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PAMANTASAN NG CABUYAOCOLLEGE OF HEALTH ALLIED SCIENCES
COLLEGE OF NURSING
CASE ABSTRACT:•This is a case of patient a 5 yr. old female residing at Mercedes Vill, Sala, Cabuyao Laguna., the patient was received at St.James Hospital last Sept 30, 2009 at 7:50 pm with a chief complaint of fever. Initial vital signs were taken T-38.5˚C, RR- 40bpm, PR- 130bpm. Initial diagnosis was Pediatric Community Acquired Pneumonia-C. The patient was subjected for Urinalysis, Blood Chemistry, Hematology and Radiologic exam and was given Cefaclor, Salbutamol, Erdostien, Polynerv syrup b1+b6+b12 as prescribed. Upon further history taking we found 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 patient’s health status utilizing a holistic approach of promoting and rehabilitative process of nursing managements.
1. Identify nursing problems and the corresponding nursing considerations and managements involved for promotion and maintenance of patient’s 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.
REVIEW OF ANATOMY AND PHYSIOLOGY: RESPIRATORY SYSTEM
•The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: 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 is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain.
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 (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs.
The LungsStructure
• The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for 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. These are 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 takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'.
• These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply.
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 times throughout 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 little blood 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 close together, 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 the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Traveling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.
Blood Supply• The lungs are very vascular organs, meaning
they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs.
Passes to the pharynx, larynx and trachea
Enters through nose or mouth by inhalation
Streptococcal Pneumoniae
Precipitating Factor: EnvironmentPredisposing Factor: age
Microorganism enters and affects both airway and lung parenchyma
Airway damageLung invasion
Activates macrophages and 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 the body
Fever
Narrowing of air passage
Difficulty of Breathing
Macrophages destroys RBC
Decreased RBC count
Bilirubin Production
jaundice
Health History
Patient Name: Patient AAge: 5 Yrs. OldSex: FemaleNationality: FilipinoCivil Status: SingleReligion: Roman CatholicHighest Educational Attainment: PreparatoryRank in the Family: Second Child of Three siblingsAddress: Mercedes Vill. Sala Cabuyao, LagunaInclusive Date of Confinement: Four DaysAdmission Date and Time: Sept. 30, 2009 at 7:50 PMDischarge Date: Oct. 4, 2009 at 1:36 PMAttending Physician: Mariano M. Carteciano M.D.Initial Diagnosis: PCAP – CFinal Diagnosis: PCAP – CSource of History: MotherChief Complaint: Fever
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 is obedient in taking her medications.
II. Nutrition-Metabolic PatternA. Height: 3 ft., 5 in. tallB. Weight: 19.1 kg.C. Appetite: GoodD. Usual Eating E. Pattern: 3 meals a dayUsual Daily Menu
a. Breakfast: Chocolate Drink / Milkb. Lunch: Usually hotdog with ricec. Dinner: Typical viand (meat, vegetable, etc.) with
riced. Snacks: Chocolate Cookies
F. Diet: usual dietG. Has good skin turgor
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 device4 – Dependent and does not participate
B. 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
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 patient’s
hospitalization>Patient states good relationship with friends
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
I. GENERAL SURVEY
II. VITAL SIGNS DAY 1 DAY 2 DAY 3 DAY 4Temperature 38.5 37.5 36.9 36.1 Pulse/cardiac rate 130 124 104 88 Respiratory rate 40 36 38 32Blood pressure
III. INTEGUMENTARY
•Skin: >with slight jaundice on facial area, mild dryness, good skin turgor
•Mucous membrane: >pink oral mucosa•Nails: >no clubbing, smooth in texture, capillary refill
at 2-3 seconds•Hair: >evenly distributed, mild thinning of hair,
no infestation
5 year old female child admitted to ERAppears normally on her ageMild irritability but cooperativeMild weaknessGood posture(+) cough; productive(+) difficulty of breathing(-) retraction19.1kg in weight3ft 5 in height
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 are not reddened• Face
>Symmetry: Symmetrically equal >Facial Musculature: has the ability to frown and smile
IV. NECK/LYMPHa. Symmetry: equally symmetrical musclesb. 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 AREASa. Symmetry: equal in size and symmetry for her age
Growth: normal for ageb. Retraction: no retraction notedc. 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
VIII. PERIPHERAL/VASCULARPeripheral Pulses (state if equal-bilaterally)
Grade:4 Temporal: equally bilateral
Grade: 4 Carotid: equally bilateral
Grade: 4 Brachial: equally bilateral Grade: 3 Radial: equally bilateral Grade: N/A Femoral: N/AGrade:2 Popliteal: equally bilateral Grade: 2 Posterior Tibialis equally bilateral Grade: 3 Dorsalis Pedis equally bilateral
Legend:Peripheral Pulse Scale
0>Absent 1>Markedly diminished 2>Moderately
diminished 3>Slightly diminished 4>Normal
Legend:Peripheral Pulse Scale
0>Absent 1>Markedly diminished 2>Moderately
diminished 3>Slightly diminished 4>Normal
IX. ABDOMENa. General Contour: rounded abdomen
Tenderness: rated 6 on pain scale at LUQb. Bowel Sounds: normal bowel soundsc. Abdominal Sounds: N/A
X. MUSCOLO-SKELETAL A. 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 Scale0> no response1> low normal2> normal3> brisk4> hyperactive
Legend: Reflex Scale0> no response1> low normal2> normal3> brisk4> 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
-5Confuse -4Inappropriate -3Incomprehensive
-2No response
-1
C. Best Motor ResponseFollows direction
-6Localizes pain
-5Withdraws from pain -4Decorticate posturing-3Decerebrate posturing-2No 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
-5Confuse -4Inappropriate -3Incomprehensive
-2No response
-1
C. Best Motor ResponseFollows direction
-6Localizes pain
-5Withdraws from pain -4Decorticate posturing-3Decerebrate posturing-2No response
Urinalysis Result Normal value SignificanceMACROSCOPIC
COLOR
TRANCEPARENCY
Ph
Color
Slightly Hazy
6.5
Clear
Clear
4.6- 6.5
Change of appearance of the
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
Specific gravity 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 in urine
indicated urinary tract infection.
-Alteration of RBC in urine indicated Urinary tract
infection.-Presence of bacteria indicates infection.
Blood chemistry Result Normal value significanceSodium 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, neuro muscular impulses.
Hematology Result Normal value significanceHemoglobin 12.2 11-16q/dL NormalHematocrit 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 WBC indicates infecton
Platelets 335,000 150000-450000/uL Alteration of platelet counts
will affect coagulation,hemo
stasis,and clothing
formation.
• 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”
A. DIET:• Diet appropriate for age (5 yr. old)• High caloric food such as rice• Increased Fluid intake• Low fiber diet
NAME OFDRUGS
THERAPEUTIC
ACTION
INDICATION
CONTRAINDICATION
/CAUTIONS
DOSAGE ADVERSE EFFECT
NURSING CONSIDER
ATION
GENERICNAME:Cefaclor BRAND
NAME:CecavilCefaclorApo-Cefaclor
CLASSIFICATION:
Anti Biotic
BactericidalInhibitssynthesis ofBacterialwallcausing cellDeath.
Treatment of
otitis media,
phryngitis,tonsillitis,AcuteBacterialExacerbatio
nof chronicbronchitis,pneumonia,Uncomplica
-tedd skin andSkinstructure,lower UTI
>patient with allergy to cephalosporin
>hypersensitivity to beta lactam antibiotics
>may induce anaphylactic shock
Children:Suspen-sion5ml per8hrsthree
timesaday for 5daysAdult:500mg per8hrs
CNS:Headache,dizziness,lethargyGI:Nausea,vomiting,diarrhea,anorexia,Abdominalpain,flatulenceHematologic:bone marrowdepressionHypersensitivity:ranging fromrash to fever
>assess for the history of drug allergy, pregnancy and lactation
>assess patient for signs and symptoms of infection before and during therapy
>assess for renal function test, respiratory status, culture and sensitivity to test of infected area
>take the drugs with meal or food to prevent the GI discomfort..
B.1 STANDING ORDER
NAME OF DRUG
S
THERAPEUTIC ACTION
INDICATION
CONTRAINDICATION
CAUTIONS
DOSAGE ADVERSE EFFEC
T
NURSING CONSIDERAT
ION
Genericname:Salbutamol
oralbuterol
Brand name:
Ventolin CombiventSalbutamol
Classification:
RespiratorydrugsAntiasthmatic
Stimulates beta 2
receptors ofbronchioles byincreasing
levelsof camp whichrelaxes smoothmuscles toProduceBronchodilata-
tion.
Relief ofBronchospa
smin
bronchial
asthma chronic
BronchitisEmphysemaand otherReversibleObstructivePulmonarydiseases.
>Hypersensitivity to Salbutamol, also to atropine and its derivatives.
>Threatened abortion during 1st and 2nd trimester.
>cardiac arrhythmia associated w/ tachycardia caused by digitalis intoxication.
>prevention of premature labor associated w/ toxemia of pregnancy or ante partum hemorrhage.
Adults andchildren over12 years: TheRecommendd 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.TheMaximaldaily dosemust notexceed 4 mg,3 timesdaily, andthe daily dose for6 - 12 years-old
children isto 24 mg daily,
divided in 3 or 4 doses.
Headache;tremor;tachycardia
;hypertensio
n;anxiety.Rarelynausea,vomiting,
andskin rash
canbe observed
The drug should be
avoided duringpregnancy,particularlyduring 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
drugshould be usedcautiously in
driversand people
workingwith machines.
NAME OF DRUGS THERAPEUTIC ACTION
INDICATION CONTRAINDICATION/CAUTIONS
DOSAGE ADVERSE EFFECT
NURSING CONSIDERATION
GENERIC NAME:Erdostien
BRAND NAME:Zertin
CLASSIFICATION:For respiratory Drugs
Erdostien is an original derivative of natural mercapto-aminoacid in thiolactonic form. Following oral administration Erdostien is rapidly metabolized in the liver. The product acts as a prod rug and its metabolites are mainly responsible for mucolytic activity, due to the presence of free thiol groups which cause the splitting up of the intra- and intermolecular disulfide bridges of several proteins and mucoproteins present in the expectoration, resulting in a reduction of the mucus elasticity and viscosity.
Treatment of acute & chronic bronchopulmonary diseases, rhino sinusitis, laryngopharyngitis or exacerbations of these chronic diseases in association w/ mucus production & transport.
Hepatic disorders & abnormalities, renal insufficiency, homocystinuria, phenylketonuria
Adult 1 cap bid. Susp 8.5 mL bid. Childn 2-6 yr (10-20 kg) 2.5 mL bid, 7-12 yr (21-30 kg) 5 mL bid, 5 mL tid or 7.5 mL bid.
Gastric burning, nausea; ageusia or dysgeusia.
>assess for the history of drug allergy, pregnancy and lactation
>assess for renal function test, respiratory status, culture and sensitivity to test of infected area
>take the drugs with meal or food to prevent the GI discomfort
>do not give to the patient 2yrs old below
NAME OF DRUGS THERAPEUTIC ACTION INDICATION DOSAGE NURSING CONSIDERATION
GENERIC NAME:Polynerv syrup b1+b6+b120 BRAND NAME:Polynerv b1+b6+b12
CLASSIFICATION:vitamins
VITAMINS B1, B6 & B12 (POLYNERV™ Syrup) is valuable in conditions where the requirements for B vitamins 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 surgical procedures.
VITAMINS B1, B6 & B12 (POLYNERV™ Syrup) is indicated for the prevention and treatment of deficiency disorders arising from poor dietary intake, impaired B vitamins absorption (as in prolonged diarrhea, excessive vomiting and antibiotic therapy) intake of drugs which interfere with the utilization of the B vitamins (i.e. isoniazid).As a nutritional supplement to promote appetite, weight gain and height 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
NAME OF DRUGS THERAPEUTIC ACTION
INDICATION DOSAGE NURSING CONSIDERATION
Generic name: Paracetamol or Acetaminophen
Brand Name: Calpol
Classification:Anti-pyreticanalgesic
Decreases fever by inhibiting the effects of pyrogens on the hypothalamic action leading to sweating and vasodilation.Relieves pain by inhibiting the prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.
Relief of mild to moderate pain and treatment of fever
children's dosages are based on a single dose of 10mg Paracetamol per kilogram bodyweight, which can be repeated 4-6 hourly, not exceeding four doses per 24 hours.
Asses pt. fever or pain
Assess allergic reaction
Assess hepatotoxicityMonitor liver and renal function
Inform pts. That urine may dark brown as a result of phenacetin (a metabolite of acetaminophen)
Verify the doctor’s order
C. INTRAVENOUS THERAPY
IVFluid
Classification INDICATION Actions Side Effect NURSING Precaution
5% dextrose and 0.3% sodium
chlorideD50.3%NaCl
Hypertonic Fluid Challenges
Fluid replacement in
patient with DKA,
hyponatremia shock
Replenish fluid nutrient
Carbohydrates and electrolytes
>hypernatremia
Don’t use in patient with heart failure
Edema or hypernatremia because it can
lead to overload
IVFluid
Classification INDICATION Actions Side Effect NURSING Precaution
5% dextrose with multiple balance
solutionD5IMB
Isotonic For dehydrationFor patient with
respiratory problems
ION multiple balance
All IONs either positive or
negative are present.
Replaces fluid and electrolyte of
the body
Increase secretion of
anti diuretics hormone
Do not use to the patient without
case of dehydration
PROCEDURE INDICATIONS NURSING PRECAUTIONS
1. Positioning (High back rest or Fowler’s position)
2. Oxygen Administration
When the client is in this position, gravity pulls the diaphragm downward, allowing greater chest expansion and lung ventilation. Client’s confines to bed but capable of eating, watching television or visiting find this procedure comfortable.
>Used when patient will need oxygen need oxygen therapy when hypoxia results from a respiratory or cardiac emergency or an increase in metabolic function( offensive for low of concentrations)
>Supplies the body w/ enough oxygen to meet its cellular needs.
> The nurse should not place an overly large pillow or more than one pillow behind the client’s head. This error promotes the development of neck flexion contractures. If the client desires several head pillows, the nurse should encourage the client to rest w/out a pillow for several hours each day to extend the neck fully and counteract the effects of poor neck alignment.
>Put pillows under forearms to eliminate pull on shoulder and assist venous blood flow from hands and lower extremities.
> Keep side rails securely up. For patient’s falls prevention.
>Ensure the patency of the patient’s nostrils.
> Never administer O2 by nasal cannula at more than 2L/min to a patient w/ chronic lung disease unless you have a specific order to do so.
D. THERAPEUTIC MEASURES
PROCEDURE INDICATIONS NURSING PRECAUTIONS
3. Nebulizer Therapy >Nebulization is a process of adding moisture or medication to inspired air by mixing particles of varying sizes w/ the air. The moisture added to the resp. system through Nebulization improves clearances of pulmonary secretions.
>Aids bronchial hygiene by restoring and maintaining mucous blanket continuity, hydrating dried, retained secretions, promoting expectoration of secretions; humidifying inspired O2; delivering medication.
> Used for administration of bronchodilators and mucolytic agents
> Be alert for signs of over dehydration exhibited by unexplained weight occurring over several days after the beginning of therapy) when using high output nebulizers.
Cont…
D. REFERRALS
Respiratory Therapist:-Noel A. Co, RN
Pediatrician:-Dr. Estillore
Pulmonologist:-Dr. Alonzo
Attending physician:-Dr. Carteciano
E. Prognosis/Current Status of Patient
• The patient experiencing CAP manifest signs and symptoms of productive cough, difficulty of breathing, fever and jaundice. CAP is caused by streptococcus Pneumoniae which is normally acquired by inhalation of respiratory secretion through droplets, direct and contact, contact with contaminated hands and fomites. The child must be guided by SO’s to facilitate health care process not to aggreviate the child’s 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’
to facilitate expectoration of sputum or discharge.
TREATMENT:• The patient must cooperate with the maintenance of medication and
Nebulization therapy for the continuity of treatment.
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 avoid allergens such as smoky places that might precipitate the current status.
• The Significant other especially the mother should guide her daughter in practicing the above guidelines
• The mother or the other SO’s must ensure the patient will follow the discharge orders required for the patient especially the intake of home meds.
• Teach the patient and SO’s to encourage patient to increase oral intake and how it helps the patient in her condition.
FOLLOW UP CHECK-UP:• October 16, 2009, for patient’s 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.
CUES
PATHOPHYSIO
LOGIC BASIS
NURSING
DIAGNOSIS
PLANNING
INTERVENTI
ON
RATIONALE
EVALUATION
Subjective:“ Mainit atmasakit ang
uloniya”, asverbalized by
themother.. Objective:• flushed skin• febrile 38.9• skin warm totouch• not inRespiratorydistress• conscious,coherent, andambulatory• (-)
dehydration
• irritable
Microorganism
enters the airway
passages
Triggers the immune
system to fight the foreign objects
Neutrophils kills the
bacteriaAs a result of
fever, chills and
ineffectivethermoregulatio
n
• Thermoregulation Ineffectiverelated toDiseaseProcess(presence ofBacterialinfection) asmanifested byelevated bodytemperature.
• After 3 hours
of nursing intervention, the patient’s body temperature will alleviate at normal/desirable level.
• Provide tepid
sponge bath
• Change dress
into loose clothing
• Ensure proper room ventilation
• Advised patient oral fluid intake
• Administer analgesics as ordered by the physician
• Ambulate the patient
• Maintain bed
rest
• to decreasetemperature bymeans ofevaporation andconduction• to reduce
bodytemperature• to provide
coolenvironment • to release
heat from he body
• to facilitate
fast recovery
• to facilitateblood
circulationturn side by
side)• to metabolicdemands/Oxygenconsumption
• After 3 hours
ofNursingintervention,
thepatient’s bodyTemperaturealleviated atnormal/
desirablelevel.• Goal met.
CUES
PATHOPHYSIOLOGI
C BASIS
NURSING
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective:“Hirap humingaang anak kodahil sa ubo.” Asverbalized bythe patient’smother. Objective:• (+) productivecough• afebrile 37.4 • dyspnic inappearance• no cyanosisnoted• conscious, coherent, andambulatory• GCS – 15• (+) cracklesUponauscultation
Microorganism
enters the airway passages
small blood vessels in the lungs (
capillaries) become leaky,
and protein-rich fluid seeps into
the alveoli
results in a less functional area
for oxygen-carbon dioxide
exchange
patient becomes relatively oxygen
deprived, while retaining
potentially damaging
carbon dioxide
Mucus production is increased
through the leaky densities
• IneffectiveBreathingrelated toRetainedsecretions inthe bronchi.
• After 4 hoursof nursingintervention,the patient willLoosensecretions inthe lungs.
• Advise
increase fluid intake
• Perform Chest Physio therapy (Back
Tapping)
• Administer medication
s as ordered
• Check the consistency
of secretions
• Instruct
patient to expectorate the mucus secretion
•Provide health teaching regarding
the importance of personal
hygiene
• To liquefy
secretion • To facilitate
expectorations of retained secretions
• to facilitate fast recovery
• As baseline
data for medication administration
• To prevent further retention of secretions
•
• After 4 hoursof nursingInterventionthe patient’ssecretion hasbeen loosenand she hasbeen ableto breathAt tolerable
level. Goal partially
met
CUES
PATHOPHYSIOLOGIC
BASIS
NURSING
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective:“ Nahihirapan
siyahuminga dahil
sa plema”,as verbalized byher mother. Objective:• (+)
productive cough
• (+) crackles• (+) DOB• afebrile 37.3
distress• restlessness• irritability
Microorganism enters the
airway passages
small blood vessels in the lungs (
capillaries) become leaky,
and protein-rich fluid seeps into
the alveoli
results in a less functional area
for oxygen-carbon dioxide
exchange
patient becomes relatively oxygen
deprived, while retaining
potentially damaging
carbon dioxide
Mucus production is
increased, and the leaky
capillaries
• IneffectiveAirwayClearancerelated topresence ofSecretionssecondary topneumonia
• After 3-4
hoursof nursingintervention,
thepatient’srespiration willimprove anddifficulty ofbreathing willrelieved.
• Assess patient’s
condition • Monitor and
record vital signs
•Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds
• Assist patient to change position every 30 minutes
• Elevate head of bed and align head in the middle
• Provide health teachings regarding effective coughing and deep breathing exercise.
• Encourage increase fluid intake
• Encourage steam inhalation
• Administer
medications as ordered
• To know and
determine patient’s needs
• to established baseline data
• To determine possible bronchospasm or obstruction
• To mobilize
secretions • To facilitate
breathing • To expel the
mucous • To liquefy
secretions • To moisten
secretions and alleviate congestion
• To reduce bronchospasm and mobilize secretions
• After 3-4
hours of nursing intervention, the patient’s respiration has been improved and difficulty of breathing has bbeen relieved.
• Goal met.
ARRIETA, MA. PAMELA GUTIERREZ, FROILAN
CABINTOY, AGNES PENALBA, CYRON
CASTRILLO, JENELYNN LUNAS, JUDITH
DELOS REYES, RENIER SABALLO, JEFFREY
FERNANDEZ, BARBARA YUDELMO, RYAN
“The beginning of knowledge is the discovery of
something we do not understand “
- FRANK HERBERT