Aldersgate College

Solano , Nueva Vizcaya

COLLEGE OF NURSING
Bachelor of Science in Nursing

In partial fulfillment of the course requirement in

Care of clients with problems in inflammatory

Severe Pneumonia in a Six Month Old Baby

Submitted by:
Kingsly A. Tavara
Jepthhah Isaac M. Valdez

Date Submitted:
Friday , February 17, 2017

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After having presented, the Case Study is hereby approved by the members of the
panelist

Blanche , Bernadette, RN
Clinical Instructor

Clinical Instructor

Dean, College of Nursing

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 TABLE OF CONTENTS

Introduction
Inspiration and rationale 4

Objectives
General and Specific 5

Health History 6
Patient Data
Present Health History
Past Health History

Physical Assessment 7

Gordons Functional Pattern 12

Definition of Complete Medical Diagnosis 14

Anatomy and Physiology 15

Pathophysiology 17

Laboratory and Diagnostic Examinations 19

Course in Ward 20
Medical/Surgical Management
Nursing Management

Nursing Care Management 23

Nursing Care Plan

Drug Study 27

Prognosis and Evaluation 37

Discharge Plan 39

Bibliography 40

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 INTRODUCTION

Pneumonia is an inflammation of the lungs caused by an infection. It is also called

pneumonitis or bronchopneumonia. It can be a serious threat to our health, although it is
a special concern for older adults and those with chronic illnesses, it can also strike
young, healthy people as well. It is a common illness that affects thousands of people
each year in the Philippines, thus it remains an important cause of morbidity and
mortality in the country. For our case study, we chose a patient with the said disease
because it instigated our curiosity. In spite of current innovations and development in the
health sector, pneumonia still poses a threat in the ordinary Filipino. Our client is a 6-
month old baby boy admitted on February 5, 2017 at 4:30pm in Veterans Regional
Hospital with complaints of cough and difficulty of breathing. After medical and
laboratory tests, she was diagnosed of having pneumonia.
Our case study would be tackling the nursing process and interventions done
during the course of our duty. This case study gave us new insights to the disease
process and the normal reactions to a disease. We realized that becoming a nurse
requires learning the underlying principles, analyzing them, and then applying the
principles to many different clients with similar problems, but very individual needs. We
student nurses must use our hearts and minds, as well as our hands and our senses to
be successful professional nurses in todays challenging health care world.
Through this case study we learned to embrace a continuum of service that
encompasses every level of care in a diversified system throughout the lifespan,
regardless of the patients status, race, gender, age, ethics, religion, or sexual
preference. We believe that each nurse has the responsibility to deliver high quality,
competent, effective, and collaborative care based not just on established nursing
standards but as humans as well.

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 OBJECTIVES

GENERAL OBJECTIVE

This case study aims to apply professional pediatric health nursing knowledge,
skills, and attitude in caring for a patient with community acquired pneumonia through
appropriate, efficient and pro-active nursing interventions.

SPECIFIC OBJECTIVES

After the completion of this study,

1. Pneumonia will be defined;
2. Pathophysiology of Pneumonia will be traced, and signs and symptoms will be
enumerated;
3. Different types of treatment for Pneumonia will be identified and understood;
4. Preventive measures against pneumonia will be understood; and
5. Nursing care plans utilizing the nursing process will be formulated and applied.

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 HEALTH HISTORY
I. Patients Data
Biographic Data
Client Patniel Abanagsky, a 6-month old Filipino male, was born on August 1, 2016
via home delivery. He lives with her father and grandparents in Vista Alegra Bayombong,
Nueva Vizcaya. His father works as a farmer and he finances the clients healthcare.
Chief Complaint
Medical help was sought due to severe coughing and difficulty of breathing. Ubo
ng ubo tapos nahihirapan siyang huminga, as verbalized by the grandmother.
Admitting Diagnosis
Pneumonia
Final Diagnosis
Pneumonia
II. History of Present Illness
January 28, 2017, seven days prior to admission, Patniels mother took her for a
four day vacation. Three days PTA, Patniel was brought back to her grandmother with
cough and colds. For three days, medical help was not sought and no medications were
taken. Due to severe coughing and difficulty in breathing, Patniel was brought to the
Emergency Room of Veterans Regional Hospital on January 5, 2017 at 2:30pm. After two
hours, Patniel was referred and admitted to the Pediatric Ward where an IVF of D 5
0.3NaCl 330cc for 8hours was administered.
Maternal Data
Patient Patniel was delivered at her mothers house. Few days after delivery,
patient Patniel was handed over to his father and his paternal grandparents. The
grandmother was unable to provide the obstetric history because she and Patniels
mother does not communicate with each other because the grandmother does not
approve with Patniels mother. Naiinis nga ako sa anak ko, bakit pa niya pinatulan yung
babaeng yun marami na kasi yun anak sa iba-ibang lalake. as stated by the
grandmother.
Past Medical History

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 Patniel has no history of mumps, measles, rubella, polio, hepatitis and chickenpox.
Patniel has completed all immunizations except for Measles vaccine. He has no known
allergies. This is Patniels first hospitalization.
Family History of Illness
According to Patniels father, Patniels mother has a history of asthma. The family
has no history of rheumatism, tuberculosis, hypertension, and diabetes mellitus.

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 PHYSICAL ASSESSMENT
February 6, 2017

General Appearance
Patient is in cardiorespiratory distress and appears calm. He is mesomorphic,
fairly nourished, and fairly groomed.
Vital Signs

Date and Temperature Cardiac Rate Respiratory Rate

time
08:00:00 AM 37.3 120 45
09:00:00 AM 36.8 128 43
10:00:00 AM 37.2 124 45
11:00:00 AM 36.5 130 43
12:00:00 AM 36.6 140 44
01:00:00 PM 36.5 120 42

Neurological
The patient is calm and alert. Responds minimally to stimuli by moving away from
the stimuli. Patient exhibited good sucking reflex.
Head
The head is normocephalic and symmetrical. Upon palpation, no masses were
noted. Anterior fontanel was open while the posterior fontanel has already closed. Hair is
fine and evenly distributed. Scalp is clean and without lice or dandruff.
Eyes
Eyelids are symmetrical, non-edematous and free of lesions. Also, no ptosis or
reddening was noted. The periorbital region showed no edema or discoloration. The
conjunctive was moist and pink, and no discharges were noted. The sclera was anicteric.
Pupils were equal and briskly reactive to light.
Ears
External pinnae are symmetrical with no lesions or abnormalities. No discharges
were observed. Client turns her head towards her caregivers voice.

Nose

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 Nasal flaring was noted. The nasal septum is in midline, there is no sinus
tenderness but the nasal mucosa was pale. No discharges, masses and lesions were
noted. Both nostrils were patent.
Mouth
Lips were pale and dry. Buccal mucosa was found pinkish and without lesions.
No teeth can be seen. Gums were pink and no bleeding was noted.
Neck
Trachea was noted to be in midline, lymph nodes and thyroid gland were non
palpable. There were no masses or swelling, and no neck engorgement observed. Full
range-of-motion was observed, no nuchal rigidity.
Chest and Lungs
No masses, lesions or rashes were noted on the chest of the client. Skin is intact.
Nipples are everted with no signs of discharge. Axillary lymph nodes were non palpable.
Breathing was shallow and irregular. Dyspnea was noted with no retractions or use of
accessory muscles. Chest is barrel shaped. Lung expansion is symmetrical. Testing for
tactile fremitus could not be done. Crackles were heard predominantly on the base of the
left lobe. The child is not able to expectorate secretions by coughing.
Heart
The precordial area is nontender and flat. Upon palpation, no heaves or thrills
were felt. Heart sounds is loud and distinct. Increased heart rate with regular rhythm
was observed upon auscultation.
Abdomen
The abdomen appeared globular in configuration. Normoactive bowel sounds
were heard on all 4
quadrants. LLQ at 20 per minute. No rebound tenderness was noted upon palpation. No
masses or
lesions were found on the abdomen.
Musculoskeletal and Extremities
Peripheral pulses are present and strong. The most distinct pulses are the radial
and brachial pulses. Capillary refill on both upper and lower extremities take less than 2
seconds. Nails are pinkish with no signs of clubbings. Nails are short and clean. No
inflammation was observed. ROM is limted in the right foot because of an IV insertion
site. No swelling or tenderness was noted on the joints of the extremeties.

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 February 7, 2017

Date and Temperature Cardiac Rate Respiratory Rate

time
08:00:00 AM 37.5 120 104
09:00:00 AM 37.5 128 98
10:00:00 AM 38 124 45
11:00:00 AM 36.8 130 39
12:00:00 AM 36.5 140 43
01:00:00 PM 37.2 120 42

CHEST AND LUNGS: Wheezes were heard upon expiration. Cardiorespiratory distress
was evident.

February 8, 2017

Date and Temperature Cardiac Rate Respiratory Rate

time
08:00:00 AM 35.5 100 45
09:00:00 AM 35.5 68 43
10:00:00 AM 35.8 72 45
11:00:00 AM 35.9 68 43
12:00:00 AM 36 86 44
01:00:00 PM 36.5 95 42

MOUTH: Dry and pale oral mucosa

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 February 9, 2017

Date and Temperature Cardiac Rate Respiratory Rate

time
08:00:00 AM 37.1 102 100
09:00:00 AM 37 109 60
10:00:00 AM 36.9 111 44
11:00:00 AM 36.6 120 52
12:00:00 AM 36.9 109 56
01:00:00 PM 36.9 112 54

February 10, 2017

Date and Temperature Cardiac Rate Respiratory Rate

time
08:00:00 AM 36.6 150 84
09:00:00 AM 36.8 156 86
10:00:00 AM 36.3 130 83
11:00:00 AM 36.6 150 84
12:00:00 AM 36.7 142 70
01:00:00 PM 36.9 149 74

CHEST AND LUNGS: The client developed productive coughs.

GORDONS FUNCTIONAL HEALTH PATTERNS

Informant: Grandmother

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Nutritional and Metabolic Pattern
Patniels typical diet since birth is approximately four 5ounces feeding bottles of
Bonamil which is 600ml of formula milk. He was never breastfed. He doesnt take vitamin
supplements. During his illness, no change in his appetite was observed. Since admission
he receives an IVF 330cc of D 50.3NaCl every 8 hours. He also receives multivitamins and
ascorbic acid + zinc along with his other medications only on February 4, 2017. Patniel
was on NPO on his first and third day of admission.
Day Oral Parenteral Total
February 6, 2017 NPO 490mL 490mL
February 7, 2017 60mL + FF 775mL 835mL + FF
February 8, 2017 NPO 450mL 450mL
February 9, 2017 60mL + FF 470mL 530mL + FF
February 10, 2017 240mL 550ml 790mL

Elimination Pattern
Patient Patniel changes diapers 4-6 times in 24 hours, all stained with yellowish urine
and 2 with stool. No change in his elimination pattern was observed during his illness.
Day Urine Drainage Others Total
February 6, -
20mL 15mL 35mL
2017
February 7, -
7D 1S 7D + 1S
2017
February 8, -
3D - 3D
2017
February 9, -
4D - 4D
2017
February 10, -
5D 2S 5D + 2S
2017

Activity
During the time before hospitalization, Patniel crawls around the bed every day. He is
able to sit with support and grabs objects that he wants to play with. Masiyahing bata
naman si Patniel, paborito niyang laruin yung mga bilog [bola].
For the duration of his hospitalization, Patniel had limited activity due to the IV lines
and his difficulty in breathing. Patniel doesnt play, does not move much and often wants
to be carried.

Sleep- Rest Pattern

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 Before hospitalization, Patniel usually sleeps from 9:00pm to 7:00am, but
occasionally wakes up to feed. He usually takes a 2-hour nap during mid-afternoon. It is
not hard to put him to sleep and he usually sleeps soundly.
During Patniels first day of admission, He experienced difficulty in sleeping. Siguro
kasi naninibago sa ospital at hirap huminga, as verbalized by the grandmother. On the
succeeding days, He easily falls asleep but is easily disturbed especially when he
experiences difficulty in breathing. His sleep (approximately 12-14 hours scattered
throughout the day) is not continuous and only lasts for 4 hours at most.
Role Relationship Pattern
The client lives with his father and grandparents. The grandmother is the primary
caregiver. The grandfather helps in taking care of Patniel. The father is the sole provider.
He seldom interacts with Patniel because of his hectic schedule. He only goes home
during the weekends.
The clients grandmother is very concerned and protective of her grandson. She thinks
Patniel got sick because her mother did not take good care of him. This is one of the
reasons why she did not contact Patniels mother about the illness.
Coping-Stress Tolerance
The family does not find it difficult to take care of Patniel. However during his stay in
the hospital, his grandmother found the hospitalization stressful. She is unable to sleep
soundly because she constantly worries about Patniel. She tells Patniel, Pagaling ka na
para makauwi na tayo, para di na rin lumaki bayarin.
Patniel cries minimally whenever he is manipulated (oxygen and medication
administration, position changes, vital signs). However, at times when he cries
vigorously, his grandmother needs to carry him to calm him down.

DEFINITION OF COMPLETE MEDICAL DIAGNOSIS

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 Severe Pneumonia

Pneumonia is an inflammation of the lung tissue usually due to infection. Air

pockets in the lungs fill with pus and fluid, making breathing and the absorption of
oxygen difficult. It is characterized by fever, sweats, shivers, fatigue, decreased of
appetite and cough with sputum that is yellow/green and sometimes bloodstained. The
disease is commonly divided into two types: hospital acquired (pneumococcal or
streptococcal pneumonia) and community acquired (streptococcal, chlamydia, viral
pneumonias).

Severe pneumonia is most often associated with streptococcal and staphylococcal

infections. Since the client is a six-month old infant, the mortality rate is higher.
Administration of antibiotics and oxygen is usually ordered by the doctor.

ANATOMY AND PHYSIOLOGY

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 THE RESPIRATORY SYSTEM
In facilitating metabolic reactions to produce ATP, the cells in our body use oxygen
(O2) and release carbon dioxide (CO 2). The need for intake of O2 and elimination of CO2
are provided for by the respiratory system.
The respiratory system, which can be divided into the upper and lower respiratory
tract, has various functions, most importantly for gas exchange. It also regulates serum
pH, filters inspired air, removes excess heat and water and produces sounds.
Structurally, the upper respiratory system includes:
Nose
Composed of a bony and cartilaginous framework, the nose is both rigid and
flexible. Air goes in and out of two openings called external nares, which communicates
with the internal nares. The nasal cavity is divided by a septum. The nose functions to
warm, moisten and filter incoming air; detect olfactory stimuli and; modify speech
vibrations
Pharynx
Lying posterior to the nasal and oral cavities and anterior to the cervical
vertebrae, the pharynx is a funnel-shaped tube connecting the internal nares to the
larynx. The nasopharynx receives air and dust-laden mucus from the nasal cavity. The
oropharynx, which is a passageway for both food and air, has the palatine and lingual
tonsils. The laryngopharynx connects the esophagus to the larynx.
Larynx
This voice box connects the laryngopharynx to the trachea. Its wall is composed of
cartilages including thyroid and cricoid. The larynx also has mucus that helps trap dust.
Trachea
Located anterior to the esophagus, this windpipe has deep to superficial layers of
mucosa, submucosa, hyaline cartilage and adventitia. Its epithelium provides protection
from dust. C-shaped cartilage rings prevent inward collapse of the tracheal wall and
obstruction of the passageway.
The lower respiratory tract includes:
Bronchi
A shorter wider and more vertical bronchus than the left bronchus starts to divide
at an internal ridge called carina. This is very sensitive in triggering a cough reflex.
Primary bronchi divide to form secondary then tertiary bronchi then bronchioles until it

15
branches out into the smallest tubes called terminal bronchioles. Being composed of
smooth muscles, relaxation and contraction of the bronchi affects ventilation.
Lungs
Two cone-shaped organs floating in the thoracic cavity, the lungs are protected by
the pleural membrane. The pleural cavity contains fluids to reduce friction from the
sliding of the parietal and visceral pleura during breathing.
Alveoli
Cup-shaped outpouching covered by thin elastic membrane, an alveolus is able to
secrete surfactant that lowers tension of alveolar fluid, reducing the tendency of alveolar
collapse. Alveolar macrophages remove the fine dust particles and other foreign debris.
Oxygen is transported from blood to cells via capillary diffusion. Carbon dioxide
also diffuses but in the opposite direction. After these capillary exchanges, venous blood
goes into pulmonary circulation to replenish oxygen stores and remove carbon dioxide.
Through ventilation, air is able to flow in (inspiration) and out (expiration) of the
lungs. During inspiration, lowering of pressure to draw air into the lungs is facilitated by
the contraction of the diaphragm which enlarges the thoracic cavity. When the
diaphragm relaxes, the thoracic cavity ceases, increasing the alveolar pressure, pushing
air outside the lungs. Airway resistance which is affected by size of airway is another
determinant of respiratory effort. Also needed for adequate ventilation is lung
compliance: elasticity, expandability and distensibility.
Respiratory Tract Differences in Children
Because of ongoing lung and chest wall maturation, childrens respiratory tract
differs from adults significantly. Infants airways are more prone to collapse due to lesser
cartilage. Their bronchial lumens are small, so excessive production of mucus can easily
cause obstruction. Chest muscles are not fully developed and therefore have poor recoil;
abdominal muscles are used for breathing. Weakness in accessory muscles for breathing
could easily result to respiratory difficulties. Peripheral airway resistance is higher in
children younger than five years making them more prone to develop an obstructive
airway. On the other hand, bronchospasm is less likely to occur in because of lesser
smooth muscles in the airway.

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 PATHOPHYSIOLOGY
PNEUMONIA
Normally, physiologic characteristics of the upper airway prevent infectious
particles from reaching the lower respiratory tract. However, a person whose resistance
has been altered may aspirate flora normally present in the oropharynx. The aspirated
flora causes inflammation in the alveoli, producing exudates. White blood cells migrate
into the alveoli and fill its air-containing spaces. Secretions and edema cause partial
occlusion of the bronchi or alveoli. Alveolar oxygen tension decreases, hypoventilation
occurs. Ventilation-perfusion mismatch results in poorly oxygenated blood, which in turn
will lead to arterial hypoxemia. Complications of untreated pneumonia include shock,
respiratory failure, atelectasis, pleural effusion and superinfection.

Pneumonia in children could be bacterial, viral or mycoplasmal in origin; aspiration

of lipid or hydrocarbon substances may also be a cause. It could be hospital (onset of
symptoms more than 48 hours after admission to the hospital) or community- acquired
(in the community setting or within the first 48 hours of hospitalization). Pneumonia can
occur all through childhood and often follows after an upper respiratory infection. The
most common symptoms manifested in children are productive cough, high fever,
decreased breath sounds, rales, dyspnea, fatigue, restlessness and shallow respirations.
For client Patniel, pneumonia was acquired from the community. With regards to the risk
factors and symptoms of the disease present in client Patniel, please refer to Figure 1.

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 Figure 1. Pathophysiology of Pneumonia in Client Patniel

Impaired host Age: 6 months 25

defenses days

Aspiration of flora in the

oropharynx

Inflammatory reaction in the Feve

alveoli r

Coug Formation of exudates,

secretions and mucosal WBCs fill the air-containing
Rale spaces
edema

Interference of O2 and CO2 Partial occlusion of Wheezi

diffusion ng
Decreased Tachypnea

Nasal
Ventilation-perfusion flaring
Use of accessory
mismatch muscles

Tachycard Poorly oxygenated

ia blood
Dyspnea, cool
Arterial extremities, pale
appearance

Good prognosis with administration of antibiotics, antipyretics, anti-

inflammatory, bronchodilators, mucolytics, antihistamine, multivitamins;
nebulization, oxygen administration, chest physiotherapy, hydration,
maintenance of nutrition, promotion of rest

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 LABORATORY AND DIAGNOSTIC EXAMINATIONS
Date Lab. Test Interpretation Nursing Responsibility
Actual Result Normal values
Hematology
February -A high leukocyte
6, 2017 WBC 20.8 5-10 x 109 count may indicate a
presence of an Monitor vital signs
infection. based on the
Neutrophils 0.77 0.51-0.67 hospitals protocol.
-A high neutrophil
count may also Assess for any signs
Lymphocytes indicate presence of of hypoxia.
0.23 0.21-0.35 infection.
Asses general signs of
-A normal infection.
lymphocyte count may
Hemoglobin
rule-out suspected Offer pharmacological
109mg/dl 120-160 viral infection. treatment for any
possible infection
-A low hemoglobin
count may result to
poor oxygenation
Platelet count
especially to
626 x 109 150-400 x 109 extremities.

-A high platelet count

may indicate presence
of bleeding.
Hematocrit
-A normal hematocrit
32 30-36
indicates a normal
percentage of RBC in
the blood.
Radiological Report
Chest APL
Findings: Bronchopneumonia

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 COURSE IN THE WARD
MEDICAL/SURGICAL NURSING MANAGEMENT
MANAGEMENT
February 5, 2017
Ordered Cefuroxime 220mg IV q8
hours
Ordered Gentamicin 33mg IV OD
Rationale: Antibiotics can help fight
off possible bacterial infections.

Ordered Combivent Nebulization q6

hours
Rationale: Nebulizers offers a
bronchodilation effect. Combivent
has anti-secretory properties and,
when applied locally, inhibits
secretions from the serous and
seromucous glands lining the nasal
mucosa

Ordered D5 0.3 NaCl 330ml q8 hours

Rationale: Fluids helps loosen
secretions.

Order NPO
Rationale: Prevents possible
aspiration

Ordered a CXR
Rationale: This is done to rule out
PTB.

Ordered Oxygen @ 1-2 liters nasal

cannula
Rationale: Administering pure oxygen
helps the lungs obtain more oxygen
for the body to use. This is done in
case the body has a hard time
obtaining oxygen.
February 6,2017
Asses VS q1 hour
Rationale: This will help monitor the
well-being of the patient. Increased
respiratory rate can demonstrate
difficulty in breathing.

February 6, 2017 Administer humidified oxygen

D/C Oxygen support
Rationale: The patient seems to be
breathing well without supplementary
oxygen.
Continue:
Cefuroxime 220mg IV q8 hours
Gentamycin 33mg IV OD
Rationale: Humidified oxygen helps
loosen secretions.
Instruct the care giver to keep the
child in a sitting position or keep the
head of the patient elevated at least
45 degrees.
Rationale: The sitting position
promotes more effective coughing by
Combivent Nebulization q6 hours
February 7, 2017
Ordered Hydrocortisone 30 mg IV q6
hours
Rationale: Hydrocortisone is a
corticosteroid, an anti-inflammatory
agent. It is used for
bronchoconstricting disorders.
Ordered Paracetamol 100 mg IV q4
hours
Rationale: The patient developed a
fever.
Ordered Oxygen @2-3 liters nasal
cannula
Rationale: Administering pure oxygen
helps the lungs obtain more oxygen
for the body to use.
increasing abdominal pressure and
upward diaphragmatic movement.
Keeping the head at 45 degrees
promote better lung expansion and
improved air exchange
Instruct the caregiver to change the
position of the child
Rationale: Splinting the abdomen
promote more effective coughing by
increasing abdominal pressure and
upward diaphragmatic movement.
Position client on her side. Do not
leave the client on her back.
Rationale: Lying flat causes the
abdominal organs to shift forward the
chest, thereby crowding the lungs
and making it more difficult to breath.
February 7, 2017
Continue to asses VS q1 hour
Maintain IV order of D5 0.3 NaCl
330ml q8 hours.
Rationale: It keeps the child well
hydrated to help loosen secretions
Continue to Nebulize q6 hours
TSB done
Rationale: this helps with
hyperthermia as it using the
principles of conduction to decrease
temperature.
Explain to the caregiver what
Pneumonia is, and the infecting
agents mode of transportation
Rationale: To prevent transmission of
infection, the mode of transmission
(droplet) must be known.
Order NPO

Continue:
Cefuroxime 220mg IV q8 hours
Gentamycin 33mg IV OD
Combivent Nebulization q6 hours
February 8, 2017
February 8, 2017
Educate the care giver of the client
on proper precautions when dealing
with droplet precautions
Rationale: Pneumonia is a droplet
precaution. Educating the care giver
about droplet precaution can prevent
spread of infection.

Vol/vol replacement
Rationale: To prevent fluid imbalance
and dehydration, fluid replacement is
necessary. The amount of fluids lost
should be replaced
Continue Oxygen @ 2-3 liters nasal
cannula.
February 8, 2017
Educate the caregiver of the client
about the proper Daily Nutritional
Requirements for 6 month old
children.
Rationale: Educating the mother/care
giver can help them provide better
care their child.

February 8, 2017

Order D5 IMB q8 hours

Rationale: The patient has been NPO
for D5 IMB offers complete fluid and
electrolytes.

Claritin 125mg/2mL BID

Rationale: Claritin is an antihistamine
and antihistamines help with
bronchodilation

Salbutamol syrup 2mL TID

Rationale: Salbutamol helps loosens
secretion.
February 9, 2017
Ascorbic Acid + Zinc 2mL TID
Rationale: Vitamin C can help Tapping the upper back of the
increase the immune systems ability patient.
to fight off infection. Rationale: This helps move secretion
for the baby to properly expel.
Multivitamins 0.2 mL OD
Rationale: Because the patient has
been on an NPO status, she is in need
vitamins to support her body
functions.

February 9, 2017
Continue
Claritin 125mg/2mL BID
Salbutamol syrup 2mL TID
Ascorbic Acid + Zinc 2mL TID
Multivitamins 0.2 mL OD
Combivent Nebulization q6 hours
 NURSING CARE MANAGEMENT
NURSING CARE PLAN

Assessment Nursing Expected Interventions Rationale Evaluation

Diagnosis Outcome
Ineffective Airway
Subjective Data: Clearance r/t Short Term: 1) Nebulize the 1) Nebulizing with - patient responds
Ubo ng ubo stasis of - The patient will patient with Combivent promotes to treatment but still
tapos secretion and be able to Combivent q6 loosening of secretions showed labored
nahihirapan ineffective cough mobilize hours and halts the production breathing
siyang huminga secondary to secretions well of secretions. intermittently.
pneumonia within 2-3 days
2) Pulmonary clapping - at the end of shift,
Objective Data: A state in which a - The patient will 2) Provide is used to assist in the patients respiratory
- Patient cannot person not have labored pulmonary mobilization of rate decreased
expectorate experiences a breathing at the clapping secretions in smaller (42,42,54 for Feb
secretions by threat to end of the shift airways. 7 ,8 and 9)
coughing respiratory status
- Crackles on the related to - Patient will 3)This allows the body to - The patient has not
base of the left inability to cough tolerate proper 3)Administer obtain oxygen easier to maintained an
lobe effectively. treatment of oxygen @ 1-2 satisfy its needs airway free of
- Nasal Flaring severe liters nasal secretions in the last
- Wheezes pneumonia and canula 4) This ensures adequate 4 days (crackles still
- RR: Feb8: 104, its symptoms hydration. It liquefies present till the 4th
98 bpm; Feb 9: during her stay in 4) Administer D5 secretions, enabling day).
100 bpm the hospital 0.3 NaCl 330cc easier expectoration and
 q8 preventing stasis of - By the 5th day, the
secretion. patient was able to
Long Term: 5) For prophylaxis mobilize secretion
- The patient will purposes, gentamicin well.
be free from 5) Administer can fight against
adventitious gentamicin and bacteria that affects - Patient was able to
breath sounds cefuroxime as a respiratory function. tolerate all the
within 5-7 days. form of treatments, without
prophylaxis developing any
- Patient will be treatment. 6) Lying flat for adverse reaction
able to maintain prolonged periods
an airway free of 6) Position client causes stasis of
secretions within on her side. Do secretions; also, the
5-7 days. not leave the abdominal organs shift
client on her back forward to the chest,
or on one crowding the lungs and
position for making it more difficult
prolonged to breathe.
periods..
7) The sitting position
promotes more effective
coughing by increasing
7) Instruct the abdominal pressure and
care giver to upward diaphragmatic
keep the child in
a sitting position
 (when coughing)
or keep the head
of the patient
elevated at least
45 degrees.

Assessment Nursing Expected Interventions Rationale Evaluation

Diagnosis Outcome

Subject Data: Risk for infection Short Term 1) Explain to the 1) To prevent - The caregiver was
- simula nung Transmission r/t - By the end of caregiver what transmission of able to identify the
sinauli sya ng airborne the shift, the Pneumonia is, and infection, the mode of transmission of
nanay nya transmission caregiver will be infecting agents mode of the infecting agent
nagkaroon na sya exposure. able to identify mode of transmission within the end of the
ng ubo at sipon the mode of transportation (droplet) must be shift.
transmission of known.
Objective Data: the infecting - The caregiver has not
- patient is agent. 2) Educate the care 2) Pneumonia is a been infected by
diagnosed with The state in giver of the client on droplet pneumonia since the
Pneumonia. which an Long Term proper precautions precaution. patients admission.
individual is at - The caregiver when dealing with
- Patient was risk for of the client will droplet precautions
born outside of a transferring an not be infected
hospital setting in opportunistic or by the clients 3) Educate the client
a setting prone to pathogenic agent current and about proper hand 3) Proper hand
infectious to others. future outbreaks washing techniques washing can help
diseases. of pneumonia. prevent
development of
- Patient coughs diseases and
with caregiver illness
not protecting
herself from
droplet
transmission.

Assessment Nursing Expected Intervention Rationale Evaluation

Diagnosis Outcomes
Subjective Data: Short Term: 1) Performed To decrease Patients
May sakit siya. Hyperthermia After 3 hours of surface cooling by temperature temperature
Inuubo at related to illness nursing means of tepid through decreased and she
nilalagnat siya intervention, sponge bath evaporation and was able to keep
ngayon, katulad Patients body patient will conduction. up normal
kagabi, as temperature was maintain core 2) Covered the temperature level
verbalized by the elevated above temperature within extremities with
patients grand normal range normal range blanket. To prevent or
mother. (Feb. 6, (36.4C to 37.2C). minimize shivering
2017). When there is of the patient.
presence of illness, 3) Administered
Objective Data: our body reacts, antipyretic drug
(February 07, endocrine and (paracetamol) Antipyretic drug
2011) autonomic orally as ordered reduces fever by
Vital signs taken as responses are by the physician. lowering the body
follows: activated which temperature.
cause blood To facilitate fast
Temperature vessels to dilate
08 AM - 37.5C and cardiac output, recovery.
09 AM - 37.5C heart rate and
10 AM - 38C sweating to
01 PM - 37.2C increase, thus
moving more heat
RR from the body.
08 AM 104 cpm Heat remains in
09 AM 98 cpm the body, causing
10 AM 45 cpm body temperature
01 PM 42 cpm to rise.

HR
08 AM 120 bpm
09 AM 128 bpm
10 AM 124 bpm
01 PM 120 bpm

DRUG STUDY
DRUG /
CLASSIFICATIO
MECHANISM OF ADVERSE/SIDE NURSING
N / DOSE, INDICATION
ACTION EFFECTS RESPONSIBILITIES
ROUTE AND
FREQUENCY
 Strict IV regulation.

Lactic acidosis, severe sepsis,

initial post-trauma phase,
hypoproteinemia, peripheral
or pulmonary edema
When a cells
cytoplasm is bathed Do not administer
in a hypotonic unlesssolution is clear
solution the water will andcontainer is undamaged.
Fever, irritation or
be drawn out of the
infection at injection
D50.3NaCl / solution and into the Caution must be exercisedin
Replacement & site, thrombosis or
Hypotonic cell by osmosis. This the administration
maintenance of phlebitis extending
Electrolytes / helps hydrate the of parenteral fluids,
fluid & from injection site &
330cc IV every 8 cells. If water especiallythose containing
electrolytes. extravasation,
hours molecules continue to sodiumions to patients
hyperglycemia of the
diffuse into the cell, it receivingcorticosteroids
newborn.
will cause the cell to or corticotrophin.
swell, up to the point
that cytolysis In very low birth
(rupture) may occur. weightinfants, excessive or
rapidadministration of
dextroseinjection may result
inincreased serumosmolality
and possibleintracerebral
hemorrhage.

DRUG /
CLASSIFICATIO
MECHANISM OF ADVERSE/SIDE NURSING
N / DOSE, INDICATION
ACTION EFFECTS RESPONSIBILITIES
ROUTE AND
FREQUENCY
 Common Reactions: Assessment
injection site reaction, History: Liver and kidney
anemia, eosinophilia, dysfunction, lactation,
elevated liver pregnancy
transaminases, Physical: Skin status, liver and
elevated alk phos, kidney function test, culture of
renal impairment, affected area, sensitivity tests
diarrhea Implementation
Culture infection, arrange for
Zinacef Serious Reactions: sensitivity tests before and
(Cefuroxime) / Prevention and Bactericidal: inhibits anaphylaxis, toxic during therapy if expected
2nd Generation treatment of synthesis of bacterial epidermal necrolysis, response is not seen.
Cephalosporin / antibacterial cell wall, causing cell Stevens-Johnson Give oral drug with food to
220mg IV every infection. death syndrome, decrease GI upset and
8 hours angioedema, enhance absorption.
interstitial nephritis, Give oral drug to children who
pseudomembranous can swallow tablets; crushing
colitis, pancytopenia, the drug results in a bitter,
agranulocytosis, unpleasant taste.
thrombocytopenia, Have vitamin K available in
leucopenia, case hypoprothrombinemia
neutropenia, anemia, occurs.
hemolytic seizures, Discontinue if hypersensitivity
cutaneous vasculitis reaction occurs.

DRUG /
CLASSIFICATIO
MECHANISM OF ADVERSE/SIDE NURSING
N / DOSE, INDICATION
ACTION EFFECTS RESPONSIBILITIES
ROUTE AND
FREQUENCY
 Assessment
Severe side effects: History: Allergy to any
Treatment of
Allergic reaction aminoglycosides; renal or
bacterial
(shortness of breath; hepatic disease; fungal
infections of the
closing of the throat; infections,
following
hives; swelling of the infant botulism
strains: Aminoglycosides
lips, face, or tongue; Physical: Site of infection; skin
Pseudomonas irreversibly bind to
rash; or fainting); little color, lesions; orientation,
aeruginosa, the 30S ribosome and
or no urine; reflexes, eighth cranial
Proteus species freeze the 30S
decreased hearing or nerve function; P, BP; R,
(indole-positive initiation complex
ringing in the ears; adventitious sounds; bowel
Garamycin and indole- (30S-mRNA-tRNA), so
dizziness, clumsiness, sounds, liver evaluation;
(Gentamicin) / negative), that no further
or unsteadiness; urinalysis, BUN, serum
Aminoglycoside Escherichia coli, initiation can occur.
numbness, skin creatinine, serum electrolytes,
Antibiotic / Klebsiella - The aminoglycosides
tingling, muscle liver function tests, CBC
33mg IV OD Enterobacter- also slow down
twitching, or seizures; Health Teaching:
Serratia species, protein synthesis that
or severe watery Report pain at injection site,
Citrobacter has already initiated
diarrhea and severe headache, dizziness,
species, and and induce
abdominal cramps. loss of hearing, changes
Staphylococcus misreading of the
in urine pattern, difficulty
species mRNA.
breathing, rash or skin lesions;
(coagulase-
Mild Side effects: itching or irritation
positive and
Increased thirst, loss (ophthalmic preparations);
coagulase-
of appetite, nausea worsening of the condition,
negative)
and vomiting, rash rash, irritation
(dermatologic preparation).

DRUG /
CLASSIFICATIO
MECHANISM OF ADVERSE/SIDE NURSING
N / DOSE, INDICATION
ACTION EFFECTS RESPONSIBILITIES
ROUTE AND
FREQUENCY
Combivent
(Ipratropium
bromide) /
Antiasthmatic /
1 Nebule
Inhalation Every
6 hours
An anticholinergic
agent that inhibits
History: Hypersensitivity to
vagally-mediated
atropine, soy beans, peanuts
reflexes by
(aerosol preparation);
antagonizing the
Acute asthmatic Mild Side Effects: acute bronchospasm
action of
attacks & headache, epistaxis,
acetylcholine at the
exacerbations of rhinitis, pharyngitis, Physical: Skin color, lesions,
cholinergic receptor.
chronic nausea texture; orientation, reflexes,
Ipratropium bromide
bronchitis. bilateral grip strength; affect;
has anti-secretory
Management of Severe Side Effects: ophthalmic exam;
properties and, when
bronchospasm Upper respiratory adventitious sounds; bowel
applied locally,
in COPD. tract infection sounds, normal output;
inhibits secretions
normal urinary output,
from the serous and
prostate palpation
seromucous glands
lining the nasal
mucosa.

DRUG /
CLASSIFICATIO
MECHANISM OF ADVERSE/SIDE NURSING
N / DOSE, INDICATION
ACTION EFFECTS RESPONSIBILITIES
ROUTE AND
FREQUENCY
 Contraindicated with fungal
infections, amoebiasis,
hepatitis B, vaccinia, or
varicella, and antibiotic-
resistant infections.
Enter cells where they
combine with steroid
receptors in - Assess body weight, skin
Respiratory cytoplasm. color,
Diseases: Combination enters V/S, urinalysis, serum
symptomatic nucleus where it electrolytes,
Iatrogenic Cushings,
sarcoidosis, controls synthesis of X-rays, CBC.
avascular necrosis of
berylliosis, protein, including
bone, depression and - Arrange for increased dosage
fulminating or enzymes that
psychosis, peptic when patient is subject to
disseminated regulate vital cell
ulceration, others unusual stress.
pulmonary activities over a wide
Solu Cortef include cataract
tuberculosis range of metabolic - Do not give live vaccines
(Hydrocortisone) (chronic use),
when used functions including all with
/ Glucocorticoids glaucoma (prolonged
concurrently aspects of immunosuppressive doses of
/ 30mg IV Every use of eye drops),
with appropriate inflammation. hydrocortisone.
6 Hours raised ICP and
antituberculous Formation of a protein
convulsions, blood
chemotherapy, that inhibits the - Use minimal doses for
hypercoagulability,
Lffler's enzyme minimal
menstrual disorders,
syndrome not phospholipase A2 duration to minimize adverse
fever,
manageable by which is needed to effects.
immunosuppression
other means, allow the supply of - Taper doses when
aspiration arachidonic acid. discontinuing
pneumonitis. Latter is essential for high-dose or long-term
the formation of therapy.
inflammatory
mediators
- Monitor client for at least 30
minutes.
- Educate client on the side
effects of the medication and
what to expect.
DRUG / INDICATION MECHANISM OF ADVERSE/SIDE NURSING
CLASSIFICATIO ACTION EFFECTS RESPONSIBILITIES
N / DOSE,
ROUTE AND
 FREQUENCY

The main mechanism

of action of
paracetamol is
considered to be the
inhibition of
cyclooxygenase
(COX), and recent
findings suggest that -Monitor renal function
it is highly selective -Monitor blood especially CBC
for COX-2. While it has and pro-time if
analgesic and Increase in the patient is on
antipyretic properties incidence of long-term
Paracetamol / comparable to those asthmatic symptoms, therapy.
Aniline Relief of fevers, of aspirin or other increased incidence of -Check I&O ratio: decreasing
Analgesics / aches, and NSAIDs, its peripheral rhinoconjunctivitis output may indicate renal
100mg IV Every pains anti-inflammatory and eczema. failure.
4 hours activity is usually Upper gastrointestinal - Assess for fever and pain
limited by several stomach bleeding. - Assess hepatotoxicity:
factors, one of which Stomach irritation. dark urine, clay-
is high level of colored stools
peroxides present in - Assess allergic reactions:
inflammatory lesions. rash, urticuria
However, in some
circumstances, even
peripheral anti-
inflammatory activity
comparable to other
NSAIDs can be
observed.
 DRUG /
CLASSIFICATIO
MECHANISM OF ADVERSE/SIDE NURSING
N / DOSE, INDICATION
ACTION EFFECTS RESPONSIBILITIES
ROUTE AND
FREQUENCY

History: Allergy to any

antihistamines; narrow-angle
Claritin is glaucoma, stenosing peptic
indicated for the ulcer, symptomatic prostatic
Loratadine is a
relief of nasal -Drowsiness
tricyclic hypertrophy, asthma, bladder
and non-nasal -Sedation
antihistamine, which neck obstruction,
symptoms of -Urinary Retention
acts as a selective pyloroduodenal obstruction;
Claritin seasonal allergic -Dry mouth
inverse agonists of lactation, pregnancy
(Loratadine) / rhinitis and for -Blurred Vision
peripheral histamine
Antihistamine / the treatment of -Possible psychomotor
H1-receptors. Physical: Skin color, lesions,
5mg Oral BID chronic retardation
Histamine is texture; orientation, reflexes,
idiopathic
responsible for many affect; vision examinations; R,
urticaria in -Gastrointestinal
features of allergic adventitious sounds; prostate
patients 2 years Disturbances
reactions. palpation; serum
of age or
transaminase levels
younger.
 DRUG /
CLASSIFICATIO
MECHANISM OF ADVERSE/SIDE NURSING
N / DOSE, INDICATION
ACTION EFFECTS RESPONSIBILITIES
ROUTE AND
FREQUENCY
Monitor therapeutic
effectiveness which is
CNS: indicated by significant
Tremor, nervousness, subjective improvement in
dizziness, insomnia, pulmonary function within
headache, 6090 min after drug
hyperactivity, administration.
weakness, CNS
Stimulation, malaise Monitor for: S&S of fine
CV: tremor in fingers, which may
Tachycardia, interfere with precision
palpitation handwork; CNS stimulation,
To prevent or particularly in children 26 y,
EENT:
treat Relaxes bronchial, (hyperactivity, excitement,
Ventolin Nasal congestion,
bronchospasm uterine and vascular nervousness, insomnia),
(Salbutamol) / epistaxis, hoarseness
in patients with smooth muscle by tachycardia, GI symptoms.
Bronchodilator / GI:
reversible stimulating beta2 Report promptly to
2ml Oral TID Heartburn, nausea,
obstructive receptors. physician.
vomiting, bad taste,
airway disease
increased appetite
Metabolic: Lab tests: Periodic ABGs,
Hypokalemia pulmonary functions, and
Musculoskeletal: pulse oximetry.
Muscle cramps
Respiratory: Consult physician about
Bronchospasm, giving last albuterol dose
cough, wheezing, several hours before
dyspnea, bronchitis, bedtime, if drug-induced
increased sputum insomnia is a problem.
 DRUG /
CLASSIFICATIO
MECHANISM OF ADVERSE/SIDE NURSING
N / DOSE, INDICATION
ACTION EFFECTS RESPONSIBILITIES
ROUTE AND
FREQUENCY

CNS:
-When giving for urine
Required Daily Faintness and
acidification, check urine pH
Allowance dizziness
to ensure efficacy
Vitamin C (40mg), to GI:
Stimulates collagen -Protect solution from light
(Ascorbic Acid + prevent vitamin Diarrhea, heartburn,
formation and tissue and refrigerate
Zinc) / C deficiency in nausea and vomiting
repair; involved in
Nutritional patients with GU:
oxidation-reduction Patient Teaching:
Drug / 2mL Oral poor nutritional Acid urine, oxaluria
reactions. -Inform patient that Vitamin C
OD habits or and renal calculi
is readily absorbed from citrus
increased Other:
fruits, tomatoes, potatoes, and
requirements. Discomfort at
leafy vegetables
injection site.
 DRUG /
CLASSIFICATIO
MECHANISM OF ADVERSE/SIDE NURSING
N / DOSE, INDICATION
ACTION EFFECTS RESPONSIBILITIES
ROUTE AND
FREQUENCY

These vitamins are

Dietary GU:
needed for normal Should be avoided in patients
Multivitamins / supplement for Urine discoloration.
growth and with known hypersensitivity to
Nutritional the treatment Others:
development. Many preservatives, colorants, or
Drug / 0.2mL and prevention Allergic reactions to
act as coenzymes or additives including tartrazine,
Oral OD of vitamin preservatives,
catalysts in numerous saccharine and aspartame.
deficiencies. additives or colorants.
metabolic processes.
 PROGNOSIS/EVALUATION

Criteria (Based on Gordon's Poor Fair Good Justification

Functional Pattern)
1. Nutrition and Metabolic The client was not receiving
Pattern sufficient nutrients. Apart
from not being breastfed, the
client was being given
inadequate amount of
formula milk.
2. Elimination Pattern The client elimination was
normal. No findings were out
of the ordinary.
3. Activity and Exercise Pattern The client had limited activity
during her hospital stay. Due
to the IV lines, the client
movement was restricted.
The play of the infant was
absent.
4. Sleep and Rest Pattern The client's sleep was often
disrupted due to discomfort
from her condition. Before
her hospitalization, her
sleeping pattern was normal.
In comparison, during her
hospital stay, her sleeping
pattern was negatively
affected. Having difficulty in
breathing made it hard for
the client to have a
continuous and adequate
amount of sleep and rest.
5. Role and Relationship Pattern
6. Coping and Stress Tolerance
Pattern
The client has an uncommon
living situation with her
grandparents. Her father is
not always around to interact
with her. Her relationship
with her mother is non-
existent due to the fact that
her grandmother thinks that
her mother is unfit. Due to
the fact that her parents are
estranged, her grandparents
are the ones who are taking
care of her. They act as her
parental figures.
The client, as an infant, cries
whenever she is
manipulated. Her
grandmother has been stress
throughout the patient's
hospital stay. Worrying about
her granddaughter makes
sleeping difficult.
 DISCHARGE PLAN
DISCHARGE INSTRUCTIONS

Follow-up: Guardians would be reminded on the date of the next check-up and why it
would be necessary to do so (to check clients response to the treatment and ensure there
is no relapse of the infection). Any signs of complications such as: high-fever, nasal flaring,
retractions, chills, and dyspnea should be reported to the nearest healthcare provider.

Health Management: If the child will still have secretions, guardian would be instructed on
how to perform proper nebulization and pulmonary clapping at home; and will be taught
the rationale for the said actions. Demonstration would be done as needed.

Medications: If oral antibiotics will be prescribed, clients guardian will be taught on proper
administration and potential side effects. She would be educated on the significance of
strict compliance to antibiotic regimen to ensure effective treatment of the infection and
prevent microbial resistance.

Nutrition: Child should be fed frequently in small amounts or as tolerated. Supplementary

feeding would be strongly advised (i.e. mashed potatoes, peas, carrots, porridge,
pulverized protein). Sample meal plan will be provided as needed.

Elimination: The clients grandparents should continue monitoring the elimination pattern
and should report to the nearest healthcare provider if there are any changes in the
frequency, consistency and character of urine and stools.

Activity: Guardian will be informed that it would be normal for JM to tire easily at least a
week following pneumonia. It would be emphasized that this is an expected outcome and
not a complication. Every effort should be done to provide rest and adequate feedings to
the child. Passive ROM exercises (to maintain muscle tone) could be done to the client by
the guardian.

Play and stimulation: Activities (such as going out of the house) or strenuous play should
be minimized if not avoided. Bath toys will be enjoyed by the infant (but for the week
following illness, bathing/playing time should be minimized) Tactile and audiovisual
stimulation would still be very much encouraged (massaging, touching and talking to the
child).

Rest: Home environment should be made conducive for rest. The client must have periods
of adequate rest whenever she appears sleepy or listless. The clients grandparents should
be encouraged to provide an environment conducive for rest (soothing sounds, minimal
noise, no offensive smells, appropriate and minimal lighting, and good ventilation)

Hygiene: Warm water should be used for bathing (thermoregulation kept in mind).
Swallowing of water while bathing should be prevented (proper head positioning). Advise
guardian to start performing oral hygiene. She can use cloth for cleaning the tongue and
the teeth (for when it erupts).
BIBLIOGRAPHY

References

Maternal and Child Health Nursing 6th Edition Volume 1. Pillitteri, A. 2010.

Maternal and Child Health Nursing 6th Edition Volume 2. Pillitteri, A. 2010.

Ricci, S.S. (2007). Essentials of Maternity, Newborn, and Womens Health Nursing.
Lippincott.
p332-422

PPDs Nursing Drug Guide 2nd Edition (2008) Malan Press