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Name: H.K.A.G. Age/Sex: 8 year old/Male Address: Gonzaga St.

t.Pavia,Iloilo Religion: Roman Catholic Nationality: Filipino Date of Birth: April 5, 2001 Birth of place: Molo, Iloilo City Informant: E.H

Relationship: Mother

ASSESSMENT

A. Chief complaint: Loss of Consciouseness B. History:

a. history of present illness Two weeks prior to admission. Patient was noted to have intermittent fever, low moderately grade fever of 38-39 degree Celsius, no other associated sign and symptoms noted. Negative cough,negative loss of appetite, positive vomiting One week prior to admission, there is persistence of fever they sought consult and was given Ibuprofen(Dolan) 2.5ml every 6 hours,and was noted to give temporary relief. On the day of admission, there is still persistence of fever they sought consult and was given advise for admission. b. Past medical History Negative previous hospitalization Positive bronchial asthma- given Co-amoxiclav (3 weeks prior to admission) patient 4 months.

C. Physical Examination General Assessment Skin-Brown Complexion, varies from light to deep brown, generally uniform, no edema, no abrasion, no lesion, excessive moisture, localized hyperthermia, when pinched skins goes back to previous state Level of Consciousness-conscious, oriented, response immediately. Body Built-weight: 11kilogram, height-90cm Mental-Emotional status- stressful , irritable, emotional Speech-unclear, still not able to speak fluently Body Movement-Move in full range of motion Hygiene and Grooming- good body hygiene. Specific Assessment: Head-Elongated head symmetrical Eyes-Eyebrows hair are evenly distributed, with equal movement. Eyelashes are equally distributed ,curled slightly outward ,Eyelids skin is intact with discharges, sclera appears yellowish, pupils are black, equal in size normally 3-7mm diameter, round

Ears-color same as facial skin, symmetrical, contains hair follicles, dry cerumen, tympanic pearly gray color ,semi transparent, normal tone audible, able to hear in both ears, sound is heard in both ears. Nose-Symmetric and straight with discharges, uniform in color, not tender, no lesion, air movement is restricted in one or both nares, clear watery discharges. Mouth- Uniform pink color, soft, moist smooth texture, symmetry of contour, with 6 baby teeth, pink gums, no retraction, pink tongue ,moist, slightly rough smooth, no lesion, no tenderness Neck-Muscles equal in size, lead centered, coordinated smooth movements, with no discomfort, no enlargement of lymph nodes, palpable lymph nodes. Chest- flat, symmetrical, crackles heard upon auscultation Abdomen-unblemished skin, uniform color, symmetric contour, flat rounded, soft, no tenderness noted, umbilicus is centrally locatedBackSpinal cord are aligned, no lesion, no tenderness Upper extremities- with full range of motion, with swelling at the right metacarpal, uniform skin color, warm to touch temperature 39.4 degrees Celsius per axilla. Lower extremities- With full range of motion, no edema, uniform skin color no tenderness. Genito-anal area- able to void 30cc/hr, rashes noted between

PATHOPHYSIOLOGY

Modifiable modifiable environment nature


BACTERIA AIRBORNE DROPLETS

Non age gender

NOSE, MOUTH, SINUSES PASSES THROUGH THE BLOODSTREAM

LUNGS ACUTE INFLAMMATION OF THE WALLS OF BRONCHIOLES INVADES THE SPACES BETWEEN CELLSAND ALVEOLI THROUGH CONNECTING PORES TRIGGERS IMMNUE SYSTEM TO SEND NEUTROPHILS ENGULF AND KILL THE OFFENDING ORGANISM AND RELEASE CYTOKINASE

LEADS TO FEVER CHILLS AN D FATIGUE BACTERIA AND FLUID SURROUNDING THE BLOOD VESSEL FILLS THE ALVEOLI AND INTERRUPT THE OXYGEN TRANSPORTATION

LABORATORIES

January 9,2009 Myoblast Promyelocytes Myelocytes 0% 0% 0% WBC: 25.8x10 9/L Hemoglobin 7.2gms/dL Hematocrit 24.0vol% Platelets Neutrophils Eosinophils Basophils Metamyelocytes 0% 0% 0% MCV-720 MCH-230a MCHC-29 Neutrophilic Eosinophilic Basophilic Neutrophils S Stabs Eosinophils Basophils Monocytes Lymphocytes Total (2) 5% 0% 3% 14% 100% S Segments (76) 0% 0% 0% 78% 392x10 9/L

RBC- gnerally micicyrocytic-hyprochonic, mild anistosis, no

polychnesia, no fragments, no nombrlast.


WBC- invased with predominances of neutrophils , no toxic granules,

lymphocytes, eosinophils slightly increased, no evidence of leukemia.


PLATELETS- adequate and of normal morphology

Remarks:Microcyte, hypochronic anemia, moderate leukocytes with neutrophilic and mild eosinophilia normal platelet number

January 10,a2009 Time released: Bloodtype: A+Rb Serial No. 807603 Volume: 196 cc Saline Phase: Albumin Phase: Anti-human globulin:

HEMATOLOGY

RESULT Hemoglobin 109g/L

NORMAL VALUE 135-180g/l

INDICATION Decrease of hemoglobin leads to symptoms of anemia. A condition in which your body is not getting enough oxygen, causing fatigue and weakness Decrease amount may indicate hemorrhage and blood diseases involving red blood cell NORMAL Increase may indicate bacterial infection or Drug Infection A decreased lymphocyte count of less than 500 places a patient at very high risk of infection, particularly viral infections and anemia. NORMAL Decreased by viral or fungal infection Normal.

Erythrocyte, volfr

o.3L/L

0.40-0.54l/l

Erythrocyte,numc Segmentor Neutophils Lymphocyte

4.70x 10 12/L 0.87 o.10

4.6-6.2x10 12/l 0.05-0.7 o.22-0.40

Eosinophils Monocytes Basophils Total

0.01 0.00 0.00 1.00

0,01-0.04 0.03-0.08 0.00-0.001

January 9, 2009 PM
Hemoglobin

Time extracted:5:15 PM
NORMAL VALUE 135-180g/l

Time released: 6:45


INDICATION Decrease of hemoglobin leads to symptoms of anemia. A condition in which your body is not getting enough oxygen, causing fatigue and weakness.amount may Decrease indicate hemorrhage and blood diseases involving red blood cell

RESULT 67g/l

E Erythrocyte,(Fe)

9.23l/l

0.40-0.54l/l

Erythrocyte,numc

2.97x10 12/l

4.6-6.2x10 12/l

Decrease may lead to hemorrhage. Severe blood loss may cause anemia. Increase may indicate bacterial infection.Leukocytosis increase leukocyte/WBC. A decreased lymphocyte count of less than 500 places a patient at very high risk of infection, particularly viral infections and anemia. Normal. Decreased by viral or fungal Normal.

Segmentor Neutophils Lymphocyte

0.87

0.05-0.7

0.12

o.22-0.40

Eosinopshils Monocytes Basophils

0.01 o.00 0.00 1.00

0,01-0.04 0.03-0.08 0.00-0.001

RESULT Hemoglobin 126g/L

NORMAL VALUE 135-180g/l

INDICATION Decrease of hemoglobin leads to symptoms of anemia. A condition in which your body is not getting enough oxygen, causing fatigue and weakness. Decrease amount may indicate hemorrhage and blood diseases involving red blood cell Decrease amount may lead to hemorrhage. Severe blood loss may cause anemia Increase may indicate bacterial infection or Drug Infection A decreased lymphocyte count of less than 500 places a patient at very high risk of infection, particularly viral infections and anemia. Decreases in the eosinophil count maybe seen when a patient is receiving in a corticosteroid drug. Decreased by viral or fungal infection Normal. Normal.

Erythrocyte, volfr

0.37l/l

0.40-0.54l/l

Erythrocyte,numc

3.90x 10 12/L

4.6-6.2x10 12/l

Segmentor Neutophils Lymphocyte

0.83 o.09

0.05-0.7 o.22-0.40

Eosinophils

0.00

0,01-0.04

Monocytes Basophils Total Thrombocytes

0.00 0.00 1.00 300x10 9/1

0.03-0.08 0.00-0.001 150-450x10 9/1

RESULT Hemoglobin 107g/L

NORMAL VALUE 135-180g/l

INDICATION Decrease of hemoglobin leads to symptoms of anemia. A condition in which your body is not getting enough oxygen, causing fatigue and weakness. Decrease amount may indicate hemorrhage and blood diseases involving red blood cell amount may lead to Decrease hemorrhage. Severe blood loss may cause anemia. Increase may indicate bacterial infection or sepsis, viral, fungal or parasitic infection. Leukocytosis increase leukocyte or WBC. Increase may indicate acute bacterial infection. It may increase Normal. due to inflammatory processes. Increase may indicate erythematous. Lymphocytes increase in many viral infections with tuberculosis. Normal.

Erythrocyte, volfr

0.31l/l

0.40-0.54l/l

Erythrocyte,numc Leukocyte, numc Band Neutrophils

3.28x 10 12/L 12.70x10 9/1 0.01

4.6-6.2x10 12/l 4.5-11x10 9/1 o.o2-0.05

Segmentor Neutrophils Lymphocyte

0.55 o.42

0.05-0.7 o.22-0.40

Eosinophils

0.001

0,01-0.04

sBasophils Total Thrombocytes

0.00 ____ 1.00 566x10 9/1

0.00-0.001

Normal.

150-450x10 9/1

Normal.

DRUG STUDY

Prescribed Drug (Dosage, Route, Frequency, T Timing) Mupirocin Frequency: BID Timing: 11 6 Brand Name: Foskin Ointment

Classification and Mechanism of Action

Indication and Contraindication

Side effects or Adverse Reactions

Special Precautions

Nursing Responsibility

Classification: Dermatologicals Mechanism of Action: Binds to bacterial isoleucyl transfer RNA synthetase, which results ton inhibition of bacterial protein synthesis.

Indication: Topical treatment of impetigo, folliculitis, ecthyma, infected dermatoses, infected abrasions, insect bites, minor wounds and burns. Prophylaxis to prevent bacterial contamination of small cuts and wounds abrasions, incisions, and other clean lesions. Contraindications: Hypersensitivity. Not for opthalmic use.

Localized burning, stinging, and itching.

In case of sensitivity or chemical irritation, discontinue use and institute appropriate alternative therapy. Prolonged use may result in over growth of non susceptible organisms, including fungi. Avoid contact with eyes.

Check doctors order. Observe ten rights in giving medication. Assess for allergic reaction: burning, stinging, swelling, redness. Monitor for possible induced adverse reactions: Topical: headache, rash, abdominal pain, burning, stinging, itching, erythema, swelling, dermatitis, increased exudates.

Prescribed Drug (Dosage, Route, Frequency, T Timing) Meropenem Dosage: 450mg Route: IVTT Frequency: Q8H Timing: 14 12

Classification and Mechanism of Action

Indication and Contraindicatio n

Side effects or Adverse Reactions

Special Precautions

Nursing Responsibility

Classification: Anti-infectives Mechanism of Action: Bactericidal, it interferes with bacterial cell wall replication of susceptible organisms at readily penetrates the cell wall of most gram negative and gram positive bacteria to reach penicillin-binding protein targets where it inhibits cell wall synthesis to render the cell wall osmotically unstable.

Indication: Treatment of infections caused or multiple susceptible bacteria sensitive to meropenem. Pneumonia including hospital acquired, septicemia, nuetropenia, intra-abdominal infections, meningitis, urinary tract, gynecological, and skin and soft tissue infections.

Imflammation: Trombophlebitis and pain at the site of injection. Rash, pruritus, urticaria. Abdominal pain, nausea and vomiting , diarrhea, headache, paresthesia, oral candidiasis.

History of Gastrointestinal complaints, particularly colitis.

Check doctors orders Observe 10 rights in giving medication. Assess patient for previous sensitivity reaction to carbapenem antibiotics, penicillins, cephalosporinsv, and other betalactants.

Prescribed Drug (Dosage, Route, Frequency, Dephyhyndramin T Timing) Hcl Dosage: 3 ml/5ml Frequency: Q8h Timing: 8 4 12 Brand name: Benadryl Elixer or syrup

Classification and Mechanism of Action Classification: Anti-allergics Mechanism of Action: Acts on blood vessels, GI, respiratory system by antagonizing the effects of histamine for H1receptor site; decreases allergic response by blocking histamine; causes heart rate, vasodilation, secretions

Indication and Contraindication

Side effects or Adverse Reactions Orthostatic hypotension; palpitations; bradycardia; tachycardia; extra systoles; faintness;. Drowsiness; sedation; dizziness; disturbed coordination. Nasal stuffiness; dry mouth; sore throat. Epigastric distress; nausea; vomiting; constipation; change in bowel habits.

Special Precautions

Nursing Responsibility

Indication: It used for symptomatic relief of allergic reactions including urticaria, and angiodema, rhinitis, and conjunctivitis, and in pruritic skin disorders. Contraindication: Hypersensitivity to antihistamines.

May cause drowsiness and dulling of mental alertness.

Check doctors order. Observe 10 rights in giving medication. Assess respiratory status: rate rhythm, and increased in bronchial secretions, wheezing, and chest tightness: provide fluids 2 liter per day to decrease secretion thickness. Assess the degree of itching, skin rash, and inflammation. Assess nausea, vomiting,

Prescribed Drug (Dosage, Route, Frequency, T Timing) Ampicillin Dosage: 330mg Route: IVTT Frequency: Q8h Timing: 8 4 12 Brand name: Ampicin

Classification and Mechanism of Action

Indication and Contraindicatio n

Side effects or Adverse Reactions

Special Precautions

Nursing Responsibility

Classification: Anti-infectives Mechanism of Action: Interferes with cell wall synthesis of susceptible organism, preventing bacterial multiplication, it also renders to cell wall osmotically unstable and burst due to osmotic pressure. Deactivated by betalactamase, an enzyme produced by resistant bacteria.

Indication: Treatment of respiratory tract and soft tissue infections, bacterial meningitis, septicimia and gonococcal infections caused by susceptible microorganism. Contraindication: Hypersensitivity to penicillin, cephalosporin's or emipenem .

Thrombophlebitis at injection site, dizziness, fatigue, insomnia, reversible hyperactivity, neurotoxicity(leth argy neuromuscular, irritability, hallucinations, convulsions, seizures), urticaria.

Use cautiously in cephalosporinsensitive patient because of possible crossallergenity. Super infection: may result in overgrowth of no susceptible bacterial or fungal organism.

Check doctors orders. Observe 10 rights in giving medication.

Prescribed Drug (Dosage, Route, Frequency, Ibupropen Timing)tee Dosage: 100mg/5ml Frequency: Q6H RTC 12 6 12 6 Brand name: Dolan

Classification and Mechanism of Action Classification: Analgesics Mechanism of Action: Inhibition of prostaglandin synthesis by decreasing enzyme needed for biosynthesis; decreased pain and inflammation, reduction of fever.

Indication and Contraindicatio n Indication: Reduction of fever. Contraindication: Hypersensitivity to Ibuprofen.

Side effects or Adverse Reactions Allergic reaction, redness and swelling at the painful area. GI disturbances including dyspepsia, nausea, heartburn, anorexia, diarrhea, constipation, flatulence, bloating, epigastric, and abdominal pain. Renal, hepatic, CNS, otic, and ocular, dermatologic effects, and fluid retention, increased blood pressure, hypotension, cerebrovascular accident and palpitations.

Special Precautions

Nursing Responsibility

Hypersensitivity. Severe allergic reaction. Do not use more than 3 days.

Check doctors order. Observe 10 rights in giving medication. Monitor patient temperature, note signs associated with fever(diaphosis, malaise, and t tachycardia) Assess for allergic reactions: rash, urticaria: if these occur drug may have to be discontinued. Check input and output ratio: decreasing output may indicate renal failure if patient is long-term therapy.

Prescribed Drug (Dosage, Route, Frequency, Timing)tee Ceelin Dosage: 2.5ml Route: Oral Frequency: OD Timing: 8 Brand Name: Ascorbic acid

Classification and Mechanism of Action

Indication and Contraindicatio n

Side effects or Adverse Reactions

Special Precautions

Nursing Responsibility

Classification: Dietary/Nutrition al Preparations Mechanism Action: Needed for wound healing, collagen synthesis, antioxidant, carbohydrate metabolism, protein, lipid synthesis, prevention of infection.

Indication: Enhance bodys natural immune system function.

Faintness, dizziness, diarrhea, heartburn, nausea, vomiting, acid urine, oxaluria, renal calculi, discomfort at injection site.

The risk category will be C only if used in dosages above RDA. Phynelketonurics - this product contain phenylalanine as one of the metabolites of aspartame.

Check doctor's order. Observe 10 rights in giving medication. Assess for Vitamin C deficiency before, during, and after treatment: scurvy (gingivitis, bleeding gums, loose teeth): poor bone development. Monitor outputinput ratio: polyuria.

Prescribed Drug (Dosage, Route, Frequency, Timing)tee Clarithromycin Dosage: 125mg/5ml Route: Oral Frequency: BID Timing: 86

Classification and Mechanism of Action

Indication and Contraindicatio n

Side effects or Adverse Reactions

Special Precautions

Nursing Responsibility

Classification: Miscellaneous Anti-infectives. Mechanism of Action: A microlide antibiotic that is derivative of erythromycin. Binds to the 50S submit of bacterial ribosome, blocking protein synthesis. Bacteriostatic of bactericidal, depending on concentration.

Indication: Indicated for the treatment of mild to moderate infections cause by susceptible strains of the designated microorganisms. Contraindication: Contraindicated in patient with hypersensitivity to erythromycin or other macrolides.

Common reactions are in italics; life threatening reactions are in bold italics. Headache. Diarrhea, nausea, abnormal taste, dyspepsia, abdominal pain or discomfort.

Obtain specimen for culture and sensitivity test before first dose. Therapy may begin pending test results. Drug may be taken without regard to meals.

Check doctors order. Observe ten rights in giving medications. Tell patient to take all medication prescribed, even after even he feels better.

Prescribed Drug (Dosage, Route, Frequency, Timing)tee Ferrous sulfate Dosage: 1 ml Route: Oral Frequency: TID Timing: 11 6 Brand Name: Ferlin drops

Classification and Mechanism of Action

Indication and Contraindicatio n

Side effects or Adverse Reactions

Special Precautions

Nursing Responsibilitya

Classification: Dietary/Nutrition al Preparation. Mechanism of Action: Provides/Replace s elemental iron, an essential component in formation of hemoglobin in red blood cell development.

Indication: Prevention and treatment of iron deficiency anemia. Contraindication: Hypersensitivity to any ingredient, hemosiderosis. Hemolytic anemia.

Gastrointestinal irritation, anorexia, vomiting, diarrhea, constipation, dark stool.

Use cautiously in peptic ulcer, ulcerative colitis, and regional enteritis. Use cautiously in long term basis.

Check doctors order. Observe ten rights in giving medication. Obtain baseline assessment of iron deficiency before starting therapy. Monitor for any adverse reactions: Gastrointestinal: nausea, epigastric pain, constipation, diarrhea, black stool, anorexia.

Prescribed Drug Classification and Indication and Side effects or (Dosage, Route, Mechanism of contraindication Adverse Frequency, Action Reactions Timing)tee

Special precaution

Nursing Responsibility

Albuterol Dosage: I nebule Frequency: Q8H Timing: 8 4 12 Brand name: Salbutamol

Classification bronchodilator

Indication: Headache, Use cautiously in Check Doctors Prevention and dizziness, light cardiovascular order treatment of headedness, disorder, including Observe 10 rights Mechanism of bronchospasm in insomnia, tremor or coronary in giving action: patients with nervousness,sweati insuffiency and medication relaxes bronchial reversible ng, nausea, hypertension, in and uterine smooth obstructive airway vomiting or dirrhea hyperthyroidism or Warn patient about muscle by acting disease or dry mouth diabetes mellitus the possibility of on beta 2 and in patients who paradoxical adrenergic Contraindication: are usually bronchospasm, receptors Hypertonic saline responsive to discontinue if this will provoke cough adrenergics occurs in some patients. It is harsh on the Teach patient how airways and may to perform oral trigger severe inhalation correctly bronchospasm. It will not be used in patient with known airway hypersensitivity.pat ients who experience severe bronchospasm after a sputum induction may be candidate.

Prescribed Drug Classification and Indication and Side effects or (Dosage, Route, Mechanism of contraindication Adverse Frequency, Action Reactions Timing)tee

Special precaution

Nursing Responsibility

Ceftazidine Dosage: 330mg Route: IVTT Frequency: Q8H Timing: 8 4 12 Brand name: Ziptrigen/Fortum

Classification: Cephalosporins

Indication: Headaches, Use cautiously to Treatment of the dizziness, dyspnea, patients with serious infection of elevated history of Mechanism of the lower temperature sensitivity to action: respiratory and penicillin Inhibits cell wall urinary tract, synthesis, gynecologic promoting osmotic infections, instability, usually bactenemia, bactericidal septicemia,intra abdominal infection Contraindication: Hypersensitiv to other cephalosporons

Check Doctors order observe 10 rights in giving medication with large doses or prolonged therapy, monitor for infection especially in high risk patients.

Prescribed Drug Classification and Indication and Side effects or (Dosage, Route, Mechanism of contraindication Adverse Frequency, Action Reactions Timing)tee or 200mm

Special precaution

Nursing Responsibility

Paracetamol Dosage: 11o mg Route: IVTT Frequency: Q4H

Classification: Analgesics

Indication: Stimulation, Treatment for fever drowsiness, nausea, vomiting, Mechanism of Contraindication: abdominal pain, action: hypersensitivity hepatoxocity, Decrease fever by hepatic inhbiting the seizure(overdose), effects of pyrogen renal failure on the hypothalamic heat regulating center and by hypothalamic action leading to sweating and vasodilation

The toxic dose of Checks Doctors paracetamol is Order highly variable. In adults, single doses Observe 10t rights above 10 grams or in giving 200mg/kg of body medication weight, which ever is lower, hve a Assess patients for reasonavle frver, temperature, likelihood of diaphoresis causing toxicity. Assess allergic reactions: rash, uticaraia, if these occurs drug may have to be dicontinued Assess for chronic poisoning, rapid weak pulse, dyspnea, cold and clammy extremities, rreport immediately to describer

NURSING CARE PLAN

Defining characterist ic masakit na gid nga indi ko ma agwantahan ang lower portion sang akon hawak as verbalized.

Diagnosis Lumbo sacral pain related to labor.

Goals of Care GENERAL OBJECTIVES: After 4 hours of intervention client: would have less discomfort during the first stage of labor. SPECIFIC OBJECTIVES: After 2 hours of intervention client: may verbalize less discomfort, diminished facial grimace, able to divert attention

Intervention INDEPENDENT : Assist client to her most comfortable position. Encourage verbalization of feelings provide emotional and spiritual support.

Rationale

Evaluation Goals fully met, after the delivery of fetal head and later the delivery of the fetus pain is absolutely relieved as evidence by patient verbalizes baw daw na haw-asan man ako kag nag mag.an akon pamatyag. BP: 180/20 Pain scale of 3 out of 10.

OBJECTIVE: Facial grimace noted Increase bloody show 7 cm cervical dilatation upon internal examination by physician on duty. BP: 130/90

RATIONALE: As cervical dilatation increases, the pressure of the fetal head on the pelvic area does it causes pain.

Diverting attention of a woman who is in labor pain is the most effective way to lessen pain since we all know that the increase of cervical dilatation also increases the pressure of fetal head to pelvic area which causes pain.

Defining characterist ic January 12, 2009 Subjective: Laka lang gid siya mag-ubo as verbalized by the mother Objective: Occasional cough noted Respiration rate: 48 breaths per minute Breathing: abnormal rate with wheezing sound upon auscultatio n Irritability restlessnes s

Diagnosis

Goals of Care

Intervention

Rationale

Evaluation

Ineffective airway clearance related to retained mucus secretion Rationale: Pathogenic organism such as bacteria enters the body through different portals. This invades specific parts in the body where infection occurs as an e inflammation response. White blood cells as secondary defense act upon it by engulfing this organism through the process of phagocytosis causing cell death then mucus secretion are produced. Increase in amount blocks airway passages which make breathing pattern ineffective. References 1.Nurses Pocket Giude Diagnosis, Prioriize interventions and Rationales by Marilyn E. Doenges, Mary Frances Moorhouse, Alice C. Murr 2.Medical-Surgical

General: after 2 weeks of nursing interventions, the patient will be able to maintain airway patency. Specific: After 8 hours of nursing interventions the patient will be able to: 1.Expectorate the mucus secretions 2.Improve breathing pattern 3.Demonstrat e the behaviors to improve clear airway 4.Able to rest and sleep

Independent: Asses for characteristic of cough to elevate head using pillows To increase oral fluid intake Chest tapping done after nebulization Observe for signs and symptoms of infection Dependent: Pulmo Aid Inhalation given as ordered, Salbutamol 1 Nebule Q8H

To assess changes and note possible complications To maintain adequate airway patency To help liquefy secretions To help loosen secretions into central airways To identify infection process and promote timely intervention To reduce bronchospasm, opening tight or congested airways and facilitating ventilation. It also dilate bronchioles and improve breathing.

Occasional cough still noted Patient was able to improve breathing Patient able to drink plenty of fluids Able spit out whitish phlegm. Approximately teaspoon per day No possible infection noted

Demonstrate improve airway. Able to rest and sleep after nebulization.

Defining characteristic January 12,2009 Subjected: Ginahilant naman siya as verbalized by the mother.

Diagnosis

Goals of Care

Intervention

Rationale

Evaluation

Body temperature General: Independent: elevated above after 2 weeks Continuous sponge normal range related of nursing bathing was to lung infection intervention the performed patient will be Rationale: able to maintain Increased oral fluid Objecive: Pathogens may body intake Temperature -39.4 enter the body temperature degrees Celsius through respiratory within normal Respiration rate: 48tract. This is inhaled range Provided adequate breaths per minute by a susceptible host rest and sleep Skin warm to touch that localize in the Specific: Cardiac rate: 150 lungs or distributed after 8 hours Monitored rate and beats per minute via lymphatic system of nursing cardiac rate or bloodstream. A intervention the leukocyte, patient will be particularly is able to: responsible for 1.Lower body Dependent: engulfing, killing and temperature as PRN medication disposing the 37 degrees was given: invading organism in Celsius Paracetamol drops the process of 2.Respiratory (Tempra) 1.2 ml phagocytosis. rate in the range Q4H as needed for phagocytic pyrogens of 30-40 breaths fever released endogenous per minute pyrogens that cause 3.Able to rest and the hypothalamus to sleep increase body temperature Refernce: Administered Medical Surgical replacement of Nursing by fluids and Ignativicius and electrolytes Workman

To increase heat Decreased body loss by evaporation temperature from and conduction 39.4 to 37. 4 degrees Celsius To replace fluid Patient was able to lose and prevent drink fluid dehydration approximately 1000ml per day To reduce Able to rest and metabolic rate and sleep oxygen consumption Respiration rate of To note the 36 breath s per changes whether minute and cardiac there is rate of 130 beats improvement or per minute nothing Body temperature was decreased to Decreases fever by 37.4 degrees inhibiting the Celsius and effects of pyrogen sweating noted on the hypothalamic heat regulating center. Also by hypothalamic action leading to sweating and vasodilation Intravenous Fluid To support was infusing circulating volume and tissue perfusion

DISCHARGE PLAN

General Objective:

To enable the folks to provide continuity of care at home with the absence of health workers and to educate them for further clients health management. Specific Objective:

1) To teach the mother the knowledge about the disease. 2) To give information on how to prevent the reoccurrence of the present condition. 3) Give instruction on how to manage fever at home.

Knowledge about the Disease

Fever is the elevation of the temperature above normal due to a disturbance of the heart regulating center. It is an indication of a pathological process within the body. The onset of fever maybe accompanied by a subjective sense of malaise, fatigue, loss of appetite, headache and generalized and pains of mild degree. Of the onset is rapid, the symptoms includes chills, occasional nausea and vomiting and mental changes ranging from mild confusion to delirium. The patient usually feel cold even if his temperature is above normal fever is classified into three, intermittent, remittent and relapsing. Intermittent fever is one which the temperature falls to normal and rises within 24 hours while later manifest a variation of 1 or 2 degrees but does not reach the normal within 24 hours, while relapsing fever occurs when there are alternating periods of 1 or several days of normal and elevated temperature.

Personal Hygiene

When there is a fever the mouth becomes very dry and a source of discomfort to the patient with fever. We will tell the folks to clean and rinsed with a mild antiseptic solution every 2 hours. Vaseline, or cold cream maybe applied to the lips to prevent cracking. It is also to prevent the development of herpes and other viral disease. Frequent bathing is also advised because of the increase perspiration and to minimize the spread of microorganisms. Advice folks to take care of the skin by daily use of soap and water.

Activities of Daily Living Medication and Treatment

After the temperature return to normal the patient should remain in bed for atleast 24 hours. This is to protect the heart from exertion at the time when it is fired.

If the patient is experiencing chills, advise mother to cover him with warm blanket. If the temperature is very high sponging the surface of the body with a cold solution of 35% alcohol in water or may apply ice bags to the head or axillae. Room should be kept cool and ventilated. Hydrotherapy is also recommended.

Medications Follow-up Visit

Paracetamol (Dolan) 10 ml for fever C Clarithromycin (Klaricid) 125 mg/5 ml 3.5ml twice a day for 7 days (8am-6pm) C Cititrizine (Zytec) oral suspension, 1ml twice a day to consume stocks (8am-6pm)

Remind mother to their follow-up check-up as indicated by the doctor on January 27, 2009 and advise her to report any untoward signs and symptoms even before the date schedules.