOGY The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in and disposing of those gases. Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body. Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.

V.

PATHOPHYSIOLOGY
Predisposing factors:inherent, influence

Precipitating factors:smoking, malnutrition, dehydration, immobility

LEGEND: Signs/symptoms Sequence of events Affecting factors

COMMUNITY ACQUIRED PNEUMONIA Definition: Community acquired pneumonia is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs. CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. Symptoms:
 problems breathing  coughing that produces greenish or yellow sputum  a high fever that may be accompanied with sweating, chills,

and uncontrollable shaking

 sharp or stabbing chest pain  rapid, shallow breathing that is often painful

Synthesis: As noted, patient FCB experienced fever during the days before admission to the hospital. She also had cough and cold which persisted until she was admitted to the hospital. The patients cough is unproductive and so the color, consistency and amount were undetermined. The patient was taking medications to alleviate fever, cough and cold. She also undergoes nebulization to loosen up sticky secretions that were present in her lungs. These mucus secretions were due to immune response of the patients body to fight the infection that caused pneumonia she acquired from the community.

VI.

MEDICAL SURGICAL MANAGEMENT 1. PROCEDURE Procedure/Date -

Indication/Analysis -

Nursing Responsibilities -

2. PHARMACOTHERAPEUTICS/MEDICINES Generic Indication, dosage, name, brand frequency name, classification, stock Albuterol 1. To control and prevent reversible airway Salbutamol obstruction caused by asthma or chronic Bronchodilator obstructive pulmonary disorder (COPD) 500mg/tab 2. Quick relief for bronchospasm 3. For the prevention of exercise-induced bronchospasm 4. Long-term control agent for patients with chronic or persistent bronchospasm PO 0.1 mg/kg 3 times a day

Nursing responsibilities

y Assess lung sounds, PR and BP before drug administration and during peak of medication. y Observe fore paradoxical spasm and withhold medication and notify physician if condition occurs. y Administer PO medications with meals to minimize gastric irritation. y Extendedrelease tablet should be swallowed-whole. It should not be crushed or chewed. y If administering medication through inhalation, allow at least 1 minute between inhalation ofaerosol medication. y Advise the patient to rinse mouth with water after each inhalation to minimize dry mouth. y Inform the patient that Albuterol may cause an unusual or bad taste.

Paracetamol Biogesic

Fever, Relief of mild to moderate pain like headaches, muscular aches and pain, toothache,

y If to be given as analgesia, assess onset, type, location, duration of pain.

Antipyretic 250mg tablet

colds, earache, fever due to tonsillectomy, inoculations, and vaccinations. 250mg Q4

y Can be given without regards to meals. y Tablets can be crushed. y Assess temperature directly before and 1 hour after giving medication. y If respirations are <12/min (<20/min in children), withhold the medication and contact the physician. y Evaluate for therapeutic response: relief of pain, stiffness, swelling; increasing in joint mobility; reduced joint tenderness; improve grip strength. y Therapeutic blood serum level: 10-30 mcg/mL; toxic serum level: >200 mcg/mL.

Cefuroxime Ceftin Antibiotic 50-100 mg/kg/day divided every 12 hours

Cefuroxime is used to treat otitis media, respiratory tract, genitourniary tract, gynecologic, skin, and bone infections. It is also used in the treatment of speticemia, bacterial meningitis, gonorrhea, and other gonococcal infections. Cefuroxime can also be used for ampicillinresistant influenza, perioperative prophylaxis, impetigo, acute bacterial maxillary sinusitis, and early Lyme disease.

y Question for history of

allergies, particularly cephalosporins and penicillins.

y Give without regards to

meals. If GI upset occurs give with food or milk.

y Avoid crushing tablets

due to bitter taste.

y Suspension must be

given with food.

y Intramuscular injections

must be administered

50-100 mg/kg/day Q12

deep IM to minimize discomfort.

y Assess mouth for white

patches on mucous membranes and tongue.

y Monitor bowel activity

and stool consistency carefully.

y Mild GI effects may be

tolerable but increasing severity may indicate onset of antibioticassociated colitis.

y Monitor input and output

and renal function reports for nephrotoxicity.

y Be alert for

superinfection: severe genital or anal pruritus, abdominal pain, severe mouth soreness, moderate to severe diarrhea.

VII.

PROGRESS NOTES Day 1 y The patient is ambulatory y He was feeling mild general weakness y She felt no pain at all y She is slightly irritable due to fear of nurses y Patient was crying y The patient was not able to take food, only breastmilk y The patient has fever y The patient is ambulatory y She was still feeling mild general

Day 2

weakness y Irritability of the patient was decreased not like the day before y Patient was not crying anymore y The patient still was not able to take food, only breastmilk y Fever alleviated

VIII.

SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT

Date: August 19, 2011 The patient seems to be still slightly sick. Presence of cough and colds still persist. The patient was able to communicate with the nurse assigned to her not like the first day. She was not still able to take any meal aside from breast milk. Crackles were still present. The patient seems to like sleeping more than playing. She still cry when she see a nurse in white uniform try to take her vital signs. Medications are continued and oral fluid intake was increased to eliminate sticky lung secretions.