EXECUTIVE SUMMARY

INTRODUCTION

According to Schulman (2018), “Tuberculosis is the main cause of morbidity and

mortality in tropical, developing countries where the access to running water and primary
healthcare is difficult. The factors which increase the risk of becoming infected with tuberculosis
include: Poverty, overpopulation, illiteracy, malnutrition, alcoholism, drug addiction, diabetes,
immunosuppressive therapy and HIV infection. The disease affects people regardless of sex and
age. The highest percentage of cases reported in 2018 was observed in men older than 15 years
(57%), women (32%), and children below 15 years of age (11%).”
Tuberculosis is caused in people by Mycobacterium tuberculosis bacteria, and markedly
less frequently by Mycobacterium bovis or BCG. The infection spreads through the blood or
lymph. It most commonly originates from the primary focus in the lungs (50% to 60% of cases
of tuberculosis with osseo-articular involvement). Tuberculosis with osseoarticular involvement
is almost always a manifestation of systemic tuberculosis with the primary focus usually being
located in the lungs or in the urogenital system. However, in the majority of cases (80%) the
focus is difficult to find.

According to Longhurst (2019) there are 2 types of Tuberculosis: active & latent tuberculosis.
The Active Tuberculosis causes symptoms and is contagious. The symptoms of active TB vary
depending on whether it’s pulmonary or extrapulmonary. The general symptoms of active TB
include: unexplained weight loss, loss of appetite, fever, chills, fatigue and night sweats. Active
TB can be life-threatening if not properly treated. The Latent Tuberculosis is inactive. It means
patient don’t experience any symptoms. They aren’t contagious. Still, have a positive result from
TB blood and skin tests. Latent TB can turn into active TB in 5-10 %. This risk is higher for
those with a weakened immune system due to medication or an underlying condition. Another
type of Tuberculosis are Pulmonary and Extrapulmonary Tuberculosis. Pulmonary TB is active
TB that involves the lungs. It’s likely what most people think of when they hear tuberculosis. It
can contract by breathing in air exhaled by someone who has TB. The germs can remain in the
air for several hours. Another type is Extrapulmonary TB is involves parts of the body outside of
the lungs, such as the bones or organs. Symptoms depend on the part of the body affected.

Overall, tuberculosis progression is different from most infectious diseases, where

someone is exposed and gets sick within a week or two. Tuberculosis, even latent TB, may also
spread to other parts of the body. If a large number of bacteria spread through the bloodstream
and trigger active disease, tuberculosis may be life-threatening. The number of TB infections
worldwide has been falling slowly since 2015; however, multidrug-resistant forms of
tuberculosis are on the rise. Tuberculosis prognosis can be improved by following a course of
treatment exactly as prescribed. Treatment cures the disease in most cases. In areas where people
can be easily screened, diagnosed and treated, the treatment success rate nears 90% and the
prognosis is good. Most people with active TB must take several different medications at one
time to fight the disease. Researchers have found that people who have survived active
tuberculosis disease through successful treatment may have a lower life expectancy than people
with a latent infection, estimating a loss of 3 to 4 years of life. With this in mind, doctors say it’s
important to treat a latent TB infection as soon as it’s diagnosed, before it becomes active
tuberculosis disease. Without early treatment or without finishing the prescribed treatment, a
person with a tuberculosis infection could suffer lifelong damage to the lungs. If the infection has
spread to other areas of the body, you could suffer either short-term or long-term damage or
symptoms. Without any kind of treatment, tuberculosis can be fatal. People who have multidrug-
resistant forms of TB or who have a compromised immune system have the poorest prognosis
and lowest tuberculosis life expectancy among infected people. The risk of death for people who
are HIV-positive is very high if the TB infection goes untreated. It’s important to get treated as
soon as possible if you have been diagnosed with a TB infection, especially if you have a
compromised immune system. It’s especially important to follow the drug treatment exactly as
prescribed to reduce your risk of creating resistant TB bacteria (Festa, 2021).

This paper is a compilation of detailed nursing care of a 15-year old patient diagnosed
with Tuberculosis. The patient was admitted in Eastern Bicol Medical Center (Pediatric Ward)
and was taken care of by the student nurse from all phases of the rendering health care until the
last day of clinical duty. The Nursing process was utilized to plan and deliver appropriate care to
the patient. “The nursing process is a systematic problem-solving approach used to identify,
prevent and treat actual or potential health problems and promote wellness. It has five steps;
Assessment, Diagnosis, planning, implementation and evaluation” (Semachew, 2018). “Using
the nursing process enables the nurses to use critical thinking for clinical judgment and their care
activities. On the other hand, the implementation of the nursing process is a systematic patient-
centered, goal-oriented approach that provides a framework for nursing practice” (Movlavi, S., &
Salehi, S., 2019). Nursing care plays a pivotal role in ensuring the patient’s safety by ensuring
that the patient is well monitored in all phases of the disease. Prompt assessment and formulation
of a highly individualized care plan will aid the patient with timely healing. “The nurses have a
central role in offering emotional and psychological support to patients and their families in all
settings, such as supporting the patient through diagnosis and ensuring optimum care given to
them. Besides the provision of technical care, nurses must have the qualified professional
knowledge, attitudes and skills, providing the informational, emotional and practical support.”
(Karaca, A., & Durna, Z., 2019).
We present a case of a young man with non-traumatic back pain, afebrile, anorexic, with
progressive general weakness, which raised the suspicion of tuberculosis. The pathological
masses adjacent to the spine visualized in X-ray were found to be abscesses. The care of the
patient was based on the nursing process which started from planning to the implementation of
the whole nursing care. This paper would talk about the nursing process implemented in the
whole duration of nursing care for the patient as well as the evaluation of each to ensure the
effectiveness of the interventions.
 CLIENT DATABASE
The nursing health history was taken on September 2, 2022 at Pediatric ward of the
Eastern Bicol Medical Center (EBMC). Primary information about the patient’s health history
was provided by the mother and from the chart review.
BIOGRAPHIC DATA
Name: Patient W
Address: Batong Paloway, San Andres, Catanduanes
Gender: Male
Birthdate: 06/22/2005
Civil Status: Single
Religion: Catholic
Occupation: Student
CLIENT DATABASE
The nursing health history was taken on September 2, 2022 at Pediatric Ward of the
Eastern Bicol Medical Center (EBMC). Because of the patient’s current condition and age which
led to his inability to provide information about his health history, chart review and interview of
his mother was utilized in order to gather data.
I. Client Profile:
Patient W, 17 year old male from San Andres, Philippines, catholic. He was
born on June 22, 2005. In a family of five, including the mother and the father, patient W
is the second eldest in the family. His father work as a security guard while his mother is
a house-wife. He currently enrolled in grade 12 at San Andres Vocational School.
II. Chief complaint:
Patient was brought to the emergency room with chief complaints of body
weakness.

III. History of Present Illness

A month prior to hospitalization, patient W experienced fever but failed to
do check-ups.
IV. Course in the Ward
Patient W was admitted last August 21, 2022 with chief complaint of body
weakness. His condition was managed with PNSS drip and placed comfortably at bed.
Laboratory orders were done. Patient W become febrile, tepid sponge bath and paracetamol 300
mg given through IV.
On the 2nd day, patient complains hypogastric pain, managed by applying warm
and cold compress at the hypogastric area. The patient complain with weakness at the both lower
extremities, with difficulty of walking, remain bed rest is advised. Fever persist and verbalized
statement that “nahihilo ako”.
On the 3rd day, patient was transferred at the pediatric intensive care unit. His
doctor ordered for lumbosacral APL and chest x-ray
On the 4th day, patient experience difficulty of breathing, with of GCS10 E4 V2
M4, desaturations noted with O2 saturation of 68%, ET tube placement due to diaphragmatic
respiration and cold clammy skin. O2 support is given via nasal cannula at 5 lpm on high back
rest position. The doctor ordered to start anti tuberculosis drugs. Suctioned secretions done
aseptically, wth indwelling catheter with urine bag at bed side. His doctor ordered for cranial CT
scan with contrast
Received patient on his 11th day, lying on bed, weak in appearance, conscious,
with mechanical ventilator, with GCS of 11, with high blood pressure of 150/100, with O2
saturation of 87%, febrile with temperature of 38 C with skin warm to touch. TSB is instructed to
watcher and administration of paracetamol through IV. Due meds are given on this shift.
V. Family History
Patient’s father-side has history of asthma and maternal side has hypertension
and tuberculosis since last 2015.
VI. Birth History
The patient was delivered via spontaneous vaginal delivery at full term at Sta.
Maria Bulacan, Philippines. No pre-natal and post-natal complications were noted.
Mother does not completed prenatal check-ups and ultrasound. She only take ferrous
sulphate for her pregnancy.
VII. Medical History
Patient has completed all immunizations shots (BGC, measles, hepatitis, OPV,
DPT, MMR, and 2 shots of Covid-19 vaccines). He has not experienced any childhood
illnesses such as mumps, measles, rubella, varicella, and typhoid fever. He only
experienced asthma when he is 3 years old.
VIII. Developmental Milestones
Patient W has no noted developmental delays. Developmental milestones are on
par with age.
IX. Nutrition and Metabolic Pattern
During pre-hospitalization, patient W is not a picky eater and usually eats
vegetables as stated by mother. Patient W likes junk foods and soda. He also drink
alcohol and he is a second hand smoker.
X. Elimination Pattern
Patient’s mother reported that W has no constipation and regularly defecate. His
stool was described as semi-formed to formed, brown in color and no particular different
odor. He urinates about 4-6 times a day with urine characteristics of black to brown color,
and has peculiar odor. The patient experience excessive perspiration or body odor.
XI. Sleep Rest Pattern
Her mother stated that W always sleeps late and usually go to his friends at
night. He usually sleeps 4-5 hours. Playing basketball is his usual leisure activity and
would play mobile games.
XII. Independence-Dependence
Patient became dependent to his parents since last month up to present.

Reason for Choosing this Client

This case was chosen upon the recommendation of the Nurse on Duty and Clinical
Instructor. Upon the discussion among the Student Nurses, it was find out that it is an interesting
case to be studied. The patient’s diagnosis of Systemic Viral Illness and to consider Urinary
Tract Infection. With all the medications that are being given for the different problems that the
patients is experiencing that will be very beneficial for the treatment. Identification and
prioritization of different nursing care management alongside with the nursing diagnosis. It will
be a good learning opportunity for the Student Nurses to improve their capability in doing
different nursing knowledge, skills and attitude development. It is very useful for the treatment
of the patient. Upon the assessment of the case of the patient and the different data that is taken
and recorded, the Student Nurses are able to formulate an appropriate Nursing Care Plan. To sum
it up, it is a good learning experience to know how to manage, treat and be able to provide care
for the patient that will be very essential for the Student Nurses to be familiarized with all the
Nursing techniques that is needed for the Nursing profession.
 PATIENT ASSESSMENT AND PROBLEM IDENTIFICATION
Physical Examination
A physical examination allows one to confirm the diagnosis that is suspected on basis of
the history without any additional expenditure. Physical exam also informs us about the pattern
and the severity of the disease. It also allows one to rationally plan the next pillar of diagnosis-
choosing laboratory investigations. Contrarily, etiology of the disease is suspected on history and
confirmed on laboratory test results with examination playing a minor role.
Not performing or doing a poor physical examination are a threat to patient safety as the
probability of diagnostic errors and oversights is increased. A careful physical exam can help a
clinician refine the next steps in the diagnostic process, can prevent unnecessary diagnostic
testing, and can aid in building trust through touch, with the patient.
Patient-informed consent means patients understand the risks, alternatives, and possible
benefits of any treatment they receive. With informed consent, a patient can consent to treatment
that they understand. This is important since even treatments which are meant to help a patient
come with risks, and it is essential for patients to accept those risks when getting care.
Assessment (September 2, 2022)
General survey
 Patient was received lying on bed, conscious, and looks appropriate to age.
 With IVF of D5 IMB 1/2 L on left arm and PNSS 1L on right arm.
 With NGT, ET tube-MV, diaper, and indwelling Foley catheter in place
 Hygiene: Kept
 GCS of 11: E4, V1, M6
 Both pupil are normal
Shock Parameters
 Blood pressure 159/120
 Febrile 38.20oC
 With above normal heart rate of 145 bpm
 With an increase respiration: 34 breaths/min
Respiratory Parameters
 With an increase respiration: 34 breaths/min
 Clear breath sounds
 Oxygen Saturation: 94%
 With increase white blood cell count: 32.54
 With shallow deep breathing
Cardiovascular Parameters
 Pale conjunctiva and mucosa (oral and nasal)
 Cyanosis of nail beds
 Decrease Hemoglobin count: 80
 Decrease hematocrit count: 0.28
 Increase blood pressure (159/120)
 Regular pulse rhythm
 (-) bruits
 (-) non-pitting edema
Urologic Parameters
 With indwelling foley catheter
 Yellowish urine
 (-) peculiar odor
Gastrointestinal Parameters
 Attached NGT
 Normal abdomen
 Pale skin color of abdomen
Integumentary Parameters
 With bedsores
 Skin warm to touch
Neurologic Parameters
 GCS of 11: E4, V1, M6
 Conscious with no regard and verbal output
Interpretation of Significant Findings
Three days prior to admission, according to the mother, the patient experiences severe
lower back pain and consulted to Doctor Romano and was given medication then experienced
body weakness
During this clinical phase, the patient was received in bed and conscious. The patient has
normal blood pressure and is afebrile and is experiencing generalized body weakness and severe
lower back pain with a period of generalized abdominal pain that localizes to lower quadrants of
the abdomen, burning and painful urination was seen based on the subjective data gathered from
the mother can be presented as one of the symptoms of the said illness. Based on his laboratory
results. Facial grimace and guarding behaviour was also noted. Increased pulse rate was also
observed. Complete blood sugar was taken with a result of 57 mg/dl. Based on his laboratory
 results, Hematology and Blood Chemistry results appeared to have abnormal results which is an
important cues and indication to patient condition.
Laboratory Examinations and Diagnostic Test Findings
1. Complete Blood Count
Hematology is the study of blood and blood disorders. Hematologists and
hematopathologists are highly trained healthcare providers who specialize in diseases of the
blood and blood components. These include blood and bone marrow cells. One of the most
common hematology tests is the complete blood count, or CBC. This test is often conducted
during a routine exam and can detect anemia, clotting problems, blood cancers, immune system
disorders and infections.
Hematology is the specialty responsible for the diagnosis and management of a wide
range of benign and malignant disorders of the red and white blood cells, platelets and the
coagulation system in adults and children.
The TB blood test, also called Interferon Gamma Release Assay or IGRA, is a way to
find out if a person has TB germs in the body. TB blood test can be done instead of Mantoux.
Anemia is a common hematologic complication among TB patients and is a strong

COMPLETE BLOOD COUNT

SI SI Value SI Result SI Value
Result
Hematocrit 0.35 M-0.40-0.54 Eosinophils 0.02-0.04
F-0.37-0.47 Basophils 0.00-0.01
Hemoglobin 105 M-140-160g/L ESR M-0-10mm/hr
F-120-140g/L F-0-20mm/hr
RBC Count 4.0-4.2x1012/L Platelet Count 435 150-350x109/L
WBC Count 32.54 5-10x109/L Bleeding Time: 2-2.30 minutes
Clotting Time: 2-4 minutes
Differential Count CRT 15-45 minutes
Neutrophils MCV 77.5-85.5
Segmenters 0.93 0.58-0.66 MCH 26.5-31.3
Stabs 0.03-0.05 MCHC 32.4-35.4
Juveniles 0.00-0.02 Blood Type
Myclocytes 0.00-0.01 Others:
Lymphocytes 0.03 0.21-0.3
Monocytes 0.04 0.04-0.06

A low hematocrit level means there are too few red blood cells in the body. In this case, a
person may experience symptoms that signal anemia. Common symptoms include fatigue,
weakness, and low energy it also notes that having anemia is a condition in which you lack
enough healthy red blood cells to carry adequate oxygen to your body's tissues, which notes that
the patient is having low haemoglobin levels, which makes him feel tired and weak. Any
condition that causes inflammation in your body can increase your neutrophil count which leads
to acute hypoxia that cause lack of oxygen. Therefore, the student nurse should promote the
desired position of comfort to increase oxygen supply in the body.
Lymphocytopenia, also referred to as lymphopenia, occurs when lymphocyte count in the
blood stream is lower than normal. Severe or chronic low counts can indicate a possible infection
or other significant illness.T-lymphocytes plays a crucial role in immunity against
mycobacterium infections. Patients with tuberculosis have increased neutrophil count and
decreased lymphocyte count. When there is a decrease in lymphocyte, it means the patient is not
having enough protein and calorie intake. TB patients typically have high platelet counts, which
correlates with disease severity and a hypercoagulable profile. Platelets are key component of the
innate immune response to tuberculosis.
Anemia is a common hematologic complication among TB patients and is a strong risk
factor for mortality. Godwin et al. (2010) mentioned that an acute decline in the serum phosphate
concentration may result in rapid complications and altered red blood cell function, especially in
the immune-compromised. In conclusion, this laboratory result demonstrated that serum
hemoglobin levels and hematocrit levels is decreased in TB patients whereas the WBC count is
increased during infection, due to the increased polymorphonuclear leukocytes and macrophages
as a part of the body’s immune defense mechanism to combat the invading bacterial population.
The decreased hemoglobin and hematocrit levels and the increase in WBC count explains the
observed anemia in the patient.
 2. Blood Chemistry
A blood chemistry study is a procedure in which a blood sample is checked to measure the
amounts of certain substances released into the blood by organs and tissues in the body. An
unusual (higher or lower than normal) amount of a substance can be a sign of disease in the
organ or tissue that makes it.
BLOOD CHEMISTRY RESULT
Results Normal Values Results Normal Values
FBS 3.35-5.60mmol/L Triglyceride 0.0-1.70mmol/L

SGOT(AST) 0-40.0u/L HDL Cholesterol 0.93-1.56mmol/L

SGPT(ALT) 0-41u/L LDL Cholesterol <2.6mmol/L

Creatinine 53 53-115.0umol/L VLDL Cholesterol mmol/L

BUN/Urea 4.12 2.14-7.4mmol/L Troponin I Negative <1ng/ml cTnl
Positive >= 1ng/ml cTnl
Uric Acid 150-420umol/L HbA1c 4.0-6.0%

Total Bilirubin 0.0-34.0umol/L

SERUM ELECTROLYTES
Direct Bilirubin 0.0-6.8umol/L CBS-50
Indirect Bilirubin umol/L Sodium (Na+) 135.9 136-145mmol/L

Total Protein 60.0-83.0g/L Potassium (K+) 2.45 3.5-5.5mmol/L

Albumin 35.0-50.0g/L Chloride (Cl-) 108.0 96-108mmol/L

Globulin g/L Ionized Calcium 1.04-1.35mmol/L

(iCa)
A/G Ratio g/L Normalized 1.04-1.35mmol/L
Calcium (nCa)
Cholesterol 0.00-5.20mmol/L Total Calcium 2.08-2.70mmol/L

When sodium levels in the blood become too low, it leads to hyponatremia, causing symptoms
that include lethargy, confusion, and fatigue. The potassium level of was noted to be decreased
which leads to hypokalaemia therefore large drop in potassium level may lead to abnormal heart
rhythms, especially in people with heart disease. Through this case the student nurse should
monitor the patient`s input and output and requiring the student nurse to monitor heart rhythm.
 Hyponatremia is among the most common abnormalities. The Syndrome of Inappropriate
Antidiuretic Hormone Secretion (SIADH) is one of the several causes of hyponatremia,
particularly in patients with pulmonary disease.
Hypokalemia is one of the adverse reactions commonly found in patients with multi-drug
resistant TB (MOR-TB) treated with tablets or injectable agents. Hypokalemia is a rare
association with pulmonary tuberculosis.
In conclusion, despite hypokalemia being a rare association with tuberculosis,
disseminated tuberculosis can be considered the possible cause in patients presenting with severe
hypokalemia.

Blood Chemistry Result

Results Normal Values Results Normal Values
FBS 3.35-5.60mmol/L Triglyceride 0.0-1.70mmol/L

SGOT(AST) 0-40.0u/L HDL Cholesterol 0.93-1.56mmol/L

SGPT(ALT) 0-41u/L LDL Cholesterol <2.6mmol/L

Creatinine 53-115.0umol/L VLDL Cholesterol mmol/L

BUN/Urea 2.14-7.4mmol/L Troponin I Negative <1ng/ml cTnl
Positive >= 1ng/ml cTnl
Uric Acid 150-420umol/L HbA1c 4.0-6.0%

Total Bilirubin 0.0-34.0umol/L

SERUM ELECTROLYTES
Direct Bilirubin 0.0-6.8umol/L Arkay Spotchem EI
Indirect Bilirubin umol/L Sodium (Na+) 128.1 136-145mmol/L

Total Protein 60.0-83.0g/L Potassium (K+) 3.72 3.5-5.5mmol/L

Albumin 35.0-50.0g/L Chloride (Cl-) 101.4 96-108mmol/L

Globulin g/L Ionized Calcium 1.04-1.35mmol/L

(iCa)
A/G Ratio g/L Normalized 1.04-1.35mmol/L
Calcium (nCa)
Cholesterol 0.00-5.20mmol/L Total Calcium 2.08-2.70mmol/L
 3. Fecalysis
A fecalysis is a series of tests done on a stool (feces) sample to help diagnose certain
conditions affecting the digestive tract. These conditions can include infection (such as from
parasites, viruses, or bacteria), poor nutrient absorption, or cancer. This helps in finding the
cause of symptoms affecting the digestive tract, including prolonged diarrhea, bloody diarrhea,
an increased amount of gas, nausea, vomiting, loss of appetite, bloating, abdominal pain and
cramping, and fever. Screen for colon cancer by checking for hidden (occult) blood.
Stool cultures might offer an alternative method for TB diagnosis when sputum is
difficult to obtain from PLHIV. Tuberculous bacteria are believed to be present in stool when
bacteria are transported from the lungs to the oropharynx, are swallowed and then transit through
the gastrointestinal tract.
MACROSCOPIC
Color Brown Occult Blood

Consistency Soft

MICROSCOPIC
Red Cells 0-2/hpf G. lambia (a) Cyst

Pus Cells 2-3/hpf (b) Trophozoite

Macrophages E. hitolytica (a) Cyst

Trichuris Ova (b) Trophozoite

Ascaris Ova Bacteria Many

Hookworm Others No intestinal parasite seen

T. hominis

Pus in the stool is an indication of infection. Mucous in the stool can be related to
infection, inflammation, cancer, constipation, or conditions of the anus or rectum. Tuberculous
abscesses are an uncommon presentation of tuberculosis, most often encountered in
immunocompromised individuals (e.g. HIV/AIDS). Unlike far more common tuberculomas
(tuberculous granuloma), tuberculous abscesses contain pus with abundant identifiable
organisms. Although ulceration and mucous diarrhea are relatively common with secondary
 intestinal TB, hemorrhage and the presence of gross blood in the stool are distinctly uncommon,
perhaps because of the associated obliterative endarteritis.
4. Urinalysis
It's used to detect and manage a wide range of disorders, such as urinary tract infections,
kidney disease and diabetes. A urinalysis involves checking the appearance, concentration and
content of urine. For example, a urinary tract infection can make urine look cloudy instead of
clear.
Urine-based TB diagnostics have the potential to reduce missed TB diagnoses and reduce
mortality in patients with advanced HIV disease. Urine is easily obtainable and can be tested
using either a lateral flow assay (LFA) for TB-lipoarabinomannan (TB-LAM) or the Xpert
MTB/RIF assay (Xpert; Cepheid, Sunnyvale, CA).
Macroscopic Microscopic

Color Light yellow Epithelial Cells Occasional

Transparency Slightly turbid Red Cells 0-2/hpf

Sp. Gravity 1.000 Pus Cells 0-2/hpf

Reaction (pH) Acidic Bacteria

Albumin Negative Casts

Sugar Negative

Others Amorphous Urates- Few

Specific gravity results will fall between 1.002 and 1.030 if kidneys are functioning
normally. Above 1.010 may indicate mild dehydration. Higher the number the more dehydrated
the patient is. Very low specific gravity means dilute urine, which may be caused by drinking too
much fluid, severe kidney disease, or the use of diuretics. Low urine specific gravity test
indicates that the concentration of the urine is close to that of water.
It’s normal to have a small number of epithelial cells on the urine. Large number of
epithelial cells may indicate UTI, kidney disease, or other serious medical condition. Presence of
pus cells in urine as pyuria is an important accompaniment of bacteriuria which may be
asymptomatic or can indicate toward underlying UTI.
 RADIOLOGIC REPORT
Examination: CHEST AP
Comparison: Previous chest radiograph date 29 August 2022
FINDINGS:
Present study taken with the patient in supine position and with obliquity still shows
consolidation/atelectasis in the right upper lobe.
Heterogenous densities are still evident in the right mid to lower lung zones.
Homogenous opacities are still observed in the right lower hemothorax, obscuring the ipsilateral
costophrenic angle and hemidiaphragm.
The heart is not enlarged. The pulmonary vascular markings are unremarkable.
The trachea is midline. A partially imaged endotracheal tube is seen, with its tip located
approximately 5.0cm from the carina. The rest of the previous findings are unchanged.

Comparison: Previous chest radiograph dated 25 August 2022.

FINDINGS:
Present study done with the patient in supine position and with significant obliquity now shows
consolidation/atelectasis of the right upper lobe. There is now note of hazy densities in the right
lower hemithorax, obscuring the ipsilateral costophrenic angle and hemidiaphragm.
Heterogenous densities are now more evident in the right lung.
There is a partial resolution of the previously noted heterogenous densities in the left lung.
The heart is not enlarged. The pulmonary vascular markings are unremarkable.
The trachea is midline. A partially imaged endotracheal tube is now seen, with its tip located
approximately 3.0cm from the carina.
Metallic ECG lead wires are again seen.
IMPRESSION:
Lung findings suggestive of pneumonia with radiographic signs of disease progression.
Interpretation of Significant Findings
The performance of CXR expressed as sensitivity and specificity to pick-up culture-
positive TB cases depends on the intensity and the presentation of the disease, which in turn is
influenced by a range of other factors. A chest x-ray upon completing a course of therapy for
pulmonary TB disease is important to establish a baseline for further comparison in the event
that the individual should develop symptoms suggestive of TB.
In the case of the patient, the test was done to check the lungs and the heart for any
abnormalities since the patient is having a low oxygen saturation. The result showed that he has
heterogeneous densities which is evident in the right mid to lower lung zones. It was also noted
that homogeneous opacities are observed in the right lower hemothorax.
This implies the student nurse should monitor the ET tube and continue to monitor the
desired amount of oxygenation support, as ordered to prevent the patient from having
desaturation of the lungs. Furthermore, the student nurse should also monitor for episodes
dyspnea, cyanosis and assess the peripheral perfusion for sudden blood flow decrease.

CT SCAN RESULT
If a chest X-ray does not produce a clear enough image or is not definitive, your doctor
may order a CT scan. A series of X-rays is taken from different angles to form clear images of
the bones and soft tissues in your body. A CT scan can detect more subtle signs that might
indicate tuberculosis. The diagnosis of PTB with radiography is initially correct in only 49% of
all cases: 34% for primary and 59% for post-primary PTB. On the other hand, CT can correctly
diagnose 91% of cases of PTB and correctly characterize 80% of patients with active disease and
89% with inactive disease.
CONTRAST-ENHANCED CRANIAL CT SCAN
Clinical Data: CNS infection; (+) fever nuchal rigidity and decreased verbal output
Comparison: None
Technique: Plain and contrast-enhanced multiaxial tomographic sections of the head were
obtained. No adverse reaction was observed.
Findings:
The brain parenchyma is intact, with no focal mass lesions or abnormal calcifications noted.
There is no evidence of parenchymal hemorrhage or infarction.
There is normal gray-white matter demarcation.
The midline structures are undisplaced.
The sulci, Sylvian fissures, and cerebral folia are intact.
The ventricles are normal in size.
No extra-axial fluid collection or hematoma is noted.
The calvarium and basal skull structures are unremarkable.
Post-contrast study shows no abnormal parenchymal or leptomeningeal enhancement.
Mucosal thickening are seen in the paranasal sinuses and bilateral mastoid air cells.
IMPRESSION:
1. Unremarkable contrast-enhanced cranial CT scan
2. Polysinusitis
3. Bilateral matoiditis

Examination: Chest AP (08-25-22)

RADIOLOGIC FINDINGS:
Follow-up examination dated 8/25/22 as compared to study taken 8/23/22 shows interval
increase in the previously noted infiltrates. There are no infiltrates in both lung fields. Heart is
not enlarged. Aorta is unremarkable, both hemidiaphragms, costophrenic sulci and visualized
bones are intact.
The ET tip is at the level of T3.

Examination: LUMBOSACRAL APL (08-23-22)

Both Plain X-Rays and MRI are important imaging modalities for diagnosis of spinal
tuberculosis and are also useful to monitor the response of the patients to the treatment. Plain X-
ray remains the primary and the first imaging modality to evaluate the disease.
RADIOLOGIC FINDINGS:
There is straightening of the normal lumbar lordosis which may be due to muscle spasm.
The vertebral heights and disc spaces are maintained. The pedicles and laminae are intact. No
definite evidence of fracture noted.
IMPRESSION:
Lumbar straightening.
 Examination: Chest AP (08-23-22)
RADIOLOGIC FINDINGS:
There are hazed infiltrates in both upper lobes. Heart is not enlarged. Aorta is
unremarkable. Both hemidiaphragms and costophrenic sulci and visualized bones are intact.
IMPRESSION:
Findings may be suggestive of pulmonary tuberculosis, both upper lobes.

Analysis and Theoretical Background

The patient was initially diagnosed with Systemic Viral Infection and suggestive to
Tuberculosis. Systemic viral infection is one that can affect multiple systems in the body. Often,
this means they cause fevers, muscle or body aches, and chills in addition to symptoms that
target specific systems, such as the respiratory system. A great example of a systemic viral
infection is influenza, also called the flu. However, combined with Tuberculosis, which is multi-
systemic disease with a protean presentation. The organ system most commonly affected
includes the respiratory system, the gastrointestinal (GI) system, the lymphoreticular system, the
skin, the central nervous system, the musculoskeletal system, the reproductive system, and the
liver.
Furthermore, due to the patient having systemic viral infection, Systemic infection can
result to Pulmonary Tuberculosis. They can involve infection of the lungs. The most common
cause is bacteria, but they can also be caused by viruses or fungi. While the bacterial pathogen
causes the initiation of the disease process, the host response drives and defines sepsis and its
severity. The immune response of the host is triggered when the proteins of the microbial
pathogen interact with those of the host’s cell membrane. The severe pro-inflammatory response
can lead to cell necrosis, an increase in neutrophil production that produces bactericidal
substances, and increased permeability of endothelial cells that lead to edema formation. After
this initial phase, there is an anti-inflammatory response that leads to immunosuppression in the
body where neutrophils become dysfunctional and cause further damage to nearby cells. Other
systems in the body affected by this inflammatory response include respiration, coagulation,
autonomic, and endocrine systems.
Sign and symptoms of Systemic Viral Infection always include fever, fatigue, malaise,
myalgia and headache are normally the first evidence of the organism's reaction to the presence
of the invading pathogen. These symptoms are manifested upon infection with a broad array of
infections including those contained in a single organ, such as the lung, liver, or gut. While
Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent
period following initial infection. Symptoms include productive cough, fever, weight loss, and
malaise.
At the site of infection, the production of pro-inflammatory molecules and the massive
recruitment of cells from the periphery are hallmarks of inflammation and indicate that the
hematopoietic system is actively engaged in combating the pathogen. The mechanisms by which
distinct systems are engaged in the response to distal infection, discern the type of response
required, and support the development of immunity, are subjects of vigorous investigation. New
evidence indicates that type I interferons (IFNs) generated at the site of infection act as primary
systemic alarm signals that promote the development of effective innate and adaptive responses.
Both viral infections that extend to several body compartments and infections that are
restricted to a single organ show evidence of systemic involvement in the immune response to
viruses. Since it is challenging to distinguish between the effects of direct infection and signals
that originate in distal sites, viruses that spread throughout the body, such as the Epstein-Barr
virus (EBV), lymphocytic choriomeningitis virus (LCMV), human immunodeficiency virus
(HIV), vaccinia virus (VV), and mouse hepatitis virus (MHV), are complex systems for studying
the mechanisms that underlie the systemic response to infection. The systemic actions that
happen in response to tissue signals produced after infection can be better understood using
viruses that do not spread systemically from the site of infection. These models do not suffer
from the direct detection of viral products in tissues that react to systemic signals, even though
they enable the evaluation of in vivo responses. Some of these viruses, such as human
parainfluenza virus, mouse homolog Sendai virus (SeV), respiratory syncytial virus, human
metapneumovirus, and specific influenza virus strains, replicate almost exclusively in the
respiratory tract. It's vital to remember that changing virus strains or the immune system of the
host may affect the virus' capacity to infect several organs.
Infections can cause some people to briefly have higher levels of blood pressure, body
temperature, and respiratory rate. As the immune system battles the pathogenic germs,
inflammation develops in the body, which is probably the cause of the infection. Furthermore,
severe bacterial infections can occasionally coexist with viral infections in patients with
influenza and other viruses. Pneumonia already developed as a result of, for instance, the flu and
other viral respiratory infections such as Pulmonary Tuberculosis.
Different viruses assault specific cells in the body of the patient, such as those in the
respiratory system and urinary system, over time, and the body's compensating mechanisms are
insufficient to boost immune response. Deterioration and the respiratory infection such as the
latest complication which is Tuberculosis are not surprising given the degree of the infection in
the body.
Pathophysiologic Diagram
Nursing Problem Identification and Rationale
Below are the nursing problems identified by the student nurses including the cues that support
these problems:

Risk for Septic shock

as evidenced by episodes of persistent fever, tachypnea, dyspnea, increase in blood pressure,
decreased oxygen saturation.
Risk for Shock as defined by NANDA is stated as “an inadequate blood flow to the
body's tissues that may lead to life-threatening cellular dysfunction, which may compromise
health.”
The patient, as described in the etiologic factors, had incidences of persistent fever,
tachypnea, dyspnea, desaturations, and increases in blood pressure, all of which increase the
patient’s risk for shock. During his hospitalization the patient experience a febrile episodes
which may lead to cellular dehydration, and hypoxemia, increase in blood pressure
compromises the inadequate supply of blood throughout the body.
The patient’s WBC level is relatively high this indicates that the patient’s s having an
infection. A white blood cell count rises to fight an infection. Usually the body immune
system
Subsumed Nursing Diagnoses:

1. Risk for Impaired Gas Exchange

2. Ineffective Airway Clearance

3. Risk for Injury related to decreased sensorium

4. Risk for deficient fluid volume

5. Risk for cardiopulmonary arrest

6. Altered mental status related to decrease oxygenation

7. Risk for aspiration

8. Risk for Infection

9. Acute Pain

10. Impaired Urinary Elimination

 PLAN OF CARE AND NURSING INTERVENTIONS
In line with the patient’s diagnosis of systemic viral illness, urinary tract infection and
pulmonary tuberculosis interventions were mostly aimed at maintaining patent and clear airway,
ensuring comfort and safety, administering medications to resolve infections, practicing strict
asepsis and hygiene to prevent further infection, optimizing body functioning and ensuring
proper growth and development of the patient while in the ward.

Risk for Septic shock as evidenced by episodes of persistent fever, tachypnea, dyspnea,
increase in blood pressure, decreased oxygen saturation.
Subsumed Nursing Diagnoses:

1. Risk for Impaired Gas Exchange

2. Ineffective Airway Clearance

3. Risk for Injury related to decreased sensorium

4. Risk for deficient fluid volume

5. Risk for cardiopulmonary arrest

6. Altered mental status related to decrease oxygenation

7. Risk for aspiration

8. Risk for Infection

9. Acute Pain

10. Impaired Urinary Elimination

Goal: After the nursing interventions, the patient will demonstrate stable vital signs.
Short Term Objectives: The client will:
1. NOC: Circulation Status; Cardiac Pump Effectiveness

● Demonstrate hemodynamic stability

● Maintain O2 Saturation of >75%

● Be free from cardiopulmonary arrest

2. NOC: Respiration Status: Ventilation; Respiration Status: Gas Exchange; Respiratory
Monitoring; Oxygen Therapy

● Demonstrate adequate ventilation and oxygenation

● Maintain normal levels of blood gases concentration

● Respond appropriately to oxygen therapy

3. NOC: Neurologic Monitoring

● Exhibit stable neurologic status

● Be free from complications and injuries of possible seizures

4. NOC: Risk Control: Infectious Process

● Be free from present and emergent infection

5. NOC: Shock Management

● Be free from complications of shock

6. NOC: Tissue Perfusion: Peripheral

● Demonstrate adequate peripheral tissue perfusion

● Be free from thromboembolism

7. NOC: Fluid Balance; Kidney Function

● Maintain adequate fluid balance

● Maintain optimal levels of electrolytes

8. NOC: Risk Control: Bleeding

● Be free from signs of bleeding

9. NOC: Immobility Consequences: Physiological

● Exhibit (-) pressure ulcers

● Exhibit no contractures
Long term Objectives: At the end of nursing interventions,
1. The patient will be free from any complications from his condition

2. The mother will have increased knowledge about the condition of the patient as well as
appropriate interventions upon discharge

Assessment Nursing Planning Intervention Evaluation

Diagnosis
Subjective: Risk for The patient will Assess and After 8 hours of
“ Nasakitan po mag Impaired demonstrate monitor nursing
hangos ang aki ko” Gas Exchange improved respiratory rate, intervention
as stated by the related to ventilation and depth, and patient
mother atelectasis adequate rhythm. Note demonstrate
oxygenation of reports of improved
tissues by dyspnea or use ventilation and
Objective data: ABGs within of accessory adequate
 (+) wheezes acceptable muscles, nasal oxygenation
 Crackles range as flaring, and with O2 sat
heard evidenced by altered chest level of 93%
 Dyspnea decreased excursion.
 Tachypnea dyspnea Rationale:
 O2 sat level Changes such as
of 87% tachypnea,
 Abnormal dyspnea, and
respiration use of accessory
rate muscles, may
 Use of indicate
accessory progression of
muscle respiratory
 With
Monitor patient
mechanical
behavior and
ventilator
mental status
Rationale:
changes of
behavior and
mental status
can be an early
sign of impaired
gas exchange it
may occur with
chronic hypoxia

Place client in
position of
comfort, usually
with head of bed
elevated or
sitting upright,
leaning forward
with weight
supported on
arms, and feet
dangling
Rationale:
Maximizes lung
expansion,
decreases work
of breathing,
and reduces risk
of aspiration.

Evaluate skin
color, noting
pallor or
development of
cyanosis,
particularly in
nailbeds, ear
lobes, and lips.
Rationale:
anemia can
reduce oxygen-
carrying
capacity of the
blood, leading to
hypoxemia.

Reposition and
assist with
turning
periodically.
Rationale: To
promote lung
expansion

Provide calm,
quiet
environment.
Rationale:
Promotes
 relaxation,
conserving
energy and
reducing oxygen
demand.

Provide
supplemental
oxygen.
Rationale: aids
in reducing
hypoxemia.
Subjective data: Ineffective Maintain patent Assess After 8 hours of
“Ga tulo na po sa airway airway respiratory nursing
kimot nya su mga clearance function noting intervention
riwoy. Nasakitan related to breath sounds, patient maintain
po siya mag decreased lung rate, rhythm and patent airway
hangos” as capacity as depth, and use
verbalized by the evidenced by of accessory
mother tachypnea, muscles
presence of Rationale:
Objective data: crackles and diminished
 (+) wheezes dyspnea breath sounds
 Crackles may reflect
heard atelectasis
 Dyspnea
 Tachypnea Clear secretions
 O2 sat level from mouth and
of 87% trachea, suction
 Abnormal as necessary
respiration Rationale:
rate prevents
obstruction and
 Unable to
aspiration.
expectorate
phlegm
Maintain
hydration unless
contraindicated
Rationale: high
fluid intake
helps thin
secretions and
easier to
expectorate
Administer
medication as
indicated e.g.
 mucolytic
Rationale: to
liquefy
secretions
Subjective: Ineffective Patient will be Assist position After 8 hours of
“dai nya po tissue perfusion free from changes nursing
nahiwas ang mga related to low thrombosis Rationale: intervention the
legs buda bitis nya. hemoglobin gently reposition patients mother
May lugad na po count the patient, demonstrate
ngani sa may immobility are understanding
lubot” as stated by prone to and assist
the mother pressure ulcers patient to turn
and DVT the patient
Objective:
 (+) pressure Promote
ulcer active/passive
 Non-pitting ROM exercises
edema Rationale:
 Poor prevents venous
healing statis and futher
 Pale circulatory
looking compromise
 Pulse rate
of Position the
patient semi
 Hemoglobi
fowler’s to high
n count of
fowlers as
105
tolerated
Rationale:
upright position
promotes
improved
alveolar gas
exchange

Observe for
signs of DVT
including pain,
tenderness,
swelling in the
thigh and calf
and redness
Rationale:
thrombosis clot
formation
usually detected
as swelling of
 the involved leg
and there is pain

Administer
medication as
indicated e.g.
zinc
Rationale: to
promote healing

PROCEDURES AND TREATMENT MODALITIES

 IV
Insertion of intravenous cannula involves connecting a tube into a patient’s vein so that infusions
can be directly into the patient’s bloodstream. In the condition of the patient it is important to
give intravenous medication to relieve his pain and used for parenteral nutrition throughout the
hospitalization for farther examination of the patient condition.

 Oxygen Therapy

Oxygen therapy or supplemental oxygen is used to maintain the targeted levels of SpO2 in
children by providing additional oxygen in safe and effective manner that children can tolerated.
The indication of oxygen therapy is necessary for basic metabolic demand in the body, and it is
an important part of resuscitation in many acute illnesses, as well as maintenance of chronic
hypoxemic diseases.

 Intubation
Intubation is a procedure that can help save a life when someone can’t breathe. A healthcare
provider uses a laryngoscope to guide an endotracheal tube (ETT) into the mouth or nose,
voicebox, then trachea. The tube keeps the airway open so air can get to the lungs. Intubation is
usually performed in a hospital during an emergency or before surgery. Indications for intubation
to secure the airway include respiratory failure (hypoxic or hypercapnic), apnea, a reduced level
of consciousness, rapid change of mental status, airway injury or impending airway compromise,
high risk for aspiration, or 'trauma.

In this case, the patient condition is being congested by the secretions resulting in impaired gas
exchange, altered level of conscious maybe at risk for injury, and aspiration. These indications
are assessed by evaluating the patient’s mental status, conditions that may compromise the
airway, level of consciousness, respiratory rate, respiratory acidosis, and level of oxygenation. In
the setting of trauma, a Glasgow Coma Scale of 8 or less is generally an indication for
intubation. With that, assistance in ventilation was required and indicated. In the preparation of
the intubation, the first step in preparation is to perform an airway evaluation, which includes a
history of intubation and difficult intubations. Evaluation of the external anatomy may be
predictive of a difficult airway. Once the external evaluation of the patient is complete, the head
position should be optimized to get the best possible view of the vocal cords. The “sniffing
position” has traditionally been considered the optimal position for direct laryngoscopy as it
aligns the oral, pharyngeal, and laryngeal axes. This position is achieved by elevating the
patient’s head, extending the head at the neck, and aligning the ears horizontally with the sternal
notch. In morbidly obese patients, rolls may be utilized to elevate the head until the external
auditory meatus aligns with the sternal notch. Adequate nursing staff and respiratory therapist
must be present with intubation, monitoring, administering drugs and to prepare the ventilator.
(Alvarado, Andrea C. Panakos Patricia, 2022; Alvarado, Andrea C. Panakos Patricia, 2022).

 Indwelling Foley Catheter

The use of indwelling catheter is to drain urine from the bladder. Urine is drained through a tube
connected to a connection bag. The catheter is held in the bladder by water-filled balloon, which
prevents from falling out. The indication of inserting a foley catheter is for closed monitoring of
input and output.

The condition of the patient complaining hypogastric pain and unable to void are needed for
insertion of foley catheter. It is important to know that patient with indwelling catheter are prone
to susceptible bacteria.

 CT Scan

Computed tomography is commonly referred to as a CT scan. A CT scan is a diagnostic imaging

procedure that uses a combination of X-rays and computer technology to produce images of the
inside of the body. It shows detailed images of any part of the body, including the bones,
muscles, fat, organs and blood vessels. The patient undergo this procedure called cranial CT scan
because the patient is having legs paralysis, nuchal rigidity and suspected to have a CNS
infection that may result to a neurologic disorder that can affect muscles, balance and
coordination.

 Chest and Lumbar X-ray

An X-ray is a quick, painless test that produces images of the structures inside of the body. Chest
and lumbar x-ray are procedure that shows cancers and tumors, an enlarged heart, blood vessel
blockages, fluid in lungs, digestive problems, bone fractures, dislocated joints, and infections.
The condition of the patient need to undergo this procedure because the patient is showing
decrease in SpO2 and the patient manifest lumbar pain.
 PHARMACOLOGIC THERAPY
Rifampicin
Drug class: Antimycobacterials

Rifampin is an antibiotic that is used to treat or prevent tuberculosis (TB). Rifampin may also
be used to reduce certain bacteria in your nose and throat that could cause meningitis or other
infections. Rifampin prevents you from spreading these bacteria to other people, but rifampin
will not treat an active meningitis infection. Rifampin may also be used for purposes not listed
in this medication guide.

Along with their useful effects, most medicines can cause unwanted side-effects although not
everyone experiences them. The table below contains some of the most common ones
associated with rifampicin. You will find a full list in the manufacturer's information leaflet
supplied with the medicine. The unwanted effects often improve as your body adjusts to the
new medicine, but speak with your doctor or pharmacist if any of the following continue or
become troublesome.

You should take rifampicin 'on an empty stomach'. This means that you should take your
doses about an hour before a meal, or wait until two hours afterwards. This is because your
body absorbs less rifampicin if taken at the same time as food, which means it is less effective.
Lactulose 15ml @ Bedtime ( Monitor BM)

Drug class: Lactose derivative. Hyperosmotic laxative, ammonia detoxicant

Prevention, treatment of portal-systemic encephalopathy (including hepatic precoma, coma);

treatment of constipation.

Baseline Assessment
Question usual stool pattern, frequency, characteristics. Conduct neurological exam in patients
with elevated serum ammonia levels, symptoms of encephalopathy. Assess hydration status.

Intervention/evaluation
Encourage adequate fluid intake. Assess bowel sounds for peristalsis. Monitor daily pattern of
bowel activity, stool consistency; record time of evacuation. Assess for abdominal
disturbances. Monitor serum electrolytes in patients with prolonged, frequent, excessive use of
medication. Monitor encephalopathic patients
Levofloxacin 500mg 1 tab OD

Drug class: Fluoroquinolone. Antibiotics

Treatment of susceptible infections due to S. pneumoniae, S. aureus, E. faecalis, H. influenzae,

M. catarrhalis, Serratia marcescens, K. pneumoniae, E. coli, P mirabilis, P. aeruginosa, C.
pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae, including acute bacterial
exacerbation of chronic bronchitis, acute bacterial sinusitis, community-acquired pneumonia,
nosocomial pneumonia, complicated and uncomplicated UTI, acute pyelonephritis,
complicated and uncomplicated mild to moderate skin/skin structure infections, prostatitis.
Inhalation anthrax (postexposure); plague. Ophthalmic: Treatment of superficial infections to
conjunctiva (0.5%), cornea (1.5%). OFF-LABEL: Urethritis, traveller’s diarrhea, diverticulitis,
enterocolitis, Legionnaire’s disease, peritonitis. Treatment of prosthetic joint infection. Inhibits
DNA enzyme gyrase in susceptible microorganisms, interfering with bacterial cell replication,
repair. Therapeutic Effect: Bactericidal.

Baseline assessment
Question for hypersensitivity to levoFLOXacin, other fluoroquinolones. Question history as
listed in Precautions. Receive full medication history, and screen for interactions, esp.
medications that prolong QT interval. Obtain baseline EKG.

Intervention/evaluation
Monitor serum glucose, renal function, LFT. Monitor daily pattern of bowel activity, stool
consistency. Promptly report hypersensitivity reaction: skin rash, urticaria, pruritus, and
photosensitivity. Be alert for superinfection: fever, vomiting, diarrhea, anal/genital pruritus,
oral mucosal changes (ulceration, pain, and erythema). Monitor for muscle weakness, voice
dystonia in pts with myasthenia gravis; pain, swelling, bruising, popping of tendons.

Patient/ family teaching. It is essential to complete drug therapy despite symptom

improvement. Early discontinuation may result in antibacterial resistance or increase risk of
recurrent infection. Report any episodes of diarrhea, esp. the first few mos after final dose.
Frequent diarrhea, fever, abdominal pain, blood-streaked stool may indicate infectious
diarrhea, which may be contagious to others. Severe allergic reactions, such as hives,
palpitations, rash, shortness of breath, tongue swelling, may occur. Tendon
inflammation/swelling, tendon rupture may occur; report bruising, pain, swelling in tendon
areas or snapping, popping of tendons. Immediately report nervous system problems such as
anxiety, confusion, dizziness, nervousness, nightmares, thoughts of suicide, seizures, tremors,
trouble sleeping. Treatment may cause heart problems such as low heart rate, palpitations;
permanent nerve damage such as burning, numbness, tingling, weakness. Do not take
aluminum- or magnesium-containing antacids, multivitamins, zinc or iron products at least 2
hrs before or 6 hrs after dose. Drink plenty of fluids.
Nacl tablet, 1 tablet OD

Sodium chloride is used as an electrolyte replenisher to help prevent heat cramps caused by
too much sweating. This medicine is also used for the preparation of normal isotonic solution
of sodium chloride.
N-acetylcysteine 600 ml dilute in ½ glass OD
Drug class: Amino acid derivative, mucolytic, antidote for acetaminophen overdose N-
Acetylcysteine (NAC) 600mg 1 glass dissolve in ½ glass water Drug Class: Amino acid
derivative, mucolytic, antidote for acetaminophen overdose N-acetyl cysteine (NAC) is used
by the body to build antioxidants. Antioxidants are vitamins, minerals, and other nutrients that
protect and repair cells from damage. In addition to its antioxidant action, it increases
respiratory tract fluids to help liquefy tenacious secretions and thins the respiratory tract
secretions.

Monitor other signs of allergic reactions and anaphylaxis, especially after IV administration.
Signs include pulmonary symptoms (tightness in the throat and chest, wheezing, cough,
dyspnea) and skin reactions (rash, pruritus, urticaria). Notify physician or nursing staff
immediately if these reactions occur.
Carvedilol 6.25 1 tab ½ tab BID

Drug class: Beta-adrenergic blocker. Antihypertensive

Treatment of mild to severe HF, left ventricular dysfunction following MI, hypertension. OFF-
LABEL: Treatment of angina pectoris, idiopathic cardiomyopathy. Possesses nonselective
beta-blocking and alpha-adrenergic blocking activity. Causes vasodilation. Therapeutic Effect:
Hypertension: Reduces cardiac output, exercise-induced tachycardia, and reflex orthostatic
tachycardia; reduces peripheral vascular resistance. HF: Decreases pulmonary capillary wedge
pressure, heart rate, systemic vascular resistance; increases stroke volume index.

Assess B/P, apical pulse immediately before drug is administered (if pulse is 60 beats/min or
less or systolic B/P is less than 90 mm Hg, withhold medication, contact physician). Receive
full medication history and screen for interactions.

Intervention/Evaluation. Monitor B/P for hypotension, respirations for dyspnea. Take standing
systolic BP 1 hr after dosing as guide for tolerance. Assess pulse for quality, regularity, rate;
monitor for bradycardia. Monitor EKG for cardiac arrhythmias. Assist with ambulation if
dizziness occurs. Assess for evidence of HF: dyspnea (particularly on exertion or lying down),
night cough, peripheral edema, and distended neck veins. Monitor I&O (increase in weight,
decrease in urine output may indicate HF). Monitor renal/hepatic function tests.

Patients Teaching. Full therapeutic effect of B/P may take 1–2 wks. Contact lens wearers may
experience decreased lacrimation. Take with food. Monitor B/P, pulse before taking
medication. Restrict salt, alcohol intake.
Levetiracetam 500mg 1tab 1 tablet OD

Drug class: Pyrrolidine derivative. Anticonvulsant

Adjunctive therapy in treatment of partial-onset, myoclonic, and/or primary generalized tonic-

clonic seizures. Exact mechanism unknown. May inhibit voltage-dependent calcium channels,
facilitate GABA inhibitory transmission, reduce potassium current, or bind to synaptic
proteins that modulate neurotransmitter release. Therapeutic Effect: Prevents seizure activity.

Baseline assessment
Review history of seizure disorder (intensity, frequency, duration, LOC). Initiate seizure
precautions. Question prior hypersensitivity reaction. Obtain renal function test.

Intervention/evaluation
Observe for recurrence of seizure activity. Assess for clinical improvement (decrease in
intensity/frequency of seizures). Monitor renal function tests. Observe for suicidal ideation,
depression, behavioural changes. Assist with ambulation if dizziness occurs.

Patient/ family teaching. Drowsiness usually diminishes with continued therapy. Avoid tasks
that require alertness, motor skills until response to drug is established. Avoid alcohol. Do not
abruptly discontinue medication (may precipitate seizures). Strict maintenance of drug therapy
is essential for seizure control. Report mood swings, hostile behavior, suicidal ideation,
unusual changes in
behavior.
Hydrocortisone 100mg IV

Drug class: Glucocorticoid , Adrenocorticoid replacement, anti-inflammatory

Systemic: Management of adrenocortical insufficiency, anti-inflammatory,

immunosuppressive. Topical: Inflammatory dermatoses, adjunctive treatment of ulcerative
colitis, atopic dermatitis, inflamed hemorrhoids. OFF-LABEL: Management of septic shock.
Treatment of thyroid storm. Inhibits accumulation of inflammatory cells at inflammation sites,
phagocytosis, lysosomal enzyme release, synthesis and/or release of mediators of
inflammation. Reverses increased capillary permeability. Therapeutic Effect:
Prevents/suppresses cell-mediated immune reactions. Decreases/prevents tissue response to
inflammatory process.

Baseline assessment
Obtain baseline weight, B/P, serum glucose, cholesterol, electrolytes. Screen for infections
including fungal infections, TB, viral skin lesions. Question medical history as listed in
Precautions.

Intervention/evaluation
Assess for edema. Be alert to infection (reduced immune response): sore throat, fever, vague
symptoms. Monitor daily pattern of bowel activity, stool consistency. Monitor electrolytes,
B/P, weight, serum glucose. Monitor for hypocalcemia (muscle twitching, cramps),
hypokalemia (weakness, paresthesia [esp. lower extremities], nausea/vomiting, irritability,
EKG changes). Assess emotional status, ability to sleep.

Patient/family teaching. Report fever, sore throat, muscle aches, sudden weight gain, swelling,
visual disturbances, behavioral changes. Do not take aspirin or any other medication without
consulting physician. Limit caffeine; avoid alcohol. Inform dentist, other physicians of
cortisone therapy now or within past 12 mos. Caution against overusing joints injected for
symptomatic relief. Topical: Apply after shower or bath for best absorption. Do not cover or
use occlusive dressings unless ordered by physician; do not use tight diapers, plastic pants, and
coverings. Avoid contact with eyes.
Diazepam 5mg TIV For Seizure For 2min (Max Of 30mg/Day)

Drug class: Benzodiazepine (Schedule IV), Antianxiety, skeletal muscle relaxant,

anticonvulsant

Short-term relief of anxiety symptoms, relief of acute alcohol withdrawal. Adjunct for relief of
acute musculoskeletal conditions, treatment of seizures (IV route used for termination of status
epilepticus). Gel: Control of increased seizure activity in refractory epilepsy in patients on
stable regimens. OFF-LABEL: Treatment of panic disorder. Short-term treatment of spasticity
in children with cerebral palsy. Sedation for mechanically vented patiens in ICU.
Baseline assessment
Assess B/P, pulse, respirations immediately before administration. Anxiety: Assess autonomic
response (cold, clammy hands; diaphoresis), motor response (agitation, trembling, tension).
Musculoskeletal spasm: Record onset, type, location, duration of pain. Check for immobility,
stiffness, and swelling. Seizures: Review history of seizure disorder (length, intensity,
frequency, duration, LOC). Observe frequently for recurrence of seizure activity

Intervention/evaluation
Monitor heart rate, respiratory rate, B/P, mental status. Assess children, elderly for paradoxical
reaction, particularly during early therapy. Evaluate for therapeutic response (decrease in
intensity/frequency of seizures; calm facial expression, decreased restlessness; decreased
intensity of skeletal muscle pain). Therapeutic serum level: 0.5–2 mcg/mL; toxic serum level:
greater than 3 mcg/mL.

Patient/family teaching. Avoid alcohol. Limit caffeine. May cause drowsiness; avoid tasks that
require alertness, motor skills until response to drug is established. May be habit forming.
Avoid abrupt discontinuation after prolonged use
Paracetamol 300mg TIV Q4 RTC

Drug class: Analgesics and antipyretics

Paracetamol is a common painkiller used to treat aches and pain. It can also be used to reduce
a high temperature. It's available combined with other painkillers and anti-sickness medicines.

Nursing responsibilities include do not drink alcohol, monitor sign of liver dysfunction.
Ceftriaxone 2g TIV q12

Drug class: Third-generation cephalosporin, antibiotic

Treatment of susceptible infections due to gram-negative aerobic organisms, some gram-

positive organisms, including respiratory tract, GU tract, skin and skin structure, bone and
joint, intra-abdominal, pelvic inflammatory disease (PID), biliary tract/urinary tract infections;
bacterial septicemia, meningitis, perioperative prophylaxis, acute bacterial otitis media. OFF-
LABEL: Complicated gonococcal infections, STDs, Lyme disease, salmonellosis, shigellosis,
atypical community-acquired pneumonia. Binds to bacterial cell membranes, inhibits cell wall
synthesis. Therapeutic Effect: Bactericidal

Baseline assessment
Obtain CBC, renal function tests. Question for history of allergies, particularly cephalosporins,
penicillins.

Intervention/evaluation
Assess oral cavity for white patches on mucous membranes, tongue (thrush). Monitor daily
pattern of bowel activity, stool consistency. Mild GI effects may be tolerable (increasing
severity may indicate onset of antibiotic-associated colitis). Monitor I&O, renal function tests
for nephrotoxicity, CBC. Be alert for superinfection: fever, vomiting, diarrhea, anal/genital
pruritus, oral mucosal changes (ulceration, pain, and erythema).

Patient/family teaching. Discomfort may occur with IM injection. Doses should be evenly
spaced. Continue antibiotic therapy for full length of treatment.
Dexamethazone 4mg tiv q6

Drug class: Glucocorticoid, anti-inflammatory, immunosuppressant

Used primarily as an anti-inflammatory or immunosuppressant agent in a variety of diseases

(e.g., allergic, inflammatory, autoimmune). OFF-LABEL: Antiemetic, treatment of croup,
dexamethasone suppression test (indicator consistent with suicide and/or depression),
accelerate fetal lung maturation. Treatment of acute mountain sickness, high-altitude cerebral
edema. Suppresses neutrophil migration, decreases production of inflammatory mediators,
reverses increased capillary permeability. Therapeutic Effect: Decreases inflammation.
Suppresses normal immune response.

Baseline assessment
Question for hypersensitivity to any corticosteroids. Obtain baselines for height, weight, B/P,
serum glucose, electrolytes. Question medical history as listed in Precautions.

Intervention/evaluation
Monitor I&O, daily weight, serum glucose. Assess for edema. Evaluate food tolerance.
Monitor daily pattern of bowel activity, stool consistency. Report hyperacidity promptly.
Check vital signs at least twice daily. Be alert to infection (sore throat, fever, vague
symptoms). Monitor serum electrolytes, esp. for hypercalcemia, hypokalemia, paresthesia
(esp. lower extremities, nausea/vomiting, irritability), Hgb, occult blood loss. Assess
emotional status, ability to sleep. Abrupt withdrawal may cause adrenal insufficiency; taper
dose gradually.

Patient/family teaching. Do not change dose/schedule or stop taking drug. Must taper off
gradually under medical supervision. Report fever, sore throat, muscle aches, sudden weight
gain, edema, exposure to measles/chickenpox. Severe stress (serious infection, surgery,
trauma) may require increased dosage. Inform dentist, other physicians of dexamethasone
therapy within past 12 mos. Avoid alcohol, limit caffeine.
Phenytoin 100 MG TIV X 30min

Drug class: Hydantoin. Anticonvulsant, antiarrhythmic

Management of generalized tonic-clonic seizures (grand mal), complex partial seizures, status
epilepticus. Prevention of seizures following head trauma/neurosurgery. OFF-LABEL:
Prevention of early post-traumatic seizures following traumatic brain injury. Anticonvulsant:
Stabilizes neuronal membranes in motor cortex. Decreases influx of sodium during generation
of nerve impulses. Therapeutic Effect: Decreases seizure activity.

Baseline assessment. Anticonvulsant: Review history of seizure disorder (intensity, frequency,

duration, LOC). Initiate seizure precautions. LFT, CBC should be performed before beginning
therapy and periodically during therapy. Repeat CBC 2 weeks following initiation of therapy
and 2 weeks following administration of maintenance dose.

Intervention/evaluation Observe frequently for recurrence of seizure activity. Monitor ECG for
cardiac arrhythmia. Assess for clinical improvement (decrease in intensity/frequency of
seizures). Monitor for signs/symptoms of depression, suicidal tendencies, and unusual
behavior. Monitor CBC with differential, renal function, LFT, B/P (with IV use). Assist with
ambulation if drowsiness, lethargy occurs. Monitor for therapeutic serum level (10–20
mcg/mL). Therapeutic serum level: 10–20 mcg/mL; toxic serum level: greater than 20
mcg/mL. Free unbound levels: Therapeutic: 1–2 mcg/mL; toxic: more than 2 mcg/mL.

Patient/family teaching. Pain may occur with IV injection. To prevent gingival hyperplasia
(bleeding, tenderness, swelling of gums), maintain good oral hygiene, gum massage, regular
dental visits. Serum levels should be performed every mo for 1 yr after maintenance dose is
established and q3mos thereafter. Report sore throat, fever, glandular swelling, skin reaction
(hematologic toxicity). Drowsiness usually diminishes with continued therapy. Avoid tasks
that require alertness, motor skills until response to drug is established. Do not abruptly
withdraw medication after long-term use (may precipitate seizures). Strict maintenance of drug
therapy is essential for seizure control, arrhythmias. Avoid alcohol. Report any unusual
changes in behaviour.
Ranitidine 50mg TIV OD

Drug class: Histamine H2-receptor antagonist. Antiulcer

Short-term treatment of active duodenal ulcer. Prevention of duodenal ulcer recurrence.

Treatment of active benign gastric ulcer, pathologic GI hypersecretory conditions, acute
gastroesophageal reflux disease (GERD), including erosive esophagitis. Maintenance of
healed erosive esophagitis. OTC: Relief of heartburn, acid indigestion, sour stomach. OFF-
LABEL: Treatment of upper GI bleeding. Prevention of stress-induced ulcers in ICU.
Anaphylaxis (adjunct therapy). Premedication to prevent taxane hypersensitivity.

Baseline assessment. Obtain history of epigastric/abdominal pain. Intervention/evaluation.

Assess mental status in elderly. Question present abdominal pain, GI distress. Patient/family
teaching. Smoking decreases effectiveness of medication. Do not take medicine within 1 hr of
magnesium- or aluminum-containing antacids. Transient burning/pruritus may occur with IV
administration. Report headache. Avoid alcohol, aspirin.
Furosemide 20mg

Drug class: Loop diuretic.

Treatment of edema associated with HF and renal/hepatic disease; acute pulmonary edema.
Treatment of hypertension (not recommended as initial treatment). Enhances excretion of
sodium, chloride, potassium by direct action at ascending limb of loop of Henle. Therapeutic
Effect: Produces diuresis, lowers B/P.
Baseline assessment
Check vital signs, esp. B/P, and pulse, for hypotension before administration. Assess baseline
renal function, serum electrolytes, esp. serum sodium, and potassium. Assess skin turgor,
mucous membranes for hydration status; observe for edema. Assess muscle strength, mental
status. Note skin temperature, moisture. Obtain baseline weight. Initiate I&O monitoring.
Auscultate lung sounds. In pts with hepatic cirrhosis and ascites, consider giving initial doses
in a hospital setting.

Intervention/evaluation
Monitor B/P, vital signs, serum electrolytes, I&O, weight. Note extent of diuresis. Watch for
symptoms of electrolyte imbalance: Hypokalemia may result in changes in muscle strength,
tremor, muscle cramps, altered mental status, cardiac arrhythmias; hyponatremia may result in
confusion, thirst, cold/clammy skin. Consider potassium supplementation if hypokalemia
occurs.

Patient/family teaching. Expect increased frequency, volume of urination. Report palpitations,

signs of electrolyte imbalances (noted previously), hearing abnormalities (sense of fullness in
ears, tinnitus). Eat foods high in potassium such as whole grains (cereals), legumes, meat,
bananas, apricots, orange juice, potatoes (white, sweet), and raisins. Avoid sunlight, sunlamps

Digoxin ½ amp TIV now

Drug class: Cardiac glycoside. Antiarrhythmic, cardiotonic.

Treatment of mild to moderate HF. Control ventricular response rate in patients with chronic
atrial fibrillation. OFF-LABEL: Fetal tachycardia with or without hydrops; decrease
ventricular rate in supraventricular tachyarrhythmias. HF: Inhibits sodium/potassium ATPase
pump in myocardial cells. Promotes calcium influx. Supraventricular Arrhythmias: Suppresses
AV node conduction. Therapeutic Effect: HF: Increases contractility. Supraventricular
Arrhythmias: Increases effective refractory period/decreases conduction velocity, decreases
heart rate.

Baseline assessment. Assess apical pulse. If pulse is 60 or less/min (70 or less/min for
children), withhold drug, contact physician. Blood samples are best taken 6–8 hrs after dose or
just before next dose.

Intervention/evaluation. Monitor pulse for bradycardia, EKG for arrhythmias for 1–2 hrs after
administration (excessive slowing of pulse may be first clinical sign of toxicity). Assess for GI
disturbances, neurologic abnormalities (signs of toxicity) q2–4h during loading dose (daily
during maintenance). Monitor serum potassium, magnesium, calcium, renal function.
Therapeutic serum level: 0.8–2 ng/mL; toxic serum level: greater than 2 ng/mL.

Patient/family teaching. Follow-up visits, blood tests are an important part of therapy. Follow
guidelines to take apical pulse and report pulse of 60 or less/min (or as indicated by
physician). Wear/carry identification of digoxin therapy and inform dentist, other physician of
taking digoxin. Do not increase or skip doses. Do not take OTC medications without
consulting physician. Report decreased appetite, nausea/vomiting, diarrhea, visual changes.
Salbutamol Neb + 2cc PNSS q8

Drug class: Sympathomimetic (adrenergic agonist). Bronchodilator.

Treatment or prevention of bronchospasm due to reversible obstructive airway disease,

prevention of exercise-induced bronchospasm. Stimulates beta2-adrenergic receptors in lungs,
resulting in relaxation of bronchial smooth muscle. Therapeutic Effect: Relieves
bronchospasm and reduces airway resistance.

Baseline assessment. Assess lung sounds, pulse, B/P, color, characteristics of sputum noted.
Offer emotional support (high incidence of anxiety due to difficulty in breathing and
sympathomimetic response to drug).

Intervention/evaluation. Monitor rate, depth, rhythm, type of respiration; quality and rate of
pulse; EKG; serum potassium, glucose; ABG determinations. Assess lung sounds for
wheezing (bronchoconstriction), rales.

Patient/family teaching. Follow guidelines for proper use of inhaler. A health care provider
will show you know to properly prepare and use your medication. You must demonstrate
correct preparation and injection techniques before using medication. Increase fluid intake
(decreases lung secretion viscosity). Do not take more than 2 inhalations at any one time
(excessive use may produce paradoxical bronchoconstriction or decreased bronchodilating
effect). Rinsing mouth with water immediately after inhalation may prevent mouth/throat
dryness. Avoid excessive use of caffeine derivatives (chocolate, coffee, tea, cola, cocoa).
Zinc Oxide cream or affected area TID

Drug class: Miscellaneous topical agents

ZINC OXIDE (zingk OX ide) is used to treat or prevent minor skin irritations such as burns,
cuts, and diaper rash. Some products may be used as a sunscreen. This medicine may be used
for other purposes; ask your health care provider or pharmacist if you have questions.

IVF
PNSS 1L (0.9 NaCl solution)

Normal Saline is a prescription medicine used for fluid and electrolyte replenishment for
intravenous administration. Normal Saline may be used alone or with other medications.
Normal Saline belongs to a class of drugs called Crystalloid Fluid. Sodium Chloride (sodium
chloride (sodium chloride injection) injection) Injection, USP is a sterile, nonpyrogenic
solution for fluid and electrolyte replenishment in single dose containers for intravenous
administration. It contains no antimicrobial agents. The nominal pH is 5.5 (4.5 to 7.0).
Composition, osmolarity, and ionic concentration are shown below:

0.45% Sodium Chloride Injection, USP contains 4.5 g/L Sodium Chloride (sodium chloride
(sodium chloride injection) injection) , USP (NaCl) with an osmolarity of 154 mOsmol/L
(calc). It contains 77 mEq/L sodium and 77 mEq/L chloride.

0.9% Sodium Chloride Injection, USP contains 9 g/L Sodium Chloride (sodium chloride
(sodium chloride injection) injection) , USP (NaCl) with an osmolarity of 308 mOsmol/L
(calc). It contains 154 mEq/L sodium and 154 mEq/L chloride.

D5LR 1L

Lactated Ringers in 5% Dextrose is a prescription medicine used to treat the symptoms of

[conditions]. Lactated Ringers in 5% Dextrose may be used alone or with other medications.
Lactated Ringers in 5% Dextrose belongs to a class of drugs called Intravenous Nutritional
Products.

Lactated Ringer's and 5% Dextrose Injection, USP is a sterile, nonpyrogenic solution for fluid
and electrolyte replenishment and caloric supply in a single dose container for intravenous
administration. Each 100 mL contains 5 g Dextrose Hydrous, USP*; 600 mg Sodium Chloride,
USP (NaCl); 310 mg Sodium Lactate (C3H5Na03); 30 mg of Potassium Chloride, USP (KCl);
and 20 mg Calcium Chloride, USP (CaCl2·2H20). It contains no antimicrobial agents.
Approximate pH 5.0 (4.0 to 6.5).

Lactated Ringer's and 5% Dextrose Injection, USP administered intravenously has value as a
source of water, electrolytes, and calories. One liter has an ionic concentration of 130 mEq
sodium, 4 mEq potassium, 2.7 mEq calcium, 109 mEq chloride and 28 mEq lactate. The
osmolarity is 525 mOsmol/L (calc). Normal physiologic range is approximately 280 to 310
mOsmol/L. Administration of substantially hypertonic solutions may cause vein damage. The
caloric content is 180 kcal/L

(https://www.rxlist.com/lactated-ringers-in-5-dextrose-drug.htm#:~:text=Lactated%20Ringers
%20in%205%25%20Dextrose%20is%20a%20prescription%20medicine%20used,drugs
%20called%20Intravenous%20Nutritional%20Products.)
D5IMB ½ - D5 Water (Balanced Multiple Maintenance Solution with 5% Dextrose)

Formulation:
Each 100ml contains 5g of Dextrose Monohydrate, 189mg of Sodium Acetate Anhydrous,
141mg of Potassium Chloride, 21.4mg of Sodium Phosphate Monobasic, 30.5mg of
Magnesium Chloride Hexahydrate, 15mg of Monopotassium Phosphate, and 20mg (approx.
1.1mmol/L) of Sodium Metabisulfite.

Electrolytes in 1L:
Sodium..............................25mmol
Potassium..........................20mmol
Magnesium......................1.5mmol
Acetate...............................23mmol
Chloride............................ 22mmol
Phosphate..........................3mmol

Osmolarity: 350 mOsm/L

 pH: 4.0 to 6.5
Type: Hypertonic

Indication: For maintenance of fluid and electrolytes especially to patients who need calories
and hydration.

Precaution: Should not be given to new born babies whose body weight is low; patients who
have damaged blood vessels and weakened kidneys, and heart problems.

Warning: Contains Sodium Metabisulfite, a sulfite that may cause allergic-type reactions
including anaphylactoid symptoms and life-threatening or less severe asthmatic episodes in
certain susceptible persons.

D5050

Health Instructions Provided

EVALUATION
Nursing Objectives and Evaluation: Effectiveness of Care

Modifications of Plan of Care

There is difference in the plan of care that is given between an adult and a child. Caring
on a child has been dependent on the management that is being given by a nurse but still depends
on the case of the patient. During our shift, there are a lot of nursing intervention that are done
especially in NGT feeding, suctioning and pharmacological treatment. There are a lot of
circumstances that arise that needs immediate attention and be given priority.
The changes in the plan of care is inevitable because the patient conditions are
unpredictable. The condition is critical because there are times that the patient’s SPO2 becomes
desaturated and some of the treatment and intervention are being to hold temporarily.
The prioritization of treatment is flexible because there are times that the patient’s
condition becomes unstable. Pharmacologic treatment also changed because of the condition
where desaturation takes place and it is put into hold. Since the plan of care is flexible there are
still a lot of intervention and treatment are put into work that is directly needed for the
improvement of the patient’s condition.
Learning Experience
 Compared to dealing with adults, pediatric nursing clinical practice processes
were more complex given that children exhibit dependent behaviors and nursing care requires
more detail improvement.
The nursing students thought about their recent learning and practice. From the student
nurses reflections, these have emerged: significant knowledge for learning practice; improved
self-confidence for applying nursing skills; patient and family centered; concentration and
attention skills; rechecking and completing tasks before doing practices; making the student
nurses to have a sense of accountability, honesty, and professional work ethics; and mirror for
improving intervention in the future as professional nurses.
Based on the patient's clinical indications and symptoms and the involvement of the
family, patient and family centers were used for nursing diagnosis and interventions. Nursing
students concentrated on the nursing care method, integrated knowledge, and nursing art. Family
involvement promotes health education and illness prevention and improves the patient’s well-
being. The student nurses’ learning experience showed their awareness of concentration, and the
need to pay close attention before starting clinical practice.
Future nursing profession will require a greater amount of information, especially in
order to prepare for pediatric practice. Clinical nursing standards, drug management,
understanding of pediatric issues, and clinical problem-solving skills are all necessary.

CONCLUSIONS AND RECOMMENDATIONS

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