UST College of Nursing

Pediatric Care Record

Patient P.D.J, with his preferred nickname Packard, a 3 year old male child, was born on August 27, 2011 at Malabon. The child lives at 1078 Torres Bugalion St. Tondo, Manila. According to his father, on the start of classes for the year 2015-2016, he will enroll his son in a daycare center. The age of his parents are his father is 30 years old and his mother is 28 years old. The child’s parents has their own business of selling ink and ink refill for printers. The child has also a two older siblings, ages 7 years old and 5 years old.

Upon the admission of the patient, the chief complaint was shortness of breath accompanied by cough and colds. The child had also fever at 39 degrees Celsius and with nasal discharges prior to admission and his father verbalized that he don’t eat much. The child’s past illness was 3 asthma attack last year. The admitting diagnosis of the physician is bronchial asthma.

The child was reviewed thoroughly of his body systems to assess abnormal functioning or any that contributes to the illness. Upon assessing, the child has a normal skin color, has a good skin texture, no lesions, abrasions nor scars were found on his skin. There were no swelling or bruises seen. His eyes were symmetrical and has moist/ clear conjunctiva, normal pupillary reflex and peripheral vision and has a normal sclera. His auricles were consistent and symmetrical. No discharge from his ears is present. There is some nasal discharges due to his colds and an inflamed throat due to the cough.

Based on the observation, the child didn’t experience any nausea, vomiting, diarrhea. He is drinking milk and eating what is being served for him. But the child don’t’ eat too much of what was served. There are no signs of neurologic disorders and the child doesn’t experience any tingling or numbness. There is no swelling or edema present.

When the father calls him, the child responded accordingly, he can also see what his father is doing so the child loves to interfere. The child could smell and differentiates one smell from the other. He can also differentiates bitter form sweet and other tastes. While he is sleeping, he can still feel some touches from the nurse when the nurse is getting his vital signs and abruptly reacted when the temperature scale was put on his axillary and show sign of unlikeness.

The father mentioned that his child was at around 4 to 5 months old when he had his head control, when he started to roll over and turn side to side. The child was able to sit with support at 6 months old and later on the father can’t remember the exact month but latter part of his 6 to 7 months old he was able to sit down in a chair without support then started to crawl and creep. According to the father, the child had started to stand at his 10 months old but they still support him to while standing. The father also shared that around 5 to 6 months after before his 11 months old, the child could almost walk without any support from the family. And by the middle of his 11 months old he could now stands alone and tried to walk but they still assists the child to walk. Before his 1 st

birthday the child was able to walk without any support from the family especially to his parents.

In 3 years of age, the child could also use alternate feet while climbing or going up the stairs. According to the father, his son loves to go out with him and rides a motorcycle. He could also draw circles and how to imitate a cross. When the child was asked about what is his name and age and gender, the child could respond by giving out his full name. He also knows how to wash hands before eating or when he went to the comfort room. Based on the assessment made, around 900 words the child could speak and utter but in their age the child is experiencing telegraphic speech wherein 3 to 4 words in a sentence. At this age, the child could ask many questions after what they have observed and curious about.

Based on the observation, the child could watch movies in his father’s cellphone, he follows and obeys his father. The child is an early bloomer since he can now understand action movies such as watching Fast and Furious 6. The father said that he loves to watch Fast and Furious series.

THEORIES

Erikson Freud PiagetThe Child is on the stage of having an energetic learning. In this stage, he loves to find out what he can do as a 3 year old child. A child in this stage, likes to imitate adults, and based on the observation, he loves to interfere with his father whenever the father is doing things. He is now in the stage where creativity and imaginative starts. And he is learning how to assert his own way that will not make him feel guilty.

The child is in Phallic Stage, primarily in the oedipal period where he has a strong attachment to the opposite sex parents.In this stage, the child may explore sexually by manipulating his genitals, also may ask questions about his own sex such as gender differences and sexual reproduction.

The client can already see viewpoints of other people especially the view point of his parents. He is now in the stage where he could think magically, that he believes that he can make things happen.He is also in the stage of Animism.

DIAGNOSTIC EXAM

Test Purpose ImplicationChest X-RAY It is used to help

find the cause of common symptoms such as a cough, shortness of breath, or chest pain.

•Find lung conditions—such as pneumonia.

Lung fields are clearDiaphragm and sinuses are normalThe heart is not enlargedImpression: Normal Chest

LABORATORY TEST: Complete Blood Count

Test Result Normal Values ImplicationHGB = 124RBC = 4.55HCT = 0.37MCV = 80.70

MCH = 27.30MCHC = 33.80RDW = 13.10MPV = 8.10Platelet = 279WBC = 14.20

Differential countNeutrophils = 0.58Metamyelocytes = - Bands = -Segmenters = 0.58Lymphocytes = 0.32Monocytes = 0.03Eosinophils = 0.07

Basophils = -

(120-157g/L)(4.0-6.0 10^12/L)(0.37-0.54)(87 + -5)

(29 + -2)(34 + -2)(11.6-14.6)(7.4-10.4)(150-450)(4.5-10.0)

(0.50 – 0.70)

(0.50 – 0.70)(0.20-0.40)(0.00-0.07)(0.00 – 0.05)

RBCs are smaller than normal; caused by iron deficiency anemia.

Known as leukocytosis due to infection, either bacterial or viral, inflammation, allergies, asthma, intense exercise or sever stress.

Caused by asthma, allergies, drug reactionInflammatory disorders.

Medical Intervention ordered. (Drugs and procedures)

Intervention Implication Nursing ResponsibilityMedications

Cetirizine (alnix) 5ml Relief of allergic symptoms caused by histamine release including: Seasonal and perennial allergic rhinitis, Chronic

• Assess allergy symptoms.

• Assess lung sounds and character of bronchial

Cefuroxime (Profuret) 500 mg/IV infusion ANST (negative) Q8

Nisuelrin syrup 2.5 ml Q8

Salbutamol neb 1

uticaria

used to treat many kinds of bacterial infections, including severe or life-threatening forms

Used as a bronchodilator to control and prevent

secretions.• Inform the patient to

take the drug without regard to meals.

• Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify physician or other health care professional immediately if these symptoms occur. Keep thromepinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.

• Assess patient for signs and symptoms of infection prior to and throughout therapy.

• Assess lung sounds, pulse, and blood pressure

neb Q4

Ipatropium + Salbutamol neb (Duavent) 1 neb Q6

reversible airway obstruction caused by asthma

Used as a bronchodilator to control and prevent reversible airway obstruction caused by asthma

during peak of medication.

• Note amount, color and amount of sputum produced.

• Assess lung sounds, pulse, and blood pressure during peak of medication.

• Note amount, color and amount of sputum produced.