NURSING HEALTH HISTORY

A. Biographical Data Name: Jaissen Malong Address: Sitio Daang Bakal Sta Cruz Guiguinto, Bulacan Age: 1 year and 2 months old. Sex: Female Race: Filipino Marital Status: Single Occupation: None Religious Orientation: Roman Catholic Health Care Financing and Usual Source of Medical Care: None B. Chief Complaint or Reason for Visit The patient was brought to the hospital due to cough, colds, fever and diarrhea. C. History of Present Illness As narrated by the client’s mother, one week prior to admission the patient developed on and off fever with cough and colds. The patient also passes out soft stools but no consult done. The patient was given paracetamol and carboceistein. They brought her to the hospital for further medication and management last morning of September 21, 2009. She was then diagnosed with Broncho Pneumonia; the physician prescribed her with Paracetamol drops every 9 hours, Vitamin K TIV (thru intravenous) and Combivent Nebulizer q8 (every 8 hours). D. Past history Upon interview, her mother told the student nurses that Jaissen does have a complete immunization. She has also no other diseases from past except from some fevers. She has no known allergies. Prior to admission she was taking multivitamins as her dietary supplement.

E. Family History of Illness The patient’s grandmother has history of high blood pressure, one of her aunt from the mother’s side and grandfather from her father’s side have a history of Tuberculosis. One of her aunt in her mother’s side is clubfooted.

F. Functional Health Pattern Psychological 1. Self Perception-Self Concept Pattern As stated by the client’s mother as part of their health maintenance she is always giving her child with supplements such as multivitamins and giving her appropriate foods for her growth. She also brings her child to the hospital when home remedy is not effective. The only family member in their house who’s using tobacco is the client’s father. 2. Role Relationship Pattern She has a very close bond with her family especially with her mother since she takes care of her 24/7. She is the first and only child in her family. Her mother said that she is a very sweet child. 3. Sexuality and Reproductive Pattern N/A 4. Cognitive Perceptual Pattern As stated by the patient’s mother, the patient is normal in terms of her cognitive abilities. She has good memory and she obeys simple commands. She has no problem with her senses.

5. Coping Stress Tolerance Pattern Her mother said that she usually cry and have tantrums when something is wrong or when she is not feeling well. Value Belief Pattern She is a Roman Catholic and her parents bring her to mass every Sunday. They teach her to believe and fear God. They usually believe in quack doctors. Elimination The client’s bowel movement PTA was 2-3 times a day. A week before hospitalization the client’s bowel movement was 6 times a day, with soft and watery stools. After admission, the patient’s bowel movement goes back to normal to 2-3 times a day. She urinates frequently with a 6 diaper pad change a day. The client has no excess perspiration and no odor problems. Rest and Activity The client sleeps approximately about 9-10 hours during night time. She has no problem in sleeping. She doesn’t take naps during morning and afternoon. Activity-Exercise Pattern According to the mother, PTA the client is very fond of watching educational television shows like Barney and Friend. She’s also fond of playing with her doll and the patient is “napaka likot” as verbalized by the mother. In the hospital the client is unable to move freely due to her health condition and her IV infusion. Because of her young age and her condition she requires assistance and supervision from her parents in all her daily activities. Nutritional and Metabolic Pattern Prior to hospitalization Jaissen’s usual food intake are milk, porridge, rice with soups and she’s also fond of eating biscuits, drinking zesto and other juice products. At the hospital she was advised to eat porridge, apple, banana and crackers. She is currently having +5cc distilled H2O very slow IV push every 8 hours. The only skin problem was dry and cracked lips due to the disease process.

Patient’s Name: Jaissen Malong Age: 1 yr. and 3 months Civil Status: Single Gender: Female Religion: Roman Catholic Nationality: Filipino Address: Sitio Daang Bakal Sta Cruz, Guiguinto, Bulacan PHYSICAL ASSESSMENT GENERAL SURVEY: A. State of Awareness: Patient is alert and responsive to environment and to external stimuli. B. There are no signs of respiratory distress, pain, but is a little anxious when touched and assessed by a stranger. C. Gait was not assessed because child was either lying or sitting during the whole time of assessment. D. Good Posture. E. There are no signs of immobility or other unnecessary or not purposeful movements. F. Hair is clean cut, used fresh clothes with no noticeable body odor but nails are clean. G. Speech is not clear but speaks 1 to 2 syllabic words that are simple. H. Mood is unpredictable, sometimes cooperative and sometimes not. But the child smiles or cries in accordance to his mood. INTEGUMENTARY SYSTEM Health History:  mother verbalized, “minsan nagkakaroon ng rashes dahil sa diaper.”

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The usual diaper brand name: Pampers. No food or medication allergies They have pets at home. (Dog and Cat) Patient has a stuffed animal toy. white skin color all over the body well-hydrated, perspiration was noted warm to touch smooth, soft and even easily lifted and turned back immediately to its normal state in less than 2 seconds

Skin • • • • •

Hair and Scalp • • • • Nails • • • Nail bed is pink but the translucent, white tips were free of dirt Uniformly thick and at a constant rate the shape is well-rounded and convex with a 160 degree-angle Hair is evenly distributed No presence of lice, dandruffs or nits. Hair was cut cleanly. Scalp is smooth and inelastic without the presence of lesions and nodules

RESPIRATORY SYSTEM Health History:  Heredofamilial disease: none  Had a non-productive cough PTA  Father is smoking but not anywhere near the house Posterior Chest • • • • • • • No presence of lesions and color is the same all throughout the body Thorax is symmetrical No bulging or active movement during breathing Anteroposterior diameter is 1/3-1/2 of the transverse diameter No lumps, masses or pulsations noted upon palpation Resonant sounds were felt over the lung fields and Dullness over the peripheral lung fields Bronchovesicular sounds were heard over the lung fields and vesicular sounds over the lung periphery without any adventitious sounds.

Bronchial sound was heard at the suprasternal notch, brochovesicular sounds were heard over the lung fields, and vesicular sounds over the lung periphery

CARDIOVASCULAR SYSTEM Health History:  Heredofamilial disease: Hypertension (Paternal Grandmother)  No presence of discoloration (blueness) when child is crying  No growth delay • • • • • • No visible signs of pulsations No presence of nodules and lumps Flat sounds were felt upon percussion over the bony areas and dull sounds were felt over the heart. S1 was best heard at the Mitral artery (5th ICS midclavicular line), and S2 was best heard over the pulmonic artery. No heart mumurs were heard Pulse rate = 100bpm, bounding and palpable

Anterior Chest • • • • • • RR = 30 cpm, regular , normal breathing without the use of accessory muscles Abdominal breather Protuberant tummy Symmetrical expansion upon inspiration and expiration No bulging No lumps, masses, or pulsations upon palpation MATURATION OF SYSTEMS:  Respiration is slightly slow compared during infancy period  Prone to develop upper respiratory tract infections due to short and straight internal structures of the ear and throat  Heart rate slows from 110-90, approximately  Brain develops about 90% of its adult size  Stomach has increased capacity, secretions become more acidic and GI infections becomes less common

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Complete myelination makes the control of the urinary and anal sphincters Passive immunity obtained during intrauterine life is no longer operative because IgG and IgM antibodies becomes slowly mature

COGNITION / LANGUAGE:  Cognitive Development o Stage 5 – 3P Circular Reaction  Tries to discover ways to handle objects to find new results  Involving trial and error experimentation  Patient was curious about her IV Infusion. She keeps looking at the bottle of IV.  Language Development o Uses one word sentences or holophrase or two-word  “ma-ma” “pa-pa”

DEVELOPMENTAL MILESTONE:  Gross Motor Development o Walks alone with wide stance for extra balance o Seats self on a chair o Can run  Fine Motor Development o Able to grasp a very small object IMMUNIZATION:  3 shots of Hepatitis B  BCG  OPV  DPT  Measles  Chicken Pox  Rotavirus Vaccine

NURSING CARE PLAN
Problem: Cough and Colds Nursing Diagnosis: Ineffective airway clearance related to increased mucus production secondary to broncho pneumonia Taxonomy: Activity-Exercise Pattern CUES OBJECTIVES Short Term Objectives After 8 hours of duty and appropriate nursing care interventions, the patient will be able to demonstrate behavior to achieve airway clearance and will have an improved condition Long Term Objectives Objective Cues Patient has occasional non-productive cough - RR 30 cpm - decreased sound on left chest - pt appears weak - patient looks to be lacking sleep - harsh breath sounds After 3 days of duty and appropriate nursing interventions the patient will be able to appear relaxed, noticeable improvement in airway clearance. NURSING INTERVENTIONS Independent Assessed/monitored vital signs Changes in vital signs may indicate acute pain or discomfort Improves circulation, reduces muscle tension and anxiety associated with pain. Enhances well-being Deep breathing facilitates maximum expansion of the lungs/smaller airways - Cough can be persistent but ineffective especially if the patient is elderly Patient was able to verbalize, “ ok na yung paghinga niya.maluwag na. Di na din siya inuubo ” RATIONALE EVALUATION

Subjective Cues “sobra yung ubo niya,” as verbalized by patient’s mother

Provided additional comfort measures like backrub, heat/cold application Assisted patient with deep breathing exercises

Observed characteristic of cough e.g. persistent, moist, etc. Assisted with measures to improve effectiveness of cough effort - Encouraged intake of fluid of 3000 ml per day - Encouraged/assisted with abdominal or pursed lip breathing exercises

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Encouraged to avoid allergenic substances (e.g. dust, chemicals, smoke, etc) Dependent

Fluids aid in mobilization and expectoration of secretions - Provides patient with some means to cope with/control dyspnea and reduce air trapping - Prevents development of further attacks

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Administer medications as prescribed (Combivent Nebulizer)

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Bronchodilator; relaxes bronchial, uterine, an vascular smooth muscles by stimulating beta 2 receptors

HEALTH TEACHINGS

M E T H O D S

The patient’s significant others were informed about the importance of taking proper medications on the right dose, route, and time as prescribed by the physicians. Encouraged her significant others to provide quiet environment to promote non pharmacological pain management. Instructed her significant others how to manage the patient when in pain related to bronchial asthma. Demonstrated proper hand washing and encouraged good grooming to promote self-esteem. Emphasized the importance of attending follow up check up to monitor the status of the client. Encouraged her significant others to provide diet as ordered by physicians and explained its importance on the present situation of the patient. Instructed her significant others when at home to watch out when the patient is in pain to prevent accident that may contribute in worsening of the present situation.

DRUG STUDY •Chloramphenicol •Metronidazole •Paracetamol drops •Vitamin K •Combivent Nebulizer

NAME

MECHANISM OF ACTION

INDICATION

DOSAGE, ROUTE AND FREQUENCY

CONTRAINDICATION

ADVERSE REACTION

NURSING RESPONSIBILITY

Generic name: Chloramphenicol

A broad-spectrum antibiotic effective against grampositive and gramnegative bacteria against anaerobes. It is primarily bacteriostatic. It binds to the 50S subunit of the ribosome, thereby inhibiting bacterial protein synthesis.

Salmonella infections, shigellosis, rickettsial infections, meningitis, brain abscess, and pulmonary infections.

Adult: 250-500mg 6 hourly. May be given PO every 6 hour. Infant: 25mg/kg/day. May be given TIV with distilled water every 8 hour.

History of hypersensitivity or toxic reactions, lactation, pregnancy.

Serious and fatal blood dyscrasias. GI intolerance; neurological reactions; hypersensitivity, Gray syndrome; optic neuritis.

Ask first if the patient is hypersensitive to the drug. • Advise the patient to take the medication before meal. • Be alert for the adverse reactions of the drug. • Report if the patient has shown symptoms of Gray syndrome (body limpness cyanosis, cardiovascular collapse hypothermia vomiting, refusal to suck and loose green stools.)

NAME

MECHANISM OF ACTION

INDICATION

DOSAGE, ROUTE AND FREQUENCY

CONTRAINDICATION

ADVERSE REACTION

NURSING RESPONSIBILITY

Generic Name: Metronidazole Brand Name: (Flagyl; Flagyl I.V. RTU; MetroCream; MetroGel; MetroLotion; Noritate; Rozex)

. Metronidazole is an antibiotic especially effective against anaerobic infections. Unlike many antibiotics, It penetrates the blood-brain barrier and treat central nervous system infections. It also penetrates bone, making it especially useful in oral/dental infections. In addition, it has antiinflammatory properties in the large intestine and is a very effective antidiarrhea medication. It is an effective antibiotic against certain protozoal infections, especially giardia. MECHANISM OF ACTION

A common use of this medication would be the treatment of colitis, which may or may not be caused by inflammatory bowel disease. Amoebiasis, Aspiration Pneumonia, Bacteremia, Bacterial Infection Meningitis Pelvic Inflammatory Disease Peritonitis Pneumonia.

Infants and Children: Amoebiasis: Oral: 35-50 mg/kg/day in divided doses every 8 hours for 10 days Anaerobic infections: Oral: 1535 mg/kg/day in divided doses every 8 hours I.V.: 30 mg/kg/day in divided doses every 6 hours

Hypersensitivity to metronidazole, nitroimidazole derivatives, or any component of the formulation; pregnancy (1st trimester - found to be carcinogenic in rats).

Flushing,, coordination impaired, dizziness, fever, headache, insomnia, irritability, seizure, vertigo, Erythematous rash, urticaria, dysmenorrheal, Nausea, anorexia, abdominal cramping, constipation, diarrhea, furry tongue, glossitis, proctitis, stomatitis, unusual/metallic taste, vomiting, xerostomia, Cystitis, darkened urine (rare), dysuria, incontinence, polyuria, vaginitis,Neuromuscula r & skeletal: Peripheral neuropathy, weakness, Nasal congestion, rhinitis, sinusitis, pharyngitis Flu-like syndrome, moniliasis.

1. Ask first if the patient is hypersensitive to the drug. 2. Advise the patient to take the medication after meal. 3. Be alert for the adverse reactions of the drug. 4. Do not give to pregnant woman.

NAME

INDICATION

DOSAGE, ROUTE AND FREQUENCY

CONTRAINDICATION

ADVERSE REACTION

NURSING RESPONSIBILITY

Generic Name: Paracetamol Drops Brand Name: (Tempra, Biogesic,Neokiddielets)

. Paracetamol possesses prominent antipyretic and analgesic effects. Its anti-inflammatory activity is weak and has no clinical significance. The mechanism of action is related to depression of the prostaglandin synthesis by inhibition of the specific cell cyclooxygenase, and depression of the thermoregulatory center in the medulla oblongata.

The preparation is indicated in diseases manifesting with pain and fever: headache, toothache, mild and moderate postoperative and injury pain, high temperature, infectious diseases and chills (acute catarrhal inflammations of the upper respiratory tract, flu, small-pox, parotitis, etc.).

In children: aged from 3 months to1 year - 60-120 mg (2.5-5 ml syrup), 3-4 times daily; 1-6 years - 120-240 mg (5-10 ml syrup), 3-4 times daily; children older than 6 years 250-500 mg, 3-4 times daily. In children younger than 3 months the preparation should be used only on doctor’s prescription. Duration of the treatment in children should not exceed 5 days, whereas in adults it may be continued up to 10 days.

Paracetamol should not be used in hypersensitivity to the preparation and in severe liver diseases.

In rare cases hypersensitivity reactions, predominantly skin allergy (itching and rash), may appear. Long-term treatment with high doses may cause a toxic hepatitis with following initial symptoms: nausea, vomiting, sweating, and discomfort. Occasionally a gastrointestinal discomfort may be seen.

1. Ask first if the patient is hypersensitive to the drug. 2. The preparation should be used with care in patients with liver and renal diseases. 3. The treatment with the preparation is not advisable during the first trimester of the pregnancy. In nursing women the preparation should be used with strictly observation of the therapeutic dose and duration of the treatment. 4. Report if initial symptoms of toxic hepatitis are observe.

NAME

MECHANISM OF ACTION . It is a fat-soluble vitamin that plays an important role in blood clotting

INDICATION

DOSAGE, ROUTE AND FREQUENCY Dosage forms: 5 mg; SC; IM; IV [vitamin K deficiency] Dose: 2.5-5 mg PO qd prn; Alt: 1-2 mg SC/IM/IV x1; Info: subsequent doses based on INR [anticoagulant induced] Dose: 0.5-5 mg PO/SC/IM/IV x1; Info: may repeat oral dose in 12-48h or parenteral dose in 68h based on INR hemorrhagic dz, newborn Dose: 1-2 mg SC/IM/IV x1; Info: higher doses may be necessary if mother on anticoagulant tx

CONTRAINDICATION

ADVERSE REACTION

NURSING RESPONSIBILITY 1. Ask first if the patient is hypersensitive to the drug. 2. Report for serious adverse reactions are observed. 3. Tell the mother that Vitamin K deficiency is very rare.

Vitamin K

Hypoprothrombinemia , Hemorrhagic dz, newborn renal dosing, hepatic dosing

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hypersensitive to Serious Reactions drug//component • anticoagulant hereditary resistance hypoprothrombine• hypersensitivity, mia overanticoagulation severe incl. fatal (SC, IM, IV) due to heparins • anaphylaxis (SC, caution in neonates IM, IV) caution in elderly • hyperbilirubinemi pts a (neonates) • hemolytic anemia (neonates) Common Reactions
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taste changes (SC, IM, IV) flushing (SC, IM, IV) injection site hematoma injection site pain

NAME

MECHANISM OF ACTION . It is bronchodilator. It is taken by inhalation to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema. It helps decrease coughing, wheezing, shortness of breath, and troubled breathing by increasing the flow of air into the lungs.

INDICATION

DOSAGE, ROUTE AND FREQUENCY In adults, maximum of 2 puffs tid-qid. Maximum of 12 puffs per day. More than 12 year, 1 vial every 6-8 hours. Children 2-12 year: 3 drops/kg/dose (max: 2500 mcg of salbutamol) every 6-8 hours.

CONTRAINDICATION • Hypertrophic obstructive cardiomyopathy or tachyarrhythmia. History of hypersensitivity to soya lecithin or related food products.

ADVERSE REACTION

NURSING RESPONSIBILITY 1. Ask first if the patient is allergic to albuterol, ipratropium, atropine, belladonna, hyoscyamine, or scopolamine, or to other inhalation aerosol medicines. Also ask if allergic to soya lecithin or related food substances such as soybeans and peanuts. 2. Report to the doctor if the patient’s difficulty in breathing continues after using a dose of this medicine or if r condition gets worse.

Combivent Nebulizer

Asthma, COPD. Management of reversible bronchospasm associated with obstructive airway diseases in patients who require more than a single bronchodilator.

Fine tremor of skeletal muscle; palpitations; headache, dizziness, nervousness; dryness of mouth; throat irritation; urinary retention.

Bulacan State University College of Nursing S.Y. 2009-2010

A CASE STUDY (PNEUMONIA)
Submitted by: Jill S. Tolentino BSN 2H Group 5 Submitted to: Ma’am Joicylyn Martin, RN

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