Case Study for Pediatric Nursing Clinical Rotation

Case:
Patient M, 4 year-old-female, filipino, born on february 16, 2017 in Paranaque city was
admitted on March 9, 2021. 10 am due to cough, fever, accompanied by nausea and
vomiting under the service of Dr. De Jesus. Initial Diagnosis: PCAP C (Pediatric
Community Acquired Pneumonia, Category C)
Situation: You are on duty at 6-2 shift and you receive the following data during
endorsement;
▪ Admitted at Room 201 bed A with O2 @ 2LPM via Nasal cannula
▪ With PNSS 500ml to run for 8hrs @300ml level
▪ Diet for age
▪ Meds: Paracetamol 5ml every 4hrs for temp 37.8 and above
Pen-G 200,000 U IV q 6hrs
Salbutamol 1 nebule q 6hrs
Erceflora 1 sachet TID PO
Zinc Sulfate 2ml OD PO
▪ Latest temp: 37.9C

History:
Born full term via CS in UCP Medical Center, 2nd out of 3 children of a jeepney driver
(38 years old). Both parents are hypertensive and father is smoking 2 packs/day for 8
years. Cough started 2 days prior to admission followed by an on and off fever
thereafter, nausea and vomiting followed after giving paracetamol as home remedy.
Hours prior to admission, temperature went up to 38.8C. AM shift nursing diagnosis is
Hyperthermia. Lab/radiological test done March 24: X-ray result reveals pneumonia,
WBC at 14,000 RBC and platelets normal.stool and urine analysis is also normal.
Focus assessment includes : RR 44cpm, irregular, shallow breaths through mouth, uses
accessory muscle for breathing. Unable to breath in supine position, audible breath
sounds within few feet. Auscultation reveals bilateral course crackles on lower lobes
with decreased breath sounds at posterior area. T-38.2C, PR 123cpm, SPO2 92%.
Learning Activities:
A. Application of Nursing Process
1. Document the assessment data, Specify the abnormal findings under Review
of System (ROS)
2. Illustrate and discuss the anatomy and physiology of the affected system
3. Illustrate (diagram) the Pathophysiology of PCAP C (Patient/Client based)
4. Present your drug study
5. Prepare your Nursing care Plan
6. Clinical reasoning Questions
➢ What possible COMPLICATIONS do you anticipate?
➢ What ASSESSMENT do you need to identify and respond to if this
complication develops?
7. What Heath Teachings can you provide for this patient
8. Ethico-Moral -Legal : The Doctor advised the mother for her child to be
immunized with pneumococcal vaccine. The mother refused saying that she
has read somewhere that it can cause autism. What would be your nursing
action? What ethical principle is applicable in this scenario? Justify