UST College of Nursing

Pediatric Care Record

Patient P.D.J, with his preferred nickname Packard, a 3 year old male child, was
born on August 27, 2011 at Malabon. The child lives at 1078 Torres Bugalion St. Tondo,
Manila. According to his father, on the start of classes for the year 2015-2016, he will
enroll his son in a daycare center. The age of his parents are his father is 30 years old
and his mother is 28 years old. The childs parents has their own business of selling ink
and ink refill for printers. The child has also a two older siblings, ages 7 years old and 5
years old.
Upon the admission of the patient, the chief complaint was shortness of breath
accompanied by cough and colds. The child had also fever at 39 degrees Celsius and
with nasal discharges prior to admission and his father verbalized that he dont eat
much. The childs past illness was 3 asthma attack last year. The admitting diagnosis of
the physician is bronchial asthma.
The child was reviewed thoroughly of his body systems to assess abnormal
functioning or any that contributes to the illness. Upon assessing, the child has a normal
skin color, has a good skin texture, no lesions, abrasions nor scars were found on his
skin. There were no swelling or bruises seen. His eyes were symmetrical and has moist/
clear conjunctiva, normal pupillary reflex and peripheral vision and has a normal sclera.
His auricles were consistent and symmetrical. No discharge from his ears is present.
There is some nasal discharges due to his colds and an inflamed throat due to the
cough.
Based on the observation, the child didnt experience any nausea, vomiting,
diarrhea. He is drinking milk and eating what is being served for him. But the child dont
eat too much of what was served. There are no signs of neurologic disorders and the
child doesnt experience any tingling or numbness. There is no swelling or edema
present.
When the father calls him, the child responded accordingly, he can also see what
his father is doing so the child loves to interfere. The child could smell and differentiates
one smell from the other. He can also differentiates bitter form sweet and other tastes.
While he is sleeping, he can still feel some touches from the nurse when the nurse is
getting his vital signs and abruptly reacted when the temperature scale was put on his
axillary and show sign of unlikeness.
The father mentioned that his child was at around 4 to 5 months old when he had
his head control, when he started to roll over and turn side to side. The child was able to
sit with support at 6 months old and later on the father cant remember the exact month
but latter part of his 6 to 7 months old he was able to sit down in a chair without support
then started to crawl and creep. According to the father, the child had started to stand at
his 10 months old but they still support him to while standing. The father also shared
that around 5 to 6 months after before his 11 months old, the child could almost walk
without any support from the family. And by the middle of his 11 months old he could
now stands alone and tried to walk but they still assists the child to walk. Before his 1 st
birthday the child was able to walk without any support from the family especially to his
parents.

In 3 years of age, the child could also use alternate feet while climbing or going
up the stairs. According to the father, his son loves to go out with him and rides a
motorcycle. He could also draw circles and how to imitate a cross. When the child was
asked about what is his name and age and gender, the child could respond by giving
out his full name. He also knows how to wash hands before eating or when he went to
the comfort room. Based on the assessment made, around 900 words the child could
speak and utter but in their age the child is experiencing telegraphic speech wherein 3
to 4 words in a sentence. At this age, the child could ask many questions after what they
have observed and curious about.
Based on the observation, the child could watch movies in his fathers cellphone,
he follows and obeys his father. The child is an early bloomer since he can now
understand action movies such as watching Fast and Furious 6. The father said that he
loves to watch Fast and Furious series.

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

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

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

Purpose
It is used to help
find the cause of
common symptoms
such as a cough,
shortness of breath,
or chest pain.
Find
lung
conditionssuch as
pneumonia.

Implication
Lung fields are clear
Diaphragm and sinuses
are normal
The heart is not enlarged
Impression: Normal Chest

DIAGNOSTIC EXAM
Test
Chest X-RAY

LABORATORY TEST: Complete Blood Count

Test Result
HGB = 124
RBC = 4.55
HCT = 0.37
MCV = 80.70

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

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

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

Differential count
Neutrophils = 0.58
Metamyelocytes = Bands = Segmenters = 0.58
Lymphocytes = 0.32
Monocytes = 0.03
Eosinophils = 0.07

Implication

RBCs are smaller than

normal; caused by iron
deficiency anemia.

Known as leukocytosis due

to infection, either bacterial
or
viral,
inflammation,
allergies, asthma, intense
exercise or sever stress.

(0.50 0.70)

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

Caused
by
asthma,
allergies, drug reaction
Inflammatory disorders.

Basophils = Medical Intervention ordered. (Drugs and procedures)

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

Nursing Responsibility

Assess
allergy
symptoms.
Assess lung sounds
and character of
bronchial
secretions.

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

used to treat many kinds of

bacterial
infections,
including severe or lifethreatening forms

Inform the patient to

take
the
drug
without regard to
meals.

Observe patient for

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

Nisuelrin syrup 2.5

ml Q8

Salbutamol neb 1 Used as a bronchodilator

to control and prevent
neb Q4
reversible
airway

Assess
lung
sounds, pulse, and
blood
pressure
during
peak
of

obstruction
asthma

caused

by

Used as a bronchodilator
to control and prevent
airway
Ipatropium
+ reversible
Salbutamol
neb obstruction caused by
(Duavent) 1 neb Q6 asthma

medication.
Note amount, color
and
amount
of
sputum produced.
Assess
lung
sounds, pulse, and
blood
pressure
during
peak
of
medication.
Note amount, color
and
amount
of
sputum produced.