I.

INTRODUCTION

This is the case study of baby GA born by a 33 year old G5P5 (4105) via NSD cephalic and premature at birth, from Sto. Rosario, Hagonoy, Bulacan. She was admitted at Bulacan Medical Center PICU Last June 26, 2013. Pneumonia may be acquired by intrauterine (e.g. transplacental hematogenous, ascending from birth canal), intrapartum (e.g aspiration) or postnatal routes (e.g. hematogenous, environmental). The pathogens include mainly bacteria, followed by viruses and fungi which induce an inflammatory pulmonary condition. This may cause epithelial injury to the airways, leakage of proteinaceous fluid into the alveoli and interstitium, leading to surfactant deficiency or dysfunction. Data from a German study suggest that respiratory insufficiency in pneumonia is most likely caused by inhibition of surface-tension-lowering properties of surfactant rather than by surfactant deficiency. Important predisposing factors in the evolution of pneumonia are immaturity, low birth weight, premature rupture of membranes, chorioamnionitis and factors associated with prolonged neonatal intensive care. Depending on the time of manifestation of infection neonatal pneumonia may be classified as early onset pneumonia (within the first 3 or 7 days of life, mostly within 48 hours), or late onset pneumonia (within 4 and 28 days of life). Congenital or intrauterine pneumonia can be considered a variant of early onset pneumonia. Our client is having early onset of neonatal pneumonia specifically congenital or intrauterine. Pneumonia is an important cause of neonatal infection and accounts for significant morbidity and mortality, especially in developing countries. In these countries, the World Health Organization estimates that almost 800,000 neonatal deaths occur each year from acute respiratory infections, mostly pneumonia. In a rural area in central India, for example, mortality secondary to pneumonia in the first month was 29 per 1000 live births; more than one-half of all pneumonia deaths in children occurred in newborns. These figures may be an underestimate because many newborns do not receive medical care. In developed countries, the estimated incidence of pneumonia in full-term infants is less than 1 percent. However, among ill infants of normal and low-birth-weight, the incidence may be closer to 10 percent. By contrast at autopsy, the incidence of neonatal pneumonia ranges from 20 to 32 percent of live-born and from 15 to 38 percent of stillborn infants, although the pathologic features of inflammation of the lung may not always result from infection. In one series, infection was the most common etiology of death in extremely low-birth-weight infants (56 of 111); congenital pneumonia accounted for 30 of these 56 infections. Pneumonia caused by maternal enteric organisms frequently accompanies chorioamnionitis in these congenital infections. Neonatal pneumonia kills about two million children a year worldwide. The World Health Organization recommends hospitalization of all cases of pneumonia in the first two months of infancy. Pneumonia competes with diarrhea for the number one position among fatal childhood diseases and is responsible for about four million or 25% of childhood deaths in developing countries. In the clinical routine pneumonia is diagnosed based on a combination of perinatal risk factors, signs of neonatal respiratory distress, positive laboratory studies, radiological signs and a typical clinical course. The diagnostic procedures done with our client are CBC with APC and Chest X-ray (filmless). The patients medications were Vancomycin and Famotidine. 1

The study aims to impart knowledge regarding Neonatal Pneumonia and means to restore or maintain patients health status utilizing a holistic approach of promoting and rehabilitative process of nursing managements.

II. OBJECTIVES CLIENTS OBJECTIVES GENERAL To provide the necessary nursing care and proper intervention for the wellness of patient having Neonatal Pneumonia.

SPECIFIC Knowledge Skills To conduct an assessment for the client having Neonatal Pneumonia. For the clients mother to be able to manage her daughter in times of sickness triggers. To apply the proper nursing care intervention to the client. To be familiar to necessary assessment for patient having Neonatal Pneumonia. To develop awareness for the clients mother understand her daughters disease. To able to understand the importance of complying with the clients medication.

Attitude For the clients mother, to be able to improve discipline in order to manage her daughter greatly. For the clients mother, to be able to comply with treatments to promote recovery. For the clients mother, to be able to build trust with the hospital personnel.

STUDENTS OBJECTIVES GENERAL For us, nursing students to identify nursing problems and the corresponding nursing considerations and managements involved for promotion and maintenance of patients health.

SPECIFIC Knowledge Skills To render the necessary nursing care in hospital for client with Neonatal Pneumonia. To administer properly the known medication for client with Neonatal Pneumonia. To apply skills learned from school to hospital setting. To be familiar to necessary assessment for patient having Neonatal Pneumonia. To be able to acquire the necessary knowledge with regards to the clients medication. To improve knowledge about how to do the ideal nursing intervention for clients with Neonatal Pneumonia.

Attitude To build confidence in case when handling the same case in the future. To observe and understand the behavior of client having Neonatal Pneumonia. To build up a good nurse-patient relationship conducive to good health.

III. Nursing Assessment

A. Personal History Name: B.G.A Address: Sto.Rosario, Hagonoy, Bulacan Birthday: June 26,2013 Age: 8 day old Sex: Female Civil Status: Child Religion: Roman Catholic Nationality: Filipino Date of Admission: June 26, 2013 Diagnosis: Neonatal Pneumonia, RDS Date Obtained: June 26, 2013

B. Reason for Visit My baby was born premature thats why she was brought to Pedia ICU. My baby had a problem in breathing. She was weak in appearance and needs close care and observation. as verbalized by clients mother. C. Present Health History The client was admitted to Pedia ICU with a diagnosis of neonatal Pneumonia, RDS. The client was born premature with a birth weight of 1.3kg. She was placed in an isollete to help maintain her body temperature and protect them from noise and germs. The neonate was inserted an enteral tube via mouth (oro-gastric tube) to supply the needed nutrients for her. The client was also had a blood transfusion of fresh frozen plasma. D. Past Health History N/A
Vaccine Minimum Age at 1st Dose Number of Doses Dose Minimum Interval Between Doses Route Site Reason

Bacillus CalmetteGurin Vitamin K

Birth or anytime after birth

1 dose

0.05 mL

none

Intradermal Right deltoid region of the arm

BCG given at earliest possible age protects the possibility of TB meningitis and other TB infections in which infants are prone.

At birth

1dose

0.05ml

Every after 5 days of the first dose

IM

Outer Vastus Lateralis

Vitamin K, maintains healthy blood clotting and prevents excessive bleeding and hemorrhage

E. Family Health Illness History (GENOGRAM)

50 y/o

A/W

A/W

A/W

A/W

A/W

A/W

A/W

A/W

A/W

A/W

A/W

A/W

HPN

A/W

A/W

A/W

A/W

Legend: Female Male Deceased RDS

Patient RDS Respiratory Distress Syndrome HPN Hypertension

F. Functional Health Pattern 1. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN Prior to Hospitalization During Hospitalization

N/A

The client was born premature with a birth weight of 1.3 kg. She was weak in appearance. Her skin is thin, smooth and shiny. With less/poor activity. She has problem with feeding due to difficulty of sucking. 2. NUTRITIONAL METABOLIC PATTERN

Prior to Hospitalization N/A

During Hospitalization The doctor orders to have an IVF of D10w + NaCL 0.5 + KCl 0.6 + CaGlu 1.3 + Aminosteril 32cc. She was inserted with enteral tube via mouth (oro-gastri tube) due to difficulty of sucking to supply the needed nutrients for her.

3. ELIMINATION PATTERN Prior Hospitalization N/A During Hospitalization According to the clients mother, the client first defecation was 2days after birth. Greenishblack in color, small in amount and without foul odor. She has diaper thats why her mother dont know how many times she urinate a day. Character Soft and Color GreenishOdor Frequency No foul 1 time Discomfort No discomfort 7

Stool

Urine

sticky Regular urination

black yellow

odor no foul 2-3 time No discomfort odor change of diaper a day

4. ACTIVITY/EXERCISE PATTERN Prior to Hospitalization N/A During Hospitalization Fully Dependent with his mother Feeding =4 toileting = 4 grooming = 4 Bathing =4 dressing = 4 bed mobility = 4 LEGEND: 0- Full Self Care 1- requires use of equipment or device 2- requires assistance or supervision from other person 3- requires assistance or supervision from other person/ device 4 dependent and does not participate 5. SLEEP/REST PATTERN Prior to Hospitalization N/A During Hospitalization According to the mother, the client sleeps most of the time all day. And wakes up when she hear some noise.

6. COGNITIVE PERCEPTUAL PATTERN Prior to Hospitalization During Hospitalization

N/A 7. ROLE RELATIONSHIP PATTERN Prior to Hospitalization

The clients has poor sucking reflex. And her muscle strength is weak.

During Hospitalization

N/A G. Growth and Development THEORY STAGE DEFINITION PSYCHOSOCIAL ( Erik Erikson ) Trust vs Mistrust ( 0 1 year old ) They learn to trust caregivers for feedings, protection, comfort and love; but distrust if needs are not met Failed The doctor ordered her to have an enteral tube to supply the

The client is not crying when her mother carrying her. She was just quiet.

COGNITIVE ( Jean Piaget ) Sensorimotor Stage ( 0 2 years old ) They learn to coordinate sensory experiences with physical motor actions. They also learn how to move head to follow a moving object. Failed The patient was a premature baby and weak in appearance.

PSYCHOSEXUAL ( Sigmund Freud ) Oral Stage ( birth to 1 year old ) The major source of pleasure for infants is oral, such as sucking, biting, chewing and vocalizing. Failed The patient had poor sucking reflex that why she had been

MORAL ( Kohlberg ) n/a n/a

FINDINGS REMARKS

n/a n/a

nutrients she needed.

She cannot easily turn her head to follow her mothers breast

inserted an enteral tube via mouth (oro-gastri tube) to supply the needed nutrients for her.

IV. Anatomy and Physiology

Ovary: produce female eggs/ovum and female hormones (estrogen, progesterone) Ovum: female reproductive cells that contribute X chromosomes. Fallopian tubes: tubes that transport ovum to the uterus; passageway where fertilization occurs; site of ectopic pregnancy; site where tubal ligation (sterilization) occurs. Uterus: when an egg is fertilized and implants in the lining of the uterus; when no fertilized egg is present the lining of the uterus sheds for the menstrual cycle. Cervix: lower end of the uterus; an opening between the uterus and vagina that passes sperm, menstrual fluid, and a fetus. Vagina: pathway for menstrual flow, birth canal, sperm, and STIs. Opening for sexual intercourse and contains vaginal secretions/lubrication. Urethra: opening for urine. Clitoris: sensitive tissue with sole purpose for sexual stimulation. Passageway of Ovum: Ovary - Fallopian tube - Uterus - Cervical Opening - Vagina

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V.

Pathophysiology

PATHOPHYSIOLOGY MODIFIABLE NON MODIFIABLE

Diet: Poor breastfeeding by mother

Lifestyle: the father is smoker

Environme nt: poor sanitation

Pathogens that enters the body

Age: (0-5 y/o ) immune system is still immature

Pathogens enters oral or nasal passages

Passes through larynx , pharynx to trachea

Microorganism enters lung parenchyma

Irritation of the ling parenchyma

Activation of immune response

11

Leukocytes and macrophages

Mucus production

COUGH

Pathogens multiplies in the abdomen (release toxins causing damage to the tissues

FEVER

Pyrogens in the body

Continuous mucus production (narrowing of air passage)

DOB

Impaired O2 and CO2 exchange RESPIRATORY RATE Oxygen demand PULSE RATE NEONATAL PNEUMONIA Respiratory and metabolic acidosis 12 Hypoxemia

Pulmonary vasoconstriction

Endothelial and epithelial cell injury

RDS A. PHYSICAL ASSESSMENT VITAL SIGNS: PR:125 bpm TEMPERATURE=36.9c RR=59 cpm Height = 38cm Weight = 1.3kg July 5,2013 PARTS TO BE ASSESSED TECHNIQUE NORMAL FINDINGS General appearance 1. Signs of distress in posture or facial expression 2. Obvious signs of health or illness There are sign of irritability, the patient is irritated and cries at time Weak in appearance Deviation from normal due to pain felt by the patient Deviation from normal due to pain felt by the patient ACTUAL FINDINGS REMARKS

Inspection

No distress noted

Inspection

Healthy appearance SKIN

13

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS Deviation from normal due to dryness is a sign of dehydration Deviation from normal due to fragile looking skin

1. Skin moisture

Inspection

moisture in skin fold and axillae

Dry

2. Skin Texture

Inspection

smooth PUPILS

Thin, transparent capillaries are visible

1. Color, shape & symmetry of size

Inspection

Black in color; equal in size; normally 3-7 mm in diameter; round, smooth border.

Yellowish in color

Deviation from normal due to yellowish discoloration of eyes

NOSE 1. Shape, size or color & flaring or discharge from the nares Symmetric and straight Inspection with discharge or flaring Uniform color With discharge noted Deviation from normal due to discharged secretions

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Summary of Physical Assessment:

There are sign of restlessness, the patient is irritated and cries at time. Weak in appearance. Skin: Dry, Thin, transparent capillaries are visible Pupils: Yellowish in color Nose: With discharge noted

B. Laboratories / diagnostic Examination DIAGNOSTIC/ LABORATORY PROCEDURE Clinical Chemistry DATE ORDERED INDICATION/ PURPOSES NORMAL VALUES ACTUAL VALUES ANALYSIS & INTERPRETATION OF RESULTS Normal NURSING RESPONSIBILITIES Prior Explain the procedure to the pt. Normal Monocyte % 7.8% Normal and why it is indicated Inform the patient that fluid and food restriction is not Normal If there is increase in RBC, an increase in required Inform the patient that a blood sample RBC 5.44 x 1012/L will be taken.

June 26, 2013 5:59

Laboratory tests demonstrating the presence of physiologically significant substances in the blood, urine, tissue, and body fluids with application to the diagnosis or therapy of disease. Detect or measure substances that

WBC
5.0-10.0 x 109 per liter (L)

WBC
6.4 x 109 per liter (L)

Lymphocyte % 17.0 45.0

Lymphocyte % 30%

Monocyte % 4.0 10. 0

Granulocyte % 43.0 76.0

Granulocyte % 61.6 %

RBC

15

indicate cell damage or disease

3.80 x 1012/L 5.00 x 1012/L HgB 203g/L HgB 110 g/L 165g/L HCT 0.622 HCT 0.350 0.500 MCV 114mm3 MCV 80mm3-97mm3 MCH 37.3pg MCH 26.5pg-35.5pg MCHC 326 g/L MCHC 315g/L 350 g/L RDW 17.4% RDW 10.0% -15.0% Plt 104x 109/L Plt 150x 109/L 450 x
109/L

fluids may aid to decrease blood viscosity

Tell the patient that he may experience transient discomfort

Detect or measure drugs or toxic substances

May indicate dehydration May indicate dehydration

from the needle puncture Fill up laboratory request form properly and send it to the laboratory

May indicate that there are more immature cells than mature cells

technician during the collection of sample/specimen.

May indicate that there are more immature cells than mature cells Normal

During Inform the patient that pain may be felt through prick in the needle

May indicate anemina

Instruct the patient to calm down to avoid uneasiness.

May indicate dilution MPV 8.2

After Apply brief pressure to prevent bleeding 16

MPV

6.5-11.0 PCT 0.100-0.500 PDW 10.0-15.0

PCT 0.086 PDW 9.3

Normal

Apply warm compress if Hematoma will develop at the venipuncture site

Normal

Normal WBC
8.0 x 109 per liter (L)

June 26, 2013 8:47 WBC

5.0-10.0 x 109 per liter (L)

Lymphocyte % 40.0

Normal

Lymphocyte % 17.0 45.0

Monocyte % 5.1

Normal

Monocyte % 4.0 10. 0

Granulocyte % 54.9%

Normal

Granulocyte % 43.0 76.0

RBC 6.76 x 1012/L

Normal

RBC 3.80 x 1012/L 5.00 x 1012/L

HgB 254g/L

If there is increase in RBC, an increase in fluids may aid to decrease blood viscosity

HgB

HCT 0.756 17

110 g/L 165g/L MCV 116 mm3

May indicate dehydration

HCT 0.350 0.500

MCV 80 mm3 - 97 mm3

MCH 37.6pg

May indicate dehydration

MCH 26.5 pg - 35.5 pg

MCHC 323 g/L

May indicate that there are more immature cells than mature cells

MCHC 315g/L 350 g/L

RDW 17.2%

May indicate that there are more immature cells than mature cells Normal

RDW 10.0% -15.0%

Plt 135x 109/L

Plt 150 x 109/L 450 x

109/L

MPV

May indicate anemina

8.6 PCT 0.115 PDW 9.0 May indicate dilution

MPV

6.5-11.0 PCT 0.100-0.500

Normal

18

Normal PDW 10.0 July 2, 2013 7:06 WBC

2.9 x 109 per liter (L)

Normal Lymphocyte % 24.0 WBC

5.0-10.0 x 109 per liter (L)

Monocyte % 7.5

Normal

Lymphocyte % 17.0 45.0

Granulocyte % 68.5%

Normal

Monocyte % 4.0 10. 0

RBC 3.23 x 1012/L

Normal

Granulocyte % 43.0 76.0

HgB 124 g/L

Normal

RBC 3.80 x 1012/L 5.00 x 1012/L

HCT 0.354

If there is increase in RBC, an increase in fluids may aid to decrease blood viscosity

HgB 110 g/L 165g/L

MCV 110 mm3

Normal

HCT

MCH 19

0.350 0.500

38.7pg Normal

MCV 80 mm3 - 97 mm3

MCHC 350g/L

May indicate that there are more immature cells than mature cells

MCH 26.5 pg - 35.5 pg

RDW 19.7% May indicate that there are more immature cells than mature cells Normal

MCHC 315g/L 350 g/L

Plt 59 x 109/L

RDW 10.0% -15.0%

MPV

6.1 PCT 0.036 PDW 8.7

May indicate anemina

Plt 150 x 109/L 450 x

109/L

May indicate dilution

MPV

6.5-11.0 PCT 0.100-0.500 PDW 10.0

Normal

Normal

Normal

20

VI. THE PATIENT AND HIS CARE A. MEDICAL MANAGEMENT MEDICAL MANAGEMENT TREATMENT DATE ORDERED/ GENERAL DESCRIPTION DATE PERFORMED/ DATE CHANGE OR D/C Date started: June 26, 2013 Discontinued: July 5, 2013 Isotonic solution INDICATIONS/ PURPOSES CLIENTS RESPONSE TO THE TREATMENT ________ NURSING RESPONSIBILITIES

D10 W 500cc (10% dextrose in water) 63.6 + NaCl 0.5 cc + KCl 0.6 cc + CaGluc 1.3 cc + aminosteril 32 cc = 98 cc via Soluset @ 32ugtts/min

For maintenance of fluid and electrolytes. For rehydration

Prior: Review physicians order Monitor V/S During: Watch closely for signs and symptoms of fluid overload. Report side effects to discontinue the drug. After: Maintain patent IV line, watch for irritation in the insertion site Monitor I & O continuously

D5 IMB 500cc (Balanced Multiple Maintenance Solution with 5% dextrose @ 8gtts/min

Date started: July 6, 2013 Discontinued: ------

Hypertonic Solution

For maintenance of fluid and electrolytes especially to patients who need calories and hydration

________

Prior: Hook the cannula tubing 21

Oxygen Therapy 3-11 LPM

Date ordered: July 2, 2013 Date performed: July 2, 2013

Oxygen therapy is a treatment that provides extra oxygen, a gas that the body needs to work well. Normally, lungs absorb oxygen from the air.

The body is constantly taking in oxygen and releasing carbon dioxide. If this process is inadequate, oxygen levels in the blood decrease and the patient may need supplemental oxygen. Oxygen therapy is a key treatment in respiratory care.

behind the patients ears under her chin. Monitor the oxygen delivery system After: Ensure the patency of nostril After: Avoid applying the cannula too tightly because it cause pressure to the facial structure and occlude the cannula.

OGT (Oralgastric Tube feeding)

Prior: Check the position of the tube before each fed During: Give the food slowly After: Document intake and output. Observed for abdominal distension

Prior: Verify the doctors order Make sure that the informed consent was signed by the mother. Identify the patient 22

Blood Transfusion

Blood transfusion procedures allow administration of a wide range of blood products, such as RBCs which can revive oxygen starved tissues; leucocytes which can combat infections beyond the reach of antibiotics; and clotting factors, plasma, and platelets, which can help patient with clotting disorder live virtually normal lives.

Check the expiration date, and inspect the plasma fraction for cloudiness and turbidity. During: Administer fresh frozen plasma within 4 hours because it doesnt contain preservatives Monitor for fluid over load After: Monitor the V/S

B. DRUGS Generic/ BrandName/ Classification Generic Name: Famotidine DATE (ordered, given, changed, discontinue) Date ordered: June 29,2013 Date given: Route of Administration, Dosage, Frequency TIV OD 0.6 mg Mechanism Action Clients Response ---Nursing Responsibilities

Competitive inhibitors of histamine H2 receptors leading to inhibition of

Prior: Initiate ANST Take V/S for baseline data 23

June 29, 2013 Discontinued: July 4, 2013

gastric acid secretion.

Inspect the IV line if patent Check for the right dose, right drug and right patient During: Administer the drug slowly via IV push After: Monitor for signs of GI bleeding Monitor for improvement in GI distress Monitor the v/s ---Prior: Take initial vital sign as baseline During: Disinfect the site Administer via IM @ the vastus lateralis After: Monitor patient constantly. Monitor therapeutic effectiveness. Prior: Monitor vital sign as a baseline data Inspect the IV line if patent Check for the right dose, right drug and right patient During: Administer drug slowly via IV push After: Monitor HR through period of drug administration 24

Generic Name: Phytonadione (vitamin K) Brand Name: Classification: Vitamin K derivative

Date ordered: July 2,2013 Date given: July 2,2013

q 5days 0.5ml

Essential for hepatic synthesis of factors of II,VII, IX and X, all of which are essential for blood clotting.

Generic Name: Vancomycin Hydrochloride Brand Name: Vancocin Classification: Antibiotic

Date ordered: July 3, 2013 Date given: July 3, 2013

IVT q12 15mg

Appears to bind bacterial cell wall, arresting its synthesis and lysing the cytoplasmic membrane by a mechanism that is different from that of penicillins and cephalosporins.

Assess hearing. Drug may cause damage to auditory branch. Monitor I & O

C. DIET Type of diet NPO (Nothing Per Orem) Date started June 26,2013 General description (NPO) is a medical instruction meaning to withhold oral food and fluids from a patient Indications/purpose NPO instructions are the prevention of aspiration pneumonia, or those with weak swallowing. Specific foods taken None Clients response to the diet Nursing responsibilities Prior: Explain to the mother the importance of following strictly NPO. During: Make the client do not receive any amount of food

25

Breastfeeding with Strict Aspiration Precaution

July 3,2013

Is the preferred method of feeding newborn because provides numerous healths to both the mother and the infant; it remains the ideal nutritional source for infants through the first year of life.

Breastfeeding provides the perfect nutrition for premature infants because breast milk provides just the right amount of calories, fatty acids, vitamins, and protein. It is more easily digested than formula milk which is particularly important for preemies as their digestive systems are not as mature as full term babies. Premature babies often dont have the strength or coordination needed to drink from a bottle, and their milk and medication are given to them through these feeding tubes.

Milk

Prior: Weigh the baby before each feeding to make sure that the baby receives the right amount of food. After: Record the fluid intake and output intake

OGT feeding

Date Started : July 3, 2013 Discontinued: July 1 , 2013

An orogastric tube is the same tube inserted into the mouth instead of the nose.

Milk, medications

Prior: Check the proper placement of the OGT During: Make the client do not receive any amount of food Make sure the client will not receive too much food. After: Record the fluid intake and output

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VII. Nursing Problem Prioritization DATE IDENTIFIED July 5, 2013 Objectives: > Dyspnea > Tachypnea July 5, 2013 Objective: >Dyspnea >tachypnea >depressed cough >weakness >poor activity July 5, 2013 Objective: > inability to suck and swallow > poor activity > Dyspnea > Tachypnea Activity intolerance related to decreased blood oxygen levels. -We include this in prioritization because the patient cant suck and swallow breast milk. Impaired spontaneous ventilation related to secretions in the bronchi Impaired gas exchange related to collection of secretions affecting oxygen exchange across alveolar membrane -We include this in prioritization because the patient is weak and dont have enough energy to suck. CUES PROBLEM/ NURSING DIAGNOSIS JUSTIFICATION -We include this in prioritization because the patient is in slight distress

27

VIII. Nursing Care Plan ASSESSMENT Objective: -crackles auscultated at right middle lung -wheezes - V/S taken as follows: T: 36.9 P: 125 R: 59 DIAGNOSIS Ineffective Airway Clearance related to secretions in the bronchi as manifested by dyspnea, adventitious sounds during auscultation, and increase respiratory rate PLANNING INTERVENTION RATIONALE
Indicative of respiratory distress and/or accumulation of secretions.

EVALUATION LONG TERM: At the end of 8 hours duty of rendering holistic nursing care, the client was able to: Have easy, regular and unlabored respirations. SHORT TERM: After 2-3 hours of Nursing Intervention, the client was able to: Have a decreased respiratory rate within normal range and will decrease difficulty of breathing.

LONG TERM: Monitor respiratory rate At the end of 8 hours duty and breath sounds. of rendering holistic nursing care, the client will be able to: Have easy, regular Position the head of the and unlabored client appropriately for respirations. her condition. SHORT TERM: After 2-3 hours of Nursing Elevate head of bed and/or change position Intervention, the client every2 hours will be able to: Have a decreased respiratory rate within normal range and will decrease difficulty of breathing.

To open or maintain airway when at rest.

To enhance drainage or ventilation of diff. lung segments and to promote lungexpansion.

28

ASSESSMENT Objective : -inability to suck and swallow (w/ OGT) -Depressed cough - V/S taken as follows: T: 36.9 P: 125 R: 59

DIAGNOSIS Risk for Aspiration related to impaired swallowing

PLANNING LONG TERM: At the end of 8 hours duty of rendering holistic nursing care , the clients mother will be able to : Understand the clients condition and apply necessary techniques to prevent aspiration.

INTERVENTION

RATIONALE

EVALUATION LONG TERM: (GOAL MET) At the end of 8 hours duty , of rendering holistic nursing care , the clients mother was able to : Understand the clients condition and apply necessary techniques to prevent aspiration. SHORT TERM: (GOAL MET) After 2-3 hours of Nursing Intervention, the client was able to: Show less sign of depressed cough Promote wellness

Auscultate lung sounds frequently. Suction Oral Gastric Tube

SHORT TERM: Encourage baby to burp After 2-3 hours of Nursing Intervention, the client will be able to: Show less sign of Avoid keeping client in To decrease the risk depressed cough supine position especially of aspiration Promote wellness when receiving enteral pneumonia. feedings.

To determine the presence of secretions/ silent aspiration To clear secretions while reducing potential for aspiration of secretions. To mobilize thickened secretions that may interfere with swallowing.

29

ASSESSMENT Objective: Dyspnea Tachypnea V/S taken as follows: T: 36.9 P: 125 R: 59

DIAGNOSIS Ineffective breathing pattern secondary to neonatal pneumonia as manifested by alterations in depth of breathing

PLANNING LONG TERM: After 8 hours of nursing intervention, the client will be able to:

INTERVENTION Administer oxygen at lowest concentration indicated and prescribed respiratory medications

RATIONALE
For management of underlying pulmonary condition or respiratory distress To promote physiological ease of maximal inspiration

EVALUATION LONG TERM: After 8 hours of nursing intervention, the client was be able to: Re-establish and maintain effective respiratory pattern via oxygen administration thru nasal cannula SHORT TERM: After 2-3 hours of Nursing Intervention, the client was able to:
Exhibit normal breathing pattern Promote wellness

Elevate HOB/ semiRe-establish and fowlers position maintain effective respiratory pattern via oxygen administration thru nasal cannula SHORT TERM: After 2-3 hours of Nursing Intervention, the client will be able to:
Exhibit normal breathing pattern Promote wellness

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IX. Health Teaching Objectives After 30 minutes of discussion, the clients motherwill be able to: a. Define breastfeeding based on her own understanding b. Give importance of proper positioning of breastfeeding c. Demonstrate proper positioning and attachment of infant d. Enumerate at least six guidelines of proper positioning for breastfeeding e. Verbalize the importance of letting the baby to burp after each feeding Content Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development. Proper positioning for breastfeeding is important to assist your baby to eat and transfer milk, to prevent aspiration, to help your baby to swallow and to prevent or minimize nipple soreness Follow these guidelines for proper positioning: it in a comfortable seat use a nursing pillow or bed pillows to support the weight of your baby many mothers find a nursing footstool helpful always bring your baby to your breast, do not lean your breast into the baby place your baby in a relaxed and flexed position with the head slightly extended make sure your babys head and body are at the breast level if your baby is correctly aligned, Teaching Strategies One on one discussion with the mother of the patient Resources Time: 30 minutes Man power Evaluation After 30 minutes of discussion, the clients mother was able to: a. Defined breastfeeding based on her own understanding b. Gave the importance of proper positioning of breastfeeding c. Demonstrated proper positioning and attachment of infant d. Enumerated at least six guidelines of proper positioning for breastfeeding e. Verbalized the importance of letting the baby to burp after each feeding

31

then you could draw an imaginary line from the ear to the shoulder to your babys hip offer breast support with the c-hold, thumb on top and fingers underneath the breast rotating your babys nursing positions will put the babys mouth on a different part of your breast; try using the cross cradle, cradle, side lying and football hold. Pictures are below. It is important to burp the baby after each feeding to prevent aspiration.

X. Discharge Planning Medication Advise the clients parents that medications should be taken regularly as prescribed, on exact dosage, time, and frequency. Report or go to the doctor if there are any side effects or adverse effect of the medication. Exercise/Environment

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 Advise the clients caregiver to keep the patient away from unclean environment and encourage them to always practice hand washing before handling the baby. Treatments Inform clients guardian to fully participate in continuous treatment. Make sure the patient get medication and the necessary care he would needed. Make sure that the patients guardians know the importance of breastfeeding and compliance to medications Health Teaching Teach all about the proper breastfeeding and instruct to burp after each feeding. Inform the parents to strictly watch for aspiration. Advise the clients parents to always practice hand washing before handling the baby. Out Patient Follow scheduled check-up by the doctor Advise the clients caregiver to report any unusual condition or if the patient have difficulty breathing. Diet Inform the patients caregiver that the best milk for the baby is mothers breast milk. Encourage them to breastfeed the baby on time. Spiritual Encourage the parents to always ask for Gods guidance. Always believe and always have faith in God. 33

Conclusion Based from our one week of handling and rendering care to our client with Neonatal Pneumonia, prompt treatment and adequate knowledge about the disease process is needed so that complications wont arise. Care is not only given to the patient, but also to Parents of the patient. Knowledge and appropriate skills are part of the tools of the nurse in order to be effective in handling the patient. We are able to know the necessary interventions to our client and they also learned how to do simple interventions for the clients problems. They had also recognized the importance of compliance to treatment regimen in order to manage the condition of their daughter. And at the end of this paper, we the Group 2 of BSN 4D were glad that we acquire the necessary knowledge and important nursing interventions on our chosen case, respiratory distress syndrome. We are honored to do this study and are also hoping that this study will be used as one of a source for the future student nurses in their case studies. XII. Bibliography BOOKS: FUNDAMENTALS OF NURSING, 8th Edition, Volume One, Kozier & Erbs PDQ FOR RN, 2nd Edition, Mosby Elsevier RAPID REFERENCES FOR NURSES, Karen Kowalski and Patricia Yoder Wise INTERNET: http://www.intechopen.com/books/neonatal-bacterial-infection/neonatal-pneumonia http://adc.bmj.com/content/68/5_Spec_No/550.full.pdf http://www.slideshare.net/cuddly9/neonatal-pneumonia http://www.scribd.com/doc/48677804/breast-feeding-teaching-plan http://womenshealth.beaumont.edu/positioning-your-baby http://www.mayoclinic.com/health/premature-birth/DS00137/DSECTION=symptoms 34