PAMANTASAN NG CABUYAO COLLEGE OF HEALTH ALLIED SCIENCES COLLEGE OF NURSING

CASE ABSTRACT:
This is a case of patient a 5 yr. old female residing at Mercedes Vill, Sala, Cabuyao Laguna., the patient was received at St.James Hospital last Sept 30, 2009 at 7:50 pm with a chief complaint of fever. Initial vital signs were taken T-38.5C, RR- 40bpm, PR- 130bpm. Initial diagnosis was Pediatric Community Acquired Pneumonia-C. The patient was subjected for Urinalysis, Blood Chemistry, Hematology and Radiologic exam and was given Cefaclor, Salbutamol, Erdostien, Polynerv syrup b1+b6+b12 as prescribed. Upon further history taking we found out that both of her parents were active-smokers.

LEARNING OBJECTIVE: The study aims to impart knowledge regarding community acquired pneumonia and means to restore or maintain patients health status utilizing a holistic approach of promoting and rehabilitative process of nursing managements. 1. Identify nursing problems and the corresponding nursing considerations and managements involved for promotion and maintenance of patients health. 2. Enumerate therapeutic nursing interventions through formulation of NCP. 3. Specify the appropriate laboratory and diagnostic procedures / examinations and correlate them with the case presented. 4. Discuss simple pathophysiology of case presented, its predisposing factors, signs / symptoms, complications and treatments.

REVIEW OF ANATOMY AND PHYSIOLOGY: RESPIRATORY SYSTEM The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain.

The Upper Airway and Trachea When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voice box) and into the trachea (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs.

The Lungs Structure The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply.

How they work Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Traveling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

Blood Supply
The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs.

Predisposing Factor: age

Precipitating Factor: Environment

Streptococcal Pneumoniae

Enters through nose or mouth by inhalation Passes to the pharynx, larynx and trachea Microorganism enters and affects both airway and lung parenchyma Airway damage Activates macrophages and leukocytes Infiltration of bronchi Infectious organism lodges stimulation in bronchioles Alveolar wall Collapse Mucus and Phlegm Production Coughing Productive or nonProductive
Macrophages destroys RBC

Lung invasion

Decreased RBC count

Bilirubin Production jaundice

Narrowing of air passage

Increase pyrogens in the body Fever

Difficulty of Breathing

Health History Patient Name: Age: Sex: Nationality: Civil Status: Religion: Highest Educational Attainment: Rank in the Family: Address: Inclusive Date of Confinement: Admission Date and Time: Discharge Date: Attending Physician: Initial Diagnosis: Final Diagnosis: Source of History: Chief Complaint: Patient A 5 Yrs. Old Female Filipino Single Roman Catholic Preparatory Second Child of Three siblings Mercedes Vill. Sala Cabuyao, Laguna Four Days Sept. 30, 2009 at 7:50 PM Oct. 4, 2009 at 1:36 PM Mariano M. Carteciano M.D. PCAP C PCAP C Mother Fever

I. Health Perception Health Management Pattern Before hospitalization, the patient perceives health in a way that she is not suffering from a disease. During hospitalization, the patient feels unhealthy and is obedient in taking her medications. II. Nutrition-Metabolic Pattern A. Height: 3 ft., 5 in. tall B. Weight: 19.1 kg. C. Appetite: Good D. Usual Eating E. Pattern: 3 meals a day Usual Daily Menu a. Breakfast: Chocolate Drink / Milk b. Lunch: Usually hotdog with rice c. Dinner: Typical viand (meat, vegetable, etc.) with rice d. Snacks: Chocolate Cookies F. Diet: usual diet G. Has good skin turgor

III. Elimination Pattern A. Bowel: a. Usually no problem with elimination b. Last bowel movement yesterday, formed, normal B. Bladder: a. Decreased urinary frequency

IV. Activity Exercise Pattern

A. Self Care Ability: Feeding: 0 Toileting: 0 Dressing: 0 Bathing: 0 Bed Mobility: 0 Grooming: 2 *Legend: Functional Levels Code: 0 Full self-care 1 Requires use of equipment or device 2 Requires assistance or supervision from another person 3 - Requires assistance or supervision from another person and equipment or device 4 Dependent and does not participate B. Past Health Status: b.1. Prophylactic Medical/Dental Care: None b.2. Childhood Illness: Measles b.3. Immunizations: Complete b.5. Major Illnesses/Hospitalizations: None before this current admission b.6. Current Medications: Paracetamol (Prescribed) b.7. Allergies: None

V. Sleep- Rest Pattern A. Sleep Habits:

a. 8-9 hours of sleep/night b. Occasionally takes afternoon naps B. Has no difficulty going to sleep
VI. Cognitive-Perception Pattern >No sensory deficits >Pupils 3mm, equal >Oriented to time, place and person >Responsive, but fatigued >Responds appropriately to verbal and physical stimuli >Recent and remote memory intact VII. Self-Perception Self Concept Pattern >Patient states, Marami po akong mga kalaro sa School. >Does not feel good about herself since illness started.

VIII. Role-Relationship Pattern >Patient lives with her father, mother, and two other siblings >Family members are supportive towards patients hospitalization >Patient states good relationship with friends

IX. Coping-Stress Tolerance Pattern >Anxious and Irritable >Mother helps with coping with stress

X. Sexuality Reproductive Pattern >Patient is aware of her own gender and sexuality

XI. Value-Belief Pattern >Roman Catholic >No wish to see priest at present

I. GENERAL SURVEY

5 year old female child admitted to ER Appears normally on her age Mild irritability but cooperative Mild weakness Good posture (+) cough; productive (+) difficulty of breathing (-) retraction 19.1kg in weight 3ft 5 in height

II. VITAL SIGNS Temperature Pulse/cardiac rate Respiratory rate Blood pressure III. INTEGUMENTARY Skin: Mucous membrane: Nails: Hair:

DAY 1 38.5 130 40

DAY 2 37.5 124 36

DAY 3 36.9 104 38

DAY 4 36.1 88 32

>with slight jaundice on facial area, mild dryness, good skin turgor >pink oral mucosa >no clubbing, smooth in texture, capillary refill at 2-3 seconds >evenly distributed, mild thinning of hair, no infestation

IV. HEENT Head > Size: 52 cm > Shape: Well rounded; smooth skull contour; symmetric facial movement Eyes > Color: Dark-Brown > Pupil Response: PERRLA Ears > Symmetrically equal; no tenderness > Discharge/Growth: no discharge: able to response on questions
Nose > Mucosal Condition: pinkish in color > Discharge/Growth: no discharge noted Mouth/Throat/Pharynx/Teeth: > pink moist lips; pinkish tongue; no cavities; no missing teeth ; tonsils are not reddened Face >Symmetry: Symmetrically equal >Facial Musculature: has the ability to frown and smile

IV. NECK/LYMPH a. Symmetry: equally symmetrical muscles b. Growth: inflamed lymph node c. Location: right and left anterior cervical areas V. PULMONARY (Breath Sounds) >Normal: diminished bronchial sounds; equal chest expansion >Abnormal: fine crackles at both lung fields VI. BREAST ABD AXILLARY AREAS a. Symmetry: equal in size and symmetry for her age Growth: normal for age b. Retraction: no retraction noted c. Discharges: No Discharge Lymph Nodes: No lymph inflammation VII. CARDIVASCULAR Normal: normal rhythm Abnormal: no murmurs Rhythm: regular rhythm Rate: 120-150 beats per minute

VIII. PERIPHERAL/VASCULAR Peripheral Pulses (state if equal-bilaterally)

Grade:4 Grade: 4 Grade: 4 Grade: 3 Grade: N/A Grade:2 Grade: 2 Grade: 3 Temporal: equally bilateral Carotid: equally bilateral Brachial: equally bilateral Radial: equally bilateral Femoral: N/A Popliteal: equally bilateral Posterior Tibialis equally bilateral Dorsalis Pedis equally bilateral
Legend: Peripheral Pulse Scale 0>Absent 1>Markedly diminished 2>Moderately diminished 3>Slightly diminished 4>Normal

IX. ABDOMEN a. General Contour: rounded abdomen Tenderness: rated 6 on pain scale at LUQ b. Bowel Sounds: normal bowel sounds c. Abdominal Sounds: N/A X. MUSCOLO-SKELETAL A. STRENGTH: decrease muscle strength B. ROM: within normal limits
XI.NEUROLOGICAL A. Mental Status (LOC): 15 pts. B. Pupils Size: 3-4 mm C. Cranial Nerves: N/A D. Sensory: N/A E. Deep Tendon Reflex (grade the dotted areas) XI. RECTAL/ANUS >N/A

Legend: Reflex Scale 0> no response 1> low normal 2> normal 3> brisk 4> hyperactive

Legend: Glascow coma scale A. Eyes open spontaneous -4 on command -3 to pain -2

no response - 1 B. Best Verbal Response Alert and oriented -5 Confuse -4 Inappropriate -3 Incomprehensive -2 No response -1 C. Best Motor Response Follows direction -6 Localizes pain -5 Withdraws from pain -4 Decorticate posturing-3 Decerebrate posturing-2 No response

XII. GENETALIA >Growth: N/A >Discharge: No abnormalities as stated by the mother

Urinalysis MACROSCOPIC COLOR TRANCEPARENCY Ph

Result

Normal value

Significance

Color Slightly Hazy 6.5

Clear Clear 4.6- 6.5

Change of appearance of the urine is an indication of renal or urinary track infection. Disturbance of Ph indicates acid-based disorder.

MICROSCOPIC Specific gravity Albumin Sugar Pus cells RBC Bacteria 1.010 Negative Negative 8-10/hpf 0-2/hpf None 1.015-1.030 Negative Negative 0-1/Hpf 0-1/hpf none -Alteration of Specific gravity inidactes level of consentration of urine. -Presense of albumin may indicate glomerular disease -Presence of sugar in the urine may indicates complications. -Presence of pus cells in urine indicated urinary tract infection. -Alteration of RBC in urine indicated Urinary tract infection. -Presence of bacteria indicates infection.

Blood chemistry Sodium Test

Result 129 mmol/L

Normal value 137-145 mmol/L

Potassium test

3-7 mmol/L

3.5-5.1 mmol/L

Calcuim

9-6mg/dL

8.4-10.2mg/dL

significance Low level of sodium in the blood may cause convolsions. High potassoum level indicates alteration to electrical activity on the heart. Essesial for maintaining a regular heart beat, neuro muscular impulses. significance Normal Normal Loss of RBC indicates bleeding Alteration of WBC indicates infecton Alteration of platelet counts will affect coagulation,hemostas is,and clothing formation.

Hematology Hemoglobin Hematocrit RBC TOTAL WBC Platelets

Result 12.2 36% 4.00 9.9 335,000

Normal value 11-16q/dL 38-47% 4.5-4.8 5-10/uL 150000-450000/uL

X-ray Roentgen logical findings: There are steaky densities in both lung field The vascular marking are not accentuated The heart is not enlarge Diaphragm & sulci are intact

Impression: pneumonitis bilateral

A.

DIET: Diet appropriate for age (5 yr. old) High caloric food such as rice Increased Fluid intake Low fiber diet

B.1 STANDING ORDER

NAME OF DRUGS THERAPEUTIC ACTION INDICATION CONTRAINDICATION /CAUTIONS DOSAGE ADVERSE EFFECT NURSING CONSIDER ATION >assess for the history of drug allergy, pregnancy and lactation >assess patient for signs and symptoms of infection before and during therapy >assess for renal function test, respiratory status, culture and sensitivity to test of infected area >take the drugs with meal or food to prevent the GI discomfort..

GENERIC NAME: Cefaclor BRAND NAME: Cecavil Cefaclor Apo-Cefaclor CLASSIFICATI ON: Anti Biotic

Bactericidal Inhibits synthesis of Bacterial wall causing cell Death.

Treatment of otitis media, phryngitis, tonsillitis, Acute Bacterial Exacerbation of chronic bronchitis, pneumonia, Uncomplicated d skin and Skin structure, lower UTI

>patient with allergy to cephalosporin >hypersensitivity to beta lactam antibiotics >may induce anaphylactic shock

Children: Suspension 5ml per 8hrs three times a day for 5 days Adult: 500mg per 8hrs

CNS: Headache, dizziness, lethargy GI: Nausea, vomiting, diarrhea, anorexia, Abdominal pain, flatulence Hematologic: bone marrow depression Hypersensitivit y: ranging from rash to fever

NAME OF DRUGS

THERAPEUTIC ACTION

INDICATI ON Relief of Bronchospa sm in bronchial asthma chronic Bronchitis Emphysema and other Reversible Obstructive Pulmonary diseases.

CONTRAINDICATIO N CAUTIONS >Hypersensitivity to Salbutamol, also to atropine and its derivatives. >Threatened abortion during 1st and 2nd trimester. >cardiac arrhythmia associated w/ tachycardia caused by digitalis intoxication. >prevention of premature labor associated w/ toxemia of pregnancy or ante partum hemorrhage.

DOSAGE

ADVERSE EFFEC T Headache; tremor; tachycardia; hypertensio n; anxiety. Rarely nausea, vomiting, and skin rash can be observed

NURSING CONSIDERATI ON The drug should be avoided during pregnancy, particularly during the first trimester and during labor, because it is established that the high doses can suppress the contractions of the uterus. There are no data for risks related with the administration of the drug in breast feeding women.. Because of the possibility for induction of tremor, dizziness, and weakness, the drug should be used cautiously in drivers and people working with machines.

Generic name: Salbutamol or albuterol

Brand name: Ventolin Combivent Salbutamol

Classificatio n: Respiratory drugs Anti asthmatic

Stimulates beta 2 receptors of bronchioles by increasing levels of camp which relaxes smooth muscles to Produce Bronchodilatation.

Adults and children over 12 years: The Recommend d dose is 2 4 mg (5 - 10 ml syrup) 3 4 times daily. The maximal daily dose should not exceed 32 mg (divided in 3 or 4 doses). Children: between 2 and 6 years, the dose is 0.1 - 0.2 mg/kg body Weight given 3 times daily. The Maximal daily dose must not exceed 4 mg, 3 times daily, and the daily dose for 6 - 12 years-old children is to 24 mg daily, divided in 3 or 4 doses.

NAME OF DRUGS

THERAPEUTIC ACTION

INDICATION

CONTRAINDICATION /CAUTIONS

DOSAGE

ADVERSE EFFECT

NURSING CONSIDERATION

GENERIC NAME: Erdostien

Erdostien is an original derivative of BRAND NAME: natural Zertin mercaptoaminoacid in CLASSIFICATION: thiolactonic For respiratory form. Drugs Following oral administration Erdostien is rapidly metabolized in the liver. The product acts as a prod rug and its metabolites are mainly responsible for mucolytic activity, due to the presence of free thiol groups which cause the splitting up of the intra- and intermolecular disulfide bridges of several proteins and mucoproteins present in the expectoration, resulting in a reduction of the mucus elasticity and viscosity.

Treatment of acute & chronic bronchopulm onary diseases, rhino sinusitis, laryngophary ngitis or exacerbation s of these chronic diseases in association w/ mucus production & transport.

Hepatic disorders & abnormalities, renal insufficiency, homocystinuria, phenylketonuria

Adult 1 cap Gastric burning, bid. Susp 8.5 nausea; ageusia mL bid. or dysgeusia. Childn 2-6 yr (10-20 kg) 2.5 mL bid, 7-12 yr (2130 kg) 5 mL bid, 5 mL tid or 7.5 mL bid.

>assess for the history of drug allergy, pregnancy and lactation >assess for renal function test, respiratory status, culture and sensitivity to test of infected area >take the drugs with meal or food to prevent the GI discomfort >do not give to the patient 2yrs old below

NAME OF DRUGS

THERAPEUTIC ACTION

INDICATION

DOSAGE

NURSING CONSIDERATION

GENERIC NAME: Polynerv syrup b1+b6+b12 0 BRAND NAME: Polynerv b1+b6+b12 CLASSIFICATION: vitamins

VITAMINS B1, B6 & B12 (POLYNERV Syrup) is valuable in conditions where the requirements for B vitamins are increased (as in growth, physiologic stress, decreased resistance to infection and chronic illnesses, metabolic disorders and in certain diseases of the digestive tract and nervous system). It can also be given before and after surgical procedures.

VITAMINS B1, B6 & B12 (POLYNERV Syrup) is indicated for the prevention and treatment of deficiency disorders arising from poor dietary intake, impaired B vitamins absorption (as in prolonged diarrhea, excessive vomiting and antibiotic therapy) intake of drugs which interfere with the utilization of the B vitamins (i.e. isoniazid). As a nutritional supplement to promote appetite, weight gain and height increase.

1-2 years old : 2.5 >assess for the nutritional mL (1/2 teaspoon) status of the patients daily >assess for the drug reaction to the patients 3-6 years old : 5.0 >give the vitamins with mL (1 meals or food to prevent teaspoonful) daily gastrointestinal discomfort 7-12 years old : 10.0 mL (2 teaspoonfuls) daily

NAME OF DRUGS

THERAPEUTIC ACTION Decreases fever by inhibiting the effects of pyrogens on the hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting the prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.

INDICATION

DOSAGE

NURSING CONSIDERATION Asses pt. fever or pain Assess allergic reaction Assess hepatotoxicity Monitor liver and renal function Inform pts. That urine may dark brown as a result of phenacetin (a metabolite of acetaminophen)

Generic name: Paracetamol or Acetaminophen Brand Name: Calpol Classification: Anti-pyretic analgesic

Relief of mild to moderate pain and treatment of fever

children's dosages are based on a single dose of 10mg Paracetamol per kilogram bodyweight, which can be repeated 4-6 hourly, not exceeding four doses per 24 hours.

Verify the doctors order

C. INTRAVENOUS THERAPY IV Fluid 5% dextrose and 0.3% sodium chloride D50.3%NaCl Classification INDICATION Actions Side Effect NURSING Precaution Dont use in patient with heart failure Edema or hypernatremia because it can lead to overload

Hypertonic

Fluid Challenges Fluid replacement in patient with DKA, hyponatremia shock

Replenish fluid nutrient Carbohydrates and electrolytes

>hypernatre mia

IV Fluid
5% dextrose with multiple balance solution D5IMB

Classification INDICATION

Actions

Side Effect

NURSING Precaution
Do not use to the patient without case of dehydration

Isotonic

For dehydration For patient with respiratory problems ION multiple balance All IONs either positive or negative are present.

Replaces fluid and electrolyte of the body

Increase secretion of anti diuretics hormone

D. THERAPEUTIC MEASURES
PROCEDURE 1. Positioning (High back rest or Fowlers position) INDICATIONS When the client is in this position, gravity pulls the diaphragm downward, allowing greater chest expansion and lung ventilation. Clients confines to bed but capable of eating, watching television or visiting find this procedure comfortable. NURSING PRECAUTIONS > The nurse should not place an overly large pillow or more than one pillow behind the clients head. This error promotes the development of neck flexion contractures. If the client desires several head pillows, the nurse should encourage the client to rest w/out a pillow for several hours each day to extend the neck fully and counteract the effects of poor neck alignment. >Put pillows under forearms to eliminate pull on shoulder and assist venous blood flow from hands and lower extremities. > Keep side rails securely up. For patients falls prevention. >Ensure the patency of the patients nostrils. > Never administer O2 by nasal cannula at more than 2L/min to a patient w/ chronic lung disease unless you have a specific order to do so. 2. Oxygen Administration >Used when patient will need oxygen need oxygen therapy when hypoxia results from a respiratory or cardiac emergency or an increase in metabolic function( offensive for low of concentrations) >Supplies the body w/ enough oxygen to meet its cellular needs.

Cont
PROCEDURE INDICATIONS NURSING PRECAUTIONS > Be alert for signs of over dehydration exhibited by unexplained weight occurring over several days after the beginning of therapy) when using high output nebulizers.

3. Nebulizer Therapy

>Nebulization is a process of adding moisture or medication to inspired air by mixing particles of varying sizes w/ the air. The moisture added to the resp. system through Nebulization improves clearances of pulmonary secretions.

>Aids bronchial hygiene by restoring and maintaining mucous blanket continuity, hydrating dried, retained secretions, promoting expectoration of secretions; humidifying inspired O2; delivering medication.
> Used for administration of bronchodilators and mucolytic agents

D. REFERRALS Respiratory Therapist: -Noel A. Co, RN Pediatrician: -Dr. Estillore Pulmonologist: -Dr. Alonzo

Attending physician: -Dr. Carteciano

E. Prognosis/Current Status of Patient

The patient experiencing CAP manifest signs and symptoms of productive cough, difficulty of breathing, fever and jaundice. CAP is caused by streptococcus Pneumoniae which is normally acquired by inhalation of respiratory secretion through droplets, direct and contact, contact with contaminated hands and fomites. The child must be guided by SOs to facilitate health care process not to aggreviate the childs health status.
(+) intermittent productive cough

CONDITION OF THE PATIENT UPON DISCHARGE:

(-) colds (-) retraction A febrile

HOME MEDICATION: Combivent Nebule 1 nebule every 6 hours for 5 days Cefaclor Suspension 250mg/5ml 5ml every 8 hours for 5 days Zertin syrup 5ml twice a day for 5 days Polynerv syrup 5ml once a day
EXERCISE: Encourage patient with deep breathing exercise with the help of the SO to facilitate expectoration of sputum or discharge. TREATMENT: The patient must cooperate with the maintenance of medication and Nebulization therapy for the continuity of treatment.

HEALTH TEACHING: The patient who has PCAP should practice deep breathing exercise and coughing exercise, at the same she should always cover her nose to avoid allergens such as smoky places that might precipitate the current status. The Significant other especially the mother should guide her daughter in practicing the above guidelines The mother or the other SOs must ensure the patient will follow the discharge orders required for the patient especially the intake of home meds. Teach the patient and SOs to encourage patient to increase oral intake and how it helps the patient in her condition. FOLLOW UP CHECK-UP: October 16, 2009, for patients health status evaluation. DIET: Diet for age (DFA) Patient must follow the diet required for the patient because other food contents might aggreviate her condition.

CUES

PATHOPHYSIO LOGIC BASIS

NURSING DIAGNOS IS

PLANNING

INTERVENTIO N

RATIONALE

EVALUATION

Subjective: Mainit at masakit ang ulo niya, as verbalized by the mother.. Objective: flushed skin febrile 38.9 skin warm to touch not in Respiratory distress conscious, coherent, and ambulatory (-) dehydration irritable

Microorgani sm enters the airway passages Triggers the immune system to fight the foreign objects Neutrophils kills the bacteria As a result of fever, chills and ineffective thermoregulation

Thermo regulation Ineffective related to Disease Process (presence of Bacterial infection) as manifested by elevated body temperature.

After 3 hours of nursing interventio n, the patients body temperatur e will alleviate at normal/des irable level.

Provide tepid sponge bath Change dress into loose clothing Ensure proper room ventilation Advised patient oral fluid intake Administer analgesics as ordered by the physician Ambulate the patient Maintain bed rest

to decrease temperature by means of evaporation and conduction to reduce body temperature to provide cool environment to release heat from he body to facilitate fast recovery

After 3 hours of Nursing intervention, the patients body Temperature alleviated at normal/desirable level. Goal met.

to facilitate blood circulation turn side by side) to metabolic demands/ Oxygen consumption

CUES

PATHOPHYSIOLOGIC BASIS

NURSING DIAGNOSI S

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Hirap huminga ang anak ko dahil sa ubo. As verbalized by the patients mother. Objective: (+) productive cough afebrile 37.4 dyspnic in appearance no cyanosis noted conscious, coherent, and ambulatory GCS 15 (+) crackles Upon auscultation

Microorganism enters the airway passages small blood vessels in the lungs (capillaries) become leaky, and protein-rich fluid seeps into the alveoli

Ineffective Breathing related to Retained secretions in the bronchi.

After 4 hours of nursing intervention, the patient will Loosen secretions in the lungs.

Advise increase fluid intake Perform Chest Physio therapy (Back Tapping) Administer medications as ordered Check the consistency of secretions Instruct patient to expectorate the mucus secretion Provide health teaching regarding the importance of personal hygiene

To liquefy secretion To facilitate expectoratio ns of retained secretions to facilitate fast recovery As baseline data for medication administrati on To prevent further retention of secretions

After 4 hours of nursing Intervention the patients secretion has been loosen and she has been able to breath At tolerable level. Goal partially met

results in a less functional area for oxygencarbon dioxide exchange patient becomes relatively oxygen deprived, while retaining potentially damaging carbon dioxide

Mucus production is increased through the leaky densities

CUES

PATHOPHYSIOLOGIC BASIS

NURSING DIAGNOS IS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Nahihirapan siya huminga dahil sa plema, as verbalized by her mother.

Microorganism enters the airway passages

Objective: (+) productive cough (+) crackles (+) DOB afebrile 37.3
distress restlessness irritability

small blood vessels in the lungs (capillaries) become leaky, and protein-rich fluid seeps into the alveoli

Ineffective Airway Clearance related to presence of Secretions secondary to pneumonia

After 3-4 hours of nursing intervention, the patients respiration will improve and difficulty of breathing will relieved.

results in a less functional area for oxygencarbon dioxide exchange

patient becomes relatively oxygen deprived, while retaining potentially damaging carbon dioxide Mucus production is increased, and the leaky capillaries

Assess patients condition Monitor and record vital signs Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds Assist patient to change position every 30 minutes Elevate head of bed and align head in the middle Provide health teachings regarding effective coughing and deep breathing exercise. Encourage increase fluid intake Encourage steam inhalation Administer medications as ordered

To know and determine patients needs to established baseline data To determine possible bronchospas m or obstruction

To mobilize secretions To facilitate breathing To expel the mucous To liquefy secretions To moisten secretions and alleviate congestion To reduce bronchospas m and mobilize secretions

After 3-4 hours of nursing interventi on, the patients respiratio n has been improved and difficulty of breathing has bbeen relieved. Goal met.

ARRIETA, MA. PAMELA

GUTIERREZ, FROILAN

CABINTOY, AGNES
CASTRILLO, JENELYNN DELOS REYES, RENIER FERNANDEZ, BARBARA

PENALBA, CYRON
LUNAS, JUDITH SABALLO, JEFFREY YUDELMO, RYAN

The beginning of knowledge is the discovery of something we do not understand

- FRANK HERBERT