Andres Bonifacio College

School of Nursing
College park, Dipolog City

Pediatric Ward Requirements

Submitted by: Mr. Roeder Cuerda BSN-IV

Submitted to: Ms. Jowillene Pearl O. Jatico RN,MN
Institutional Mission.

We commit to provide affordable quality education with values in industry, intelligence, integrity and undertake relevant research
and socially-responsive community service using innovative technologies.

Institutional Vision.

A center of excellence in instruction, research, technology, extension, athletics, and the arts

Mission of the school of Nursing.

The school of nursing shall generate competent, safe and compassionate professional nurse committed to:

a. Practice high standard of nursing care utilizing research and evidenced based practices that are culturally appropriate and
sensitive.

b. Active involvement on local, national and global issues affecting nursing people’s health and the environment.

c. Ongoing holistic growth of self and others.

Table of content
--------------------------------------------------------------------------Cover Page--------------------------------------------------------------------------------

-------------------------------------------------Mission and vision of Andres Bonifacio college-----------------------------------------------------------

----------------------------------------------------------------------Patient’s Profile-------------------------------------------------------------------------------
----------------------------------------------------------------Growth and development------------------------------------------------------------------------
------------------------------------------------------------------Physical Assessment---------------------------------------------------------------------------

----------------------------------------------------------Gordon’s 11 functional health pattern--------------------------------------------------------------

-----------------------------------------------------------------anatomy and physiology------------------------------------------------------------------------

------------------------------------------------------------------------------NCP1-----------------------------------------------------------------------------------
------------------------------------------------------------------------------NCP2-----------------------------------------------------------------------------------
------------------------------------------------------------------------------NCP3-----------------------------------------------------------------------------------

-------------------------------------------------------------------------references---------------------------------------------------------------------------------
Patient’s Profile
Name:X
Date of Birth: April 14 2017
Age: 1 year and 4 months
Gender: Male
Church: Roman Catholic
Address:Dipolog city
Weight: 9kgs
Height: 35 inches
BMI= 11.8 (Underweight)
Civil Status: Child
Attending Physician: Dr.Santos
Admitting Diagnosis: Pediatric Acquired Pneumonia C
ward: Pediatric Charity Ward
Room no. PCW EXT 10
Chief Complaint: cough with difficulty of breathing accompanied with fever.
History of Past Hospitalization:2017 PCAPC
2018 anemia
Allergies: None
Postnatal: breastfed
Immunizations: BCG,DPT,OPV,HEPB,Measles,MMR
History of past Illness: Mother of client reported that the client was admitted in the same hospital before with the same complaint of cough
and fever this year mother reported that the client was diagnosed with anemia.
History of present illness: 2 days PTA onset of cough, non productive in characteristic with fever and tachypnea.
Family History: + Hypertension ,+ asthma , - diabetes, - cancer,
Physical Assessment
Assessor: Roeder Cuerda
Patient: X
Vital Signs: August 30 2018

8 AM 12 PM

Blood Pressure n/A n/A

Temperature 36.4oC 36.9oC

Pulse Rate 120 123 BPM

Respiratory 44 50CPM
Rate

General Appearance:
 Received Client lying on bed with ongoing IVF D5 0.3 Nacl 250 Ml left infusing well on the left cephalic vein to be infused at 30gtts/min and oxygen
cannula attached to Oxygen tank unning at 4l/min. with mother on the bed side
 Not well groomed
 Diaphoretic
 Patient is very irritable
 Always carried by her mother and cries when her mother leaves.
 Never seen the client smile
 Fast breathing very obvious
 Difficulty breathing
 Assessment Findings

Integumentary

When skin is pinched it goes to previous state immediately (2 seconds).

With fair complexion slightly pale.
Rashes on his neck, abdomen and back
 Skin With dry skin.
Scar on his elbows knees and some parts of the legs
IV infusion site on left cephalic vein.
diaphoretic
Evenly distributed hair.
 Hair With short thin hair.

Smooth and has intact epidermis

 Nails With short and dirty fingernails and toenails.
Convex and with good capillary refill time of 2 seconds.
Pale nail beds
Rounded, normocephalic and symmetrical, smooth and has uniform consistency.Absence of
Skull
nodules or masses.
Face Symmetrical facial movement, palpebral fissures equal in size, symmetric nasolabial folds.
Eyes and Vision

 Eyebrows Hair evenly distributed with skin intact.

Eyebrows are symmetrically aligned and have equal movement.

 Eyelashes Equally distributed and curled slightly outward.

 Assessment Findings

 Eyelids Skin intact with no discharges and no discoloration.

Lids close symmetrically and blinks involuntary.

 Bulbar conjunctiva Transparent with capillaries slightly visible

 Palpebral Conjunctiva Shiny, smooth, pink

 Sclera Appears white.

 Lacrimal gland, Lacrimal sac,

No edema or tenderness over the lacrimal gland and no tearing.
Nasolacrimal duct

Cornea
Transparent, smooth and shiny upon inspection by the use of a penlight which is held in an
 Clarity and texture oblique angle of the eye and moving the light slowly across the eye.
Has black eyes.

 Corneal sensitivity Blinks when the cornea is touched through a cotton wisp from the back of the client.

Black, equal in size with consensual and direct reaction, pupils equally rounded and reactive
to light and accommodation, pupils constrict when looking at near objects, dilates at far
Pupils
objects, converge when object is moved toward the nose at four inches distance and by
using penlight.
 Assessment Findings

 External Nose Symmetric and straight, with flaring, uniform in color, air moves freely as the clients
breathes through the nares.

 Nasal Cavity Mucosa is pink, no lesions and nasal septum intact and in middle with no tenderness.

Mouth and Oropharynx Symmetrical, pale lips.

 Teeth 4 sets of upper teeth and 3 sets of lower teeth

 Tongue and floor of the mouth Central position, pink but with whitish coating which is normal, with veins prominent in the
floor of the mouth.

Uvula Positioned midline of soft palate.

Positioned at the midline without tenderness and flexes easily. No masses palpated.
Neck
Tensioned when breathing
Coordinated, smooth movement with no discomfort, head laterally flexes, head laterally
Head movement
rotates and hyperextends.

Lymph Nodes Palpable.

Thorax and lungs Visible bony prominences and witht effort in breathing and dyspnea.
Posterior thorax Chest symmetrical

 Spinal alignment Spine vertically aligned, spinal column is straight, left and right shoulders and hips are at the
same height.

Breath Sounds Fast respiration, rhonchi noted

 Assessment Findings

 Anterior Thorax Fast respiration, rhonchi noted

Abdomen With rashes on his abdomen, not distended.

Abdominal movements Symmetrical movements cause by respirations, fast movement in every respiration.

 Auscultation of bowel sounds With audible sounds of 16 bowel sounds/minute.

Upper Extremities Scar on elbow

Lower Extremities With minimal scars on lower extremities wounds on the knees and some parts of the legs.
Muscles Equal in size both sides of the body.
Bones and Joints No deformities or swelling, joints move smoothly.
Mental Status Client is alert and is irritable
Level of Consciousness A total of 15 points indicative of complete orientation and alertness.
 Gordon’s Functional Health Pattern
Usual Initial Ongoing
HEALTH PERCEPTION/ HEALTH MANAGEMENT
Vital Signs 8:00 am

Does take meds such as paracetamol when febrile Blood Pressure n/A
relies sometimes with albularyo and is taking tikitiki. Temperature 36.4oC
Pulse Rate 120 BPM
 No drug allergies Respiratory Rate 44CPM
 No food restrictions vital signs 12 pm.
 Tiki-tiki food supplement
 Does consult physician or any health Blood pressure
professionals only when sick. temperature 36.9oC
Pulse rate 123BPM
Respiratory rate, 50CPM

Medications:
Ongoing D5 with .03 Nacl 250ml left infusing
well at 30 gtts/min at Left cephalic vein.
Ampicillin sulbactam 400 mg/kg/day IV 6h
paracetamol 65mg q 4 hours or prn when
febrile IVTT
Salbutamol 5mg/2.5ml Nebuliser Solution q 4
hpours
 oxygen cannula attached to Oxygen tank
unning at 4l/min
 No drug allergies.
NPO
 Has cough
 No fever
 Diaphoretic
 Using of accessory muscle when
breathing

Nutritional Metabolic Doctor Ordered NPO for the client then DAT if RR is
breast fed until this day. <30 BPM

 Starting consuming soft food at the age of 6 BMI= 11.8 (UNDERWIGHT)

months such as porridge, cerelac half
serving. Source of nutrition/hydration: IV Solution D5 with .3
 Consumes half cup of water 118ml. Nacl infused at 30gtts/min
 No difficulty in swallowing.
 Has good appetite.
 No history of stomach anomalies.

Elimination Pattern
 Defecates in a diaper or lampin. client did not defecate
 No history of diarrhea.
 Defecated twice a day reguraly urinated in a diaper.
 No history of UTI and urinary problems.
Diarrhea absent

Bowel motility 16 ticks/minute.

Activity Exercise Pattern ADL SCALING
CRITERIA:
highly dependent to mother.
Bathing with sponge, bath, or shower=0
Usually plays and smiles when cuddled. Dressing=0
Toilet Use=0
able to stand and walk. Transferring= 0
Urine and Bowel Continence=1
bathes daily. Eating=0

Have not showered and bathed for 4 days

now always carried by her mother at all times
Sleep rest Pattern

No difficulty sleeping. mother reported that client has no difficulty sleeping

at night and also takes short naps in the morning.
usually sleeps at 7pm and wakes up at 4 am in the
morning Sleeping hours depends from day to day.
mostly she sleeps at 1 pm and wakes uo at 4 pm in
Takes short morning naps sleeps at 9 am in the the afternoon and sleeps at 7 pm at night and wakes
morning and wakes up at 12. up 3am in the morning.
Cognitive Perceptual

Mother stated that my client does respond to stimuli Unable to speak nor report signs of pain except for
like cries when there’s a strong noise, facial changes crying.
when given sampalok
client always cry.
always jolly and in a good mood.
no cognitive changes lately.

client still wake up when disturbed.

has high level of consciousness.
Self Perception/self concept

mother reported that client responds well against mother have reported that there is a slight change in
disturbing stimuli when mother is on her side. her son’s attitude and behavior he is now more
irritable and cries most of the times compared when
he was at home and is not sick.

Role Relationship

Only son

Sexually reproductive

Coping/stress tolerance

Usually cries when in pain, doesn’t eat when sick and cries when in pain
mother as her most trusted companion.
DX: Ineffective airway clearance related to copious tracheobronchial secretions.

Assessment Planning Intervention Rationale Evaluation

Objective Cues: At the end of my 8 hour duty INDEPENDENT
there will be no Establish rapport to client to ensure clients full cooperation.
Very irritable, restless and cries complications of ineffective
everytime airway clearance and Provide an environment
Improved airway patency as Rest periods can decrease
conducive for rest periods. metabolic activity preventing
Tachypnea evidenced by:
exhaustion.(Nursing Care Plans, Edition
9 - Murr, Alice, Doenges, Marilynn,
Non-productive cough normal heart rate and Moorehouse, Mary)
respiratory rate appropriate
Rhonchi noted for age Overexertion increases body
PR-100-140 BPM Encourage avoidance of
oxygen demands.(Nursing Care Plans,
Pale nail beds and buccal RR- 20-30CPM overexertion and possible Edition 9 - Murr, Alice, Doenges, Marilynn,
mucosa exacerbation of symptoms. Moorehouse, Mary)

Use of accessory muscles when irritability will minimize (less

breathing(neck)
Respiratory rate of : 50 CPM
Pulse rate : 123
Subjective Cues:
SO verbalized:
“Amo naming gipa admiot kay gi
hubak naman pud siya mag lisud
man kaau siyag ginhawa gi
oxygenan gani ni karon.”
crying episode)
Uniform skin color and
temperature.
Ability to rest and take a
nap.
decreased respiratory effort.
Facilitate in Semi-Fowler’s
position.
Instruct patient and family
about the cause of pneumonia,
management of symptoms,
signs, and symptoms, and the
need for follow-up.
should assume a comfortable
position to promote rest and
breathing and should change
positions frequently to enhance
secretion clearance and
pulmonary ventilation and
perfusion(Nursing Care Plans, Edition 9 -
Murr, Alice, Doenges, Marilynn,
Moorehouse, Mary)
To promote information about
the factors that may have
contributed to the development
of the disease.
(Nursing Care Plans, Edition 9 - Murr, Alice,
Doenges, Marilynn, Moorehouse, Mary)
 Dependent nursing
interventions:
Administer antibiotics as
prescribed :
Ampicillin sulbactam 400
mg/kg/day IV 6h
Bronchodilators as prescribed:
Salbutamol 5mg/2.5ml Nebuliser
Solution
DX. Impaired Gas exchange r/t alveolar capillary membrane changes
Inhibits bacterial spread and
growth for faster recovery.
(Nursing Care Plans, Edition 9 - Murr, Alice,
Doenges, Marilynn, Moorehouse, Mary)
Bronchodilators dilated airway
clearance to facilitate ease in
breathing and oxygenation
(Nursing Care
Plans, Edition 9 - Murr, Alice, Doenges,
Marilynn, Moorehouse, Mary)
Assessment
Objective Cues
Pale buccal mucosa and nail
beds and pale skin
Dyspnea and use of accessory
muscles when breathing.
Respiratory rate of : 50 CPM
Pulse rate : 123BPM
Temperature: 36.9oC
Rhonchi noted upon auscultation.
Alert and is able to respond to his
mother.
Planning
At the end of my 8 hour duty
there will be no signs of
complications of impaired gas
exchange and demonstrate
improved ventilation. As
evidenced by:
Decreased respiratory effort and
rate to atleast 45 BPM and
below.
absence of confusions and
alteration in mental status
Absence of drastic change in the
level of consciousness
Absence of symptoms of
respiratory distress ( a dry,
hacking cough.a fever.
Headaches)
Intervention
INDEPENDENT
Establish rapport
Assess respiratory rate, depth,
and ease.
Observe color of skin, mucous
membranes, and nailbeds,
noting presence of peripheral
cyanosis (nailbeds) or central
cyanosis (circumoral).
Assess mental status.
Monitor body temperature, as
indicated. Assist with comfort
measures to reduce fever and
Rationale Evaluation.
”
To ensure full cooperation of
interventions.(Nursing Care Plans,
Edition 9 - Murr, Alice, Doenges, Marilynn,
Moorehouse, Mary
Manifestations of respiratory
distress are dependent on, and
indicative of, the degree of lung
involvement and underlying
general health status.
(Nursing Care Plans, Edition 9 - Murr, Alice,
Doenges, Marilynn, Moorehouse, Mary)
Cyanosis of nailbeds may
represent vasoconstriction or the
body’s response to fever or
chills; however, cyanosis of
earlobes,
mucous membranes, and skin
around the mouth
(“warm membranes”) is
indicative of systemic hypoxemia
(Nursing Care Plans, Edition 9 - Murr, Alice,
Doenges, Marilynn, Moorehouse, Mary)
Restlessness, irritation,
confusion, and somnolence may
reflect
hypoxemia or decreased
cerebral oxygenation.(Nursing Care
Plans, Edition 9 - Murr, Alice, Doenges,
Marilynn, Moorehouse, Mary)
High fever, common in bacterial
pneumonia and influenza,
chills, such as addition or
removal of bedcovers,
comfortable room temperature,
and
tepid or cool water sponge bath
Maintain bedrest. Encourage use
of relaxation techniques and
diversional activities
Dependent nursing
intervention(s)
oxygen therapy
Administer O2 mask or nasal
canna 4ml/Min.
greatly increases metabolic
demands and oxygen
consumption
and alters cellular
oxygenation.(Nursing Care Plans, Edition
9 - Murr, Alice, Doenges, Marilynn,
Moorehouse, Mary)
Prevents exhaustion and
reduces oxygen consumption
and
demands to facilitate resolution
of infection.(Nursing Care Plans, Edition 9
- Murr, Alice, Doenges, Marilynn,
Moorehouse, Mary)
The purpose of oxygen therapy
is to maintain PaO2 above
60 mm Hg, or greater than 90%
O2 saturation. Oxygen is
administered by the method that
provides appropriate
delivery within the client’s
tolerance..(Nursing Care Plans, Edition 9 -
Murr, Alice, Doenges, Marilynn,
Moorehouse, Mary)
DX: Risk for fluid volume Deficit r/t excessive losses through normal route(profuse diaphoresis) .

Assessment Planning Intervention Rationale Evaluation

Objective Cues:
Diaphoretic
NPO or decreased oral intake
of fluids such as water
IV solution only source of
nutrition and hydration.
mouth breathing
At the end of my 8 hour duty there will be
adequate fluid volume as evidenced by:
such as moist mucous membranes,
good skin turgor (skin goes back <3
seconds)
prompt capillary refill (<2 seconds)
and stable vital signs.
PR-100-140 BPM
Independent
Assess vital sign changes, such as
increased temperature,
prolonged fever, tachycardia.
.
Elevated temperature or
prolonged fever increases
metabolic
rate and fluid loss through
evaporation. Orthostatic BP
changes and increasing
tachycardia may indicate systemic
fluid deficit.
(Nursing Care Plans, Edition 9 - Murr, Alice,
Doenges, Marilynn, Moorehouse, Mary)

RR- 20-30CPM
Use of supplemental Oxygen Temperature- 36.5-37.5oC
(oxygen therapy)
Indirect indicators of adequacy of
Tachypnea RR:50 BPM fluid volume, although oral
Assess skin turgor, moisture of mucous mucous membranes may be dry
because of mouth breathing
Dry Skin membranes—lips and tongue.
and supplemental oxygen
(Nursing Care Plans, Edition 9 - Murr, Alice,
Temperature: 36.9oC Doenges, Marilynn, Moorehouse, Mary)
PR:123CPM

Presence of these symptoms

reduces oral intake
Note reports of nausea and vomiting. (Nursing Care Plans, Edition 9 - Murr, Alice,
Doenges, Marilynn, Moorehouse, Mary)

Provides information about

Monitor intake and output (I&O), noting adequacy of fluid volume and
color and character of replacement
urine. needs.(Nursing Care Plans, Edition 9 - Murr,
Alice, Doenges, Marilynn, Moorehouse, Mary)
 Basic fluid needs are determined
by child’s weight—up to
Calculate fluid balance. Be aware of 10 kg: 100 mL/kg/24 hr; 10 to 20
insensible losses. kg: 50 mL/kg/24 hr; more
Weigh as indicated. than 20 kg: 20 mL/24 hr. Note that
Force fluids to at least 3000 mL per day the smaller the child, the
or as individually greater the percentage of weight
appropriate. is water (Ferki, 2011).
(Nursing Care Plans, Edition 9 - Murr, Alice,
Doenges, Marilynn, Moorehouse, Mary)

Collaborative

Provide supplemental IV fluids as In the presence of reduced intake

necessary. or excessive loss, use of
1L D5 w/ .5 Nacl at 30gtts/min. parenteral route may correct or
prevent deficiency.
(Nursing Care Plans, Edition 9 - Murr, Alice,
Doenges, Marilynn, Moorehouse, Mary)

Administer medications, as indicated,

such as antipyretics. Useful in reducing fluid loss(Nursing
Care Plans, Edition 9 - Murr, Alice, Doenges,
paracetamol 65mg q 4 hours or prn when
Marilynn, Moorehouse, Mary)es.
febrile IVTT
Anatomy and Physiology.
The main function of the lungs is the process of gas exchange called respiration (or breathing). In respiration, oxygen from incoming air enters the
blood, and carbon dioxide, a waste gas from the metabolism, leaves the blood. A reduced lung function means that the ability of lungs to
exchange gases is reduced.
Inside the lungs, oxygen is exchanged for carbon dioxide waste through the process called external respiration. This respiratory process takes place
through hundreds of millions of microscopic sacs called alveoli. Oxygen from inhaled air diffuses from the alveoli into pulmonary capillaries
surrounding them. It binds to hemoglobin molecules in red blood cells, and is pumped through the bloodstream. Meanwhile, carbon dioxide from
deoxygenated blood diffuses from the capillaries into the alveoli, and is expelled through exhalation.

PCAP C Moderate Risk

Community-acquired pneumonia (CAP) refers to pneumonia (any of several lung diseases) contracted by a person with little contact with the
healthcare system. The chief difference between hospital-acquired pneumonia (HAP) and CAP is that patients with HAP live in long-term care
facilities or have recently visited a hospital. CAP is common, affecting people of all ages, and its symptoms occur as a result of oxygen-absorbing
areas of the lung (alveoli) filling with fluid. This inhibits lung function, causing dyspnea, fever, chest pains and cough.

CAP, the most common type of pneumonia, is a leading cause of illness and death worldwide. Its causes include bacteria, viruses, fungi and
parasites.CAP is diagnosed by assessing symptoms, making a physical examination and on x-ray. Other tests, such as sputum examination,
supplement chest x-rays. Patients with CAP sometimes require hospitalization, and it is treated primarily with antibiotics, antipyretics and cough
medicine. Some forms of CAP can be prevented by vaccination and by abstaining from tobacco products.
Growth and development

Stage One – Trust vs Mistrust

The first stage of the Erikson stages starts from infant to about 18 months.
At this stage, infants must learn how to trust others, particularly those who care for their basic needs. They should feel that they are
being cared for and that all their needs are met.

Client behaviour:
As to my observation this child has been the most challenging client I have encountered yet in the pediatric ward, the child has
already stayed there for 2 days and it was the child’s second day that I have worked with him and trust me the child really had trust
issues. The child doesn’t let her mother leave him because in that environment her mother is the only person he thinks he can trust.
He just cries everytime and not to mention the child was very irritable maybe because of the environmental setting there The child
does simply refuse in everytrhing that I do. I was having problem assessing his eyes with a penlight because he just closes his eyes
and refuses to open it the same with assessing his oral mucosa was hard from getting near the child to taking his vital signs such as
the temperature, Pulse rate and Respiratory rate was hard because he just cries everytime im near him. And I cannot take those
data because those are unreliable. I have realized that one way of achieving a child’s trust is to help the child meet the childs need
at that time I cannot help him with his nutritional needs because he was at NPO order from his physician that time, others things like
grooming, sponge bath to refreshen up and make the room conducive for rest, make it well ventilated these things I guess made my
client feel better that’s why in the late afternoon he was less irritable and I was able to take his vital signs easily.
SOURCES:
Nursing Diagnoses, Definitions and Classification 2012-14 - Nanda International
Nursing Diagnoses 2015-17 - NANDA International
http://nanda-nursinginterventions.blogspot.com
www.pedscases.com
Kozier and erbs Fundamentals of Nursing 10th edition
https://www.psychologynoteshq.com/erikson-eight-stages/
(Nursing Care Plans, Edition 9 - Murr, Alice, Doenges, Marilynn, Moorehouse, Mary)