Serrano, Alyssa Marie C.

19-1527
BSN-II
Present a case study on below scenario:
A 3 years 4 months old female child brought with the history of fever since 1week, low grade, wet type Cough associated with rapid breathing. She got hospitalized and was
evaluated for fever in PMICU
ON ADMISSION Initial symptoms
Temperature was normal
S1 S2 normal, no murmur CNS;
Conscious, coherent, active and alert Respiratory system;
decreased breath sounds- mild tachypnea, subcostal retractions
On physical examination Per Abdomen; soft, no tenderness
Nothing significant Past history Family history
Birth history
Immunization history; Up to date Developmental history: Appropriate for age
PROVISIONAL DIAGNOSIS WAS THOUGHT TO BE: PNEUMONIA

Base on the signs and symptoms stated, the history of fever for 1week, wet type of cough associated with rapid breathing can be signs and symptoms of Pneumonia. Though the
initial symptoms upon admission seems to be normal, the child’s respiratory system examination shows a sign of respiratory distress which is the subcostal retractions. Pneumonia
caused by a virus is often less severe than when caused by bacteria. The symptoms usually start out like the flu. They slowly get worse over a few days. Pneumonia caused by
bacteria can come on suddenly with a high fever, fast breathing and coughing. Both types of pneumonia can cause the child’s cough to last for weeks after the fever has stopped.
Further laboratory testing must be done to determine and to make a proper diagnosis and/or to verify the provisional diagnosis of pneumonia.
NURSING CARE PLAN

ASSESSMENT NURSING PLANNING/EXPECTED NURSING RATIONALE EVALUATION

DIAGNOSIS OUTCOME INTERVENTION
Chief complain: Ineffective breathing After 8 hours of nursing Determine the presence of To know the cause of After 8 hours of nursing
Hx of fever – low grade, pattern related to intervention, patient will factors or physical conditions breathing impairments. intervention, patient’s
Wet cough associated decreased lung expansion establish a normal, effective as noted in related factors. condition partially
with rapid breathing for as evidenced by respiratory pattern without improved as evidenced by
1week subcostal retractions. any sign of respiratory Auscultate and percuss chest. To evaluate the presence and decreased sign of
distress. characteristics of breath respiratory distress.
Initial Assessment: sounds and secretion.
T: NL Oxygen administration
S1, S2: NL, (-) murmur Note rate and depth of To obtain data that can be was continued.
CNS: conscious, respirations and type of compare throughout the
coherent, active and breathing pattern. intervention. Re-assess patient, and in
alert need of another nursing
Respiratory System: Assist with/review of results To diagnose the interventions.
decreased breath of necessary testing such as presence/severity of lung
sounds- mild chest x-ray, lung volume and disease. Goal partially met.
tachypnea, subcostal pulmonary function.
retractions
Physical Examination: Note emotional responses Anxiety may be causing or
Abdomen soft, no like crying, gasping in exacerbating acute or chronic
tenderness children. hyperventilation.

Immunization hx: up to Assess for contaminant Cause that may need of

date pain/discomfort.
Developmental hx:
Appropriate for age Administer oxygen at the
lowest concentration
indicated and prescribed
restriction of respiratory
effort.
For management of the
underlying pulmonary
condition, respiratory distress,
respiratory medications.
Suction airway, if needed.
Elevate the head of bed
and/or have the patient in a
sit up position, as
appropriate.
Monitor oxygen saturation,
using pulse oximeter.
Maintain calm attitude while
dealing with the patient and
SO(s).
Emphasize the importance of
good posture and effective
use of accessory muscle to
the parent.
Educate the patient’s SO to
take medication as
prescribed. (ensuring
accuracy of dose and
frequency and monitoring
adverse effects)
or cyanosis.
To clear secretions that
obstructed.
This is to promote
physiological and
psychological ease of
maximal breathing.
To verify
maintenance/improvement in
O2 saturation.
To limit the level of anxiety.
To maximize respiratory
effort.
These measures allow patient
to participate in maintaining
health status and improve
ventilation.