NURSING CARE PLAN

Patient’s name: A.T.C.

Age : 3 mos. old Room /Ward No.: PW W14
Impression/diagnosis: Pediatric Community Acquired Pneumonia-C Physician: Dr. Serafica

CLINICAL PORTRAIT PERTINENT DATA

I. ASSESSMENT I. HISTORY OF PRESENT ILLNESS

A case of A.T.C., 3 mos. old, female, Roman
catholic, Filipino, born and currently residing in Holy name
brgy. Mabolo, Cebu City, was admitted due to cough.
Received patient side lying in bed, awake, with
ongoing #2 D5 IMB 500ml @ 20cc/hour, infusing well at the
left foot, skin is warm to the touch and has good turgor. Eyes
has pink palpebral conjunctiva and breathes sounds are clear
and equal chest expansion. Negative murmurs.
The extremities are proportional the overall body size
and shape and the limbs are also symmetrical.
Two days prior to admission, onset of cough and
colds. Condition tolerated no medication given.
12 hours prior to admission, consult done and
prescribed neozep drops, ambroxole and co-amoxiclav156/s
2ml TID. Opted admission.
II. CHIEF COMPLAINTS
cough

II. SIGNIFICANT FINDINGS III. HEALTH HISTORY RELEVANT TO PRESENT

Upon assessment, patient body parts are all intact
and symmetrical with each other. Patient has no allergies.
Maternal side has hypertension and diabetes mellitus.
ILLNESS
Patient has never been hospitalized before.
Breastfeed by mother at birth to 1 month and shift to bottle
feeding at 1 month onwards.
III. VITAL SIGNS TAKEN DURING THE FIRST IV. LABORATORY RESULT REGARDLESS OF FINDING
CONTACT WITH THE NURSE

MACROSCOPIC
BP=90//50 bpm
T= 36.6°C Color: Green
PR= 145 bpm Consistency: Mucoid
RR=41cpm
MICROSCOPIC

IV. NURSING DIAGNOSIS RBC : 0/ HPF

WBC : 0-1/HPF
 Impaired gas exchange related to collection of
secretions affecting oxygen exchange across alveolar
membrane.
CUES NURSING SCIENTIFI GOALS AND NURSING RATIONAL EVALUATIO
DIAGNOSI C BASIS OUTCOME ACTIONS AND E OF THE N
S CRITERIA ORDER NURSING
ORDERS
SUBJECTIVE Impaired Pneumonia After 4 hours of INDEPENDENT:
gas is an excess nursing  Assess Manifestatio Goal met.
exchange fluid in the intervention the respiratory n of
related to lungs patient will be rate, depth respiratory The patient
collections resulting able to: and ease. distress is achieved
of from an  Achieve dependent timely
OBJECTIVE secretions inflammator timely on indicative resolution of
affecting y process. resolution of lung current
 Dyspnea oxygen The of current involvement infection
 Tachycardia exchange inflammatio infection and without
V/S taken as across n is without underlying complication.
follows: alveolar triggered by complicati general
membrane. many ons. status.
Bp= infectious
T= 37.4°C organisms
P= 195 bpm and by
R= 59 cpm inhalation  Monitor High fever
of irritating body greatly
agents. temperature. increases
Infectious metabolic
pneumonias demands and
are oxygen
categorized consumption
as and alters
community cellular
acquired oxygenation.
(CAP) or
hospital
acquired  Limit Reduces
(nosocomial visitors as likelihood
) indicated exposure to
Depending other
on where infectious
the patient pathogens.
was
exposed to
infectious  Suction as Stimulates
agent. indicated. cough or
mechanicall
(Potter y clears
Perry, 2017) airway in
patient who
is unable to
cough.

 Assists with Facilitates

nebulizer liquefaction
treatment and removal
of
secretions.

DEPENDENT

 Follow Ensure
doctors correct
order. procedure.
COLLABORATIV
E

 Administer These drugs

antimicrobia are used to
ls as combat most
prescribed. of the
microbial
pneumonias.