Introduction- Good Day! This is Lecery Sophia Wong a student nurse calling from Pedia Ward.

I am
calling to report a newly admitted Patient P.
Situation- Patient P, admitted due to due to cough, fever, accompanied by loose watery stool
under the service of Dr. Cruz with an Initial diagnosis of PCAP-MR
Background- Patient P is a 5 year old, Male, Filipino, born on March 05, 2015 in La Trinidad,
Benguet. Born full-term via NSVD in SLUHSH. Father is smoking 1 pack/day for 5 years.
Cough started 3 days prior to admission, followed by an on & off fever 2 days thereafter.
Diarrhea followed after giving Paracetamol as home remedy. 2 hrs prior to admission,
temperature went up to 38.8 C. AM shift’s nursing diagnosis is Hyperthermia.
Lab/Radiological test done March 11: XR result reveals pneumonia, WBC at 12,000, RBC &
platelets normal. Stool analysis is also normal.
Assessment- Upon Assessment RR 40cpm, irregular, shallow, breathes through mouth, uses
accessory muscle for breathing, unable to breathe in supine position. Auscultation reveals
bilateral Crackles on lower lobes with decreased breath sounds at posterior area. T 38C, PR
120bpm, SPO2 93% with 02.

Recommendation- Doctor Cruz, recommended Paracetamol 10mL q 4h T=^37.8. Paracetamol acts

as an antipyretic and inhibits the synthesis of prostaglandin. it reduces fever by
promoting heat loss and thus help to reset the hypothalamic thermostat. Pen G
400,000 unit IV for 6hours, Pen G treat a wide range of bacterial infections, it helps
the immune system overcome and infection by killing or limiting the growth of
bacteria. Salbutamol neb 1 respoule + 2ml Nss every 6hours, Bronchodilation results
from relaxation of bronchial smooth muscles, which relieves relieves bronchospasm
and airway resistance. Elceflora 1 sachet 3 times a day PO, B. Clausii is a treatment
and prevention of gut barrier impairment.