Name: David Andrew Henerja

Assessment
A. Nursing History
Age: 2/12 Male
Weight: 6.8 kgs.
Height: 60 cm
Head Circumference:
44 cm
Abdomen
Circumference: 46 cm
Vaccines:
DPT: 1st and 2nd given
OPV: 1st and 2nd given
Hep B: 1st and 2nd given
HIB: 1st given
BCG: given
Environmental: lives in
the house with 4
occupants
Mineral water for
drinking
C. Objective
Garbage
were collected
Admitting
3x a day Diagnosis:
PCAP
Pediatric
General
Appearances:
Community
Acquired
awake, cyanosis,
in mild
Pneumonia
respiratory distress
Chest: + Retractions
September
9, 2013
+ Rales
B.Signs
Subjective
NONE
Vital
1pm
CR: 140
RR: 45
Temp: 37.6
5pm
CR: 122
RR: 48

Nursing
Diagnosis
Ineffectiv
e Airway
Clearance
related to
chronic
obstructiv
e
pulmonar
y disease
(COPD)

Rationale
One of the
patients
general
appearanc
es is being
in a mild
respiratory
distress.
Patient is
cyanotic
Patient
was
positive
on having
retractions
.
Patient
was
positive
on having
rales.

Goal
After 1-2 days of
the nursing
interventions
the caregiver
of the
patient will
be able to
verbalize
understandin
g the cause
and
management
of the
regimen.
the patient
will maintain
airway
patency.
the patient
will have a
normal
respiration
as evidenced
by absence
of cyanosis,
respiratory
distress,
retractions
and rales.
patient will

Nursing
Interventions
and Rationale
Assessed
respiratory rate.
Rationale:
Provides a
basis for
evaluating
adequacy of
ventilation
Auscultate
breath sounds
and assess air
movement.
Rationale: to
ascertain
status and
note progress.
Position head
appropriate for
age and
condition.
Rationale: To
open or
maintain open
airway in atrest or
compromised
individual.
Encourage fluid
intake (may
require IC in

Evaluation
s
The goals are met
when the patient:
the caregiver
of the patient
will
understand
the cause and
management
of pneumonia
patient will
maintain
airway
patency
patient will
have a normal
respiration
patient will
experience
normal
breathing

BLOOD MORPHOLOGY
Exam Name
Hemoglobin
Hematocrit
WBC COUNT
RBC COUNT
DIFFERENTIAL
SEGMENTERS
LYMPHOCYTE
S
MONOCYTES
MCV

Resu
Unit
lt
117
g/L
Low
0.359
Low
18.9 10^9/L
High
4.34 10^12/
Low
L
COUNT
0.488
Low
0.
465
High
0.047
82.8
fL

MCH

27.1

pg

MCHC

32.7
Low
305

Platelet
Count

10^9/L

Normal
Value
120
170
0.40
0.57
4.6 10

D.

Laboratory

4.5 6.0

0.50
0.70
0.20
0.40
0.007
80.9
99.9
27.0
31.0
33.0
37.0
150-400

Submitted by: Liza Marie C. Adarn e

Pagdilao

Submitted to: Mrs.