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