Final Case Study PCAP

University of Perpetual Help System Laguna
Dr. Jose G. Tamayo Medical University

Sto. Niño, Biñan, Laguna
COLLEGE OF NURSING
Pediatric Community-Acquired
Pneumonia (PCAP – C)
In Partial Fulfillment of the Requirements in NCM 107 B

A Case Presented By
Group 1 - 3/ N4X
Abellar, Justine A.
Acabado, Melanisol C.
Delfin, Gian Carlo D.
Fermindoza, Jenny Gay S.
Garcia, Leslie M.
Gutierrez, Joana G.
Olay, Nicole Neil N.
Regis, Melanie B.
Santos, Jeffrey M.
August 15, 2013

CONTENTS
I. Introduction
II. Patient’s Profile
III. Physical Assessment
IV. Anatomy and Physiology
V. Pathophysiology
VI. Medical Management
VII. Laboratory and Diagnostic Tests
VIII. Drug Study
IX. Nursing Care Plan

INTRODUCTION
I. Introduction
Pediatric community-acquired pneumonia (PCAP)
Pneumonia is a general term that refers to an infection of the lungs, which can be
caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites.
Pneumonia is the infection of the pulmonary tissue, including the interstitial spaces, the
alveoli, and the bronchioles. Pneumonia can be community-acquired or hospital-
acquired.
Community acquired pneumonia occurs either in the community setting or within the
first 48 hours after hospitalization or institutionalization.
Pneumonia is caused by a number of infectious agents, including viruses, bacteria and

fungi. The most common are: Streptococcus pneumoniae – the most common cause of
bacterial pneumonia in children; Haemophilusinfluenzae type b (Hib) – the second most
common cause of bacterial pneumonia; respiratory syncytial virus is the most common
viral cause of pneumonia.
Environmental Risk Factors include: indoor air pollution caused by cooking and
heating with biomass fuels (such as wood or dung), living in crowded homes, parental
smoking.
Signs and Symptoms vary depending on the age of the child and the cause of
the pneumonia, but common ones include: fever, chills, cough, nasal congestion,
unusually rapid breathing (in some cases, this is the only symptom), breathing with
grunting or wheezing sounds, labored breathing that makes the rib muscles retract
(when muscles under the ribcage or between ribs draw inward with each breath) and
causes nasal flaring, vomiting, chest pain, abdominal pain, loss of appetite (in older
kids) or poor feeding (in infants), which may lead to dehydration, in extreme cases,
bluish or gray color of the lips and fingernails.
Incidence:
Pneumonia is the single largest cause of death in children worldwide. Every year, it kills
an estimated 1.2 million children under the age of five years, accounting for 18% of all
deaths of children under five years old worldwide. Pneumonia affects children and
families everywhere, but is most prevalent in South Asia and sub-Saharan Africa.
PATIENT’S PROFILE
Name : C.R.
Age : 2 years old 9 months

Gender : Female
Status : Child
Nationality : Filipino
Religion : Roman Catholic
B-date : November 5, 2010
B-place : Binan,Laguna
Address : Cabuyao, Laguna
Admission date and time : August 4, 2013/ 9:42am
Attending Physician : Dra. G.M.
Initial Diagnosis :
PCAP-C
Final Diagnosis :
NONE
Chief Complaint
Cough
History of present illness:
Two weeks prior to admission, patient experienced cough, productive, no fever

noted, no difficulty of breathing. Patient was given Cefexime 2.5 ml and cetirizine
2.5 ml which give temporary relief. One day prior to admission suddenly
experienced fever, temperature maximum of 39 degree Celsius, patient was given
Paracetamol suppository which gave temporary relief, associated with
appearance of petechial rashes on the periorbital area. Persistence of the
symptom, prompted to have the admission.
Maternal and obstetric history:
Patient was born to a 27 years old G2P2 (2002) mother who had regular prenatal
checkup and regular intake of vitamins. No history and exposure to radiation and
teratogenic drugs. Patient had history of UTI during the course of pregnancy and
asthma at 7 months.
Birth History:
Patient was delivered live, via Caesarian Section attended by obstetrician and
pediatrician with no noted complications. Routine newborn screening was done.
Neonatal History:
Patient has no history of jaundice and cyanosis. Meconium was passed out
within 24 hour of life.
Immunization History:
(+) BCG
(+) DPT 3 doses
(+) OPV 3 doses
(+) Hep B 3 doses
(+) Varicella Vaccine
(+) Pneumonia Vaccine
Past Medical History:
(+) Hospitalization = 2012 Aug ; cough, UPHS
(+) Seizure at 5 months
(+) Asthma, 2012, Montelukast and prednisone

Family History:
(+) HPN = Paternal
(+) DM = Paternal
(+) Seizure = Paternal
(+) Asthma = Both
(-) CVD
(-) PTB
Aug. 8, 2013 vital signs:

Temperature : 36.1°C
Cardiac Rate : 107 bpm
Respiratory Rate : 35cpm
Blood pressure : 90/60
Weight : 14.1kg
Physical assessment
Psychological and social examination
 she is conscious and coherent
Erik Erikson Stages of psychosocial development
 Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt
 Toilet Training-Children need to develop a sense of personal control over

physical skills and a sense of independence. Success leads to feelings of
autonomy, failure results in feelings of shame and doubt.
Freud’s Stages of Psychosexual Development
 Anal Stage: Age Range 1 to 3 years old
 The child begins to toilet train, which brings about the child's fascination in
the erogenous zone of the anus. The erogenous zone is focused on the
bowel and bladder control. Therefore, Freud believed that the libido was
mainly focused on controlling the bladder and bowel movements. The anal
stage coincides with the start of the child’s ability to control their anal
sphincter, and therefore their ability to give or withhold gifts at will. If the
children during this stage can overcome the conflict it will result in a sense
of accomplishment and independence.
PHYSICAL ASSESSMENT (Cephalo-caudal)
August 8, 2013
Normal
Body Parts Technique Actual Findings Analysis
Findings
Skin (General) Inspection -light to dark - light to dark

Palpation brown brown
-no swelling -no swelling
Hair and scalp Inspection -good skin turgor - with good skin
turgor.
-no lesion -no lesion
- hair distribution, -color black

equal.
- Equal and
healthy hair and
distribution.
Head Inspection -face is -face is
symmetrical symmetrical
Neck Inspection -no lesion -no lesion

Eyes Inspection -symmetrically -symmetrically
align align
Eye brows Inspection -blinking -blinking
symmetrically symmetrically
Eye lashes Inspection -Evenly - Turned outward
distributed eyelashes; hair
equally
distributed
-eyelashes are
short
Eye lids Inspection -eye lid margins - Moist

are moist
Sclera Inspection -white in color -white in color
Pupil Inspection -equally round - Pupils equally

and reactive to reactive to light
light and and
accommodation accommodation.
Ears Palpation -equal in size -equal and

symmetrical
Inspection -symmetrically
align -no lesion
-no lesion -no swelling
-no swelling - no discharge
- no discharge
Nose Inspection -Symmetric and -Symmetric and

straight; no straight; no
discharge or discharge or
flaring; Uniform flaring; Uniform
color color
Lips Inspection -Pink in color, -pink, moist and

soft, moist, smooth in
smooth texture, texture.
asymmetry of -no lesion, no
contour, ability to sores.
purse lips
Buccal mucosa Inspection - Pink in color, - Pink color and
soft, moist, moist.
smooth,
glistening, and - no lesions and
elastic texture. sores noted
Tongue Inspection -no lesion -no lesion
- moisten -moist
- no sores noted
Gums Inspection -pink and moist -pink and moist,

- healthy gums.
Teeth Inspection -symmetrically -Good set of milk

aligned, no tooth teeth.
decay
Nails Inspection -Pink in color -Pink in color
Capillary refill <2 secs <2 secs
Upper Inspection -symmetrically -symmetrically

Extremities Palpation align align
-no lesion -no lesion
-light to dark -light to dark
brown in color brown in color
- can do active
range of motion.
ANTERIOR Inspection -Quiet, rhythmic, -Normal

and effortless breathing pattern
THORAX respirations. - no chest
Breathing indwelling
patterns
Auscultation Broncho -Normal breath

Anterior Thorax vesicular and sounds heard on
vesicular breath auscultation
sounds.
Auscultation Vesicular and Crackles on both Crackles are

POSTERIOR broncho lower lung fields often associated
vesicular breath with inflammation
THORAX sounds or infection of the
small bronchi,
bronchioles, and
alveoli.
Abdomen Inspection -smooth to touch -smooth to touch

Palpation -no lesion -no lesion
-warm to touch -warm to touch
-round and -round and
symmetrical symmetrical
-abdomen rises -abdomen rises
with inspiration in with inspiration in
synchromy with synchromy with
chest chest.
Lower Inspection -bilaterally -bilaterally
Extremities symmetrical and symmetrical and
equal equal
-right foot has -right foot has
complete fingers complete fingers
-skin color is as -skin color is as
same as the same as the
other parts of the other parts of the
body body
Inspection Normal skin -Normal skin

Posterior Lower and color. color
Extremities palpation.
F. Functional Health Pattern Assessment

1. Health Perception-Health Management Pattern
The child’s health is fair as describe by the mother but now it’s already poor. She
said that in maintaining the child’s health she provided the child with nutritious food as
much as possible and giving all the needs of the child like nice dress and proper
hygiene. She gave the child time to play with other kids. The child’s immunization was
complete.
The child was admitted to the hospital because of cough fever for 2 weeks. The
mother know the real cause of the illness because the ‘’yaya’’ has cough and cold. It
began on July 22, 2010 in the child was warm to touch. Patient was given Cefexime 2.5
ml and cetirizine 2.5 ml which give temporary relief. One day prior to admission
suddenly experienced fever, temperature maximum of 39 degree Celsius, patient was
given Paracetamol suppository which gave temporary relief, associated with
appearance of petechial rashes on the periorbital area. Persistence of the symptom,
prompted to have the admission.
The child was hospitalized last August 2012 because of cough as stated by her
grandmother. They expect that the child will get well soon as soon as possible so that
the child will not suffer from staying in the hospital.
During her pregnancy, the mother had her complete pre-natal check-up during
her pregnancy stage. She did not take any medications & no complications during
pregnancy.
2. Nutritional and Metabolic Pattern

The child’s appetite is usually good but upon hospitalization the child’s appetite is
poor. She doesn’t like to eat fruits and vegetables. They were not fond of going to fast
food or restaurants.
3. Elimination Pattern
The child defecates once a day, usually every morning with soft, brown, formed &
moderate in amount stool. She was toilet trained. The child doesn’t have any problems
in his urination. He doesn’t have any trouble in his skin.
4. Sleep-Rest Pattern
The child usually sleeps 9pm & wakes at 8am. She sleeps 11 hours a day with
naps. The child’s usual sleep routine was singing with his parents and listening bedtime
stories. She had no usual sleep pattern problem.
5. Activity-Exercise Pattern
Walks with steady gait, runs with few falls, walks on toes, stands on one foot,
jumps, kicks ball, throws ball overhand.
The child could eat using spoon and fork with assistance. She doesn’t want to
be helped. The child needs help in toileting since she doesn’t know where to defecate
and urinate. She defecates and urinates on their comfort room. The child needs help to
dress by herself, bath and brush his teeth.
The child watches TV for more than an hour she loves to watch cartoons. She
watches with his parents. She was prohibited watching action movies to avoid being
violent when he grows up.
6. Cognitive-Perceptual Pattern
The child did not have any sensory perception deficits. She was 2 years old. She is a
smart child
7. Self-Perception – Self-concept Pattern

The mother feels bad about her child’s illness and she was concerned about the
wellness of the child. The child verbalizes that he feels restless.
8. Role Relationship Pattern

The child uses appropriate words for his age. Spoken language in their home is
Tagalog and English. The child has one sibling. She was the youngest. Both the child’s
parents do the decision making and in disciplining the child. There was no marital
problem and violence in the family.
9. Sexuality-Reproductive Pattern
The child did not verbalize any sexual curiosity according to her mother.
10. Coping Stress Tolerance Pattern

The child needs to learn to decide for himself and if greater decisions are to be
made she should ask approval from his parents. There were no losses for the past year.
When the child is stress he turns to her mother. When the child was frustrated he plays
with her toys. She was not afraid of her mother and always try things that she is not
familiar of.
11. Value-Belief Pattern

The whole family was Roman Catholic as claimed by the mother. The mother just
likes to be prayed for her child’s wellness.
ANATOMY
AND
PHYSIOLOGY
Respiratory System
Nose or Nasal Cavity
As air passes through the nasal cavities it is warmed and humidified, so that air
that reaches the lungs is warmed and moist. The Nasal airways are lined with cilia and
kept moist by mucous secretions. The combination of cilia and mucous helps to filter out
solid particles from the air a Warm and moisten the air, which prevents damage to the
delicate tissues that form the Respiratory System. The moisture in the nose helps to
heat and humidify the air, increasing the amount of water vapour the air entering the
lungs contains. This helps to keep the air entering the nose from drying out the lungs
and other parts of our respiratory system. When air enters the respiratory system
through the mouth, much less filtering is done. It is generally better to take in air
through the nose.
To review: The nose does the following:
1. Filters the air by the hairs and mucous in the nose
2. Moistens the air
3. Warms the air

Pharynx
The pharynx is also called the throat. As we saw in the digestive system,

the epiglottis closes off the trachea when we swallow. Below the epiglottis is
the larynx or voice box. This contains 2 vocal cords, which vibrate when air passes by
them. With our tongue and lips we convert these vibrations intospeech. The area at the
top of the trachea, which contains the larynx, is called the glottis.
Trachea
The trachea or windpipe is made of muscle and elastic fibres with rings of

cartilage. The cartilage prevents the tubes of the trachea from collapsing. The trachea is
divided or branched into bronchi and then into smaller bronchioles.
The bronchioles branch off into alveoli.
Bronchi
Similar to trachea with ciliated mucous membrane and hyaline cartilage. Lower
end of trachea divides into right and left this.
Bronchioles
Thinner walls of smooth muscle, lined with ciliated epithelium. Subdivision of

bronchi.At the end, alveolar duct and cluster of alveoli.
Lungs
The lungs are spongy structure where the exchange of gases takes place. Each
lung is surrounded by a pair of pleural membranes. Between the membranes is pleural
fluid, which reduces friction while breathing. The bronchi are divided into about a million
bronchioles. The ends of the bronchioles are hollow air sacs called alveoli. There are
over 700 million alveoli in the lungs. This greatly increases the surface area through
which gas exchange occurs. Surrounding the alveoli are capillaries. The lungs give up
their oxygen to the capillaries through the alveoli. Likewise, carbon dioxide is taken from
the capillaries and into the alveoli.
pathophysiology
MEDICAL
MANAGEMENT
Time Doctors Order Rationale Nursing
Consideration
August 4, 2013
- Please admit to - Patient has a right to

ROC under the service choose his/her medical
of Dr. Malayan practitioner or
treatment
- Please secure
consent for this - An informed consent - Make sure there
admission and is a sign of patient is a witness when
management participation in medical patient signs an
treatment in written informed consent.
form.
- TPR q shift and - Observe proper

-TPR is used to create documentation.
record pls baseline parameters.
-DAT means that the

- DAT patient can eat any
meals as long as
he/she can tolerate.
- Temporary treatment
for shock if any plasma - Carefully check
expander is for regulation to
- IVF D5 0.3 NaCl unavailable and for avoid fluid
500cc x 6hrs at 20 -21 patient having overload or
gtts/min addison’s crisis. For underload.
replacement or
maintenance of fluid
and electrolytes.
-It is a diagnostic test

that gives information
about the cells in the
patient's blood.
-
Diagnostics: - It is a radiograph
a. CBC c platelet projection of the chest
count used to diagnose
conditions affecting the
chest
- Paracetamol is an
anti-pyretic and
b. Chest X-ray AP-L
analgesic drug used to
treat fever and pain.
Therapeutics
- Paracetamol 150mg - I &O is a parameter

IV every 4 hrs for temp that checks how much - Paracetamol is
38 and above. fluids has been given as a PRN
consumed or excreted order if the
- Paracetamol in the patients body. patient really
250mg/5ml, give 4ml needs it.
every 4 hrs for temp
37.8 and above
- Vital signs are
monitored to know
how the body functions
- Always check
proprerly.
for fluid intake
including IVF
consumed
- Monitor I&O every -History taking and
shift physical examination
are important tools to
know what are the
etiologic factors prior
to a disease.
- Always double
check VS
mesuring the fluid and readings if there
electrolytes losses by is doubt.
how manny times the
- Monitor VS every patient vomit througt
2hrs the use of cup method
- when doing PE
it should be from
head-toe.
-Do complete Hx and

PE c/o PCIC/PHC
-Replace volume per - It relieves

volume losses with inflammation (swelling,
PLR heat, redness, and
pain) and is used to
treat certain forms of
arthritis; skin, blood,
kidney, eye, thyroid,
and intestinal
disorders (e.g., colitis);
severe allergies; and
-Dr. Malayan informed asthma.
with this condition
- It is used in inhibition
-Refer of eosinophil
chemotaxis
- Rotate sites of
IM repository
injections to avoid
local atrophy.
Meds: - For maintenance of
losses in fluids and
- Start hydrocortisone electrolytes.
60mg/IV every 6 hrs
- Montelukast is a
leuokotreine receptor
antagonist (LTRA)
used for the - This should be
maintenance treatment given after the
of asthma and to patient has eaten.
relieve symptoms of
seasonal allergies.
- Start cetrizine + -D5IMB is an IV

phenylephrine (Alnix solution that consists
plus) 2.5ml BID in full of 5% dextrose and
stomach water level. It is
usually given to
patients in hospitals - Assess for drug
that could potentially hypersensitivity.
- Replace losses
become ill through
volume per volume as
high sodium levels or
ordered
low blood sugar levels.
- Replace patient
meds:
1:30pm
4 mg chewable tablet
or 4 mg granules orally - Carefully check
once a day. for regulation to
avoid fluid
overload or
underload.
- It is a diagnostic test
that checks the
- IVF to follow D5IMB components of your
500cc x 11hrs at urine.
45cc/hr
- NS1 (Nonstructural
Protein 1) is a test for
dengue which allows
rapid detection on the
first day of fever,
before antibodies
appear some 5 or
more days later.
- Hold D5IMB instead

3:45pm IVF to follow
D5NSS 500cc at
4cc/hr
- For repeat cbc with

platelet tomorrow at
6am
- for urinalysis
- for dengue NS1 to

include to next blood
8:46pm extraction
- cut present
management
August 5, 2013
5pm - IVF for follow D5NSS - For maintenance of - Carefully check

500cc at 42cc/hr losses in fluids and for regulation to
electrolytes. avoid fluid
overload or
- follow up CBC with underload.
7:45am
platelet result
- Dr. Malayan updated

9am
- for repeat cbc with
6am(8/6/13)
- Nebulize with
combivent 1 neb every - Combivent is a drug
6hrs via facemask used for treating
COPD through
inhalation from a
nebulizer.
- rounds with Dr,
Malayan
- continue present
9:45am
management
- start cefuroxime
250mg n every 8 - Assess for drug
ANST() - Cefuroxime is a hypersensitivity.
parenteral second
generation
cephalosphorin
antibiotic used to treat
infection.
- IVF to follow D5NSS - For maintenance of - Carefully check

500cc at 42cc/hr losses in fluids and for regulation to
3:30pm electrolytes. avoid fluid
overload or
underload.
August 6, 2013
8:30am - Continue with

present management
- for repeat cbc with

2:30pm
6am
- am present
management
12nn - For maintenance of - Carefully check

- IVF to FF: D5NSS at losses in fluids and for regulation to
42cc/hr electrolytes. avoid fluid
overload or
underload.
August 7, 2013
7:50am - continue present

management
- rounds with Dr.

11:30am
Malayan
- Heraclene 1mg/cap -Heraclene - Advise patient to

OD c/o patient meds, (Dibencozide) Capsule avoid products
continue present aids optimal that contain
management consumption of caffeine.
nutritional protein
ingestion and helps in
the development and
restoration of body
tissues and kindles in
the body the desire for
food.
- Dr. Malayan updated
- for report cbc with

platelet tom at 6am
(8/8/13)
August 8, 2013
8:25am - Continue present

management
- For maintenance of - Carefully check

- IVF to follow D5NSS losses in fluids and for regulation to
1 liter at 42cc/hr electrolytes. avoid fluid
overload or
1:20pm underload.
- continue present
management
LABORATORY
AND
DIAGNOSTIC
TESTS
COMPLETE BLOOD COUNT (CBC)

The complete blood count or CBC test is used as a broad screening test to check
for such disorders as anemia, infection, and many other diseases.
DATE REQUESTED: August 4, 2013
RESULT NORMAL INTERPRETATION SIGNIFICANCE

VALUE
Hemoglobin 132 110-140 NORMAL
Hematocrit .406 0.37-0.47 NORMAL
RBC count 4.70 4.00-5.50 NORMAL
WBC count 6.50 5.0-10.0 NORMAL
Neutrophils 3.44 1.63-6.96 NORMAL
Lymphocytes 2.25 1.09-2.99 NORMAL
Monocytes .739 0.240-0.790 NORMAL
Eosinophiles .005 0.00-0.5% NORMAL
Basophiles .064 0.00-0.80 NORMAL
MCV 86.3 80-98 NORMAL
MCH 28.1 26-32 NORMAL
MCHC 325 320-360 NORMAL
RDW 10.2 10.2-14.5% NORMAL

Indicate risk of
Platelet count 124 150-450 DECREASED bleeding

VALUE
WBC count 4.81 5.0-10.0 NORMAL
Eosinophiles 0.00 0.00-0.5% NORMAL
Basophiles .025 0.00-0.80 NORMAL
MCHC 323 320-360 NORMAL
RDW 10.3 10.2-14.5% NORMAL

Indicate risk of

VALUE

Decreased due to
WBC count 3.76 5.0-10.0 DECREASED inadequate
inflammatory defenses
to suppress infection.
Monocytes .296 0.240- NORMAL

0.790
Eosinophiles 0.00 0.00-0.5% NORMAL
Basophiles .024 0.00-.0.80 NORMAL

Indicate presence of
MCHC 316 320-360 DECREASED anemia.
RDW 10.0 10.2- DECREASED anemia.
14.5%
Indicate risk of

VALUE

Decreased due to
WBC count 4.21 5.0-10.0 DECREASED inadequate
inflammatory
defenses to suppress
infection.
Decreased. May
Neutrophils 1.42 1.63-6.96 DECREASED indicate increase risk
of infection
Eosinophiles .001 0.00-0.5% NORMAL
Basophiles .018 0.00-.080 NORMAL

MCV 26.8 80-98 DECREASED anemia

MCHC 315 320-360 DECREASED anemia
RDW 10.1 10.2-14.5% DECREASED anemia
Platelet count 176 150-400 NORMAL

CHEST X-RAY (CHEST RADIOGRAPHY)
The chest x-ray is the most commonly performed diagnostic x-ray examination. A
chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of
the spine and chest.
EXAMINATION DONE: Chest X –ray Posterior Anterior
Interpretation:
- The interstitial lung markings are accentuated with fine reticulation in the
parihilar areas.
- The heart is not enlarged
- Diaphragm and sulci are normal
- Visualized bones are intact
Impression: INTERSTITIAL PNEUMONITIS CONSIDERED

URINALYSIS
The urinalysis is used as a screening and/or diagnostic tool because it can help
detect substances or cellular material in the urine associated with different metabolic
and kidney disorders. It is ordered widely and routinely to detect any abnormalities that
require follow up.
RESULT NORMAL INTERPRETATION SINIFICANT

VALUE
Color: Light Yellow Straw to Dark NORMAL
Yellow
Transparency: Slightly Hazy Clear-Hazy NORMAL
Reaction (pH): 6.5 5-8.5 NORMAL
Glucose: Negative Negative NORMAL
Protein Negative Negative NORMAL
Ketones: - Negative
Specific 2.020 1.003-1.029 INCREASED Indicate
gravity: presence of
dehydration
Pus cells: 10-12/hpf 2-3/hpf INCREASED Indicate
presence of
infection
RBC 1-2/hpf Male: 0-3/hpf NORMAL
Female: 0-
5/hpf
Epithelial Few Rare- NORMAL
Cells moderate
DENGUE NS1 Ag Assay Test
This test is use for early diagnosis of dengue virus infection
TEST NAME RESULT
Negative
Dengue NS1Ag
: IgG Negative
: IgM Negative
Drug study
Drug Name Mode of Action Indication Interaction Side Effect Nursing Consideration
Generic Name: -Second- -Lower respiratory -Amino GI: nausea and vomiting -Determine history of
Cefuroxime axetil generation infection glycosides hypersensitivity reactions to
cephalosporin -Loop diuretics drugs.
Brand Name: that inhibits cell- -Probenecid SKIN: rash,pruritus,
Ceftin wall urticaria -Check the IV site before
synyhesis,promot giving the medicartion.
Classification: ing osmotic Contraindication:
Cephalosporin 2nd instability;usually -Instruct the parent or
generation bactericidal. -Contraindicated in guardian of the patient to
patients Notify the prescriber about
Dosage:250mg/5 hypersensitivity to rash or evidence of
ml cephalosporin superinfection.
Frequency:Q8 -Administer medication with

meals to decrease GI upset
and enhance absorption.
Route: IV
-Advise the parent or
guardian of the patient to re
portloose stools or diarrhea.
Generic Name: -A long-acting -Seasonal allergic - CNS -somnelence,head -Assess for allergy
citirizine nonsedating rhinitis depressant ache, symptoms: rhinitis, pruritus,
+penylphrine antihistamine that -Perennial allergic -Theophylline dizziness,fatigue. urticaria, watering eyes,
selective inhibits rhinitis,chronic -Barbiyuates before and periodically
Brand Name: pheripera H1 urticaria -Hypnotics -pharyngitis during treatment.
Alnix Plus receptor. -Opiod
analgesics -dry mouth,nausea, -Assess respiratory status
Classification: Contraindication: vomiting,abdominal and increase in bronchial
Antihistamine distress. secretions, wheezing, chest
-Contraindicated in tightness: provide fluids to
Dosage: 2.5ml patients -couhing,bronchospasm decrease viscosity or
hypersensitivity to thickness of secretion.
Frequency: BID drug.
-Use cautiously in -Instruct the patient’s family
patients with renal to take 1hr before or 2 hrs
Route: P.O and hepatic after a meal to facilitate
impairement. absorption.
-Advise pts family to use

sugarless gum, candy,
frequent zip of water of
minimize dry mouth.
-Instruct pts family to inform

physician if dizziness
occurs or if symptoms
persist.
Generic Name: -Inhibits protein -Bacterial infection -Alprozalam CNS:dizziness, -Assess bowel
clarithromycin synthesis in (pneumonia) - headache, vertigo, pattern,discontinue drug if
susceptible Carbamazepine fatigue severe diarrhea occurs.
Brand Name: bacteria, causing -Cyclosporine
Klaz cell death. -Digoxin GI: diarrhea, -Assess patient’s infection before
-Ritonavir abdominal pain or therapy and regularly thereafter.
Classification: -Thophylline discomfort,nausea,vo
Macrolide Contraindication: -Fluconazole miting, -Take drug with food if GI effects
Antibiotic -Warfarin pseudomembranous occur.Do not drink grapefruit
-Contraindicated in colitis. juice while taking this drugs.
Dosage:250mg/5 patients
ml hypersensitivity to SKIN: rash(pediatric) -Shake suspension before use:
clarithromycin, do not refrigerate.
Frequency: BID erythromycin, or HEMATOLOGIC:
(on full stomach) any macrolide leukopenia,coagulati -Instruct the pts family to take all
antibiotic. on abnormalities. medication prescribed for the
length of time ordered and to
Route: PO continue drug therapy as
prescribed even he feels better.
-Instruct the pts family to report

persistent adverse reactions.
-Advise the pts family to report

diarrhea, rash or itching, mouth
sores.
Generic Name: -Dibencozide -Premature babies, - GI: Constipation, -Advise the parent of the
dibencozide increases the low birth weight, Diarrhea, N/V. patient to avoid products
protein efficiency retarded growth, that contain caffeine.
BrandName: coefficient ie, the poor appetite in CV: Tachycardia
Heraclene percentage of infants, children and -Report any evidence of
bound nitrogen adults. CNS: Overstimulation, excessive stimulation
Classification: for protein build- Headache, Dizziness,
Appetite up in the body Insomnia
Stimulants compared to
ingested nitrogen Contraindication:
Dosage:1mg with food intake.
- Hypersensitivity to
Frequency:OD drugs or its
ingredients
Route:
Drug Name Mode of Action Indication Interactio Side Effect Nursing Consideration
n
Generic -Decreases -Severe -NSAID’s -headache -Assess the pt’s condition before
Name: inflammation,mainl inflammation, - - starting therapy and reassess
hydrocortisone y by stabilizing -Adrenal Cyclospori nausea/vomi regularly.
sodium leukocyte insufficiency ne ting
succinate lysosomalmembra -Shock -Oral -easy -Tell the parents or guardian of
nes;suppresses anticoagul bruising the patient not to stop drug
Brand Name: immune ants - abruptly or without prescriber’s
Solu-Cortef response;stimulate - carbohydrate consent.
s bone Pottasium- intolerance
Classification: marrow;and depleting -GI irritation -Warn the parents or guardian of
Corticosteroids/ influences drugs -growth the patient on long-term therapy
Anti- protein,fat,and Contraindication: -Skin-test suspension about cushing effects (moon
inflammatory carbohydrate antigen in face,buffalo hump) and need to
metabolism. -contraindicated in children,mus notify prescriber about sudden
Dosage:60mg patients cle weight gain or swelling,ang easy
hypersensitivity to weakness bruising.
Frequency: drug or its
Q 6hrs ingredients,in -Monitor the patient’s weight and
those receiving electrolyte level.
Route: IV immunosuppressiv
e -Instruct the parents or guardian
doses together of the patient to take Vit.D and
with live virus calcium supplement.
vaccine,and in
premature infants. -Encourage the parents or
guardian of the patient to deep
breathing exercise.
-Teach the parents or guardian

of the patient sign and
symptoms of early adrenal
insufficiency:
fatigue,muscleweakness,jointpai
n,fever,anorexia,nausea,
Shortness of
breath,dizziness,and fainting.
Generic Name: - Unknown. -Mild pain or fever - Barbiturates - hemolytic -Assess pts fever: temperature,
paracetamol Thought to - Carbamazepine anemia diaphoresis.
produce - Hydantoins - neutropenia
Brand Name: analgesia by - Fifampin - leukopenia -Give with food or milk to
Tempra blocking pain - Sulfinpyrazone - pancytopenia decrease gastric symptoms;give
impulses by - jaundice 30mins before or 2hrs after
Classification: inhibiting - rash meals;absorption may be
Analgesic/Antipyre synthesis of Contraindication: - urticaria slowed.
tic prostaglandin in
the CNS or other -Contraindicated in - Advise the parents to do tepid
Dosage: substances that patients sponge bath (TSB) to lower the
250mg/5ml sensitize pain hypersensitivity to body temperature (if the pt. is
T - >37.8 receptors to drugs. febrile 38 and above).
stimulation.The
Frequency:Q4 drug may relieve - Tell parents to consult
fever through prescriber before giving drug to
central action in children younger than age 2.
Route: PO the hypothalamic
heat regulating -Advise the parent of the patient
center. that the drug is only for short-
term used and to consult
prescriber if giving to children for
longer than 5 days.
-Tell parents to increase fluid

intake to prevent dehydration.
Generic Name: - Unknown. -Mild pain or fever - Barbiturates - hemolytic -Assess pts fever:
paracetamol Thought to - Carbamazepine anemia temperature, diaphoresis.
produce - Hydantoins - neutropenia
Brand Name: analgesia by - Fifampin - leukopenia -Give with food or milk to
blocking pain - Sulfinpyrazone - pancytopenia decrease gastric
impulses by - jaundice symptoms;give 30mins
Classification: inhibiting - rash before or 2hrs after
Analgesic/Antipyre synthesis of Contraindication: - urticaria meals;absorption may be
tic prostaglandin in slowed.
the CNS or other -Contraindicated in
Dosage: substances that patients -Assess the IV site before
150mg sensitize pain hypersensitivity to giving medication.
T - >38 receptors to drugs.
stimulation.The - Advise the parents to do
Frequency:Q4/pr drug may relieve tepid sponge bath (TSB) to
n fever through lower the body temperature
central action in (if the pt. is febrile 38 and
the hypothalamic above).
Route: IV heat regulating
center. - Tell parents to consult
prescriber before giving
drug to children younger
than age 2.
-Advise the parent of the

patient that the drug is only
for short-term used and to
consult prescriber if giving
to children for longer than 5
days.
-Tell parents to increase

fluid intake to prevent
dehydration.
Drug Name Mode of Action Indication Interaction Side Effect Nursing
Consideration
Generic Name: - -asthma - CNS:fever,headache, -Assess

montelukast Selective,competiti- -seasonal allergic Phenobarbital dizziness,fatigue. patient’s
sodium ve leukotriene rhinitis -Rifampin underlying
receptor antagonist EENT:nasal condition before
Brand Name: that reduces early congestion,dental pain therapy and
Singulair and late-phase regularly
bronchoconstriction GI:dyspepsia,infectious thereafter to
Classification: from antigen gastroenteritis,abdomina monitor drug
Bronchodilator challenge. l pain effectiveness.
Contraindication:
Dosage:4mg RESPIRATORY:cough -Assess
granules -Contraindicated in respiration
patients SKIN:rash ausculted
Frequency: hypersensitivity to bilateral lung
ODHS drug. fields:rate and
-Use cautiously rhythm.
Route: PO and with
appropriate -Assess for
monitoring in allergic
patients whose reactions: rash,
dosages of urticaria, and
systemic pruritus.
corticosteroids are
reduced. -Take with or
. without
food.May give
directly in
mouth or mixed
w/a spoon of
soft food
(carrots, apple
sauce, juice,
milk rice).
-Assess
patien’s and
family’s
knowledge of
drug therapy.
Nursing
Care
plan
CUES PROBLEM SCIENTIFIC DESIRED INTERVENTION/ EVALUATION
REASON OUTCOME RATIONALE
STANDARD CRITERIA
Ineffective Ineffective airway Short term goal: Independent:
airway clearance occurs • Auscultate breath
clearance when an artificial After 6 hours of sounds. Note The patient Outcomes
related to airway is used Nursing adventitious breath will be able partially met,
Objective: increase because normal Intervention, the sounds like wheezes, to breathes the patient
• Nasal production of mucociliary transport Patient breathes crackles and rhonchi. without nasal was able to
Flaring mucus mechanisms are without using nasal flaring with demonstrate
secretion bypassed and flaring. Rationale: RR of 35bpm behavior to
• Abnormal impaired. • Some degree of to 28bpm improved
breath Long term goal: bronchospasm is airway
sounds. present with clearance
(crackles) After 3 days of obstructions in airway
nursing intervention and may or may not be
 Productive the patient breathes manifested in
cough normally. adventitious breath
(transparent) sounds.
V/S taken as • Keep

follows: environmental
pollution to a minimum
RR-35 like dust, smoke and
feather pillows,
according to individual
situation.
Rationale:
• Precipitators of
allergic type of
respiratory reactions
that can trigger or
exacerbate onset of
acute episode.
• Encourage or
assist with abdominal
or pursed lip breathing
exercises.
Rationale:
• Provides patient
with some means to
cope with or control
dyspnea and reduce
air tapping.
• Assist with
measures to improve
effectiveness of cough
effort.
Rationale:
 Coughing is most
effective in an
upright position
after chest
percussion.
 Position
appropriately and
discourage use of
oil-based products
around nose.
Rationale:
 To prevent vomiting
with aspiration into
lungs.
 Obtain sputum
specimen,
preferable
 before antimicrobial
therapy is initiated.
Rationale:
 To verify
appropriateness of
therapy.
COLLABORATIVE:
 Administered
analgesics.
Rationale:
 To improve cough
when pain is
inhibiting effort.
REASON OUTCOME RATIONALE
STANDARD CRITERIA
Subjective: Risk for further The patient’s immune Short term goal: INDEPENDENT
infection r/t system is not fully After 8 hrs of nursing 1. assess TPR,
intervention auscultate The patient After 8 hrs of
spread of activated until will exhibit nursing
the patient will free breath sounds
pathogens sometime after birth. no signs of
Objective: from further infection - Assessments intervention
- Patient secondary to Limitation in the provide infection
the patient are
is diagnosed identified patient’s inflammatory Long term goal: information about Free from
with PCAP PCAP response result in After several days of the spread of
further
failure to recognize, nursing intervention infection,
infection will be increased RR and infection
localize, and destroy
- Vital invasive bacteria thus, prevented. HR, decreased BP
Sign are signs of
increasing risk for
RR: 35 cpm sepsis. Spread of
HR:142 bpm infection infection may
TEMP: 36.6 cause resp.
WT: 14.1 kg distress
- 2. Ensure that all
people coming
Decreased in contact with
WBC level patient. wash
4.21 their hands
well before &
after touching
the patient.
- Hand washing
prevents the
spread of
pathogens coming
from the patient to
the caregiver and
vice versa
3. Ensure that all
equipment
used for patient
is sterile,
scrupulously
clean
&disposable.
Do not share
equipment with
other patient.
- this would prevent
the spread of
pathogens to the
patient from
equipment
4. Place patient
in isolette/
isolation room
per hospital
policy
- placing the patient
in an isolette
allows close
observation of the
ill neonate &
protects other
patient from
infection
5. maintain
neutral thermal
environment
- A neutral thermal
environment
decreases the
metabolic needs of
the patient. The
patient has
difficulty
maintaining a
stable temp
6. Provide
respiratory
support
(oxygen)
- resp. support may
be needed during
the acute phase of
the infection to
prevent additional
physiological
stress
7. Monitor lab
results as
obtained.
Notify care
giver/ physician
of abnormal
findings
- lab results provide
information about
the pathogen and
patient’s response
to illness and
treatment
8. administer IV
fluids as
ordered
(D10IMB)
- IV fluids help
maintain fluid
balance
9. Administer
antibiotics as
ordered.
- Antibiotics act to
inhibit the growth
of bacteria and
destruction of
bacteria.

REASON OUTCOME RATIONALE STANDARD
Subjective: Risk for Fluid volume Short term 1. Assess vital The client will Subjective:
Deficient Fluid deficit, or goal:After 8 hrs sign changes, remain show
”Anim na bases Volume may hypovolemia, of nursing e.g., no signs and ”Anim na
na siyang includeexcessi occurs from a interventionthe increased symptoms of bases na
nagsusuka.” As ve fluid loss loss of body fluid patient will temperature/p dehydration siyang
verbalized by (fever, profuse or the shift of demonstrate fluid rolonged nagsusuka.”
the patient’s diaphoresis, fluids into the balance fever, As verbalized
caregiver mouth third space, or evidenced by tachycardia, by the
breathing/hyp from a reduced individually orthostatic patient’s
erventilation, fluid intake. appropriate hypotension. caregiver
Objective: vomiting) Common parameters, e.g.,
sources for fluid moist mucous  Elevated
•Restlessness temperature/
loss are the membranes,
gastrointestinal good skin turgor, prolonged
•Vomiting (6x) Objective:
tract, polyuria, prompt capillary fever
•Fatigue and increased refill, stable vital increases
•Restlessness
perspiration. signs. metabolic
•V/S taken as rate and fluid •Vomiting (6x)
Fluid volume
follows: Long term loss through
deficit may be an
goal:After evaporation. •Fatigue
RR: 35 cpm acute or chronic
condition several days of Orthostatic •V/S taken as
HR:142 bpm managed in the nursing BP changes follows:
hospital intervention the and
TEMP: 36.6 patient will RR: 35 cpm
outpatient increasing
WT: 14.1 kg center, or home experience fluid tachycardia
balance. HR:142 bpm
setting. may indicate
TEMP: 36.6
WT: 14.1 kg
CUES PROBLEM SCIENTIFI DESIRED INTERVENTION/ EVALUATION
C REASON OUTCOME RATIONALE STANDARD CRITERIA
Subjective: Acute pain r/t Pneumonia Short term INDEPENDENT The patient will The patient
localized is goal: relief of pain was relief on
inflammation inflammatio 1. Elevate head of and pain and
and persistent n of the After 4hrs of the bed, change demonstrate demonstrated
cough. terminal nursing position relaxed relaxed
Objective: airways and interventionthe frequently. manner, manner,
alveoli patient will relief resting/sleepin resting/sleepi
•Use of of pain and  Lowers
caused by diaphragm, g and ng and
accessory demonstrate
acute promoting chest engaging in engaging in
muscle. relaxed manner,
infection by expansion and activity activity
various resting/sleeping
•Productive
and engaging in expectoration of appropriately appropriately.
cough agents. secretions.
Pneumonia activity
(transparent)
can be appropriately. 2.Assist patient The patient will
•Restlessness divided into with deep free from pian
three breathing
•Fatigue
groups: Long term exercises
•V/S taken as community goal:
acquired,  Deep breathing
follows:
After several facilitates
hospital or
RR: 35 cpm days of nursing maximum
nursing
intervention the expansion of
HR:142 bpm home
patient will the lungs and
acquired(no
display patent smaller
TEMP: 36.6 socomial),
airway with airways.
and
breath sounds
pneumonia 3. Demonstrate or
clearing
in an help patient learn
immune to perform activity
compromis like splinting chest
ed person. and effective
Causes coughing while in
include upright position.
bacteria
(Streptococ  Coughing is a
cus, natural self-
Staphyloco cleaning
ccus mechanism.
Splinting
Haemophilu reduces chest
sinfluenzae, discomfort, and
Klebsiella,L an upright
egionella). position favors
Community deeper, more
Acquired forceful cough
Pneumonia effort.
(CAD) is a
disease in 4. Force fluids to
which at least 3000
individuals ml per day and
who have offer warm,
not recently rather than
been cold fluids.
hospitalized  Fluids
develop an especially warm
infection of liquid said in
the lungs. It mobilization
is an acute and
inflammator expectoration of
y condition secretions
that’s result
from COLLABORATIVE
aspiration 5. Administer
of medications as
oropharyng prescribe:
eal mucolytics or
secretions expectorants.
or stomach
contents in  Aids in
the lungs. reduction of
bronchospasm
and
mobilization of
secretions.
6. Provide
supplemental
fluids.
 Fluids are
required to
replace losses
and aid in
mobilization of
secretions.

Final Case Study PCAP

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Final Case Study PCAP

Uploaded by

Copyright:

Available Formats

University of Perpetual Help System Laguna

Dr. Jose G. Tamayo Medical University

In Partial Fulfillment of the Requirements in NCM 107 B

August 15, 2013

II. Patient’s Profile

III. Physical Assessment

IV. Anatomy and Physiology

VI. Medical Management

VII. Laboratory and Diagnostic Tests

VIII. Drug Study

IX. Nursing Care Plan

Pediatric community-acquired pneumonia (PCAP)

Pneumonia is caused by a number of infectious agents, including viruses, bacteria and

Age : 2 years old 9 months

Religion : Roman Catholic

B-date : November 5, 2010

Address : Cabuyao, Laguna

Admission date and time : August 4, 2013/ 9:42am

Attending Physician : Dra. G.M.

History of present illness:

Two weeks prior to admission, patient experienced cough, productive, no fever

(+) DPT 3 doses

(+) OPV 3 doses

(+) Hep B 3 doses

(+) Varicella Vaccine

(+) Pneumonia Vaccine

Past Medical History:

(+) Hospitalization = 2012 Aug ; cough, UPHS

(+) Seizure at 5 months

(+) Asthma, 2012, Montelukast and prednisone

(+) HPN = Paternal

(+) Seizure = Paternal

(+) Asthma = Both

Aug. 8, 2013 vital signs:

Cardiac Rate : 107 bpm

Respiratory Rate : 35cpm

Blood pressure : 90/60

 she is conscious and coherent

Erik Erikson Stages of psychosocial development

 Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt

 Toilet Training-Children need to develop a sense of personal control over

Freud’s Stages of Psychosexual Development

 Anal Stage: Age Range 1 to 3 years old

Skin (General) Inspection -light to dark - light to dark

-no swelling -no swelling

-no lesion -no lesion

- hair distribution, -color black

Neck Inspection -no lesion -no lesion

-no swelling -no swelling

Eye lids Inspection -eye lid margins - Moist

Pupil Inspection -equally round - Pupils equally

Ears Palpation -equal in size -equal and

Nose Inspection -Symmetric and -Symmetric and

Lips Inspection -Pink in color, -pink, moist and

Gums Inspection -pink and moist -pink and moist,

Teeth Inspection -symmetrically -Good set of milk

Upper Inspection -symmetrically -symmetrically

ANTERIOR Inspection -Quiet, rhythmic, -Normal

Auscultation Broncho -Normal breath

Auscultation Vesicular and Crackles on both Crackles are

Abdomen Inspection -smooth to touch -smooth to touch

Inspection Normal skin -Normal skin