case pres hard copy

8/3/2019 Case Pres Hard Copy

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING

Introduction

This case presentation is about C. Guillermo ( Patient X )a 3 y.o. boy from La Torre, Talavera,

Nueva Ecija which have been admitted last October 5, 2011 at San Jose District Hospital. The Patient

was diagnosed with Bronchopneumonia, moderate risk.

Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill

with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in

your blood, your body cells cant work properly. Because of this and spreading infection through

the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia

affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches

throughout both lungs.

Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is

the most common. Other pathogens include anaerobic bacteria, Staphylococcus aureus,

Haemophilus influenzae, Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella

(Branhamella) catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gram-

negative bacilli. Major pulmonary pathogens in infants and children are viruses: respiratory

syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher

bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium

tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis,Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and Pneumocystis

carinii; and rickettsiae, primarily Coxiella burnetii (Q fever).

The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and

aspirating secretions from the upper airways. Other means include hematogenous or lymphatic

dissemination and direct spread from contiguous infections. Predisposing factors include upper

respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic

obstructive airway disease, age extremes, debility, immunocompromise (as in diabetes mellitus and

chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissibleagents.

Typical symptoms include cough, fever, and sputum production, usually developing over

days and sometimes accompanied by pleurisy. Physical examination may detect tachypnea and

signs of consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly

caused by bacteria, such as S. pneumoniae and H. influenzae.
http://nursingcrib.com/microbiology/cryptococcus-neoformans/http://nursingcrib.com/microbiology/cryptococcus-neoformans/


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Bronchopneumonia or bronchial pneumonia or Bronchogenic pneumonia is the acute

inflammation of the walls of the bronchioles. It is a type of pneumonia characterized by multi faci of

isolated, acute consolidation, affecting one or more pulmonary lobules. And it is classified under

Bacterial pneumonia. The bronchopneumonia pattern has been associated with hospital- acquired

pneumonia, and with specific organisms such as Staphylococcus aureus, Klebsiella pneumonia, E.coli and

Pseudomonas. It can also be secondary (complication of some other disease): Viral infection (influenza,

measles); aspiration of food or vomiting;

obstruction of bronchus with foreign body,

neoplasm and others; inhalation of

poisonous gases; major surgery; sever

chronic diseases (tuberculosis), malnutrition;

and, hipostatics (long lying after suffering

stroke).

Hospital acquired pneumonia, also

known as nosocomial pneumonia, is defined

as the onset of pneumonia symptoms more than 48 hours after the admission in patients with no

evidence of infection at the time of admission. Pneumonia is the most common cause of death among

infectious diseases. They take the fifth place in the statistics of diseases causing death.

Bacterial and viral lower respiratory tract infections are categorized into four groups: Acute

Bronchitis, an acute inflammation of the tracheobronchial tree; Bronchiectasis is the permanent

dilatation and subsequent destruction of sub segmental bronchi; Lung abscess is the parenchymal

destruction caused by an indolent suppurative process; and, pneumonia is an infection of the distal

portion of the lungs, involving the respiratory bronchioles, alveolar ducts, sacs and alveoli. Primary care

providers frequently evaluate patients with cough, which is the single most common symptom of

respiratory illness.

The objective of this presentation is to gain more knowledge about the disease and to prevent

the development of further complications.

This study aims to:

Conduct and evaluate an assessment for the client

Render series of nursing interventions for the clients care


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Provide and disseminate important information as teachings to the client and the significant

others to boost the knowing and understanding of the nature of the said health condition.

Improve skills and knowledge as health care providers in the clinical area

Demographic data

Name : Patient X

Hospital Number : 5994

Sex : male

Age : 3 years old

Date of Birth : April 9, 2008

Birthplace : Cabanatuan City

Address : Purok 1, La Torre, Talavera, Nueva Ecija

Citizenship : Filipino

Religion : Roman Catholic

Status : Single

Weight : 14 kg.

Date of admission : October 5, 2011 at 1:53 p.m.

Name of Mother : W. Guillermo

Physician : Dr. De Guzman

Diagnosis

Bronchopneumonia, moderate risk

History of Present Illness

Last September 28, 2011, 1 week PTA, Patient X have productive cough associated with

colds (watery) without other symptoms noted. The next day, he was brought to a Pedia and

was given with home medications. After 6 days the parent doesnt noticed any improvement

with the childs condition the patient is still with productive cough and associated with on and

off fever.


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Few hours prior to admission, the patient still have cough and fever, consulted once and

then admitted. The patient shows decrease in appetite, tachypnea, and decrease in activity

level.

History of Past Illness

The patient were fully immunized, (-) allergies and (-) surgeries PTA.

Family Medical History

Unremarkable

Physical Assessment:

Pertinent physical assessment findings upon admission

Pulse rate : 115 bpm

Respiratory rate : 42 bpm

Temperature : 39.3*C

Weight : 14 kg.

HEENT : PG AS, (-) NAD , (-) TOC

Neuro Exam : Conscious and coherent

Chest and lungs : SCE, (-) retraction, tachypneic, crackles (+) right

Heart : AP

Abdomen : Soft, flat, NABI, (-) tenderness

Extremities : (-) edema

Clinical Impression : Bronchial pneumonia, moderate risk

Recent Physical Assessment

BODY PARTS METHOD USED NORMAL PATIENT FINDINGS

HAIR

*Color

* Amount and

distribution

Inspection &

Palpation

Varies

Vary

Fine

None

Black

thick

No signs of abnormality

None


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*Texture

*Presence of

parasites

SCALP

*Symmetry

*Texture

HEAD

*Size

*Shape

*Consistency

FACE

*Symmetry

*Facial Features

TRACHEA,

THYROID, LYMP

NODE

EYES

*Position &

Appearance

*Blinking

*Shape

Inspection &

Palpation

Inspection &

Palpation

Palpation

Symmetrical

Smooth, firm

Normal

Symmetrical &

Round

Hard & Smooth

Symmetrical

May vary,

centered head

position

Lids margins

moist and pink;

lashes short,

evenly spaced,

and curled

outward

Symmetrical,

involuntary, at

approximate 15

Symmetrical


Normal


Symmetrical

No lymph nodes noted


Black


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*Color of Iris

EAR

*Size & Shape

LIPS

*Color

*Consistency

ABDOMINAL

*Color

*Umbilicus

SKIN

*Generalized

color

* Color variations

in the patches of

the body

*Texture

Right Arm

Left Arm

Right Leg

Left Leg

Nails

*color

*Shape

*Texture

Inspection

Inspection

Inspection

Inspection

blinks per min

Round

Uniform color

Ears of equal size

and similar

appearance

Pinkish

Light to Dark

Brown

Moist, smooth

with no lesion

Normally pallor

Sunken centrally

In Dark Skin;

Light to dark

brown

in dark skin;

Lighter colored

palms, soles, nail

beds and lips.

Smooth, soft

Normal

Normal

Normal

Tiny Red Spots(Skin rash

caused by insect bites

skin (normal)








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Pinkish

Round Nail

Nail is round,

mobile, hard

Pathophysiology

Normal flora invades the lower resp. tract:

Escherichia Coli

Pseudomonas aeruginosa

Lung Contamination

inflammation

Release of endotoxins

Antigen- antibody response

Consolidation of lung tissue

Chest X-ray:

White atch infiltrate

Damage to bronchial tubes


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Diagnostic Tests

1. Hematology

Ref. No.: 12/05/IP Time out: 2:20 p.m.

Date : October 5, 2011

Component Result Reference Values Interpretation

RBC count 4.36Male: 4.5- 6x 10

12/ L

Female: 4- 5.5 x 1012

/L

Decreased erythrocyte counts is

associated with disorders such as

malnutrition

Hct .36Male: 0.40-0.54

Female: 0.77- 0.47

A decreased hematocrit indicate

hemodilution

Hgb 123Male: 120-170 g/ L

Female: 110-150 g/ LNormal

Platelet count 390 150- 450 x 109/ L Normal

WBC count 9.1Adult: 5-10 x 10

9/ L

Children: 6.2- 11.2 x 109/ LNormal

Segmenters 0.51 0.50 0.70 Normal

Lymphocytes 0.43 0.20- 0.40

Decreased as pneumonia is

present

Monocytes 0.06 0- 0.07Not a characteristic of specific

disorders

2. Urinalysis

Ref. No.: 17/05/IP Time out: 6:01 p.m.

Date : October 5, 2011

Physical

Color : Yellow

Clarity : Slightly turbid

Specific gravity: 1.005

pH : 5.5

Chemical

Glucose : negative

Albumin : negative

Ketone : negative

Urobilinogen : normal (0.2-1 EV/dl)

Nitrite : negative

Bilirubin : negative

Microscopic

RBC : 0-1/ HPF


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Pus cells : 0-1/ HPF

Epithelial cells : Rare/ LPF

Mucous Threads: Few/ LPF

Bacteria : Rare/ HPF

Amorphous urates: few/ LP

Urinalysis shows normal findings and has no significant relevance with the disease.

Anatomy and Physiology (normal)

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 voicebox) 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 tobreathe. It also helps to moisten and warm the air before it

reaches your lungs.

The Lungs

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


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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.

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. Travelling 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.


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The Pleurae

The lungs are covered by smooth membranes that we call pleurae. The pleurae have two

layers, a 'visceral' layer which sticks closely to the outside surface of your lungs, and a 'parietal'

layer which lines the inside of your chest wall (ribcage). The pleurae are important because they

help you breathe in and out smoothly, without any friction. They also make sure that when your

ribcage expands on breathing in; your lungs expand as well to fill the extra space.

The Diaphragm and Intercostal Muscles

When you breathe in (inspiration), your muscles need to work to fill your lungs with air.

The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does

much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in,

the diaphragm contracts and flatten out, expanding the space in your chest and drawing air into

your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also

help by moving your ribcage in and out. Breathing out (expiration) does not normally require your

muscles to work. This is because your lungs are very elastic, and when your muscles relax at the

end of inspiration your lungs simply recoil back into their resting position, pushing the air out as

they go.

The Respiratory System and Ageing

The normal process of ageing is associated with a number of changes in both the structure and

function of the respiratory system. These include:

Enlargement of the alveoli. The air spaces get bigger and lose their elasticity, meaning that

there is less area for gases to be exchanged across. This change is sometimes referred to as

'senile emphysema'.

The compliance (or springiness) of the chest wall decreases, so that it takes more effort to

breathe in and out.

The strength of the respiratory muscles (the diaphragm and intercostal muscles) decreases.

This change is closely connected to the general health of the person.

All of these changes mean that an older person might have more difficulty coping with

increased stress on their respiratory system, such as with an infection like pneumonia, than a

younger person would.

Functions:

Works closely with circulatory system, exchanging gases between air and blood:


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Takes up oxygen from air and supplies it to blood (for cellular respiration).

Removal and disposal of carbon dioxide from blood (waste product from cellular

respiration).

Homeostatic Role:

Regulates blood pH.

Regulates blood oxygen and carbon dioxide levels.

Medical Management

GENERIC NAME

cefuroxime axetil

BRAND NAME

Ceftin

ACTION

Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic

instability; usually bactericidal.

INDICATION

1. Serious lower respiratory tract infection, UTI , or secondary or skin-structure infections,

before or joint infection, septicemia, meningitis and gonorrhea.

2. Perioperative prevention.

3. Bacterial exacerbation of chronic bronchitis or secondary bacterial infection of acute

bronchitis.

4. Acute bacterial maxillary sinusitis.

5. Pharyngitis and tonsillitis.

6. Otitis media.

7. Uncomplicated skin and skin structure infection.

8. Uncomplicated UTI.

9. Uncomplicated gonorrhea.

10. Early Lyne disease.

11. Impetigo.

SIDE EFFECTS

CEREBROVASCULAR- phlebitis, thrombophlebitis

GASTROINTESTINAL- diarrhea, pseudomembranous, colitis, nausea, anorexia, vomiting


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HEMATOLOGIC- hemolytic anemia, thrombocytopenia, transient neutropenia, eosinophilia

SKIN- maculopapular and erythematous rashes, urticarial, pain, induration, sterile abscess,

temperature elevation, tissue sloughing at IM injection site

OTHER- anaphylaxis, hypersensitivity reactions, serum sickness

NURSING RESPONSIBILITIES

1. Before giving drug, ask patient if he is allergic to penicillins or cephalosporins.

2. Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin

while awaiting results.

3. For IM use, inject deep into a large muscle, such as the gluteus maximus or the side of the

thigh.

4. Absorption of oral drug is enhanced by food.

5. Alert: tablets and suspension arent bioequivalent and cant be substituted milligram-for-

milligram.

6. Monitor patient for signs and symptoms of super infection.

GENERIC NAME

gentamicin sulfate

BRAND NAME

Cudomycin, Garamycin

ACTION

Inhibits protein synthesis by binding directly to the 30S ribosomal subunit; bactericidal.

INDICATION

Serious infections caused by sensitive strains of pseudomonas acruginosa, Escherichia coli,

Proteus, Klebsiella, or Staphyloccocus. To prevent endocarditis before GI or GU procedure or

surgery.

SIDE EFFECTS

CENTRAL NERVOUS SYSTEM- encephalopathy seizure, fever, headache, lethargy, confusion,

dizziness, numbness, peripheral neuropathy, vertigo, ataxia, tingling

CEREBROVASCULAR- hypotension

EENT- ototoxicity, blurred vision, tinnitus

GI- vomiting, nausea


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GU- nephrotoxicity, possible increase in urinary exertion of casts,

HEMATOLOGIC- agranulocytosis, leukopenia, thrombocytopenia, anemia, eosinophilia

MUSCULOSKELETAL- muscle twitching, myasthenia gravis,-like syndrome

RESPIRATORY- apnea

SKIN- rash, urticarial, pruritus, injection site pain


1. Obtain specimen for culture and sensitivity test before giving. Begin therapy awaiting

results.

2. Evaluate patients hearing before and during therapy. Notify prescriber if patient complains

of tinnitus, vertigo or hearing loss.

3. Weigh patient and review renal function studies before therapy begins.

4. Monitor renal function: urine output, specific gravity, UA, BUN and creatinine levels and

creatinine clearance. Report to prescriber evidence of declining renal function.

5. Watch for signs and symptoms of super infection such as continued fever, chills and

increased pulse rate.

6. Therapy usually continues for 7 to 10 days. If no response occurs in 3 to 5 days, stop

therapy and obtain new specimens for culture sensitivity testing.

GENERIC NAME:

ipratropium bromide

BRAND NAME:

Atrovent

ACTION

Inhibits vagally mediated reflexes by antagonizing acetylcholine at muscarinic receptors on

bronchial smooth muscle.

INDICATION

Bronchospasm in chronic bronchitis and emphysema. Rhinorrhea caused by allergic and

non-allergic perennial rhinitis. Rhinorrhea caused by the common cold. Rhinorrhea caused by

seasonal allergic rhinitis.

SIDE EFFECTS

CNS- dizziness, pain, headache, nervousness

CV- palpitations, hypertension, chest pain


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EENT- blurred vision, rhinitis, pharyngitis, sinusitis, epistaxis

GI- nausea, GI distress, dry mouth

MUSCULOSKELETAL- back pain

RESPIRATORY- URTI, bronchitis, bronchospasm, cough, dyspnea, increased sputum

SKIN- rash

OTHER- flulike symptoms, hypersensitivity reactions


1. If patient uses a face mask for a nebulizer, take care to prevent leakage around the mask

because eye pain or temporary blurring of vision may occur.

2. Safety and effectiveness of use beyond 4 days in patients with a common cold havent been

established.

3. Alert: patient with a severe peanut allergy could have an anaphylactic reaction after using

Atrovent inhalation aerosol metered-dose inhaler (MDI). Get a thorough allergy history from

patient before giving any drug.

4. Look alike-sound alike: Dont confuse Atroventwith Alupent.

GENERIC NAME:

acetaminophen

BRAND NAME:

Acetaminophen

ACTION

Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of

prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The

drug may relieve fever through central action in the hypothalamic heat-regulating center.

INDICATIONS

Mild pain or fever

SIDE EFFECTS

HEMATOLOGIC- hemolytic anemia, leukopenia, neutropenia, pancytopenia

HEPATIC- jaundice

METABOLIC- hypoglycemia

SKIN-rash urticarial



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1. Alert: Many OTC and prescription products contain acetaminophen; be aware of this when

calculating total daily dose.

2. Use liquid form for children and patients who have difficulty swallowing.

3. In children, dont exceed five doses in 24 hours.

Management

(Medical Management)

Antibiotics are prescribed based on Gram stain results and antibiotic guidelines

Supportive treatment includes hydration, antypiretics, antihistamines, or nasal

decongestants

Bed rest is recommended

Oxygen therapy is given for hypoxemia

( Nursing management)

Assess clients for s/sx

Note changes in temperature; pulse; amount, odor and color of secretions; and

breath sounds

Frequency and severity of cough

Encourage hydration: fluid intake (2-3 L/day) to loosen secretions

Provide appropriate method of oxygen therapy

Place client in semi-fowlers position

Educate the parents/guardian of the patient about the disease


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Nursing Care Plan

Assessment Subjective:

Napansin ko na hirap sa paghinga yung anak ko, nag-iba yung

parang hinahabol niya yung paghinga niya. Mas nahihirapan siya kaysa

nung unang araw ng ubo niya as verbalized by the mother.

Objective:

CR= 110

RR= 35

Temp. = 38.6

Wt. = 14 kg.

Adventitious breath sound (rales)

Productive cough

Dyspnea

Diagnosis Ineffective airway clearance related to secretions in the bronchi

Planning Short term:

After 8 hour of nursing intervention the patient will be able to:

Maintain airway patency

Expectorate secretion readily Demonstrate reduction of congestion with clear breath sounds

and the mother will be able to:

Verbalize understanding of cause(s) and therapeutic management

regimen of her son

Identify potential complications and how to initiate appropriate

preventive or corrective actions

Long term

(not applicable because of one day duty in the hospital)

Implementation Independent:

Assess clients respiration and breath sounds, noting rate and sounds

Evaluate clients cough/gag reflex and swallowing ability

Position client in semi fowlers position for maximum lung


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expansion

Change position every 2 hours to decrease gravity pressure on the

diaphragm and to enhance ventilation to lung segments

Monitor clients feeding intolerance, and abdominal distention

Keep environment allergen free

Assist and teach the mother in nebulizing client accompanied with

bronchial tapping if not contraindicated

Increase fluid intake to loosen secretions

Monitor clients vital signs

Observe for signs of respiratory distress

Assess client/SOs knowledge of contributing causes, treatment plan,

specific medications, and therapeutic procedure

Provide information about the clients condition to the mother/ SO

Demonstrate/assist SO in performing specific airway clearance

techniques

Dependent:

Give expectorants/bronchodilators as ordered

Administers analgesics as ordered

Interdependent:

Assist with appropriate testing to identify causative/precipitating

factors

Assist with procedures (bronchoscopy) to clear/maintain open

airway

Assist with use of respiratory devices and treatments

Assist in obtaining sputum specimen

Evaluation After 8 hour of nursing intervention the patient was able to:

Maintain airway patency (partially met)

Expectorate secretion readily (partially met)

Demonstrate reduction of congestion with clear breath

sounds(partially met)

and the mother was able to:


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Verbalize understanding of cause(s) and therapeutic management

regimen of her son (goal met)

Identify potential complications and how to initiate appropriate

preventive or corrective actions (goal met)


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Assessment Subjective:

Yung tatay niya ay naninigarilyo as verbalized by the mother

Objective:

Risk diagnosis is not evidenced by signs and symptoms

Diagnosis Risk for infection related to insufficient knowledge to avoid exposure to

pathogens secondary to bronchopneumonia

Planning After 4 hours of nursing intervention the mother/SO will be able to:

Verbalize understanding of individual causative/risk factor(s)

Identify interventions to prevent/reduce risk of infection

Understand on how to promote safety environment on her child

Implementation Independent:

Assess client for any sign of infection and document initial finding

Educate mother for the risk factors

Stress proper hygiene by all caregivers to avoid infection

Educated significant others close to the client about the effects of

smoking to the client

Monitor/assist with the use of adjuncts

Review individual nutritional needs with the mother

Instruct client/SO in techniques to prevent spread of infection

Discuss the role of smoking in respiratory infections

Dependent:

Administer medication as ordered

Interdependent:

Obtain appropriate fluid specimen for observation and culture and

sensitivity testing

Evaluation After 4 hours of nursing intervention the mother/SO was able to:

Verbalize understanding of individual causative/risk factor(s) (goal

met)

Identify interventions to prevent/reduce risk of infection (goal met)

Understand on how to promote safety environment on her child

(goal met)


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Discharge Planning

Meds

Instruct the mother about the medicine

Evaluation

Evaluate whether the mother understand the teaching.

Evaluate the clients response to the treatment given in the ward

Evaluate the mothers need for additional learning

Treatment

Refer patient for home care to facilitate adherence to therapeutic regimen

Instruct mother about the follow-up care

Health education

Review principles of adequate nutrition and rest to the mother

Advise mother to increase the activities of the client gradually after fever subsides

Repeat instructions and explanations as needed to the mother

Observe personal hygiene

Instruct the mother to avoid smoking near the client which lower the resistance to

pneumonia

Include information about ways to reduce potential for infection

Diet

As for our client, Diet as tolerated

Instruct the mother on what is nutritional foods that her child needs

Spiritual

Assist parents to learn effective coping, for them to understand that its not their fault

but they can do something to prevent and help their child to avoid it.

case pres hard copy

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