KARDEX

DATE LABORATORY DATE NURSING PROCEDURE

October 29, 2022 - Chest x-ray with PA October 29, 2022 - Monitor vital signs q4
view - Hooked patient to high
flow nasal canula.
- Performed tepid sponge
bath.

DATE IVF DATE MEDICATION

October 29, 2022 - 1L PNSS to run for October 29, 2022 - Albuterol 2.5 mg via
8 hours. nebulizer
- Paracetamol 250 mg PO
q6 hrs.

Name: Phaedrew Thomas Age: 9 y/o Sex: Male Status: Single

Health record no.:012345
Birthday: November 15, 2013 Weight: 45 lbs
Date admitted: October 29, 2022 Diet: DAT
Chief complaint: Cough and chest pain
Diagnosis: Asthma
Final Dx/Procedure done:
Attending physician: Dr. Navarro
Adress: Magsaysay, Bayombong, Nueva Vizcaya
 NCM 119 RLE Activity: Case Study

Case: Phaedrew Thomas, age 9 years old, is sent home from school by his teacher because he is
disrupting the class by constantly coughing. Mrs. Zenaida, Phaedrew Thomas’s grandmother and
legal guardian, recently registered Phaedrew Thomas in the nearby hospital. A review of the
health history forms for medication or significant illness is negative. Phaedrew Thomas said he
got a cold and started coughing this morning on the way to school, and during gym (physical
education) class his chest was hurting.

FAMILY/SOCIAL HISTORY
Phaedrew Thomas, and his brother, age 12 years old, recently moved to Bayombong to live with
their grandmother. Their mother died in an automobile accident 3 months ago.

PAST MEDICAL HISTORY

Mrs. Zenaida was unable to add any additional information regarding past medical illnesses. She
gave Phaedrew Thomas a dose of Tylenol this morning because he felt warm.

PHYSICAL EXAMINATION
Vital Signs

Wt: 4 5 lbs., Ht: 51 inches

Temp. 100 (ax), BP 100/64; HR 92; RR 28.
General Appearance: pale, coughing, anxious, able to answer questions, but short of breath with
speaking.
Eyes: Conjunctiva clear, no discharge, no icterus
Ears: TM’s intact, light reflex present, no injection
Nose: Rhinorrhea (mild), clear in color
Throat: No injection, no exudate, + gag reflex
Lungs: Bilateral wheezing, prolonged expiratory phase, using abdominal muscles to breathe, no
nasal flaring, O2 saturation 89%.
Heart: S1S2 normal, no murmur, rate 92 and regular.
Abdomen: No organomegaly, normal bowel sounds, no tenderness.
Additional data: Unable to use peak flow meter, unable to blow hard enough.

Answer the following questions.

A. What is your assessment?

1. Highlight data from above (subjective and objective data) that is not within “normal”
parameters.
 Temperature 100 axillary
 Pale,coughing, anxious, able to answer questions however the he experienced
shortness of breath while speaking
 Rhinorrhea (mild)
 Bilateral wheezing, prolonged expiratory phase, using abdominal muscles to
breathe, O2 saturation is 89%
  Unable to use peak flow meter, unable to blow hard enough

2. What medical diagnosis should be considered for this child?

 Asthma

3. What 5 things should be included in the doctor’s admission orders?

 Hook patient to high flow nasal cannula at 3-6 LPM
 Place patient in high fowler’s position
 IVF: PNSS 1L x 8hrs
 Laboratory: Chest Xray
 Medication: Albuterol 2.5 mh via nebulizer every 20 minutes for the first hour for
mild to moderate exacerbation

4. What are the top 3 nursing diagnosis you would consider for this child?
 Impaired breathing pattern
 Impaired gas exchange
 Activity intolerance

5. Which nursing interventions should be a priority for this child, why?

 An interventions that should be prioritize is the administration of oxygen via high
flow nasal cannula because the client exhibits difficulty of breathing

B. Based on this information, what teaching should be included in your plan of care?
1. Health educate the patient as well as his legal guardian on the proper use of inhalers
2. Educate the patient on relaxed deep breathing
3. Educate the patient on how to track their symptoms using planner or calendar
4. Educate the patient on using the advance technology, browse in the internet about
the information about asthma like its symptoms, triggers, and medication
5. Educate the patient about the nature of asthma
6. Educate the patient about the purpose and action of the medication to increase their
knowledge as well as their adherence
7. Provide a list of triggers such as allergies, strong emotions, exercise, weather,
smoke, viruses or other irritants that can cause asthma attack. Teach the patients on
how to avoid them
8. Educate the patient on proper inhalation technique
9. Teach the patient to perform peak flow monitoring
10. How to implement an asthma action plan
11. When to seek assistance

Endorsement
1. Phaedrew Thomas