V.

LABORATORY RESULT AND DIAGNOSTIC EXAMINATION

Name of Test Date Done Indication Normal
Value
Actual
Result
Significance of Result
Hematology




September
14, 2013















Blood tests
such as CBC
and APC can
be used to find
out what is
happening in
many parts of
the body.
Testing blood
is easier than
obtaining a
tissue sample.
Any test
designed to
discover
abnormalities
in a sample of
blood to
determine
blood groups.
(Merk Manual
of Medical

WBC 5-9 x 10
9
/L 11.3
Increased
Leukocytosis occurs in acute
infections (Pneumonia), in
which the degree of increase
of leukocytes depends on
severity of the infection,
patient's resistance, patient's
age, and marrow efficiency
and reserve. (A Manual of
Laboratory and Diagnostic
Tests by Frances Fischbach
pp.80).

On the date of admission, the
client is febrile with a
temperature is 37.6 C which
indicates infection. Thats why
when a blood sample was
taken for a CBC test, the WBC
count was above normal.


Hemoglobin









Information
p.888).


120 190
g/L

119
Decreased
May occur in anemia, a
condition in which there is a
reduction in the number of
circulating erythrocytes, the
amount of Hemoglobin, or the
volume of packed cells (Hct).
(A Manual of Laboratory and
Diagnostic Tests by Frances
Fischbach pp.70).

The hemoglobin decreased
because the maternal iron in
the infant starts to
decreased at 6 months.


Hematocrit
0.40-0.454
g/L
0.36
Decreased
Decreased in anemias.
(Medical-Surgical Nursing 10
th

ed. By Brunner and Suddarth
pp.2215)

The hematocrit decreased
because the maternal iron in
infant starts to
decreased at 6 months
RBC
4.5-5.5 x
10
12
/L
3.96
Decreased
Decreased RBC values occur
in anemia. Anemia is
associated with cell
destruction, blood loss, or
dietary insufficiency of iron or
of certain vitamins that are
essential in the production of
RBCs. (A Manual of
Laboratory and Diagnostic
Tests by Frances Fischbach
pp.75)

The RBC decreased because
the maternal iron in infant
starts to
decreased at 6 months

Neutrophils 0.55-0.65 0.60 Normal
Lymphocytes 0.25-0.35 0.40
Increased
A lymphocytosis indicates viral
infections of the upper
respiratory tract (pneumonia).
(A Manual of Laboratory and
Diagnostic Tests by Frances
Fischbach pp.61)













Name of Test Date Done Indication Normal Value Actual Result Significance of Result
Chest X-ray
September
16, 2013
This is used to
examine soft
and bony
tissues of the
body.
Appearing and
normally
positioned chest,
bony thorax (all
bones present,
aligned,
symmetrical and
normally
shaped), soft
tissues,
mediastinum,
lungs, pleura,
heart and aortic
arch.
Hazy infiltrates
are noted in both
lungs.
Both lungs fields
are hyperaerated.
Heart and great
vessels are within
normal size and
configuration.
Other chest
structures are not
remarkable.
Pneumonitis, bilateral
with pulmonary
hyperaeration.

Abnormal
Abnormal chest x-ray
results indicate the
following lung
conditions:
Presence of foreign
bodies
Lobar pneumonia
Bronchopneumonia
Aspiration pneumonia
Viral pneumonia








IX. DRUG STUDY

Drug name Action
Indication
Contraindication
Side effects
Adverse effect
Nursing responsibilities

Generic
Name:
Gentamicin
Sulfate

Brand name:
Garamycin
Broad-spectrum
aminoglycoside
antibiotic derived
from Micromonospora
purpurea. Action is
usually bacteriocidal.



Indication
For bacterial and viral
infection

Contraindication
History of hypersensitivity
to or toxic reaction with
any aminoglycoside
antibiotic. Safe use
during pregnancy
(category C) or lactation
is not established
Side Effect
skeletal muscle
weakness, apnea
hypotension or
hypertension
Nausea, vomiting

Adverse Effect
ototoxicity (vestibular
disturbances, impaired
hearing), optic
neuritis,
neuromuscular
blockade:, respiratory
paralysis
hepatomegaly,
splenomegaly.
Increased or
decreased reticulocyte
counts;
granulocytopenia,
thrombocytopenia
anemia.
Monitor for signs of renal
toxicity including
unusual appearance of urine
(dark, cloudy)
intake and output ratio, and
the presence of
edema

Monitor for evidence of
ototoxicity, including
headache, dizziness or
vertigo, nausea or vomiting
with motion, ataxia,
nystagmus, tinnitus, roaring
noises, sensation of fullness
of ears, and hearing
impairment.

Observe for signs and
symptoms of bacterial
overgrowth due to drugs
effect to kill all bacteria,
even normal flora that can
lead to superinfection.


Drug name Action Indication
Contraindication
Side effects
Adverse effect
Nursing responsibilities

Generic
Name:
Ampicillin

Brand name:
Rimacillin
These antibiotics all
have a similar
mechanism of action.
They stop bacteria
from multiplying by
preventing bacteria
from forming the walls
that surround them.
The walls are
necessary to protect
bacteria from their
environment and to
keep the contents of
the bacterial cell
together. Bacteria
cannot survive without
a cell wall. Penicillins
are most effective
when bacteria are
actively multiplying
and forming cell
walls.




Indication
Treatment of bronchitis,
uncomplicated
community-acquired
pneumonia


Contraindication
Hypersensitivity to penicill
ins. Infectious
mononucleosis. Use
cautiously with renal
disorders
Side Effect
rash, headache, fever
and hives, nausea,
soreness of the
tongue, inflammation
in the mouth, oral
candidiasis, vomiting,
enterocolitis, diarrhea
tooth discoloration.

Adverse Effect
Severe allergic
reactions
pseudomembranous
colitis
Anaphylactic shock,
redness of skin, skin
inflammation, hives
and inflammation of
blood vessels.

Take this drug around-the-
clock.

Take the full course of
therapy; do not stop taking
the drug if you feel better.

Take the oral drug on an
empty stomach, 1 hr before
or 2 hr after meals; the oral
solution is stable for 7 days
at room temperature or 14
days refrigerated.

Report pain or discomfort at
sites, unusual bleeding or
bruising, mouth sores, rash,
hives, fever, itching, severe
diarrhea, difficulty breathing.




Drug name Action Indication
Contraindication
Side effects
Adverse effect
Nursing responsibilities

Generic
Name:
Salbutamol +
Ipatropin

Brand Name:
Combivent

Used as
bronchodilator to
control and prevent
reversible airway
obstruction caused by
asthma

Indication
Used as a quiet relief
agent for acute
bronchospasm

Contraindication
Hypersensitivity to
adrenergic amines.
Hypersensitivity to
fluorocarbons.
Side Effect
headache, insomnia

Adverse Effect
chest pain,
arrhythmias,
palpitations
nervousness,
restlessness, tremor

Assess lung sound, pulse
and blood pressure before
administration and during
peak of medication.

Observe for paradoxical
bronchospasm

Allow at least 30 minutes
intervals between
nebulization.

Provide dose as soon as
remembered spacing
remaining doses at regular
intervals.

Avoids double dose as
increase of dosage.

Provide albuterol first before
using other inhalation
medication.

Advise patient to rinse
mouth with water after each
inhalation dose to prevent
dry mouth.


Drug name Action Indication
Contraindication
Side effects
Adverse effect
Nursing responsibilities

Generic
name:
Cefuroxime

Brand name:
Zinnat
Interferes with
bacterial cell-wall
synthesis and division
by binding to cell wall,
causing cell to die.
Active against gram-
negative and gram-
positive bacteria, with
expanded activity
against gram-negative
bacteria.
Indication
Treatment of respiratory
tract infection

Contraindication
Hypersensitivity to
cephalosporin
Serious hypersensitivity
to penicillins.
Side Effect
nausea, vomiting
pain at IV site
phlebitis

Adverse Effect
cramps
rashes

Use cautiously with renal
impairment

Assess patient for infection.

Obtain culture and
sensitivity.

Provide skin test

Keep epinephrine as
antidote for anaphylactic
reaction

Provide medicine around the
clock and to finish the
medication completely even
patient feeling better.








Drug name Action Indication
Contraindication
Side effects
Adverse effect
Nursing responsibilities

Generic
Name:
Paracetamol

Brand Name:
Ileosone

Unclear. Pain relief
may result from
inhibition of
prostaglandin
synthesis in CNS, with
subsequent blockage
of pain impulses.
Fever reduction may
result from
vasodilation and
increased peripheral
blood flow in
hypothalamus, which
dissipates heat and
lowers body
temperature.
Indication
Fever, pain

Contraindication
Hypersensitivity to
products containing
alcohol, aspartame
saccharin, sugar or
tartrazine.
Side Effect
rash and urticarial

Adverse Effect
renal failure,
Use cautiously with hepatic
and renal disease.

Assess for the over all
health status.

Assess fever; note presence
of associated signs (
diaphoresis, tachycardia and
malaise)

Keep acetylcysteine as an
antidote for overdose

Avoid giving excess amount
more than recommended
dose

Advise patients and
caregivers to assess
concentration of liquids
preparatory.





X. INTRAVENOUS FLUIDS
IVF NAME
INDICATION AND
CONTRAINDCATION
SIDE EFFECT AND
ADVERSE EFFECT
NURSING
RESPONSIBILITIES
D
5
0.3 NaCl 500cc Indication
Replacement therapy in
isotonic solution particularly
in pediatrics.

Contraindication
Hypotonic dehydration
DM
Hypokalemia
Severe acidosis
Side Effect
Phlebitis on the IV site

Adverse Effect
Hypokalemia
Assess the IV site for
phlebitis or possible
infection.

Regulate properly the IVF as
prescribed.

Monitor serum electrolyte
especially Potassium

IVF NAME
INDICATION AND
CONTRAINDCATION
SIDE EFFECT AND
ADVERSE EFFECT
NURSING
RESPONSIBILITIES
D
5
IMB 500cc Indication
Maintenance of fluid and
electrolyte balance and
supply of calories

Contraindication
Shock
Water intoxication
DM
Side Effect
Phlebitis on the IV site

Adverse Effect
Hyperphosphatemia
Assess the IV site for
phlebitis or possible
infection.

Regulate properly the IVF as
prescribed.

Monitor serum electrolyte
especially Phosphate


XI. OXYGEN THERAPY
THERAPY
INDICATION AND
CONTRAINDCATION
SIDE EFFECT AND
ADVERSE EFFECT
NURSING
RESPONSIBILITIES
Oxygen Indication
For decrease paO2 in the
blood

Contraindication
Respiratory alkalosis
Side Effect
tachycardia

Adverse Effect
Respiratory alkalosis
Assess the patency of nasal
cannula, the oxygen tank


Regulate properly the level
of the oxygen as prescribed.

Monitor for adverse effect.









XII. PRIORITIZATION OF THE PROBLEM
Date Nursing Diagnosis Cues Justification
September 16,
2013
Ineffective Airway
Clearance related to
bronchial inflammation as
evidenced by adventitious
sounds (rales and
crackles)
Subjective
Nahihirapan siyang huminga. As
verbalized by the grandmother

Objective
Presence of O2 tank at the bed side
VS
T 37.6
o
C, RR 44 cpm, CR 138 bpm

Parameters
Chest x-ray result: Hazy infiltrates are
noted in both lungs.
Both lungs fields are hyperaerated

O2 of 1-2 lpm
According to the
Emergency Priority, airway
is the priority problem in
the setting.
September 16,
2013
Impaired Gas Exchange
related to altered delivery
of oxygen as manifested by
tachycardia
Subjective
Nahihirapan siayng huminga As
verbalized by the grandmother

Objectives
Weak in appearance
Bed rest
Presence of O2 at bed side
VS
T 37.6
o
C, RR 44 cpm, CR 138 bpm


Parameters
O2 of 1-2 lpm
RBC 3.96 x 10
12
/L
According to the
Emergency Priority,
breathing is the next
priority problem in the
setting.
Hbg 119g/dL
Hct 0.36 g/dL







September 16,
2013
Activity Intolerance related
to imbalance between
oxygen supply and
demand as evidenced by
tachypnea and weak in
appearance.
Subjective
Hindi pa rin siya kagaya noong dati bago
siya ma-ospital. Dati kasi nagagawa
niyang makipag-laro. As verbalized by the
grandmother

Objectives
Weak in appearance
Bed rest
Presence of O2 at bed side
VS
T 37.6
o
C, RR 44 cpm, CR 138 bpm

Parameters
O2 of 1-2 lpm
RBC 3.96 x 10
12
/L
Hbg 119g/dL
Hct 0.36 g/dL

After ABC and LOC,
Maslows Hierarchical
Needs is the last priority
problem.


XI. NURSING CARE PLAN
ASSESSMENT
NURSING
DIAGNOSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective
Nahihirapan
siyang
huminga. As
verbalized by
the
grandmother

Objective
Presence of
O2 tank at the
bed side
VS
T 37.6
o
C, RR
44 cpm, CR
138 bpm


Parameters
Chest x-ray
result: Hazy
infiltrates are
noted in both
lungs.
Both lungs
fields are
hyperaerated

Ineffective
Airway
Clearance
related to
bronchial
inflammation
as evidenced
by adventitious
sounds (rales
and crackles)
After 3 days of
nursing
interventions,
the client will
be able to
display patent
airway (RR
within normal
range of 20-30
cpm) with clear
breath sounds;
absence of
dyspnea.
Independent
>Assess rate/depth of
respirations and chest
movement.






>Assess respiratory
function, e.g., breathe
sounds, rate, rhythm,
and depth, and use of
accessory muscles.



>Monitor heart
rate/rhythm every hour.




>Encourage increase
fluid intake of at least
2500 mL/day



>Tachypnea, shallow
respirations, and
asymmetric chest
movement are frequently
present because of
discomfort of moving
chest wall and/or fluid in
lung.

>Rhonchi, wheezes
indicate accumulation of
secretions/inability to
clear airways that may
lead to use of accessory
muscles and increased
work of breathing.

>Tachycardia is usually
present as a result of
fever/dehydration but
may represent a
response to hypoxemia.

>High fluid intake helps
thin secretions, making
them easier to
expectorate.

After 3 days of
nursing
interventions,
the client was
able to display
patent airway
with the
absence of
dyspnea.

Subjective
Mas maganda
na ang
pakiramdam
niya kasi
nakikipaglaro
na siya at
nakakatawa na
ng malakas.
As verbalized
by the
grandmother

Objective
Able to laugh
and sit on the
lap of his
grandmother

O2 of 1-2 lpm >Position client in semi-
or high-Fowlers position
by placing pillows to
support the posterior
portion of the body.








>Assist patient with
frequent deep-breathing
exercises.
Demonstrate/help
patient learns to perform
activity, e.g., splinting
chest and effective
coughing while in upright
position.






>Evaluate change in
level of mentation. Note
cyanosis and/or change
in skin color, including
mucous membranes and
>Positioning helps
maximize lung
expansion and
decreases respiratory
effort. Maximal
ventilation may open
atelectatic areas and
promote movement of
secretions into larger
airways for
expectoration.


>Deep breathing
facilitates maximum
expansion of the
lungs/smaller airways.
Coughing is a natural
self-cleaning
mechanism, assisting
the cilia to maintain
patent airways.
Splinting reduces chest
discomfort, and an
upright position favors
deeper, more forceful
cough effort.

>Accumulation of
secretions in the airway
can impair oxygenation
of vital organs and
tissues.
VS
T 36.5
o
C,
RR 25 cpm,
CR 135 bpm

Parameters
O2
discontinued

Goal partially
met because
the client still
has
adventitious
sounds and no
repeat chest x-
ray ordered.
nailbeds.

DEPENDENT
>Provide humidify
inspired air/oxygen.


>Assist with/monitor
effects of nebulizer
treatments.

>Suction as indicated
(e.g., frequent or
sustained cough,
adventitious breath
sounds, desaturation
related to airway
secretions).

>Provide supplemental
fluids, e.g., IV,
humidified oxygen, and
room humidification.


>Administer medications
as indicated:
Bronchodilators
(Salbutamol Neb 1neb +
2cc NSS)






>Prevents drying of
mucous membranes;
helps thin secretions.

>Facilitates liquefaction
and removal of
secretions

>Stimulates cough or
mechanically clears
airway in patient who is
unable to do so because
of ineffective cough or
decreased level of
consciousness.

>Fluids are required to
replace losses (including
insensible) and aid in
mobilization of
secretions.

>Increases lumen size of
the tracheobronchial
tree, thus decreasing
resistance to airflow and
improving oxygen
delivery.


Corticosteroids
(Hydrocortisone )





COLLABORATIVE
>Assist for repeat Chest
X-ray, if possible.


>May be useful in
presence of extensive
involvement with
profound hypoxemia and
when inflammatory
response is life-
threatening.

>Repeat Chest X-ray
may reveal clearance of
the lungs from the
previous infection.














ASSESSMENT
NURSING
DIAGNOSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective
Nahihirapan
siayng
huminga As
verbalized by
the
grandmother

Objectives
Weak in
appearance
Bed rest
Presence of
O2 at bed side
VS
T 37.6
o
C, RR
44 cpm, CR
138 bpm


Parameters
O2 of 1-2 lpm
RBC 3.96 x
10
12
/L
Hbg 119g/dL
Hct 0.36 g/dL

Impaired Gas
Exchange
related to
altered delivery
of oxygen as
manifested by
tachycardia
After 3 days of
nursing
interventions,
the client will
be able to
demonstrate an
improved
ventilation and
oxygenation of
tissues by
discontinuing of
the O2and with
the absence of
symptoms of
respiratory
distress.
INDEPENDENT

>Assess respiratory
rate, depth, and ease.






> Assess mental status.





> Observe color of skin,
mucous membranes,
and nailbeds, noting
presence of peripheral
cyanosis (nailbeds) or
central cyanosis
(circumoral).








Manifestations of
respiratory distress are
dependent on/and
indicative of the degree
of lung involvement and
underlying general
health status.

Restlessness, irritation,
confusion, and
somnolence may reflect
hypoxemia/ decreased
cerebral oxygenation.

> Cyanosis of nailbeds
may represent
vasoconstriction or
the bodys response to
fever/chills; however,
cyanosis of earlobes,
mucous membranes,
and skin around the
mouth (warm
membranes) is
indicative of systemic
hypoxemia.

After 3 days of
nursing
interventions,
the client was
able to
demonstrate
an improved
ventilation and
oxygenation of
tissues by
discontinuing
of the O2and
with the
absence of
symptoms of
respiratory
distress.

Subjective
Mas maganda
na ang
pakiramdam
niya kasi
nakikipaglaro
na siya at
nakakatawa
na ng
malakas. As
verbalized by
> Monitor body
temperature, as
indicated. Assist with
comfort measures to
reduce fever and chills,
e.g., addition/removal
of bedcovers,
comfortable room
temperature, tepid or
cool water sponge bath.

> Maintain bedrest.
Encourage use of
relaxation techniques
and diversional
activities such as toys
and fine motor
activities.

DEPENDENT
> Administer oxygen
therapy by appropriate
means, e.g., nasal
prongs, mask, Venturi
mask.





COLLABORATIVE

> Monitor ABGs, pulse
> High fever (common in
bacterial pneumonia and
influenza) greatly
increases metabolic
demands and oxygen
consumption and alters
cellular oxygenation.




> Prevents
overexhaustion and
reduces oxygen
consumption/demands
to facilitate resolution of
infection.



> The purpose of
oxygen therapy is to
maintain PaO2 above
60 mm Hg. Oxygen is
administered by the
method that provides
appropriate delivery
within the patients
tolerance.



> Follows progress of
the
grandmother

Objective
Able to laugh
and sit on the
lap of his
grandmother

VS
T 36.5
o
C,
RR 25 cpm,
CR 135 bpm

Parameters
O2
discontinued

Goal partially
met because
the client still
has
adventitious
sounds and no
repeat chest x-
ray ordered.
oximetry, CBC, if
possible
disease process and
facilitates alterations in
pulmonary therapy.

















ASSESSMENT
NURSING
DIAGNOSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective
Hindi pa rin
siya kagaya
noong dati
bago siya ma-
ospital. Dati
kasi nagagawa
niyang
makipag-laro.
As verbalized
by the
grandmother

Objectives
Weak in
appearance
Bed rest
Presence of
O2 at bed side
VS
T 37.6
o
C, RR
44 cpm, CR
138 bpm


Parameters
O2 of 1-2 lpm
RBC 3.96 x
10
12
/L
Activity
Intolerance
related to
imbalance
between
oxygen supply
and demand
as evidenced
by tachypnea
and weak in
appearance.
After 3 days of
nursing
interventions,
the client will
be able to
demonstrate
increase in
tolerance to
activity (able to
sit on own)
with absence of
dyspnea and
vital signs
within patients
acceptable
range (RR 20-
30 cpm, CR
80-140 bpm
Temp. 36.5-
37.5).
INDEPENDENT
>Assess childs usual
level of activity, taking
into account age and
developmental level (.


>Assess patients
response to activity.
Note reports of dyspnea,
increased weakness/
fatigue, and changes in
vital signs during and
after activities.

>Monitor response to
activity including pulse,
respiratory rate, skin
color, and behavior.

>Determine usual
sleep/rest routine and
bedtime rituals/security
objects such as safety
pillows and milk prior to
sleep. Plan care with
adequate rest periods.



>Establishes baseline, in
order to determine
needed interventions
and to assess progress
of recovery.

>Establishes patients
capabilities/needs and
facilitates choice of
interventions.




>Helps identify/monitor
degree of fatigue and
potential for
complications.

>Attempting to maintain
usual sleep routines
promotes rest and
maximizes energy and
endurance.




After 3 days of
nursing
interventions,
the client was
be able to
demonstrate a
measurable
increase in
tolerance to
activity with
absence of
dyspnea and
excessive
fatigue, and
vital signs
within patients
acceptable
range.

Subjective
Mas maganda
na ang
pakiramdam
niya kasi
nakikipaglaro
na siya at
nakakatawa na
ng malakas. As
verbalized by
Hbg 119g/dL
Hct 0.36 g/dL

>Provide a quiet
environment and limit
visitor.

>Encourage use of
diversional activities
such as blocks and fine
motor puzzles.


DEPENDENT
> Provide supplemental
oxygen as indicated.


COLLABORATIVE
>Provide/monitor
response to oxygen
therapy and
medications.

> Monitor laboratory
studies, e.g., Hb/Hct and
RBC count




>Encourage small,
frequent meals with
foods according to age
group such as milled rice
(am).
>Reduces stress and
excess stimulation,
promoting rest.

>Reduces stress and
excess stimulation,
promoting rest.




> Maximizing oxygen
transport to tissues
improves ability to
function.

>May be needed to
improve tolerance to
activity, treat underlying
cause for fatigue.

> Identifies deficiencies
in RBC components
affecting oxygen
transport and treatment
needs/response to
therapy.

>Maximizes nutrient
intake without undue
fatigue/energy
expenditure from eating
large meals
the
grandmother

Objectives
Able to sit on
the lap of the
grandmother
VS
T 36.5
o
C,
RR 25 cpm,
CR 135 bpm


Parameters
Discontinue
O2.

Goal met.