Southern Luzon State University

College of Allied Medicine

NCM09 PEDIA

Worksheet No. 1
Case Analysis

Name: Andal, Carlos Miguel L. Date: February 26, 2022

Year&Section: BSN2-B

You are a Nurse caring for an Infant with common health problems. Supply the following data
required to complete the case of your patient. (Patient can be hypothetically done or if you have
seen patient inside or near your household you can politely ask them with proper permission of
the parents.)

I. Patient Data

a. Name: Cassy Reyes

b. Age: 9months old
c. Address: Concepcion I Sariaya, Quezon
d. Chief Complaint: Asthma

Noted to have series of check up from a clinic in the nearby town at Candelaria.

II. Cephalocaudal Assessment

 The patient is responding to stimulus. 

 The patient has no obvious physical deformities or abnormalities.
 Physically, the patients nutritional status and body built/stature is appropriate to his age.
 The patient shows grimace on the face
 Vital signs: Respiratory rate: 25 breaths/min , Pulse rate: 110beats/min, Body Temperature:
37.2degrees Celcius
SKIN:
The patient’s skin is fair and evenly colored from head to toe. It has no lesions, no traces of edema
and has uniform and consistent temperature. The nails were somehow yellowish in color. When a blanched
test was performed the color comes back around 5 seconds.
Head and Face
The head is symmetrically round. No found swelling and tenderness. The hair is few yet consistent in
distribution. The patient shows facial grimace.
Eye
The eyes are symmetrically aligned and can move equally. There is some swelling in the conjunctiva
are caused by continuous crying related to difficulty in breathing comfortably. The cornea is transparent, as
well as the well detailed iris. The eyes responds normally on the corneal light reflex test.
Ear
The ear canal is clear and dry. No blood traces found. Do respond to stimulus from sounds.
Nose
The patient has clogged nose. Has some discharge of mucus from common colds. Nasal flaring is
observed and catching of breath is noticeable. The nares are patent and no signs of cartilage deviation during
palpation.
Mouth and throat
The mouth is somehow bluish to pale with some traces of healthy pink color, a little dry but still
moisty and smooth. The teeth is white to yellowish in color, gums are pale pink. The tongue is on pale pink
too. The uvula is positioned in the mid line of the soft palate. The tonsils is free from swelling and pinkish in
color.
Neck
The skin on neck has no lesions. No tenderness observed after series of palpation. The trachea is
aligned in the midline of the neck. The trachea has equal spaces on the two sides making it symmetrically
placed the mid section of the neck. Uniform in temperature and has no masses found. Thyroid gland has no
abnormal activity based on physical assessment. The glands ascends properly when swallowing.
CHEST (POSTERIOR)
 Posterior thorax is asymmetric and tight, ribs are sloped downward, and muscle development is
equal.Spines are slightly aligned, are uniform in temperature, have no tenderness and masses. 6hestis
symmetric upon expansion.

CHEST (INTERIOR)
Breathing pattern is wheezing, not rhythmic and requires some effort to inspire and expire. Chest is
asymmetric upon expansion, has roughness on sound when auscultated. Sound on the part left and right back
with heavy muscles and bony prominences, tympani on the stomach,dullness on the liver and spleen,
bronchovesicular and vesicular.
HEART
The patient’s heart has no palpable pulsation over the aortic, pulmonic, and mitral valves,
nonoted abnormal heaves, and thrills felt over the apex, and no abnormal heart sounds is heard like murmurs
UPPER EXTREMITIES
Both the limbs or extremities are just the same size, have the same curves with bony protrusions of
joints, no involuntary movements, no edema, color is even, temperature is warm and even, contraction is
equal.
ABDOMEN
The patient’s skin color on the abdomen is even. No traces of edema, scar, lesions and other
abnormal findings. Extra expansion is observed when breathing due to asthma.
LOWER EXTREMITIES
Both the limbs or extremities are just the same size, have the same curves with bony protrusions of
joints, no involuntary movements, no edema, color is even, temperature is warm and even, contraction is
equal.
MUSCULOSKELETAL
The muscles of the patient are bilaterally symmetric, with no contractures or tremors found. A normal
muscle tension, and adequate muscle strength is observed. There seem to be no deformities, soreness, or
edema in the bones. Joints aren't painful, move smoothly, and have no nodules.
ANUS, RECTUM AND PROSTATE
The anus, like the exact rectal area, is free of any malformations and anomalies. The skin color is
even, and there are no blemishes, scars, redness, or soreness on the genitalia.
III. Symptoms
● Ineffective few cough

● Cyanosis on some parts of the skin (mouth area)

● Wheezing and Rhonchi sounds upon auscultation

● Cough

● Altered body temperature (slightly above normal)

IV. Nursing Management

● Continuous auscultation for monitoring- Since an x-ray isn't really an option,

this would ensure the child's health stability. Keep an eye on the intensity of
wheezing and rhonchi sounds.

● Usage of Nebulizer- This would help to alleviate the infant's lack of oxygen.
Because oxygen is provided directly, this would also help to reduce the amount of
work required by the lungs to pump it ( A dependent intervention at times)

● Lessen tiring activities such as excessive laughing and crying This is critical
because overworking the respiratory system as a result of severe emotional
pressure will aggravate and exhaust the body. When asthma is persistently severe,
reduce such exercise.

● Administration of antibiotic (when administered)- If no medication is given,

the presence of phlegm or mucus will not be completely eradicated. Asthma is
made worse by phlegm. Eliminating this element may help to improve the
patient's condition.

● Elevating the head down to upper extremities when lying on bed- This would
relieve strain on the abdominal and chest area, allowing for easier breathing.
Furthermore, a raised head has been shown to aid in the improvement of sleeping
patterns and respiration.

● Encourage more fluid/milk intake- Fluids help minimize mucosal drying and
increases ciliary action to remove secretions.
 Additional information/option if symptoms persist on the after care:

NURSING INTERVENTION RATIONALE

Administration of IV fluids and medication Clients who are dehydrated may benefit from
as ordered. IV fluid therapy. Bronchodilators and inhaled
corticosteroids are two medications that may
be administered.

Administer oxygen as ordered. Dehydrated patients may benefit from IV

fluid therapy. Inhaled corticosteroids and
bronchodilators are two drugs that may be
used.

Watch out for the need of intubation and Acute asthma attacks can result in
mechanical ventilation respiratory failure, necessitating the need of
mechanical ventilation.

For more deeper analysis monitor arterial
gasses (or the ABGs)
Carbon dioxide retention occurs as a result of
exhaustion from bronchospasm-induced
laborious breathing. Permissive hypercapnia
may be used after the client has been
mechanically ventilated to minimize lung
injury and maintain a plateau pressure of less
than 30 to 35 cm H20.

Before and after respiratory treatment, measure The maximal flow rate generated during
your peak expiratory flow rate (PEFR) or vigorous exhalation is known as the peak
forced expiratory volume in one second expiratory flow rate (PEFR). It should get
 (FEV1). better with the right treatment. The volume
expelled within the first second of a forced
expiratory maneuver starting at total lung
capacity is known as FEV1.

V. Evaluation

The patient is a friend and a relative. Following a thorough review of the patient's
medical history, she is subjected to a  check-up every 3 months to assure the patient's health.
Aside from the prescription provided by the doctor, we were able to achieve a better result with
the help of some nursing interventions. Mrs. Ghie-Ann, the mother, has a personal nebulizer,
which she claims she knows how to use because she was trained how to do so.

The patient has significantly improved after two days of doing and implementing specific
nursing interventions. When compared to how it was at the start of treatment, the patient now
enjoys better sleep and the wheezing sounds while breathing have improved (the sound is
somehow barely heard while auscultating). The cyanosis around the mouth and some pale skin
color have also improved. The altered body temperature is roughly 36.7 degrees Celsius, which
is still being monitored for better health. The prescription medication, as well as the nursing
interventions, should be continued for a better and faster recovery.
 NCM09 Pedia

RUBRICS for Case Analysis

Name: Andal, Carlos Miguel L. Score:________

Course/ Year/ Section: BSN2-B Date:February 26,2022

5 3 1
Patient Data Data are complete. Lack some important Most of the data are
data. not provided.

Cephalocaudal Comprehensive Lack some important Most of the

Assessment assessment done. assessment. assessment are not
provided

Symptoms Completely provided Lack some important Symptoms are not

according to data data of the symptoms properly enumerated.
presented. manifested.

Nursing Management Complete and Lack some important Most of the nursing
appropriate for the management to be management are not
symptoms presented. given to the patient. provided.

Evaluation Evaluated the care Lack some data on Evaluation is not

according to nursing evaluating patient related to the
management and nursing care. symptoms and
problems presented. nursing care
provided.

Promptness Submitted on time Submitted 1 -3 days Submitted 4 days and

 late. beyond.

Total Score