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.
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
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.
>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