PAMANTASAN NG CABUYAO COLLEGE OF HEALTH ALLIED SCIENCES COLLEGE OF NURSING

CASE ABSTRACT:
•This is a case of patient a 5 yr. old female residing at Mercedes Vill, Sala, Cabuyao Laguna., the patient was received at St.James Hospital last Sept 30, 2009 at 7:50 pm with a chief complaint of fever. Initial vital signs were taken T38.5˚C, RR- 40bpm, PR- 130bpm. Initial diagnosis was Pediatric Community Acquired Pneumonia-C. The patient was subjected for Urinalysis, Blood Chemistry, Hematology and Radiologic exam and was given Cefaclor, Salbutamol, Erdostien, Polynerv syrup b1+b6+b12 as prescribed. Upon further history taking we found out that both of her parents were active-smokers.

LEARNING OBJECTIVE: •The study aims to impart knowledge regarding community acquired pneumonia and means to restore or maintain patient’s health status utilizing a holistic approach of promoting and rehabilitative process of nursing managements. 1. Identify nursing problems and the corresponding nursing considerations and managements involved for promotion and maintenance of patient’s health. 2. Enumerate therapeutic nursing interventions through formulation of NCP. 3. Specify the appropriate laboratory and diagnostic procedures / examinations and correlate them with the case presented. 4. Discuss simple pathophysiology of case presented, its predisposing factors, signs / symptoms, complications and treatments.

REVIEW OF ANATOMY AND PHYSIOLOGY: RESPIRATORY SYSTEM •The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain.

The Upper Airway and Trachea • When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voice box) and into the trachea (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs.

The Lungs Structure • The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'. • These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply.

How they work • Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Traveling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

Blood Supply
• The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs.

Predisposing Factor: age

Precipitating Factor: Environment

Streptococcal Pneumoniae

Enters through nose or mouth by inhalation Passes to the pharynx, larynx and trachea Microorganism enters and affects both airway and lung parenchyma Airway damage Activates macrophages and leukocytes Infiltration of bronchi Infectious organism lodges stimulation in bronchioles Alveolar wall Collapse Increase pyrogens in the body Fever Mucus and Phlegm Production Coughing Productive or nonProductive Narrowing of air passage
Macrophages destroys RBC Decreased RBC count

Lung invasion

Bilirubin Production jaundice

Difficulty of Breathing

Health History Patient Name: Age: Sex: Nationality: Civil Status: Religion: Highest Educational Attainment: Rank in the Family: Address: Inclusive Date of Confinement: Admission Date and Time: Discharge Date: Attending Physician: Initial Diagnosis: Final Diagnosis: Source of History: Chief Complaint: Patient A 5 Yrs. Old Female Filipino Single Roman Catholic Preparatory Second Child of Three siblings Mercedes Vill. Sala Cabuyao, Laguna Four Days Sept. 30, 2009 at 7:50 PM Oct. 4, 2009 at 1:36 PM Mariano M. Carteciano M.D. PCAP – C PCAP – C Mother Fever

I. Health Perception – Health Management Pattern •Before hospitalization, the patient perceives health in a way that she is not suffering from a disease. During hospitalization, the patient feels unhealthy and is obedient in taking her medications. II. Nutrition-Metabolic Pattern A. Height: 3 ft., 5 in. tall B. Weight: 19.1 kg. C. Appetite: Good D. Usual Eating E. Pattern: 3 meals a day Usual Daily Menu a. Breakfast: Chocolate Drink / Milk b. Lunch: Usually hotdog with rice c. Dinner: Typical viand (meat, vegetable, etc.) with rice d. Snacks: Chocolate Cookies F. Diet: usual diet G. Has good skin turgor

III. Elimination Pattern A. Bowel: a. Usually no problem with elimination b. Last bowel movement yesterday, formed, normal B. Bladder: a. Decreased urinary frequency IV. Activity – Exercise Pattern A. Self Care Ability: Feeding: 0 Toileting: 0 Dressing: 0 Bathing: 0 Bed Mobility: 0 Grooming: 2 *Legend: Functional Levels Code: 0 – Full self-care 1 – Requires use of equipment or device 2 – Requires assistance or supervision from another person 3 - Requires assistance or supervision from another person and equipment or device 4 – Dependent and does not participate B. Past Health Status: b.1. Prophylactic Medical/Dental Care: None b.2. Childhood Illness: Measles b.3. Immunizations: Complete b.5. Major Illnesses/Hospitalizations: None before this current admission b.6. Current Medications: Paracetamol (Prescribed) b.7. Allergies: None

V. Sleep- Rest Pattern A. Sleep Habits: a. 8-9 hours of sleep/night b. Occasionally takes afternoon naps B. Has no difficulty going to sleep VI. Cognitive-Perception Pattern >No sensory deficits >Pupils 3mm, equal >Oriented to time, place and person >Responsive, but fatigued >Responds appropriately to verbal and physical stimuli >Recent and remote memory intact VII. Self-Perception – Self Concept Pattern >Patient states, “Marami po akong mga kalaro sa School.” >Does not feel good about herself since illness started. VIII. Role-Relationship Pattern >Patient lives with her father, mother, and two other siblings >Family members are supportive towards patient’s hospitalization >Patient states good relationship with friends

IX. Coping-Stress Tolerance Pattern >Anxious and Irritable >Mother helps with coping with stress

X. Sexuality – Reproductive Pattern >Patient is aware of her own gender and sexuality

XI. Value-Belief Pattern >Roman Catholic >No wish to see priest at present

I. GENERAL SURVEY

5 year old female child admitted to ER Appears normally on her age Mild irritability but cooperative Mild weakness Good posture (+) cough; productive (+) difficulty of breathing (-) retraction 19.1kg in weight 3ft 5 in height

II. VITAL SIGNS Temperature Pulse/cardiac rate Respiratory rate Blood pressure III. INTEGUMENTARY •Skin: •Mucous membrane: •Nails: •Hair:

DAY 1 38.5 130 40

DAY 2 37.5 124 36

DAY 3 36.9 104 38

DAY 4 36.1 88 32

>with slight jaundice on facial area, mild dryness, good skin turgor >pink oral mucosa >no clubbing, smooth in texture, capillary refill at 2-3 seconds >evenly distributed, mild thinning of hair, no infestation

IV. HEENT • Head > Size: 52 cm > Shape: Well rounded; smooth skull contour; symmetric facial movement • Eyes > Color: Dark-Brown > Pupil Response: PERRLA • Ears > Symmetrically equal; no tenderness > Discharge/Growth: no discharge: able to response on questions • Nose > Mucosal Condition: pinkish in color > Discharge/Growth: no discharge noted • • Mouth/Throat/Pharynx/Teeth: > pink moist lips; pinkish tongue; no cavities; no missing teeth ; tonsils are not reddened Face >Symmetry: Symmetrically equal >Facial Musculature: has the ability to frown and smile

IV. NECK/LYMPH a. Symmetry: equally symmetrical muscles b. Growth: inflamed lymph node c. Location: right and left anterior cervical areas V. PULMONARY (Breath Sounds) >Normal: diminished bronchial sounds; equal chest expansion >Abnormal: fine crackles at both lung fields VI. BREAST ABD AXILLARY AREAS a. Symmetry: equal in size and symmetry for her age Growth: normal for age b. Retraction: no retraction noted c. Discharges: No Discharge Lymph Nodes: No lymph inflammation VII. CARDIVASCULAR • Normal: normal rhythm Abnormal: no murmurs • Rhythm: regular rhythm • Rate: 120-150 beats per minute

VIII. PERIPHERAL/VASCULAR Peripheral Pulses (state if equal-bilaterally) Grade:4 Grade: 4 Grade: 4 Grade: 3 Grade: N/A Grade:2 Grade: 2 Grade: 3 Temporal: equally bilateral Carotid: equally bilateral Brachial: equally bilateral Radial: equally bilateral Femoral: N/A Popliteal: equally bilateral Posterior Tibialis equally bilateral Dorsalis Pedis equally bilateral
Legend: Peripheral Pulse Scale 0>Absent 1>Markedly diminished 2>Moderately diminished 3>Slightly diminished 4>Normal

IX. ABDOMEN a. General Contour: rounded abdomen Tenderness: rated 6 on pain scale at LUQ b. Bowel Sounds: normal bowel sounds c. Abdominal Sounds: N/A X. MUSCOLO-SKELETAL A. STRENGTH: decrease muscle strength B. ROM: within normal limits XI.NEUROLOGICAL A. Mental Status (LOC): 15 pts. B. Pupils Size: 3-4 mm C. Cranial Nerves: N/A D. Sensory: N/A E. Deep Tendon Reflex (grade the dotted areas) XI. RECTAL/ANUS >N/A

Legend: Reflex Scale 0> no response 1> low normal 2> normal Legend: Glascow coma 3> brisk scale 4> hyperactive A. Eyes open spontaneous -4 on command -3 to pain -2

no response - 1 B. Best Verbal Response Alert and oriented -5 Confuse -4 Inappropriate -3 Incomprehensive -2 No response -1 C. Best Motor Response Follows direction -6 Localizes pain -5 Withdraws from pain

XII. GENETALIA >Growth: N/A >Discharge: No abnormalities as stated by the mother

Urinalysis MACROSCOPIC   COLOR   TRANCEPARENCY   Ph

Result     Color   Slightly Hazy   6.5

Normal value     Clear   Clear   4.6- 6.5 

MICROSCOPIC   Specific gravity   Albumin   Sugar   Pus cells   RBC   Bacteria

    1.010   Negative   Negative   8-10/hpf   0-2/hpf   None

    1.015-1.030   Negative   Negative   0-1/Hpf   0-1/hpf   none

Significance     Change of appearance of the urine is an indication of renal or urinary track infection.   Disturbance of  Ph indicates acid-based disorder.   -Alteration of Specific gravity inidactes level of consentration of urine. -Presense of albumin may indicate glomerular disease -Presence of sugar in the urine may indicates complications. -Presence of pus cells in urine indicated urinary tract infection. -Alteration of RBC in urine indicated Urinary tract infection. -Presence of bacteria indicates infection.  

Blood chemistry Sodium Test   Potassium test     Calcuim

Result 129 mmol/L   3-7 mmol/L     9-6mg/dL

Normal value 137-145 mmol/L   3.5-5.1 mmol/L     8.4-10.2mg/dL

significance Low level of sodium in the blood may cause convolsions. High potassoum level indicates alteration to electrical activity on the heart. Essesial for maintaining a regular heart beat, neuro muscular impulses.  

Hematology Hemoglobin Hematocrit RBC TOTAL WBC Platelets

Result 12.2 36% 4.00 9.9 335,000

significance Normal Normal Loss of RBC indicates bleeding 5-10/uL Alteration of WBC indicates infecton 150000-450000/uL Alteration of platelet counts will affect coagulation,hemos tasis,and clothing formation.

Normal value 11-16q/dL 38-47% 4.5-4.8

• X-ray • Roentgen logical findings: • There are steaky densities in both lung field • The vascular marking are not accentuated • The heart is not enlarge • Diaphragm & sulci are intact • Impression: “pneumonitis bilateral”

A. • • • •

DIET: Diet appropriate for age (5 yr. old) High caloric food such as rice Increased Fluid intake Low fiber diet

B.1 STANDING ORDER
NAME OF DRUGS THERAPEUTIC ACTION INDICATION CONTRAINDICATION /CAUTIONS DOSAGE ADVERSE EFFECT NURSING CONSIDERATI ON >assess for the history of drug allergy, pregnancy and lactation >assess patient for signs and symptoms of infection before and during therapy >assess for renal function test, respiratory status, culture and sensitivity to test of infected area >take the drugs with meal or food to prevent the GI discomfort..

GENERIC NAME: Cefaclor BRAND NAME: Cecavil Cefaclor Apo-Cefaclor

Bactericidal Inhibits synthesis of Bacterial wall causing cell Death.

CLASSIFICATION: Anti Biotic

Treatment of >patient with allergy to otitis media, cephalosporin phryngitis, tonsillitis, Acute >hypersensitivity to beta Bacterial lactam antibiotics Exacerbation of chronic bronchitis, >may induce pneumonia, anaphylactic shock Uncomplica-ted d skin and Skin structure, lower UTI

Children: Suspension 5ml per 8hrs three times a day for 5 days Adult: 500mg per 8hrs

CNS: Headache, dizziness, lethargy GI: Nausea, vomiting, diarrhea, anorexia, Abdominal pain, flatulence Hematologic: bone marrow depression Hypersensitivit y: ranging from rash to fever

NAME OF DRUGS

THERAPEUTIC ACTION

INDICATION

CONTRAINDICATION CAUTIONS

DOSAGE

ADVERSE EFFECT

NURSING CONSIDERATIO N The drug should be avoided during pregnancy, particularly during the first trimester and during labor, because it is established that the high doses can suppress the contractions of the uterus. There are no data for risks related with the administration of the drug in breast feeding women.. Because of the possibility for induction of tremor, dizziness, and weakness, the drug should be used cautiously in drivers and people working with machines.

Generic name: Salbutamol or albuterol Brand name: Ventolin Combivent Salbutamol Classification: Respiratory drugs Anti asthmatic

Stimulates beta 2 receptors of bronchioles by increasing levels of camp which relaxes smooth muscles to Produce Bronchodilata-tion.

Relief of >Hypersensitivity to Bronchospasm Salbutamol, also to in bronchial atropine and its asthma chronic derivatives. Bronchitis Emphysema >Threatened abortion and other during 1st and 2nd Reversible trimester. Obstructive Pulmonary >cardiac arrhythmia diseases. associated w/ tachycardia caused by digitalis intoxication.

Adults and Headache; children over tremor; 12 years: The tachycardia; Recommend hypertension; d dose is 2 – anxiety. 4 Rarely mg (5 - 10 ml nausea, syrup) 3 – 4 vomiting, and times daily. skin rash can The maximal be observed daily dose should not exceed 32 mg (divided in 3 or 4 doses). >prevention of premature Children: labor associated w/ between 2 toxemia of pregnancy and 6 years, or ante partum the dose is hemorrhage. 0.1 - 0.2 mg/kg body Weight given 3 times daily. The Maximal daily dose must not exceed 4 mg, 3 times daily, and the daily dose for 6 - 12 years-old children is to 24 mg daily, divided in 3 or 4 doses.

NAME OF DRUGS

THERAPEUTIC ACTION

INDICATION

CONTRAINDICATION /CAUTIONS

DOSAGE

ADVERSE EFFECT

NURSING CONSIDERATION

GENERIC NAME: Erdostien

Erdostien is an original derivative of BRAND NAME: natural Zertin mercaptoaminoacid in CLASSIFICATION: thiolactonic For respiratory form. Following Drugs oral administration Erdostien is rapidly metabolized in the liver. The product acts as a prod rug and its metabolites are mainly responsible for mucolytic activity, due to the presence of free thiol groups which cause the splitting up of the intra- and intermolecular disulfide bridges of several proteins and mucoproteins present in the expectoration, resulting in a reduction of the mucus elasticity and viscosity.

Treatment of Hepatic disorders & acute & abnormalities, renal chronic insufficiency, bronchopulmo homocystinuria, nary diseases, phenylketonuria rhino sinusitis, laryngopharyn gitis or exacerbations of these chronic diseases in association w/ mucus production & transport.

Adult 1 cap Gastric burning, bid. Susp 8.5 nausea; ageusia mL bid. or dysgeusia. Childn 2-6 yr (10-20 kg) 2.5 mL bid, 7-12 yr (21-30 kg) 5 mL bid, 5 mL tid or 7.5 mL bid.

>assess for the history of drug allergy, pregnancy and lactation >assess for renal function test, respiratory status, culture and sensitivity to test of infected area >take the drugs with meal or food to prevent the GI discomfort >do not give to the patient 2yrs old below

NAME OF DRUGS

THERAPEUTIC ACTION

INDICATION

DOSAGE

NURSING CONSIDERATION >assess for the nutritional status of the patients >assess for the drug reaction to the patients >give the vitamins with meals or food to prevent gastrointestinal discomfort

GENERIC NAME: Polynerv syrup b1+b6+b12 0 BRAND NAME: Polynerv b1+b6+b12 CLASSIFICATION: vitamins

VITAMINS B1, B6 & B12 (POLYNERV™ Syrup) is valuable in conditions where the requirements for B vitamins are increased (as in growth, physiologic stress, decreased resistance to infection and chronic illnesses, metabolic disorders and in certain diseases of the digestive tract and nervous system). It can also be given before and after surgical procedures.

VITAMINS B1, B6 & 1-2 years old : 2.5 B12 (POLYNERV™ mL (1/2 teaspoon) Syrup) is indicated daily for the prevention and treatment of 3-6 years old : 5.0 deficiency disorders mL (1 teaspoonful) arising from poor daily dietary intake, impaired B vitamins 7-12 years old : absorption (as in 10.0 mL (2 prolonged diarrhea, teaspoonfuls) daily excessive vomiting and antibiotic therapy) intake of drugs which interfere with the utilization of the B vitamins (i.e. isoniazid). As a nutritional supplement to promote appetite, weight gain and height increase.

NAME OF DRUGS

THERAPEUTIC ACTION

INDICATION

DOSAGE

NURSING CONSIDERATION

Generic name: Paracetamol or Acetaminophen Brand Name: Calpol Classification: Anti-pyretic analgesic

Decreases fever by Relief of mild to inhibiting the effects moderate pain of pyrogens on the and treatment hypothalamic action of fever leading to sweating and vasodilation. Relieves pain by inhibiting the prostaglandin synthesis at the CNS but does not have antiinflammatory action because of its minimal effect on peripheral prostaglandin synthesis.

children's Asses pt. fever or dosages are pain based on a single dose of Assess allergic 10mg reaction Paracetamol per kilogram Assess bodyweight, hepatotoxicity which can be Monitor liver and repeated 4-6 renal function hourly, not exceeding four Inform pts. That doses per 24 urine may dark hours. brown as a result of phenacetin (a metabolite of acetaminophen) Verify the doctor’s order

C. INTRAVENOUS THERAPY IV Fluid 5% dextrose and 0.3% sodium chloride D50.3%NaCl Classification Hypertonic INDICATION Actions Side Effect NURSING Precaution

Fluid Challenges Replenish fluid >hypernatrem Don’t use in Fluid nutrient ia patient with heart replacement in Carbohydrates failure patient with and electrolytes Edema or DKA, hypernatremia hyponatremia because it can shock lead to overload

IV Fluid
5% dextrose with multiple balance solution D5IMB

Classification INDICATION

Actions

Side Effect

NURSING Precaution

Isotonic

For dehydration Replaces fluid and Increase Do not use to the For patient with electrolyte of the secretion of anti patient without case respiratory problems body diuretics of dehydration ION multiple balance hormone All IONs either positive or negative are present.

D. THERAPEUTIC MEASURES
PROCEDURE 1. INDICATIONS NURSING PRECAUTIONS Positioning (High back When the client is in this position, > The nurse should not place an overly large pillow or more than one rest or Fowler’s gravity pulls the diaphragm pillow behind the client’s head. This error promotes the position) downward, allowing greater development of neck flexion contractures. If the client desires chest expansion and lung several head pillows, the nurse should encourage the client to ventilation. Client’s confines to rest w/out a pillow for several hours each day to extend the neck bed but capable of eating, fully and counteract the effects of poor neck alignment. watching television or visiting >Put pillows under forearms to eliminate pull on shoulder and assist find this procedure venous blood flow from hands and lower extremities. comfortable. > Keep side rails securely up. For patient’s falls prevention. >Ensure the patency of the patient’s nostrils. > Never administer O2 by nasal cannula at more than 2L/min to a patient w/ chronic lung disease unless you have a specific order to do so. >Used when patient will need oxygen need oxygen therapy when hypoxia results from a respiratory or cardiac emergency or an increase in metabolic function( offensive for low of concentrations) >Supplies the body w/ enough oxygen to meet its cellular needs.

2. Oxygen Administration

Cont…
PROCEDURE INDICATIONS NURSING PRECAUTIONS

3. Nebulizer Therapy

>Nebulization is a process of > Be alert for signs of adding moisture or medication over dehydration to inspired air by mixing exhibited by particles of varying sizes w/ the unexplained weight air. The moisture added to the occurring over several resp. system through days after the Nebulization improves beginning of therapy) clearances of pulmonary when using high secretions. output nebulizers. >Aids bronchial hygiene by restoring and maintaining mucous blanket continuity, hydrating dried, retained secretions, promoting expectoration of secretions; humidifying inspired O2; delivering medication. > Used for administration of bronchodilators and mucolytic agents

D. REFERRALS Respiratory Therapist: -Noel A. Co, RN Pediatrician: -Dr. Estillore Pulmonologist: -Dr. Alonzo Attending physician: -Dr. Carteciano

E. Prognosis/Current Status of Patient
• The patient experiencing CAP manifest signs and symptoms of productive cough, difficulty of breathing, fever and jaundice. CAP is caused by streptococcus Pneumoniae which is normally acquired by inhalation of respiratory secretion through droplets, direct and contact, contact with contaminated hands and fomites. The child must be guided by SO’s to facilitate health care process not to aggreviate the child’s health status.
(+) intermittent productive cough

CONDITION OF THE PATIENT UPON DISCHARGE:

• • •

(-) colds (-) retraction A febrile

HOME MEDICATION: • Combivent Nebule 1 nebule every 6 hours for 5 days • Cefaclor Suspension 250mg/5ml 5ml every 8 hours for 5 days • Zertin syrup 5ml twice a day for 5 days • Polynerv syrup 5ml once a day
EXERCISE: • Encourage patient with deep breathing exercise with the help of the SO’ to facilitate expectoration of sputum or discharge. TREATMENT: • The patient must cooperate with the maintenance of medication and Nebulization therapy for the continuity of treatment.

HEALTH TEACHING: • The patient who has PCAP should practice deep breathing exercise and coughing exercise, at the same she should always cover her nose to avoid allergens such as smoky places that might precipitate the current status. • The Significant other especially the mother should guide her daughter in practicing the above guidelines • The mother or the other SO’s must ensure the patient will follow the discharge orders required for the patient especially the intake of home meds. • Teach the patient and SO’s to encourage patient to increase oral intake and how it helps the patient in her condition. FOLLOW UP CHECK-UP: • October 16, 2009, for patient’s health status evaluation. DIET: • Diet for age (DFA) • Patient must follow the diet required for the patient because other food contents might aggreviate her condition.

CUES

PATHOPHYSIOLO GIC BASIS

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: “ Mainit at masakit ang ulo niya”, as verbalized by the mother.. Objective: • flushed skin • febrile 38.9 • skin warm to touch • not in Respiratory distress • conscious, coherent, and ambulatory • (-) dehydration • irritable

Microorganism • Thermo enters the regulation airway passages Ineffective related to Disease Triggers the immune Process system to fight (presence of the foreign Bacterial objects infection) as manifested by elevated body Neutrophils kills the temperature. bacteria As a result of fever, chills and ineffective thermoregulation

• After 3 hours of nursing intervention, the patient’s body temperature will alleviate at normal/desira ble level.

• Provide tepid sponge bath

• to decrease • After 3 hours of temperature by Nursing means of intervention, the • Change dress into evaporation and patient’s body loose clothing conduction Temperature • Ensure proper room• to reduce body alleviated at ventilation temperature normal/desirable • Advised patient oral • to provide cool level. fluid intake environment • Goal met. • Administer analgesics as • to release heat from ordered by the he body physician • Ambulate the • to facilitate fast patient recovery • Maintain bed rest • to facilitate blood circulation turn side by side) • to metabolic demands/ Oxygen consumption

CUES

PATHOPHYSIOLOGIC BASIS

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: “Hirap huminga ang anak ko dahil sa ubo.” As verbalized by the patient’s mother. Objective: • (+) productive cough • afebrile 37.4 • dyspnic in appearance • no cyanosis noted • conscious, coherent, and ambulatory • GCS – 15 • (+) crackles Upon auscultation

Microorganism enters the • Ineffective airway passages Breathing related to Retained small blood vessels in the secretions in lungs (capillaries) the bronchi. become leaky, and protein-rich fluid seeps into the alveoli

• After 4 hours of nursing intervention, the patient will Loosen secretions in the lungs.

results in a less functional area for oxygencarbon dioxide exchange patient becomes relatively oxygen deprived, while retaining potentially damaging carbon dioxide

• Advise increase • To liquefy secretion fluid intake • Perform Chest • To facilitate Physio therapy expectorations (Back Tapping) of retained secretions • Administer • to facilitate fast medications as recovery ordered • Check the • As baseline data for consistency of medication secretions administration • To prevent further • Instruct patient to retention of expectorate the secretions mucus • secretion •Provide health teaching regarding the importance of personal hygiene

• After 4 hours of nursing Intervention the patient’s secretion has been loosen and she has been able to breath At tolerable level. Goal partially met

Mucus production is increased through the leaky densities

CUES

PATHOPHYSIOLOGIC BASIS

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: “ Nahihirapan siya huminga dahil sa plema”, as verbalized by her mother. Objective: • (+) productive cough • (+) crackles • (+) DOB • afebrile 37.3 distress • restlessness • irritability

• Ineffective Microorganism enters Airway the airway passages Clearance related to presence of Secretions small blood vessels in the secondary to lungs (capillaries) pneumonia become leaky, and protein-rich fluid seeps into the alveoli

• After 3-4 hours of nursing intervention, the patient’s respiration will improve and difficulty of breathing will relieved.

results in a less functional area for oxygen-carbon dioxide exchange

patient becomes relatively oxygen deprived, while retaining potentially damaging carbon dioxide Mucus production is increased, and the leaky capillaries

• Assess patient’s • To know and • After 3-4 hours of condition determine nursing • Monitor and record patient’s needs intervention, vital signs • to established the patient’s •Auscultate lung fields, baseline data respiration noting areas of • To determine has been decreased or possible improved absent airflow bronchospasm and difficulty and adventitious or obstruction of breathing breath sounds has bbeen • Assist patient to relieved. change position • Goal met. every 30 minutes • Elevate head of bed • To mobilize and align head in secretions the middle • Provide health teachings • To facilitate regarding breathing effective coughing and deep breathing • To expel the mucous exercise. • Encourage increase fluid intake • To liquefy • Encourage steam secretions inhalation • To moisten secretions and • Administer alleviate medications as congestion ordered • To reduce bronchospasm and mobilize secretions

ARRIETA, MA. PAMELA CABINTOY, AGNES CASTRILLO, JENELYNN DELOS REYES, RENIER FERNANDEZ, BARBARA

GUTIERREZ, FROILAN PENALBA, CYRON LUNAS, JUDITH SABALLO, JEFFREY YUDELMO, RYAN

“The beginning of knowledge is the discovery of something we do not understand “ FRANK HERBERT

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