Far Eastern University

Institute of Nursing

Case Presentation
Submitted by:
Maningding, Marvic
Mislang, Angel Marie
BSN 122/ group 87

Submitted to:
Mr. Oliver Sanidad
 I. Biographic Data
 Name: S.A.G
 Address: Marilao, Bulacan
 Age: 6 years old
 Gender: Male
 Religious Affiliation: Catholic
 Marital Status: single
 Room & Bed no.: 214
 Chief complaint: Fever
 Provisional diagnosis: to consider acute
tonsilopharyngitis pneumonia
 Attending physician: Dra. Alveza
II. Nursing History
A. past health history
 Childhood illness:

The patient had a tonsillitis and asthma.

 Immunization:

The mother of the patient cannot remember

some of the immunization. The mother said,” ang
naalala ko lang ay yung BCG nung 2 weeks siya
tapos every month na yung pag immunization sa
kanya. Meron ding Hepa B, polio vaccine pero wala
siyang MMR.
 Allergies: (-) allergy to food/ drug
 Accidents: none
 Hospitalization:

The child was brought to the hospital in

January 11, 2010 and this was his first time he was
confined to a hospital.
 medications used or currently taken:
 paracetamol

 salbutamol for nebulization

 opigesic

 salbutamol tablet

 combivent for nebulization

 penicillin G Na

 Gentamicin

 foreign travel: none

B. History of present illness

Five days prior to confinement, the patient began
experienced cough and fever.
Few hours prior to confinement, the patient experienced
convulsion while having high grade fever followed by two
episodes of vomiting hence consults.
 C. Family History
GENOGRAM

R.A
V.G. I.A
R.G (DM)

Son, 35
Son, 37
(asthma)
Daught
Son, 35 er, 29

Son, 33 Daught
er 33
Son, 31
Daught
Son, 29 er, 27

Daught
Daught er, 24
er, 25
Patient – 6
Daught y/o
er, (Asthma)
Legends
(asthm
a
Male Female
 D. developmental history
 2 months old- the incisor teeth are the first teeth
appeared
 - the mother said that his child know them
 - the first word to say was “tata”
 6 months – the child started to eat celerac as his food
 7 months – the patient started to crawl
 - celerac is still the food that he eats
 11 months – started to walk with guide
 1 years old – started to eat solid foods
 - say the word “mama” and can identify his
mom
 - started to walk fast and run
 2 years old – started to know his father
 3 years old – the child can identify pictures
 4 years old – started to go to school
 5 years old – started to read word by word
 6 years old – still reading word by word
 - the mother said that she is still the one
who feeds her child though the child knows
 how to eat
 Patterns of functioning
 A. Psychosocial
The patient has a good relationship with his parents. When
their family has problems, first they talk about it and decide what
action should be done. The child tells his parents what he wants but
sometimes he can’t get what he wants so he is “nagdadabog”. He
was able to express his feelings to others whether he is happy,
angry, or sad. As a family, they watch TV; go to mall, church
together. They have time to bond with each other. The child says
that he is a cheerful person. According to the mother of our client
“lageng nasa labas yan nakikipaglaro kay echo”. The client
verbalized that” si echo kalaro ko sa labas bestfriends kame forever
e tpos si shekaila un boss namin”. His closest friends are echo and
shekaila. He always plays with them, and he doesn’t have any
problems in school. The child doesn’t feel isolated in their place
because he has many playmates. When asked about the activity
when inside the house the client verbalized “ naglalaro lang ng
gameboy tska kumakaen”.
 Analysis:
Six year old children play in groups, but when they are
tired or under added stress, they prefer one-to-one contact.
In a first grade classroom, students compete actively for a
few minutes of special time with the teacher. At the end of
the day, they enjoy time spent individually with parents. You
may have to remind the parents this is not babyish behavior
but of a typical 6 year old.

(Maternal and Child Health Nursing 5th Edition Vol. 2 page 919)

 Interpretation:
The child’s behavior in his age is appropriate.
 B. Elimination:
The mother of the patient said that the child doesn’t have
any problems with regard to his urinary and bowel
elimination. The mother said, “Umiihi siya ng 5- 6 beses sa
isang araw tska wala naman siyang nararamdaman na sakit.”
When asked about the odor of his urine. The child said,
“mapanghe po yung amoy..” his mother is the one who
cleans him after he defecates. She said that his son
defecates once a day and his stool is formed. “Pero simula
nung inadmit siya dito sa hospital, hindi pa siya
nakakadumi.” The mother said. The child doesn’t experience
excess perspiration and odor problems.

 Analysis:
The school age child’s elimination system reaches
maturity during this period. The kidneys double in size
between age 5 and 10 years. During this period, the child
urinates 6-8 times a day. About 10% of all 6-year-old
experience difficulty in controlling the bladder. Bed-wetting
should not be considered a problem until after the age of 6.
(Fundamentals of nursing 8th edition Vol. 2 page 1288)
 School age children and adolescent have bowel habits similar
to those of adults. Patterns of defecation vary in frequency,
quantity, and consistency. Some school age children may
delay defecation because of an activity such as play.

(Fundamentals of nursing 8th edition Vol. 2 page 1326)

Interpretation:
The child doesn’t have problems with regards to his elimination
except on the time when he is admitted to the hospital
C. Rest and sleep
The child sleeps at 11:00 in the evening together with his
parents, “lage yang sumasabay sa amin sa oras ng pagtulog.
Hapon pa naman pasok niya kaya ayos lang.” the mother
said. But before the child sleeps, he eats his midnight snacks
which are milk and bread. The mother said, “pag natulog
nayan, hindi nay an gumigising sa madaling araw.
dirediretso na.” The child wakes up at 9:00 in the morning
and doesn’t take an afternoon nap because he is in school.
But when the child is admitted in the hospital, the child
needs to sleep earlier, “para makapagpahinga siya at
gumaling agad.” Verbalized by the mother.

Analysis:
Sleep needs vary among individual children. Younger school
age children require 10-12 hours of sleep each night., and
older school age children require about 8-10 hours. Most 6
year olds are too old for naps but do require a quiet time
after school to get them through the remainder of the day.
During school years, many children enjoy a quiet talk or a
reading time at bedtime.

(Maternal and child health nursing 5th edition Vol. 2 page 923)
 Interpretation:
The child has a good sleeping pattern and doesn’t have a problem with
regards to sleep.

D. Sexuality
The patient doesn’t have any problems in expressing his
sexuality. As a boy, he said that he plays his toys like cars and “baril-
barilan” just like what other boys do. His mother said that he is not
yet circumcised. The child doesn’t talk too much regarding his
genital organ, as his mother said,”puro laro naman yan eh”

Analysis:
Age 6-12, sexual development includes:
 has strong identification with parent of same gender
 tends to have friends of the same gender
 has increasing awareness of self
 increased modesty, desire for privacy
 continues self stimulating behavior
 learns the role and self concepts of own gender as part of the
total self concept

(Fundamentals of nursing 8th edition Vol. 2 page 1020)

 Interpretation:
The child can express his sexuality in a way that he want. He is
not shy in expressing it.

E. Oxygenation:
The child has asthma and there are times that he can’t
breathe normally. The mother said that when this happens,
she consults their doctor and nebulize the child. “nung new
year nagpaputok yan sa labas kasama yun daddy niya eh ang
usok-usok sa labas buti hindi siya hinika.” the mother said.

Analysis:
Asthma is another chronic disease often identified in
childhood. The airways of the asthmatic child react to stimuli
such as allergens, exercise, or cold air by constricting,
becoming edematous, and producing excessive mucus.
Airflow is impaired, the child may wheeze as air moves
through narrowed airpassages.

(Fundamentals of nursing 8th edition Vol. 2 page 1362)

Interpretation:
due to his asthma, the child sometimes encounter problems
but his parents take good care of him.

F. Nutrition
The child said that he like fried foods. The mother said,
“nakaka 5 baso ng tubig yan sa isang araw”. The child
doesn’t have an idea when it regards to proper nutrition. His
favorite foods are hotdog, bread, foods in jollibee. Our Client
verbalized that” paborito kong pagkaen ung sa jollibee
hotdog pati chicken”. According to the mother of the client”
Kumakaen yan tatlong beses sa isang araw ang takaw nga
nyan e”.our client verbalized that” paborito ko din kumaen ng
candy kasi masarap”. He doesn’t like to eat vegetables, as
he said, “mapait eh...” he eats in the dining room together
with his parents. Before hospitalization the mother stated
that” malakas kumaen ng ulam yan di siya gano mahilig sa
kanin” When the child is admitted to the hospital, he is in a
soft diet. When the child has wound, his mother said that it
heals fast. The child doesn’t have any skin problems but he
has dental problems. The tooth of the client is yellowish and
has 26 teeth. The mother verbalized that “hindi siya
nagpapachek-up sa dentista”.
3 Day Diet Recall
01/09/2010
 Breakfast: bread, 2 bottle of mineral water, half bottle of
Gatorade
 Lunch: spaghetti, 2 bottle of mineral water

 Dinner: milk, water but his mother said, “patikim-tikim nalng

siya nun.”
01/10/2010
 Does not eat until 5:30 pm

 Dinner: cup noodles but doesn’t able to finish

01/11/2010
 2 bottles of mineral water

 On a soft diet
 Analysis:
School age children need breakfast to provide enough energy to
get them through active morning at school. Many children qualify
for a free or reduced price school lunch and breakfast. A
government –regulated school lunch (type A) provides milk (8 oz),
protein (2 oz), one starch serving, and vegetable (¾ cup). Servings
vary according to age to provide one third of a child’s nutrition
requirements for a day. Whether they take lunch or buy it in
school, school age children should know some elementary facts of
nutrition so they do not trade a sandwich for a cake or choose only
deserts in the cafeteria. Health care personnel should play an
active role in nutrition education at health maintenance visits. Most
children are hungry after school and enjoy a snack when they
arrive at home. Because sugary foods may dull a child’s appetite
for dinner, urge parents to make the snack nutritious: fruit, cheese
or milk rather than cookies and soft drinks.

(Maternal and child health nursing 5th edition Vol. 2 page 921-922)

Interpretation:
The child’s nutrition is not good because he is not eating nutritious
foods and loves to eat candies that’s why he has dental carries.
 Activity of daily living
ADL Before After Interpretation
hospitalization hospitalization & analysis
1. Nutrition mother stated that” the client will now Analysis:
malakas kumaen ng ulam Most school age children
yan di xa gano mahilig sa
eat nutritious foods
have good appetite,
kanin” He doesn’t like to and avoid eating although any meal is
eat vegetables, as he too much candies influenced by the day’s
said, “mapait eh...” he activity. Help children who
eats in the dining room
as much as
are hospitalized to select
outside their house with possible. a diet that is enjoyable as
his parents. Our Client well as nutritious.
verbalized that” paborito (Maternal and child health
kong pagkaen ung sa nursing by Pilliteri 5th
jollibee hotdog pati edition vol. 2 page 921 &
chicken”. According to the 938 )
mother of the client”
Kumakaen yan tatlong Interpretation:
beses sa isang araw ang The client don’t like to eat
takaw nga nyan e”.our nutritious foods like
client verbalized that” vegetables, instead he
paborito ko din kumaen loves candies that's why
he has dental carries
ng candy kasi masarap”.
ADL Before After Interpretation &
hospitalization. hospitalization analysis
2. Elimination The mother said, The client will still Analysis:
School age children
“Umiihi siya ng 5- not experience and adolescent have bowel
6 beses sa isang problems in his habits similar to those of
elimination adults. Patterns of
araw tska wala defecation vary in
naman siyang frequency, quantity, and
nararamdaman consistency.
Circumstances of diet, fluid
na sakit.” intake and output, activity,
psychologic factors,
His mother is the lifestyle, medications,
one who cleans medical procedure and
disease affect defecation.
him after he (fundamentals of nursing
defecates. She by kozier and erbs 8th
edition vol. 2 page 1326)
said that his son Interpretation:
defecates once a The client has a good
day and his stool elimination pattern

is formed.
ADL Before After Interpretation &
hosp[italization hospita;ization analysis

3. Exercise Before When he is Analysis:

School age children need
hospitalization when discahrge, the daily exercise. Although they
asked about his client will start to go to school all day, they do
not automatically receive
exercise the client do some exercise much exercise because
school is basically a sit-down
verbalized that”hindi to be strong. activity. Exercise need not
aq nag eexcercise e” involve organized sports. It
can come from neighborhood
he also stated that” games, walking with
pag wala q ginagawa parents, or bicycle riding.
Urge them to participate in
sa bahay naglalaro some daily exercise, or else
lang ako ng obesity, or osteoporosis
later in life can result.
gameboy”. He also (Maternal and child health
stated that” nursing by Pilliteri 5th
edition vol. 2 page 923)
tinatawag ako ni Interpretation:
echo tyaka shikaila The child’s form of exercise
is by playing outside his
para maglaro sa house with his playmates
labas”. The mother and walking with his parents
when they go to mall and
of the client stated church.
that “walang
exercise yang
batang yan puro
kaen nga lang alam
e”.
ADL Before After Interpretation &
hospitalization hospitalization analysis
4. Hygiene When asked The child will now Analysis:
brush his teeth Children of 6 or 7 age still
about the regularly and
need in regulating the
bath water temperature
clients hygienic retain his good and in cleaning their ears
practices he hygiene. and fingernails. Boys who
are uncircumcised may
stated that develop inflammation
under the foreskin from
“isang beses increased secretions if
lang ako they do not wash
regularly.
maligo sa isang (Maternal and child
araw” he also health nursing by Pilliteri
5th edition vol. 2 page
stated that” 923)
nagtotoothbrus Interpretation:
When the child is in the
h lang ako hospital, his hygiene is
not that good because
bago po he’s not able to take a
matulog tsaka bath, only sponge bath
and doesn’t brush his
pag gising”. teeth.
ADL Before After Interpretation &
hospitalization hospitalization analysis
The client will sleep Analysis:
5. Rest / The child sleeps at
11:00 in the evening comfortably in his Sleep needs vary among
individual children.
Sleep together with his
parents, “lage yang
house and can sleep Younger school age
together with his children require 10-12
sumasabay sa hours of
parents
amin sa oras ng sleep each night., and
pagtulog. Hapon pa older school age children
naman pasok niya require about 8-10 hours.
kaya ayos lang.” the Most 6 year olds are too
old for naps but do require
mother said. But a quiet time after school to
before the child sleeps, get them through the
he eats his midnight remainder of the day.
snacks which are milk During school years, many
and bread. The mother children enjoy a quiet talk
said, “pag natulog or a reading time at
bedtime.
nayan, hindi nayan
(Maternal and child health
gumigising sa
nursing 5th edition Vol. 2
madaling araw. page 923)
dirediretso na.” The Interpretation:
child wakes up at 9:00 The child needs rest to
in the morning recover from his condition
so that he can continue
doing the things that he is
doing before.
V. Physical assessment
 Physical Assessment Findings

 Name of Client: S.A.G.

 Height: 107 cm

 Age: 6 y/o

 Weight: 24 kg

 Vital signs:

 BMI: 20.9

 Temperature: 36.1 degrees celsius

 Pulse Rate: 93 bpm

 Respiratory Rate: 21 cpm


Blood Pressure: N/A
assessmen Normal Actual analysis
t findings findings
Proportionate,
Body built,
varies with lifestyle
His weight is Normal
height, and and age
proportion to
weight in (Fundamentals of
his height
relation to nursing by kozier
client’s age, and erbs 8th edition
p.572)

Posture and Relaxed, erect posture, he has a

coordinated movement Normal
gait, standing, (Fundamentals of
relaxed erect
sitting and nursing by kozier and posture,
erbs 8th edition p.572) coordinated
walking
movement

Overall hygiene Clean, neat He has dandruff on mother said that

(Fundamentals of his head and has she just gave him a
and grooming nursing by kozier breath odor spongebath once a
and erbs 8th edition day and he is not
p.572) brushing his teeth
when he is in the
hospital
Body Odor and No body odor; no He has no body When he is in the
breath odor hospital, he doesn’t
breath odor in odor but have brush his teeth that
(Fundamentals of
relation to nursing by kozier
breath odor is why he has breath
activity level. and erbs 8th edition odor.
p.572)

Signs of distress No distress noted When I look at him Normal

in posture or (Fundamentals of there is no sign of
facial expression nursing by kozier
and erbs 8th edition
distress.
p.572)

Signs of health Healthy appearance The client looks Normal

or illness (Fundamentals of healthy
nursing by kozier
and erbs 8th edition
p.572)

Attitude Cooperative He is Normal

(Fundamentals of cooperative.
nursing by kozier
and erbs 8th edition
p.572)
Mood; Appropriate to His mood is Normal
situation
appropriateness appropriate in
(Fundamentals of
of responses nursing by kozier and
the situation.
erbs 8th edition Smiley face
p.572)

Quantity of Understandable, His quality and Normal

moderate pace, exhibits quantity of speech is
speech, quality thought association in moderate pace and
and organization (Fundamentals of understandable.
and functions of nursing by kozier and
erbs 8th edition p.572)
vagus nerve

Relevance and Logical sequence; The relevance and Normal

makes sense; has organizations of his
organization of sense of reality thought is in logical
thoughts (Fundamentals of sequence and in the
nursing by kozier and sense of reality
erbs 8th edition
p.572)
 skin
Skin color The color of his Normal
Varies from light to deep
brown; from ruddy pink to
light pink; from yellow skin is brown
overtones to olive
(Fundamentals of nursing by
kozier and erbs 8th edition
p.579)

Generally uniform except There is no skin

Uniformity in areas exposed to sun; discoloration on his Normal
of color areas of lighter
pigmentation
body
(Fundamentals of
nursing by kozier and
erbs 8th edition p.579)

Edema, if No edema There no Normal

(Fundamentals of presence of
present nursing by kozier and edema
erbs 8th edition
p.579)

Skin lesions No abrasions or Normal

Freckles, some birthmarks,
some flat and raised nevi; no
abrasions or other lesions lesions
(Fundamentals of nursing by
kozier and erbs 8th edition
p.579)
Skin moisture Moisture in skin folds
and the
It is Moist in skin Normal
axillae(Fundamentals
folds
of nursing by kozier
and erbs 8th edition
p.579)

Skin temperature Uniform; within

normal range
His body Normal
temperature is
(Fundamentals of
nursing by kozier and
slightly warm.
erbs 8th edition
p.579)

Skin turgor When pinched, skin When pinched,

springs back to Normal
(fullness or previous state
his skin springs
elasticity) (Fundamentals of
back to its
nursing by kozier and original state
erbs 8th edition p.58-)
 nails
Fingernail plate Convex curvature; angle
of nail plate about 160
His nail has a Normal
shape degrees convex curvature
(Fundamentals of
nursing by kozier and
erbs 8th edition p.583)

Fingernail and Smooth

texture(Fundamentals of
His fingernail is Normal
toenail texture nursing by kozier and smooth and it is
erbs 8th edition p.583) not dirty

Normal
Highly vascular and pink in
Fingernail and light-skinned clients; dark-
His bed color is
toenail bed color skinned clients may have pink in color and
brown or black pigmentation
in longitudinal it is highly
steaks(Fundamentals of
nursing by kozier and erbs
vascular
8th edition p.584)

Tissues Intact
epidermis(Fundamentals
The tissues Normal
surrounding nails of nursing by kozier and surrounding his
erbs 8th edition p.583) nails are intact to
his epidermis.
Blanch test of Prompt return His blanch test Normal
capillary refill of pink or usual return in its
color(Fundame original color in
ntals of nursing 1 second
by kozier and
erbs 8th edition
p.584)
 skull
Skull for size, Rounded
(Normocephalic and
His skull is Normal
shape, and symmetrical, with
rounded (norm
symmetry frontal, parietal and cephalic and
occipital symmetrical with
prominences); smooththe bone
skull contour
prominences)
(Fundamentals of
nursing by kozier and
and has a smooth
erbs 8th edition skull contour.
p.585)

Skull for nodules Smooth, uniform

consistency; absence
There are no Normal
or masses and of nodules or masses
masses and
depressions (Fundamentals of
nodules on his
nursing by kozier and skull
erbs 8th edition
p.585)
 scalp
Color and Clean, smooth, His scalp is white Normal
appearance of white in color in color but with
scalp presence of
dandruff

Areas of No tenderness There is no Normal

tenderness tenderness on his
scalp
 Hair
Evenness of Evenly His hair is evenly Normal
growth, distributed hair, distributed and
thickness thick has a thick hair
hair(Fundamenta
ls of nursing by
kozier and erbs
8th edition
p.582)

Texture and Silky, His hair is Normal

oiliness over the resilient(Fundam resilient
scalp entals of nursing
by kozier and
erbs 8th edition
p.582)
 face
Facial features . Symmetric or slightly asymmetric He has a symmetrical face, even to Normal
features; palpebral fissures equal in his body
size; symmetric nasolabial
folds(Fundamentals of nursing by
kozier and erbs 8th edition p.585)

Symmetry of facial movements and Symmetric facial He has symmetrical facial Normal
functions of facial nerve movements(Fundamentals of movements
nursing by kozier and erbs 8th
edition p.585)
 eyes
Eyebrows for hair Hair evenly distributed; his hair in the eyebrows Normal
distribution and skin intact(Fundamentals are evenly distributed,
alignment and skin of nursing by kozier and skin intact, it is
quality and movement erbs 8th edition p.588) symmetrically aligned

Eyelashes for evenness Equally distributed; His hair in the eyelashes Normal
of distribution and curled slightly is equally distributed and
direction of curl outward(Fundamentals it is slightly outward
of nursing by kozier and
erbs 8th edition p.588)

Eyelids for surface Skin intact; no discharge;His skin is intact in the Normal
characteristics, no discolorationLids eyelids and there are no
position in relation to close discharge, no
the cornea, ability symmetricallyApproxima discoloration, it closes
to blink, and frequency tely 15-20 involuntary symmetrically, no visible
of blinking and blinks per minute, above corneas and the
functions of trigeminal bilateral blinkingWhen upper lower area of the
nerve lids open, no visceral cornea is slightly
sclera above corneas, covered. Approximately
and upper and lower 10-15 blinks/min.
borders of cornea are
slightly
covered(Fundamentals
of nursing by kozier and
erbs 8th edition p.588)

Bulbar conjunctiva for Transparent; capillaries His Bulbar conjunctiva is Normal

color, texture, and the sometimes evident; transparent, no lesions,
Palpebral conjunctiva for Shiny, smooth, and His Palpebral Normal
color, texture, and the pinkish in color conjunctiva is Shiny,
presence of lesions (Fundamentals of smooth and pinkish in
nursing by kozier and color.
erbs 8th edition p.588)
Lacrimal gland No edema or No presence pf Normal Pupils for color, Black in color; His pupil is black Normal
tenderness edema or shape and equal in size; 3 to in color, equal in
over lacrimal tenderness over symmetry of size 7 mm in diameter;size, round In
gland lacrimal galnd round, smooth shape and has
border, iris flat smooth borders.
(Fundamentals of
nursing by kozier and round
and erbs 8th (Fundamentals of
edition p.588) nursing by kozier
and erbs 8th
edition p.590)

Lacrimal sac and No edema or No presence of Normal

nasolacrimal duct tearing edema or tearing Pupil’s direct and Illuminated pupil When Illuminated Normal
(Fundamentals of consensual constricts (direct his pupil
nursing by kozier reaction to light response) constricts, Non
and erbs 8th Nonilluminated illuminated his
edition p.588) pupil dilates pupil dilates
(consensual
response)

Cornea for clarity Transparent, He has a Normal

and texture shiny, and transparent
smooth; details of cornea and
the iris are visible anterior chamber.
(Fundamentals of His cornea is
nursing by kozier smooth and shiny
Pupil’s reaction to Pupils constrict His pupil Normal
and erbs 8th accommodation when looking at constricts when
edition p.589) near objects; looking at near
pupils dilate when objects and his
looking at far pupils dilate when
objects; pupils looking at far
convergence objects; pupils
when near object convergence
is moved toward when near object
Anterior chamber Transparent Transparent Normal nose is moved toward
for transparency No shadows of No shadows of nose
or depth light on iris light on iris
Depth of about 3 Depth of about 3
mm mm
 Visual fields and extra ocular muscles

Peripheral visual When looking He can see Normal Six ocular Both eyes Both eyes Normal
fields to straight ahead, objects in movements to coordinated, coordinated,
determine client can see periphery determine eye move in unison, move in unison,
function of retina objects in alignment and with parallel with parallel
and neuronial periphery coordination and alignment alignment
visual pathways (Fundamentals of functions of (Fundamentals of
to brain and nursing by kozier oculomotor, nursing by kozier
optic cranial and erbs 8th trochlear and and erbs 8th
nerve edition p.591) abducens nerve edition p.592)

Color, Symmetry of size, and
position
Ears
Auricles
Color same as facial -his auricle is the same as his Normal
skinSymmetricalAuricle aligned facial skin.- it symmetrical to his
with outer canthus of eye, face.- his auricle is aligned with
about 10 degrees from the other canthus of the eye
vertical(Fundamentals of
nursing by kozier and erbs 8th
edition p.596)

Texture, elasticity, and areas of Mobile, firm, and not tender; His ear is firm and not tender Normal
tenderness pinna recoils after it is and after being folded it recoils
folded(Fundamentals of nursing
by kozier and erbs 8th edition
p.596)

External ear canal
Distal ends contains hair
follicles and glands; Dry
cerumen, grayish-tan color; or
sticky wet cerumen in various
shades of brown
his eardrum have a dry Normal
cerumen, the distal has some
hair follicles and glands.- No
lesions, pus or blood In his
eardrum.
 Hearing Acuity Test
Response to normal voice tones Normal voice tones He can hear normal voice tones Normal
audible(Fundamentals of
nursing by kozier and erbs 8th
edition p.597)

Watch tick test Able to hear ticking in both He is able to hear the ticking of Normal
ears(Fundamentals of nursing the watch in both ears
by kozier and erbs 8th edition
p.597)

Weber’s test Sound is heard in both ears or isHe can hear the sound in both Normal
localized at center of the ears
head(Fundamentals of nursing
by kozier and erbs 8th edition
p.597)

Rinne’s test Air-conduction hearing is air conduction: 12 seconds Normal

greater than bone-conduction bone conduction: 10 seconds
hearing
(Fundamentals of nursing by
kozier and erbs 8th edition
p.598)

External Nose for nay
deviations in shape, size and
color and flaring, or dishcharge
from the nares
Nose
Symmetric and Straight; No
discharge or flaring; Uniform
Color(Fundamentals of nursing
by kozier and erbs 8th edition
p.600)
-His nose is symmetrical and Normal
straight.- No discharge or
flaring on his nose.- The nose is
uniform in color.

Palpate external nose to
determine any areas of
tenderness, masses, and
displacements of bone and
cartilage.
Not tender; no His nose is not tender and no Normal
lesions(Fundamentals of presence of lesions
nursing by kozier and erbs 8th
edition p.600)

Patency of both nasal cavities
Air move freely as the client The air moves freely as he Normal
breathes through the breath through the nares
nares(Fundamentals of nursing
by kozier and erbs 8th edition
p.600)
 Nasal Cavity and Facial
Sinuses
Observe for any presence of Mucosa pink, clear, watery His nasal cavities are pink in Normal
redness, swelling, growths, and discharge, no lesions, color, clear, watery discharge
discharge. (Fundamentals of nursing by
kozier and erbs 8th edition
p.600)

Nasal Septum Nasal septum intact and in His nasal septum is intact and Normal
midline(Fundamentals of in the midline.
nursing by kozier and erbs 8th
edition p.600)

Palpate the Maxillary and No tenderness, not There are no tenderness in Normal
Frontal sinuses for tenderness palpable(Fundamentals of maxilla and frontal sinuses
and functions of olfactory nerve Nursing, 8th Ed.by Barbara
Kozier Pp.600)

Outer lips for symmetry of
contour, color and texture
Inner lips and buccal mucosa for Uniform pink color; moist;
color, moisture, texture, and the smooth; soft; glistening, and
presence
The Teeth and Gums
MOUTH
Uniform pink color; soft; moist; His lips is uniform, pink in color, Normal
smooth texture; symmetry of moist, smooth in texture, has
contour; ability to purse symmetric contour and his lips
lips(Fundamentals of nursing by has the ability to purse.
kozier and erbs 8th edition p.602)
His buccal mucosa is uniform in
pink color, moist, soft, glistening
elastic texture(Fundamentals of and elastic in texture and has no
nursing by kozier and erbs 8th lesions
edition p.602)
Teeth and Gums
Deciduous teeth are lost and 26 teeth with dental carries and The child like to eat candies and
permanent teeth erupt during the yellowish in color doesn’t have a dental check-up
school age period. The average
child gains 28 teeth between 6
and 12 years of age
(maternal and child health
nursing volume 2, 5th edition
page 913)
 TONGUE/FLOOR of the
MOUTH
Surface of the Tongue for
position, color, and texture
Central position
slightly rough; thin whitish
coating; smooth; lateral
margins; no lesions; raised
papillae
(Fundamentals of nursing by
kozier and erbs 8th edition
p.602)
His tongue is in central position, Normal
pink in color raised taste buds
moist, slightly rough, thin
whitish coating, lateral margins
visible.

Tongue Movement and Moves freely; no tenderness His tongue moves freely and Normal
functions of hypoglossal nerve (Fundamentals of nursing by there is no tenderness
kozier and erbs 8th edition
p.602)

Base of the Tongue, the mouth Smooth tongue base with
floor, and the frenulum prominent veins
(Fundamentals of nursing by
kozier and erbs 8th edition
p.602)
His tongue is pink in color, Normal
smooth tongue base with
prominent veins.

Palpate the tongue and floor of
the mouth for any modules,
lumps, or excoriated areas and
functions of glosopharyngeal
nerve
Smooth with no palpable The tongue is smooth and there Normal
nodules are no palpable nodules
(Fundamentals of nursing by
kozier and erbs 8th edition
p.603)
 PALATES and UVULA
Hard and Soft Palate, its color, Light pink, smooth, soft palate, His soft palate light pink in color Normal
shape, texture, and the lighter pink hard palate, more and it is smooth while the hard
presence of bony prominences irregular texture palate is lighter pink in color
(Fundamentals of nursing by and it is irregular in texture
kozier and erbs 8th edition
p.603)

Uvula, its positioning, and
mobility while examining the
palates
Positioned in midline of soft
palate
(Fundamentals of nursing by
kozier and erbs 8th edition
p.603)
-his uvula is positioned midline. Normal
-it appears in pink and smooth
and no discharge.
 OROPHARYNX and TONSILS
The Oropharynx, its texture and Pink and smooth posterior wall
color
The Tonsils, its color, any
discharges and size
Elicit gag reflex
(Fundamentals of nursing by
kozier and erbs 8th edition
p.603)
Pink and smooth; no discharge; The tonsils is pink and it is
of normal size
(Fundamentals of nursing by
kozier and erbs 8th edition
p.603)
Present
The color of his oropharynx is Normal
pink and it is smooth on
posterior wall
Normal
smooth and there are no
discharge; Grade 1
It is present Normal

Lymph Nodes
Trachea
Thyroid Gland; observe
lower half of the neck
overlying the thyroid gland
for symmetry and visible
masses.
Palpate the Thyroid gland for Lobes may not be palpated; The lobes are not palbable
smoothness and areas of
enlargement, masses or
nodules
Neck
Not Palpable His lymph nodes are not Normal
(Fundamentals of nursing by palpable
kozier and erbs 8th edition
p.607)
Central placement in midline His trachea is in central Normal
of neck; spaces are equal on placement in the midline of
both sides the neck, spaces are equal
on both sides.
Not visible on inspection The thyroid gland is not Normal
(Fundamentals of nursing by visible on inspection
kozier and erbs 8th edition
p.608)
Normal
if palpated, lobes are small, and it rise freely when he
smooth, centrally located, swallows
painless, and rise freely with
swallowing
(Fundamentals of nursing by
kozier and erbs 8th edition
p.608)
 Posterior thorax
Shape, Symmetry, size and Anteroposterior to transverse Anteroposterior to transverse Normal
diameter of anteriorposterior diameter in ratio 1:2; Chest diameter in ratio 1:2; Chest
thorax to transverse diameter symmetric symmetric

Spine alignment Spine vertically aligned; Spinal His spine is vertically aligned, Normal
column is straight, right and left straight shoulders and hips are
shoulders and hips are at same the same as the height.
height

Palpate the posterior thorax; for Skin intact, uniform His thorax skin is intact, it Normal
clients who have no respiratory temperature; chest wall intact; uniform in temperature and
complaints, rapidly assess the no tenderness; no masses there are no masses or lesions
temperature and integrity of all were seen in the thorax of the
chest skin client.

Palpate the posterior chest for Full symmetric chest expansion; It is Full and symmetric chest Normal
respiratory excursion normally the thumbs separate expansion.
3-5 cm(1.5-2 in.) during deep
inspiration
Palpate the chest for vocal Bilaterally symmetry of vocal The vocal fremetus is bilaterally Normal
fremitus fremitus; fremitus is heard most symmetrical and it is heard
clearly at the apex of the lungs more clearly at the apex of the
lungs

Percuss the posterior thorax Percussion notes resonate, His posterior resonant sound Normal
except over scapula; lower will be heard during percussion.
point of resonance is at the
diaphragm

Auscultate the posterior thorax Vesicular and Bronchiovesicular During his auscultation on his Normal
breath sounds thorax, there is a wheezing
sound
 ANTERIOR THORAX
Breathing patterns Quiet, rhythmic and effortless Quiet sound and effortless Normal

Palpate for temperature, Uniformly warm, no tenderness, His Anteriror thorax has uniform Normal
tenderness, masses no masses temperature, no tenderness
and masses

Palpate the anterior chest for Full symmetric excursion; he has a full symmetric chest Normal
respiratory excursion thumbs normally separate 3-5 expansion.
cm (1.5-2 in)

Palpate the vocal fremitus Same as the posterior vocal He has bilateral symmetry of Normal
femitus; fremitus is normally vocal fremetus.
decreased over heart and
breast tissue
Percuss the anterior thorax Percussion notes resonate downIn percussing his thorax, there Normal
to the sixth rib at the level of is a resonate down to the sixth
the diaphragm but are flat over rib at the level of the
areas of heavy muscles and diaphragm but flat over the
bone, dull on areas over the heavy muscle and bone, dull on
heart and the liver, and the areas over the heart at the
tympanic over the underlying liver, tympanic over the
underlying stomach.

Auscultate the Trachea Bronchial and tubular breath There is a bronchial and breath Normal
sounds sound on his trachea.

Auscultate the anterior thorax Bronchiovesicular and vesicular During his auscultation on his The child has an asthma
breath sounds thorax, there is a wheezing
sound
 CARDIOVASCULAR
Inspect and palpate the aortic
and pulmonic areas
Inspect and palpate the
tricuspid areas
Inspect and palpate the apical
area
Auscultate the aortic, pulmonic, S1:usually heard at all
tricuspid and apical valves
No masses, no pulsations, no liftNo pulsation on his aortic Normal
or heave(Fundamentals of area.No pulsation and no lift or
nursing by kozier and erbs 8th heave.
edition p.621)
No pulsations and no heaves or No pulsations and no lift or Normal
lift heaves
Pulsation visible 50% of adults Pulsation is palpable Normal
and palpable in most PMI in fifth
LICS at or medial to MCL
Diameter of 1 to 2 cm (1/3 to ½
in.) No lift or heave
In auscultating his thorax, S1 is Normal
sitesUsually louder at apical usually heard at all sites, S2
areS2: usually heard at all usually heard at all sites
sitesUsually louder at the base
of the heartSystole: silent
interval; slightly shorter
duration than diastole at normal
heart rateDiastole: silent
interval; slightly longer duration
than systole at normal heart
rates
 Carotid artery and Jugular
Vein
Carotid Artery Symmetric pulse volumes; it has a full thrusting quality. Normal
pulse volumes; full pulsation, there is no sound heard
thrusting quality; quality
remains same when client
breaths; turns head, and
changes from sitting to supine
position; Elastic arterial wall; no
sound heard on
auscultation(Fundamentals of
nursing by kozier and erbs 8th
edition p.622)

Jugular Vein Veins not visible(Fundamentals His veins are not visible Normal
of nursing by kozier and erbs
8th edition p.623)
 Breast and Axillae
Breast size; symmetry; and Males: Round, slightly unequal his breasts are rounded in Normal
contour or shape in size shape slightly unequal in size;
generally symmetric.-his
breasts skin uniform in color.
His skin is intact and smooth

Inspect the skin of the breast
for discolorations or hyper
pigmentation, retraction or
dimpling, localized hyper
vascular areas, swelling or
edema
Skin uniform in color; skin his breasts skin uniform in Normal
smooth and intact; diffuse color. His skin is intact and
symmetric horizontal or vertical smooth
vascular pattern in light-
skinned people; striae; moles
and nevi

Inspect the Areola for size, Round or oval and bilaterally His areola is round and Normal
shape, symmetry, color, surface the same; Color varies widely, bilaterally the same. The color
characteristics, and any masses from light to pink to dark of his areola is brownish. He has
or lesions brown; Irregular placement of an irregular placement of the
sebaceous gland on the surface sebaceous glands on the
of the areola surface of the area.

Inspect the Nipples for size, Round everted, and equal in
shape, position, color, dischargesize; similar in color; soft and
and lesions smooth; both nipples point in
same direction; no discharge,
except from pregnant or breast
feeding females; inversion of
one or both nipples that is
present from puberty
His nipples are round in shape Normal
everted and equal in
size.similar in color. Both nipple
point in the same direction
-it has no discharge
- his breasts nipples have no
tenderness, masses or nodules.
Palpate the axillary,
subclavicular and
supraclavicular lymph nodes
Palpate breasts for masses and No tenderness, masses, nodules There is no tenderness or
tenderness
Palpate the nipples for
tenderness and discharge
No tenderness, masses or
nodules
No tenderness, masses,
nodules, or nipple discharge
(Fundamentals of Nursing by
Barbara Kozier,8th Ed. Pp.628-
630)
There is no tenderness, masses Normal
or nodules on the axillary.
Normal
masses around his breast
There is no tenderness masses, Normal
nodules or nipple discharge

Inspect the abdomen for skin
integrity
ABDOMEN
Unblemished skin; Uniform
Color; Silver white striae or
surgical scars
His abdomen In skin is Normal
Unblemished in skin,has
uniform in color,silver with
striae or surgical scars

Inspect the abdominal contour Flat, rounded (convex), or It is rounded Normal

scaphoid (convex)

Inspect for an enlarged liver or no evidence of enlargement of Not done Not done
spleen liver or spleen;

Assess the symmetry of contour symmetric contour Not done l

while standing at the foot of the
bed
Observe abdominal movement Symmetric movement cause by Symmetric movement cause by Normal
associated with respiration, respiration; Visible peristalsis in respiration; Aortic pulsation in
peristalsis, or aortic pulsation very lean people; Aortic thin persons at epigastric area
pulsation in thin persons at
epigastric area
(Fundamentals of nursing by
kozier and erbs 8th edition
p.633)

Observe vascular No visible vascular pattern No visible vascular pattern Normal

patternsAuscultate the
abdomen for bowel sounds,
vascular sounds, and peritoneal
friction rubs

Auscultate the abdomen for Audible bowel sounds; Absence
bowel sounds, vascular sounds, of Arterial bruits
and peritoneal friction rubs Absence of friction rub
(Fundamentals of nursing by
kozier and erbs 8th edition
p.634)
Audible bowel sounds are heard Normal
and absence of Arterial bruits
and
friction rub

Percuss several areas in each of Tympany over the stomach and Tympany over the stomach and Normal
the four quadrants to determine gas-filled bowels; dullness, gas-filled bowels
presence of tympany and especially overt the liver and
dullness. spleen, or a full bladder

Perform light/deep palpation No tenderness; relaxed No tenderness and relaxed Normal

first to detect areas of
tenderness and/or muscle
guarding
abdomen with smooth, abdomen
consistent tension
(Fundamentals of Nursing by
Barbara Kozier,8th Ed. Pp.634-
636)
 MUSCULOSKELETAL
SYSTEM
Inspect the muscle for size; Equal size on both sides of the The muscles are equal in size Normal
compare the muscles on one body on both sides of the body
side of the body to the same
muscle on the other side

Inspect the muscle and tendons No contractures No contractures Normal

for contractures

Inspect the muscles for No fasciculation or tremors No tremors or fasciculation Normal

fasciculation and tremors

Palpate muscle tonicity Normally firm His muscles are firm Normal
Test muscle strength (Neck) Equal strength on each body Cannot rotate his head on the (+) torticollis
part left side, only in the right side
(Fundamentals of Nursing by
Barbara Kozier,8th Ed. P. 640)

Test for muscle strength (Upper Equal strength on each body Equal strength on each body Normal
extremities) part part
(Fundamentals of Nursing by
Barbara Kozier,8th Ed. P. 640)

Test for muscle strength (Lower Equal strength on each body Equal strength on each body Normal
extremities) part part
(Fundamentals of Nursing by
Barbara Kozier,8th Ed. P. 640)
 Bones and Joints
Inspect for normal bone No deformities No deformities Normal
structure and deformities (Fundamentals of Nursing by
Barbara Kozier,8th Ed. P. 641)

Palpate the bones to locate any No tenderness or swelling No tenderness or swelling Normal
areas of edema or tenderness

Inspect the joints for swelling,
palpate each joint for
tenderness, smoothness of
movements, swelling,
crepitation, Snodules
No swelling; no tenderness, There are no swelling of joints Normal
swelling, or nodules; Joints and it moves smoothly and
move smoothly there is no tenderness
 Range of Motion
Upper Extremities Can perform the range of He can perform the range of Normal
(shoulder and motion in the shoulder and motion in the shoulder and
scapula Reference: scapula
Scapula)
(Fundamentals of nursing 8th
edition Vol. 2 page 1108-1111)

Upper extremities Can perform the range of He can perform the range of Normal
(elbows) motion in the elbows motion in the elbows

Upper Extremities Can perform the range of He can perform the range of Normal
(hands) motion in the hands motion in the hands

Lower Extremities Can perform the range of He can perform the range of Normal
(acetabulum/ motion in the inguinal motion in the inguinal
inguinal area)

Lower Extremities Can perform the range of He can perform the range of Normal
(popliteal) motion in the popliteal motion in the popliteal

Lower Extremities Can perform the range of He can perform the range of Normal
(ankles) motion in the ankles motion in the ankles
 Laboratory and Diagnostic
Examination
Urinalysis

Physical examination chemical

examination:
Color: yellow albumin: 1+
Reaction: acidic sugar: negative
Transparency: clear
Specific gravity: 1.025
 Microscopic examination
Epithelial cells: rare amorphous urates:
rare
Pus cells: 0-2/hpf amorphous
phosphates:
Red cells: 1-2/hpf N mucus threads: rare

Bacteria: occasional
 Hematology
Test N.M units results
Hemoglobi M = 140- g/dl 120
n 170
F120-150
Hematocrit M = 0.41- Vol% 0.36
0.54F =
0.37-0.47
Leucocytes 5-10 X 10 g/l 8.3 N

Erythrocyt M = 4.1-
es 5.4F =
4.3-5.5
 Drug study
Generic/Trade Dosage/Frequ Classification Indication Contraindicati Side effects
ency on Nursing Responsibilities
name

Generic T neb every 6 Bronchodilator Salbutamol is Hypersensitivt Headache,tremo -Assess pulse, respiration,
name: used in cases ty to agents r, tachycardia lung sounds, and character
Salbutamol hours of -avoid use in hypertension, of secretions before and
bronchospasm uncontrolled anxiety. Rarely throughout the therapy.
Trade name: in patients nausea,
arrythmias
Ventolin, with reversible vomiting, and
airway skin rash can be
obstruction: observed.
Albuterol
mild and
moderate
attacks of
dyspnea in
patients
suffering from
bronchial
asthma; mild
and moderate
bronchoobstru
ction in
patients with
chronic
bronchitis and
lung
emphysema.
Generic Name: 250 mg per Anti-pyretics Symptomatic Nephropathy. Hematological -Assess fever (note
Opigesic(supp rectum relief of fever reactions, rashes presence of
ository) associated w/ & other allergic associated
common reactions. symptoms
childhood diaphoresis,
infections. tachycardia and
Relief of minor malaise)
pains eg
headache,
headache,
toothache &
earache.
earache.

Paracetamol 240 mg TIV Anti-pyretics Mild to Contraindicate GI:hepatic -Assess fever (note
Generic Name: EVERY 4 moderate pain d in previous necrosis(overdose presence of
Acetaminophe HOURS and fever. hypersensitivit )Derm: Rashes associated
y products symptoms
n
containing diaphoresis,
Trade Name: alcohol,asparta tachycardia and
Tempra, me,saccharin, malaise)
Tylenol sugar or
tartrazine
should be
avoided in
patients who
have
hypersensitivit
y or
intolerance in
these
compounds.
Salbutamol(ta PO( 6-14 yrs BronchodilatorSalbutamol
BronchodilatorSalbutamol Hypersensitivity to CNS: -Assess pulse,
blets) old) 2 mg 3-4 tablets may adrenergic amines. nervousness,restl respiration, lung
Albuterol times daily. be used in Contraindicated essness.EENT: sounds, and character
asthma, to during broncho- eye irritation, of secretions before
relieve the spasm. blurred and throughout the
narrowing of vision.RESP: therapy.
the airways. Pulmonary
chronic edema(tocolytic
bronchitis. use of
emphysema terbutaline).GI:
Nausea and
vomitingEndo:
Hyperglycemia.
Hypoglycemia.F
and E:
hypokalemia

Penicillin G 800,000iu/IV Antibiotics Treatment of Contraindicated Severe allergic -Assess fever (note
sodium severe with allergy to reactions, presence of
infections penicillins, tightness in the associated symptoms
caused by cephalosporins, chest, swelling of diaphoresis,
sensitive beta lactamase the mouth, face, tachycardia and
organisms, inhibitors and other lips, or tongue, malaise)
treatment of allergens chills,convulsions,
syphilis and decreased
gonococcal urination
infections
Combivent Two sprays of Bronchodilator Management of Hypersensitivit Nervousness, -Assess pulse,
Generic name: Combivent four reversible y to adrenergic restlessness, respiration, lung
ipratropium times a day. airway disease amines, use pulmonary edema, sounds, and
(inhalation) due to asthma cautiously in hypertension, character of
cardiac tachycardia. secretions before
Trade name:
Combivent, disesase, and throughout the
diabetes, therapy
Duoneb
bronchospasm

Neurotoxicity: Dizziness, Lab tests: Perform C&S

tinnitus, vertigo, roaring in the and renal function prior to
ears, hearing loss. Peripheral first dose and periodically
neuropathy or
during therapy; therapy
Gentamicin 40 mg/ IV antibiotic Treatment of Hypersensitivit encephalopathy: Numbness, may begin pending test
skin tingling, muscle twitching,
serious UTI, y to convulsions & myasthenia results
bacteremia, aminoglycoside gravis-like syndrome. Resp
Draw blood specimens for
depression, lethargy,
meningitis, s. confusion, depression, visual peak serum gentamicin
cerebral disturbances, decreased concentration 30 min–1h
appetite, wt loss, hypotension after IM administration,
ventriculitis, & hypertension, rash, itching, and 30 min after
osteomyelitis, urticaria, generalized burning, completion of a 30–60
laryngeal edema, min IV infusion. Draw
pneumonia, anaphylactoid reactions, fever,
blood specimens for
peritonitis & headache, nausea, vomiting,
trough levels just before
increased salivation,
otitis caused by stomatitis, purpura, the next IM or IV dose.
suspected gm- pseudotumor cerebri, acute Use nonheparinized tubes
organic brain syndrome,
ve bacteria. pulmonary fibrosis, alopecia,
joint pain, transient to collect blood.
hepatomegaly &
splenomegaly.
Nursing Care
Plan
Nursing problem analysis Goal/objectives Nursing rationale evaluation
cues interventions
Ineffective breathing Pneumonia is an After 15 1. Assess the client’s 1. Tachypnea and diminished Client’s condition
pattern related to inflammation of the minutes of respiratory rate every ar adventitious breath sounds
4 hours or more may be early indicators of improved as
Hyperventilation lungs caused by an nursing frequently as respiratory compromise. Early manifested by
infection. It is also intervention, the indicated. intervention can prevent breathing
Subjective: called Pneumonitis client will be atelectasis and significant normally without
The child has asthma andor able to breathe 2. Place the client tissue hypoxia
there are times that he difficulty
can’t breathe normally. Bronchopneumonia normally without comfortably in an
The mother said that . Pneumonia can be obstruction upright or semi- 2. This position promotes lung
when this happens, she a serious threat to upright position. expansion and ventilationas
consults their doctor and our health. well as comfort
nebulize the child. “nung 3. Provide for a period
new year nagpaputok yanAlthough of rest. 3. Rest is important to reduce
sa labas kasama yun pneumonia is a fatigue and the work of
daddy niya eh ang usok- special concern for breathing
usok sa labas buti hindi 4. Assess and
older adults and document pleuritic
siya hinika.” the mother
said. those with chronic discomfort. Provide 4. Adequate pain relief
illnesses, it can analgesic as ordered. minimizes splinting and
Objective: also strike young, promotes adequate ventilation
>adventitious breath healthy people as 5. Provide
sounds (wheezes) upon well.  It is a reassurance when the 5. Hypoxia and respiratory
auscultation common illness client is experiencing diatress produce high levels of
>vital signs: respiratory distress. anxiety in the client, which
that affects tends to further increase
T = 36.1˚C thousands of
PR = 93bpm 6. Administer oxygen tachypnea and fatigue and
people each year in as ordered. decrease ventilation.
RR = 21cpm
the Philippines,
>nasal flaring
thus, it remains an 7. Teach the client to 6. Supplemental oxygen
important cause of reduces hypoxia and
use slow abdominal
morbidity and associated anxiety
breathing.
mortality in the
country. 8. Teach the client 7. This promotes lung

(www.nursingcrib.c how to use relaxation expansion

techniques such as
om) visualization and 8. These techniques help
meditation. reduce anxiety and slow the
client's breathing pattern.
Nursing problem analysis Goal/objectives Nursing rationale evaluation
cues interventions
The client’s
Impaired Good oral hygiene After 2 weeks of Discuss to the To provide knowledge to condition
dentition related results in a mouth thatnursing significant other the client improves as
to ineffective oral looks and smells intervention the the proper way of manifested by
hygiene healthy. This means: client would be effective oral doing proper
able to learn hygiene oral care.
Your teeth are clean essential
Subjective: The and free of debris To guide the patient on the
tooth of the client Gums are pink and do knowledge about Demonstrate the proper care of teeth
is yellowish and not hurt or bleed when effective oral correct brushing of
hygiene.
has 26 teeth. The you brush or floss his teeth
mother
verbalized that Bad breath is not a To be free from plaque on
Encourage the
“hindi siya constant problem client to brush his the surfaces of the teeth
nagpapachek-up If your gums do hurt or teeth every after
sa dentista”. our bleed while brushing or meal
client verbalized flossing, or you are
that” paborito ko experiencing persistent To avoid frequent
din kumaen ng Advice the client to toothaches and fractured
bad breath, see your
candy kasi avoid sweet foods teeth
dentist. Any of these
masarap”. conditions may indicate
“nagtotoothbrush a problem. Advice to eat foods To keep the teeth strong
lang ako bago po that can help to and clean
matulog tsaka Your dentist or clean the teeth
pag gising” the hygienist can help you
To take advice from the
client verbalize learn good oral hygiene
Advice the professionals
techniques and can significant other to
Objective: help point out areas of bring his child to
halitosis your mouth that may dentist every six
require extra attention months
excessive plaque
during brushing and
missing teeth
flossing.

(www.colgate.com )
Nursing problem analysis Goal/objectives Nursing interventions rationale evaluation
cues
Risk for infection Hemoglobin is the After 2 hours of Monitor vital signs Reflective of Patient was able
related to protein molecule nursing Especially inflammatory process/ to minimize the
decreased in red blood cells intervention, the temperature infection requiring sign of infection
hemoglobin that carries client will evaluation & treatment
production oxygen from the minimize sign of Demonstrate to the client
lungs to the infection and significant other
Prevents cross
body's tissues and Thorough
Cues: contamination/ bacterial
returns carbon Hand washing
colonization
dioxide from the
Hematology: tissues to the Encourage frequent
Hemoglobin = 120 lungs. position changes/ Promotes ventilation of
Hematocrit = 0.36 Hemoglobin also ambulation, all lung segments and
plays an coughing, & deep aids in mobilizing
Leucocytes = 8.3 secretions to prevent
important role in breathing exercises
maintaining the pneumonia
vital signs: shape of the red Promote adequate
T = 36.1˚C blood cells. fluid intake
PR = 93bpm
Assist in liquefying
Abnormal respiratory secretions to
RR = 21cpm Hemoglobin Obtain specimen facilitate expectoration
structure can, For & prevents stasis of
therefore, disrupt culture/ sensitivity
Body fluids
the shape of red as indicated
blood cells and
impede its (http://nursingdepart Verifies presence of
function and its ent.blogspot.com/200 infection, identifies
flow through /08/nursing-care-plan specific pathogens&
blood vessels risk-for-infection.html) influences choice of
treatment
(http://www.medi
cinenet.com/heog
lobin/article.h
m).
 Anatomy and physiology
 The lungs constitute the largest organ in the respiratory system.
They play an important role in respiration, or the process of
providing the body with oxygen and releasing carbon dioxide. The
lungs expand and contract up to 20 times per minute taking in and
disposing of those gases.
Air that is breathed in is filled with oxygen and goes to the trachea,
which branches off into one of two bronchi. Each bronchus enters a
lung. There are two lungs, one on each side of the breastbone and
protected by the ribs. Each lung is made up of lobes, or sections.
There are three lobes in the right lung and two lobes in the left
one. The lungs are cone shaped and made of elastic, spongy
tissue. Within the lungs, the bronchi branch out into minute
pathways that go through the lung tissue. The pathways are called
bronchioles, and they end at microscopic air sacs called alveoli.
The alveoli are surrounded by capillaries and provide oxygen for
the blood in these vessels. The oxygenated blood is then pumped
by the heart throughout the body. The alveoli also take in carbon
dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles
between the ribs. Exhaling results from relaxation of those
muscles. Each lung is surrounded by a two-layered membrane, or
the pleura, that under normal circumstances has a very, very small
amount of fluid between the layers. The fluid allows the
membranes to easily slide over each other during breathing.
 Respiratory system
Pathophysiology of Pneumonia
Droplets S. Pneumoniae aspirated into
the lungs

Inflammatory response
initiated

Alveolar Edema Exudate

Formation

Alveoli and respiratory bronchioles fill

with serous exudate, blood cells, fibrin,
and bacteria

Consolidation of lung tissue

Pnemonia

Signs and symptoms:

high fever , shaking chills, cough with sputum production,
shortness of breath
 Discharge plan
Medicine:
Take the entire course of any prescribed medications. After a patient’s
temperature returns to normal, medication must be continued according to the doctor’s
instructions, otherwise the pneumonia may recur. Relapses can be far more serious than
the first attack.
Exercise:
>Walk or jog
>Dancing, Aerobics, Gymnastics, Stretching ...
>Swimming
>Do not exhaust yourself !
>Do not exercise with full stomach !  (You may take a walk!)
Treatment:
Get plenty of rest. Adequate rest is important to maintain progress toward full
recovery and to avoid relapse.

Drink lots of fluids, especially water. Liquids will keep patient from becoming
dehydrated and help loosen mucus in the lungs.
Health Teaching:
Tell guardians to avoid exposing the patient to an environment with too much
pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses
against respiratory infections.
 Protect others from infection. Try to stay away from anyone with
a compromised immune system. When that isn’t possible, a
person can help protect others by wearing a face mask and
always coughing into a tissue.

 Give supportive treatment. Proper diet and oxygen to increase oxygen

in the blood when needed.

 Encourage the guardians to wash patient’s hands. The hands come

in daily contact with germs that can cause pneumonia. These germs enter
one’s body when he touch his eyes or rub his nose. Washing hands
thoroughly and often can help reduce the risk.

Out- patient referral:

Keep all of follow-up appointments. Even though the patient feels
better, his lungs may still be infected. It’s important to have the
doctor monitor his progress.

Diet:
Eat nutritious foods like fruits and vegetables to recover well.