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PAMANTASAN NG CABUYAO

COLLEGE OF HEALTH ALLIED SCIENCES

COLLEGE OF NURSING

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CASE ABSTRACT:

This is a case of patient a 5 yr. old female residing at Mercedes Vill, Sala, Cabuyao Laguna., thepatient was received at St.James Hospital last Sept 30, 2009 at 7:50 pm with a chiefcomplaint of fever. Initial vital signs were taken T-38.5C, RR- 40bpm, PR- 130bpm.

Initial diagnosis was Pediatric Community Acquired Pneumonia-C. The patient was subjectedfor Urinalysis, Blood Chemistry, Hematology and Radiologic exam and was given Cefaclor,Salbutamol, Erdostien, Polynerv syrup b1+b6+b12 as prescribed. Upon further history taking wefound out that both of her parents were active-smokers.

LEARNING OBJECTIVE:

The study aims to impart knowledgeregarding community acquired pneumonia and means to restore or maintain

patients health status utilizing a holistic approach of promoting and rehabilitativeprocess of nursing managements.

1. Identify nursing problems and the corresponding nursing considerations andmanagements involved for promotion and maintenance of patients health.

2. Enumerate therapeutic nursing interventions through formulation of NCP.

3. Specify the appropriate laboratory

and diagnostic procedures / examinations and correlate them with the casepresented.

4. Discuss simple pathophysiology ofcase presented, its predisposing factors, signs / symptoms, complications andtreatments.

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REVIEW OF ANATOMY AND PHYSIOLOGY: RESPIRATORY SYSTEM

The respiratory system consists of all the organs involved in breathing. These include thenose, pharynx, larynx, trachea,bronchi and lungs. The respiratory system does two very importantthings: 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 isfunneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into thebloodstream and carbon dioxide is pushed from the blood out into the air. When something goeswrong with part of the respiratory system, such as an infection like pneumonia, it makes it harderfor us to get the oxygen we need and to get rid of the waste product carbon dioxide. Commonrespiratory symptoms includebreathlessness, cough, and chest pain.

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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 (orwindpipe) before entering your lungs. All these structures act to funnel fresh air downfrom the outside world into your body. The upper airwayis important because it mustalways stay open for you to be able to breathe. It also helps to moisten and warm theair before it reaches your lungs.

The LungsStructure

The lungs are paired, cone-shaped organs which take up most of the space in ourchests, along with the heart. Their role is to take oxygen into the body, which we needfor 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. Theseare 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 takesup some of the space in the left side of our chest. The lungs can also be divided up intoeven smaller portions, called 'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other bymembranes. There are about 10 of them in each lung. Each segment receives its ownblood supply and air supply.

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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 timesthroughout 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 littleblood 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 closetogether, 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 thealveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel acrossthe walls of the alveoli into your bloodstream. Traveling in the opposite direction iscarbon dioxide, which crosses from the blood in the capillaries into the air in the alveoliand is then breathed out. In this way, you bring in to your body the oxygen that youneed to live, and get rid of the waste product carbon dioxide.

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Blood Supply

The lungs are very vascular organs, meaning theyreceive a very large blood supply. This is because thepulmonary arteries, which supply the lungs, comedirectly from the right side of your heart. They carryblood which is low in oxygen and high in carbon

dioxide into your lungs so that the carbon dioxide canbe blown off, and more oxygen can be absorbed into thebloodstream. The newly oxygen-rich blood then travelsback through the paired pulmonary veins into the leftside of your heart. From there, it is pumped all aroundyour body to supply oxygen to cells and organs.

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Passes to the pharynx, larynxand trachea

Enters through nose or mouthby inhalation

Streptococcal Pneumoniae

Precipitating Factor:EnvironmentPredisposing Factor: age

Microorganism enters and affects

both airway and lung parenchymaAirway damage

Lung invasion

Activates macrophagesand leukocytes

Mucus and Phlegm Production

Coughing Productive or non-Productive

Infiltration of bronchi

Infectious organism lodges

stimulation in bronchioles

Alveolar wall Collapse

Increase pyrogens in thebody

Fever

Narrowing of air passage

Difficulty of Breathing

Macrophages destroys RBC

Decreased RBC count

Bilirubin Production

jaundice

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Health History

Patient Name: Patient AAge: 5 Yrs. Old

Sex: FemaleNationality: FilipinoCivil Status: SingleReligion: Roman CatholicHighest EducationalAttainment: PreparatoryRank in the

Family: Second Child of Three siblingsAddress: Mercedes Vill. Sala Cabuyao, LagunaInclusive Dateof Confinement: Four DaysAdmission Dateand Time: Sept. 30, 2009 at 7:50 PMDischarge Date: Oct. 4, 2009 at 1:36 PM

AttendingPhysician: Mariano M. Carteciano M.D.Initial Diagnosis: PCAP CFinal Diagnosis: PCAP CSource ofHistory: MotherChief Complaint: Fever

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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 isobedient in taking her medications.

II. Nutrition-Metabolic Pattern A. Height: 3 ft., 5 in. tall

B. Weight: 19.1 kg.C. Appetite: GoodD. Usual EatingE. Pattern: 3 meals a dayUsual Daily Menu

a. Breakfast: Chocolate Drink / Milk

b. Lunch: Usually hotdog with ricec. Dinner: Typical viand (meat, vegetable, etc.) with riced. Snacks: Chocolate Cookies

F. Diet: usual dietG. Has good skin turgor

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III. Elimination Pattern

A. Bowel:a. Usually no problem with eliminationb. 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-care1 Requires use of equipment or device2 Requires assistance or supervision from another person3 - Requires assistance or supervision from another person and

equipmentor device

4 Dependent and does not participateB. Past Health Status:

b.1. Prophylactic Medical/Dental Care: Noneb.2. Childhood Illness: Measlesb.3. Immunizations: Completeb.5. Major Illnesses/Hospitalizations: None before this current

admissionb.6. Current Medications: Paracetamol (Prescribed)

b.7. Allergies: None

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V. Sleep- Rest PatternA. Sleep Habits:

a. 8-9 hours of sleep/nightb. 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 patients hospitalization>Patient states good relationship with friends

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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

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I. GENERAL SURVEY

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

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

III. INTEGUMENTARY

Skin: >with slight jaundice on facial area, mild dryness,good skin turgor

Mucous membrane: >pink oral mucosaNails: >no clubbing, smooth in texture, capillary refill

at 2-3 secondsHair: >evenly distributed, mild thinning of hair,

no infestation

5 year old female child admitted to ERAppears normally on her ageMild irritability but cooperativeMild weakness

Good posture(+) cough; productive(+) difficulty of breathing(-) retraction19.1kg in weight3ft 5 in height

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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 arenot reddened Face

>Symmetry: Symmetrically equal>Facial Musculature: has the ability to frown and smile

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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 ageGrowth: 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

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IX. ABDOMENa. General Contour: rounded abdomen

Tenderness: rated 6 on pain scale at LUQ

b. Bowel Sounds: normal bowel soundsc. Abdominal Sounds: N/A

X. MUSCOLO-SKELETALA. STRENGTH: decrease muscle strengthB. ROM: within normal limits

XI.NEUROLOGICALA. Mental Status (LOC): 15 pts.B. Pupils Size: 3-4 mmC. Cranial Nerves: N/AD. Sensory: N/AE. Deep Tendon Reflex (grade the dotted areas)

XI. RECTAL/ANUS>N/A

XII. GENETALIA>Growth: N/A>Discharge: No abnormalities as stated by the mother

Legend:

Reflex Scale

0> no response

1> low normal2> normal

3> brisk

4> hyperactive

Legend:

Reflex Scale

0> no response

1> low normal2> normal

3> brisk

4> hyperactive

Legend: Glascow coma scale

A. Eyes open

spontaneous -4

on command -3

to pain -2

no response - 1

B. Best Verbal Response

Alert and oriented -5

Confuse -4

Inappropriate -3

Incomprehensive -2

No response -1

C. Best Motor Response

Follows direction -6Localizes pain -5

Withdraws from pain -4

Decorticate posturing-3

Decerebrate posturing-2

No response

Legend: Glascow coma scale

A. Eyes open

spontaneous -4

on command -3

to pain -2

no response - 1

B. Best Verbal Response

Alert and oriented -5

Confuse -4

Inappropriate -3

Incomprehensive -2

No response -1

C. Best Motor Response

Follows direction -6Localizes pain -5

Withdraws from pain -4

Decorticate posturing-3

Decerebrate posturing-2

No response

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Urinalysis Result Normal value Significance

MACROSCOPIC

COLOR

TRANCEPARENCY

Ph

Color

Slightly Hazy

6.5

Clear

Clear

4.6- 6.5

Change of appearance ofthe urine is an indication

of renal or urinary track

infection.

Disturbance of Ph

indicates acid-based

disorder.

MICROSCOPIC

Specific gravity

Albumin

Sugar

Pus cells

RBC

Bacteria

1.010

Negative

Negative

8-10/hpf

0-2/hpf

None

1.015-1.030

Negative

Negative

0-1/Hpf

0-1/hpf

none

-Alteration of Specificgravity inidactes level of

consentration of urine.

-Presense of albumin

may indicate glomerular

disease

-Presence of sugar in the

urine may indicates

complications.

-Presence of pus cells inurine indicated urinary

tract infection.

-Alteration of RBC in

urine indicated Urinary

tract infection.

-Presence of bacteria

indicates infection.

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Blood chemistry Result Normal value significance

Sodium Test

Potassium test

Calcuim

129 mmol/L

3-7 mmol/L

9-6mg/dL

137-145 mmol/L

3.5-5.1 mmol/L

8.4-10.2mg/dL

Low level of sodium

in the blood may

cause convolsions.

High potassoum level

indicates alteration to

electrical activity on

the heart.

Essesial for

maintaining a regular

heart beat, neuromuscular 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 WBCindicates infecton

Platelets 335,000 150000-450000/uL Alteration of platelet

counts will affect

coagulation,hemostas

is,and clothing

formation.

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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

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A. DIET:

Diet appropriate for age (5 yr. old)

High caloric food such as rice

Increased Fluid intake

Low fiber diet

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NAME OFDRUGS

THERAPEUTICACTION

INDICATION CONTRAINDICATION/CAUTIONS

DOSAGE ADVERSEEFFECT

NURSINGCONSIDER

ATION

GENERICNAME:Cefaclor

BRAND NAME:CecavilCefaclorApo-Cefaclor

CLASSIFICATI

ON:Anti Biotic

BactericidalInhibitssynthesis ofBacterialwallcausing cellDeath.

Treatment ofotitis media,phryngitis,tonsillitis,AcuteBacterialExacerbationof chronicbronchitis,pneumonia,

Uncomplica-tedd skin andSkinstructure,lower UTI

>patient with allergyto cephalosporin

>hypersensitivity tobeta lactamantibiotics

>may induce

anaphylacticshock

Children:Suspen-sion5ml per8hrsthree timesaday for 5daysAdult:

500mg per8hrs

CNS:Headache,dizziness,lethargyGI:Nausea,vomiting,diarrhea,anorexia,Abdominal

pain,flatulenceHematologic:bone marrowdepressionHypersensitivity:ranging fromrash to fever

>assess for thehistory ofdrugallergy,pregnancyandlactation

>assess patientfor signsandsymptoms

of infectionbefore andduringtherapy

>assess for renalfunctiontest,respiratorystatus,culture andsensitivity

to test ofinfectedarea

>take the drugswith meal orfood toprevent theGIdiscomfort..

B.1 STANDING ORDER

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NAME OFDRUGS

THERAPEUTICACTION

INDICATION

CONTRAINDICATION

CAUTIONS

DOSAGE ADVERSEEFFEC

T

NURSINGCONSIDERATI

ON

Genericname:Salbutamol

oralbuterol

Brandname:

VentolinCombiventSalbutamol

Classification:

RespiratorydrugsAntiasthmatic

Stimulates beta 2receptors ofbronchioles by

increasing levelsof camp whichrelaxes smoothmuscles toProduceBronchodilata-

tion.

Relief ofBronchospa

smin bronchial

asthmachronic

BronchitisEmphysemaand otherReversibleObstructivePulmonarydiseases.

>Hypersensitivity toSalbutamol, alsoto atropine and itsderivatives.

>Threatened abortionduring 1st and 2nd

trimester.

>cardiac arrhythmiaassociated w/tachycardiacaused by digitalisintoxication.

>prevention ofpremature laborassociated w/toxemia ofpregnancy or antepartumhemorrhage.

Adults andchildren over12 years: TheRecommend

d dose is 2 4mg (5 - 10 mlsyrup) 3 4times daily.The maximaldaily doseshould notexceed 32 mg(divided in 3or 4 doses).

Children:between 2and 6 years,the dose is0.1 - 0.2mg/kg bodyWeightgiven 3times daily.TheMaximal

daily dosemust notexceed 4 mg,3 timesdaily, andthe daily dose for6 - 12 years-old

children isto 24 mg daily,

divided in 3or 4 doses.

Headache;tremor;tachycardia;hypertensio

n;anxiety.Rarelynausea,vomiting,

andskin rash

canbe observed

The drug should beavoided duringpregnancy,particularly

during the firsttrimester and

duringlabor, because it isestablished that thehigh doses cansuppress thecontractions of theuterus. There are

nodata for risks

relatedwith theadministrationof the drug in breastfeeding women..Because of thepossibility forinduction of

tremor,dizziness, andweakness, the drug

should be usedcautiously indrivers

and people workingwith machines.

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NAME OF DRUGS THERAPEUTICACTION

INDICATION CONTRAINDICATION/CAUTIONS

DOSAGE ADVERSEEFFECT

NURSINGCONSIDERATION

GENERIC NAME:Erdostien

BRAND NAME:

Zertin

CLASSIFICATION:For respiratoryDrugs

Erdostien is anoriginalderivative ofnatural

mercapto-aminoacid inthiolactonicform.Following oraladministrationErdostien israpidlymetabolized inthe liver. Theproduct acts as

a prod rug andits metabolitesare mainlyresponsible formucolyticactivity, due tothe presence offree thiolgroups whichcause thesplitting up of

the intra- andintermoleculardisulfidebridges ofseveralproteins andmucoproteinspresent in theexpectoration,resulting in areduction ofthe mucuselasticity andviscosity.

Treatment ofacute &chronicbronchopulm

onarydiseases,rhinosinusitis,laryngopharyngitis orexacerbations of thesechronicdiseases inassociation

w/ mucusproduction &transport.

Hepatic disorders &abnormalities, renalinsufficiency,homocystinuria,

phenylketonuria

Adult 1 capbid. Susp 8.5mL bid.Childn 2-6 yr

(10-20 kg)2.5 mL bid,7-12 yr (21-30 kg) 5 mLbid, 5 mL tidor 7.5 mLbid.

Gastric burning,nausea; ageusiaor dysgeusia.

>assess for thehistory of drugallergy, pregnancyand lactation

>assess for renalfunction test,respiratorystatus, cultureand sensitivity totest of infectedarea

>take the drugswith meal or food

to prevent the GIdiscomfort

>do not give to thepatient 2yrs oldbelow

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NAME OF DRUGS THERAPEUTIC ACTION INDICATION DOSAGE NURSING

CONSIDERATION

GENERIC NAME:

Polynerv syrup b1+b6+b12

0

BRAND NAME:Polynerv b1+b6+b12

CLASSIFICATION:

vitamins

VITAMINS B1, B6 & B12

(POLYNERV Syrup) is

valuable in conditions where

the requirements for Bvitamins are increased (as in

growth, physiologic stress,

decreased resistance to

infection and chronic

illnesses, metabolic

disorders and in certain

diseases of the digestive

tract and nervous system).

It can also be given before

and after surgicalprocedures.

VITAMINS B1, B6

& B12

(POLYNERV

Syrup) is indicatedfor the prevention

and treatment of

deficiency disorders

arising from poor

dietary intake,

impaired B vitamins

absorption (as in

prolonged diarrhea,

excessive vomiting

and antibiotictherapy) intake of

drugs which

interfere with the

utilization of the B

vitamins (i.e.

isoniazid).

As a nutritional

supplement to

promote appetite,

weight gain andheight increase.

1-2 years old : 2.5

mL (1/2 teaspoon)

daily

3-6 years old : 5.0

mL (1

teaspoonful) daily

7-12 years old :

10.0 mL (2

teaspoonfuls)

daily

>assess for the nutritional

status of the patients

>assess for the drug

reaction to the patients>give the vitamins with

meals or food to prevent

gastrointestinal

discomfort

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NAME OF DRUGS THERAPEUTICACTION

INDICATION DOSAGE NURSINGCONSIDERATION

Generic name:Paracetamol or

Acetaminophen

Brand Name:Calpol

Classification:Anti-pyreticanalgesic

Decreases fever byinhibiting the effectsof pyrogens on the

hypothalamic actionleading to sweatingand vasodilation.Relieves pain byinhibiting theprostaglandinsynthesis at the CNS

but does not haveanti-inflammatory

action because of itsminimal effect onperipheralprostaglandinsynthesis.

Relief of mildto moderatepain and

treatment offever

children'sdosages are

based on a

single dose of10mgParacetamolper kilogram

bodyweight,which can berepeated 4-6hourly, notexceeding

four dosesper 24 hours.

Asses pt. fever orpain

Assess allergicreaction

AssesshepatotoxicityMonitor liver andrenal function

Inform pts. That

urine may darkbrown as a result ofphenacetin (ametabolite ofacetaminophen)

Verify the doctorsorder

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C. INTRAVENOUS THERAPY

IV

Fluid

Classification INDICATION Actions Side Effect NURSING

Precaution

5% dextrose and0.3% sodium

chloride

D50.3%NaCl

Hypertonic FluidChallenges

Fluid

replacement in

patient with

DKA,

hyponatremia

shock

Replenish fluidnutrient

Carbohydrates

and electrolytes

>hypernatremia

Dont use inpatient with

heart failure

Edema or

hypernatremia

because it can

lead to overload

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PROCEDURE INDICATIONS NURSING PRECAUTIONS

1. Positioning (Highback rest orFowlers position)

2. Oxygen Administration

When the client is in thisposition, gravity pulls thediaphragm downward,allowing greater chest

expansion and lungventilation. Clientsconfines to bed but capableof eating, watchingtelevision or visiting findthis procedure comfortable.

>Used when patient will needoxygen need oxygen therapywhen hypoxia results froma respiratory or cardiacemergency or an increase inmetabolic function(offensive for low ofconcentrations)

>Supplies the body w/ enoughoxygen to meet its cellularneeds.

> The nurse should not place an overly large pillow or more thanone pillow behind the clients head. This error promotes thedevelopment of neck flexion contractures. If the client desiresseveral head pillows, the nurse should encourage the client to

rest w/out a pillow for several hours each day to extend theneck fully and counteract the effects of poor neck alignment.

>Put pillows under forearms to eliminate pull on shoulder andassist venous blood flow from hands and lower extremities.

>Keep side rails securely up. For patients falls prevention.

>Ensure the patency of the patients nostrils.

>Never administer O2 by nasal cannula at more than 2L/min to apatient w/ chronic lung disease unless you have a specific

order to do so.

D. THERAPEUTIC MEASURES

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PROCEDURE INDICATIONS NURSINGPRECAUTIONS

3. Nebulizer Therapy >Nebulization is a process ofadding moisture ormedication to inspired air bymixing particles of varyingsizes w/ the air. The moistureadded to the resp. systemthrough Nebulization

improves clearances ofpulmonary secretions.

>Aids bronchial hygiene byrestoring and maintainingmucous blanket continuity,hydrating dried, retainedsecretions, promoting

expectoration of secretions;humidifying inspired O2;delivering medication.

>Used for administration ofbronchodilators andmucolytic agents

> Be alert for signs ofover dehydrationexhibited byunexplained weightoccurring overseveral days afterthe beginning of

therapy) when usinghigh outputnebulizers.

Cont

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E. Prognosis/Current Status of Patient

The patient experiencing CAP manifest signs and symptoms of productivecough, difficulty of breathing, fever and jaundice. CAP is caused bystreptococcus Pneumoniae which is normally acquired by inhalation of

respiratory secretion through droplets, direct and contact, contact withcontaminated hands and fomites. The child must be guided by SOs to facilitatehealth care process not to aggreviate the childs 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 tofacilitate expectoration of sputum or discharge.

TREATMENT: The patient must cooperate with the maintenance of medication and

Nebulization therapy for the continuity of treatment.

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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 avoidallergens such as smoky places that might precipitate the current status.

The Significant other especially the mother should guide her daughter inpracticing the above guidelines

The mother or the other SOs must ensure the patient will follow the dischargeorders required for the patient especially the intake of home meds.

Teach the patient and SOs to encourage patient to increase oral intake and howit helps the patient in her condition.

FOLLOW UP CHECK-UP: October 16, 2009, for patients 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.

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CUESPATHOPHYSIO

LOGICBASIS

NURSINGDIAGNOS

IS

PLANNING INTERVENTION

RATIONALE EVALUATION

Subjective: Mainit at

masakit ang uloniya, as

verbalized by themother..

Objective: flushed skin febrile 38.9 skin warm totouch not in

Respiratorydistress conscious,coherent, andambulatory (-) dehydration irritable

Microorganism enters

the airwaypassages

Triggers theimmunesystem tofight theforeignobjects

Neutrophils killsthe bacteria

As a result of fever,chills andineffective

thermoregulation

Thermoregulation

Ineffectiverelated toDiseaseProcess(presence ofBacterialinfection) asmanifested byelevated bodytemperature.

After 3 hours ofnursing

intervention, thepatients

bodytemperature willalleviate atnormal/desirable level.

Provide tepidsponge bath

Change dressinto looseclothing

Ensure properroom

ventilation Advised patient

oral fluidintake

Administer

analgesicsas ordered

by thephysician

Ambulate thepatient

Maintain bedrest

to decreasetemperature by

means ofevaporation andconduction to reduce bodytemperature to provide coolenvironment

to release heatfrom he

body

to facilitate fastrecovery

to facilitateblood circulationturn side by side) to metabolicdemands/Oxygen

consumption

After 3 hours ofNursing

intervention, thepatients bodyTemperaturealleviated atnormal/desirablelevel. Goal met.

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CUES PATHOPHYSIOLOGIC

BASIS

NURSING

DIAGNOSI

S

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

Hirap huminga

ang anak kodahil sa ubo. As

verbalized bythe patientsmother.

Objective:

(+) productivecough afebrile 37.4

dyspnic in

appearance

no cyanosisnoted

conscious,coherent, andambulatory GCS 15 (+) crackles

Uponauscultation

Microorganism enters

the airway

passages

small blood vessels inthe lungs

(capillaries)become leaky,

and protein-richfluid seeps into

the alveoli

results in a less

functional areafor oxygen-

carbon dioxideexchange

patient becomesrelatively oxygen

deprived, while

retainingpotentially

damaging carbon

dioxide

Mucus production is

increasedthrough the leaky

densities

Ineffective

Breathing

related toRetained

secretions inthe bronchi.

After 4 hours

of nursing

intervention,the patient will

Loosensecretions inthe lungs.

Advise increase

fluid intake

Perform ChestPhysio

therapy(Back

Tapping)

Administer

medicationsas ordered

Check the

consistency

of secretions

Instruct patient

toexpectoratethe mucussecretion

Provide health

teachingregarding

the

importance

of personalhygiene

To liquefy

secretion

To facilitate

expectorations ofretainedsecretions

to facilitate fast

recovery

As baseline data

for

medication

administration

To preventfurtherretention ofsecretions

After 4 hours

of nursing

Interventionthe patients

secretion hasbeen loosenand she has

been ableto breath

At tolerable level.

Goal partially met

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CUES PATHOPHYSIOLOGICBASIS

NURSINGDIAGNOS

IS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

Nahihirapansiya

huminga dahil saplema,

as verbalized byher mother.

Objective:

(+) productivecough

(+) crackles

(+) DOB

afebrile 37.3

distress restlessness

irritability

Microorganism entersthe airway

passages

small blood vessels inthe lungs

(capillaries)become leaky,

and protein-richfluid seeps into

the alveoli

results in a less

functional areafor oxygen-

carbon dioxide

exchange

patient becomesrelatively oxygen

deprived, while

retainingpotentially

damagingcarbon dioxide

Mucusproduction is

increased, andthe leaky

capillaries

Ineffective

AirwayClearance

related topresence of

Secretionssecondary topneumonia

After 3-4 hours

of nursingintervention, the

patientsrespiration will

improve anddifficulty of

breathing willrelieved.

Assess patients

condition Monitor and

record vitalsigns

Auscultate lungfields, notingareas ofdecreased or

absent airflowandadventitious

breath sounds

Assist patient tochange

position every30 minutes

Elevate head of

bed and alignhead in themiddle

Provide healthteachingsregardingeffective

coughing anddeep

breathingexercise.

Encourage

increase fluidintake

Encourage steam

inhalation

Administer

medicationsas ordered

To know and

determinepatients

needs to established

baselinedata

To determinepossible

bronchospasm orobstruction

To mobilize

secretions

To facilitate

breathing

To expel the

mucous

To liquefy

secretions

To moistensecretions

and alleviatecongestion

To reducebronchospas

m andmobilizesecretions

After 3-4

hours ofnursing

intervention, the

patientsrespiration has

been

improvedanddifficulty

of

breathinghas bbeen

relieved. Goal met.

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ARRIETA, MA. PAMELA GUTIERREZ, FROILANCABINTOY, AGNES PENALBA, CYRON

CASTRILLO, JENELYNN LUNAS, JUDITH

DELOS REYES, RENIER SABALLO, JEFFREY

FERNANDEZ, BARBARA YUDELMO, RYAN

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The beginning of knowledge is the discovery of

something we do not

understand

-FRANK HERBERT