Misamis University

Ozamiz City 7200, Philippines

Tel No. +63 088 521-0367 / Telefax No. +63 088 521-2917
E-mail Address: mu@mu.edu.ph
COLLEGE OF NURSING, MIDWIFERY AND RADIOLOGIC TECHNOLOGY

MINI CASE STUDY:

A PEDIATRIC
PATIENT

Student-Nurses: Albiso,

Marianne Thea O.

Gravino, Veinz Ryan C.

 ABSTRACT

This case study focuses on the care of a 10-year old pediatric patient Zakk Jhudiel C. Laroya

who lives in P-2 Bañadero, Ozamiz City. A comprehensive assessment using the Nursing

Assessment Tool/Guide for Pediatric Clients in the Community was performed by formulation of

ten nursing diagnoses. An effective patient-centered nursing care plan was then developed based

on the top two most priority nursing diagnoses. In accordance with that, the purpose of this case

study is to help the child alleviate the problem and improve his health through an assessment

performed by student-nurses Marianne Albiso and Veinz Gravino. Data stipulated in the

assessment tool were gathered through the patient’s grandmother, subjective cues from the

patient, and observations made by the proponents. Thereafter, nursing diagnoses were formulated

and ranked. Subsequently, patient-centered nursing care plans were developed alongside nursing

process-focused drug studies based on the medications administered on the patient.

 TABLE OF CONTENTS

A. ASSESSMENT TOOL…………………………………………………………………

I. Demographic Profile ……………………………………………………….

II. Physical Assessment ……………………………………………………..

III. Birth History and Immunization………………………………….

IV. Developmental Level……………………………………………………

V. Functional Health Patterns……………………………………………..

i. Health Perception-Health Management Pattern

ii. Nutritional and Metabolic Pattern

iii. Elimination Pattern

iv. Sleep-Rest Pattern

v. Activity-Exercise Pattern

vi. Cognitive-Perceptual Pattern

vii. Self-Perception-Self-Concept Pattern

viii. Role Relationship Pattern

ix. Sexuality-Reproductive Pattern

x. Coping Stress Tolerance Pattern

xi. Value-Belief Pattern

 NURSING ASSESSMENT ON A PEDIATRIC CLIENT (COMMUNITY)
Gordon’s Functional Health Pattern Assessment
I. DEMOGRAPHIC PROFILE
(Write the demographic profile of the client and
family, including home environment, living
conditions, family interaction, siblings and order
and other pertinent data, in a paragraph form)
Zakk Jhudiel C. Laroya is a 10-year old male child
born on February 8, 2012. He weighs 47.3 kg and
is 54 inches tall. Based on the height and
weight, his BMI is 26.1, placing the BMI-for-
age at the
98th percentile. This falls in the BMI category
obesity. His parents separated when he was 6 years
old and with that, his grandmother raised him since
then. He is the eldest son, he has one brother, and a
half sister both living with his mother Margill
T.
Cardines, 37 years old in the province of Batangas.
However, Zakk seldomly interacts with his siblings
through video calls via facebook messenger. They
are an extended family since the child is living
with his grandmother Myrna 60 years old and his
27-year old uncle Joffy, who is the
youngest brother of the child’s father Jeffy O.
Laroya 36 years old and is currently working
abroad. The Laroya family resides in a one-
storey apartment with 6 attached units at P-2
Bañadero, Ozamiz City, Misamis Occidental
made of concrete with two bedrooms, a living
room, kitchen, and one comfort room. They
have a regular water supply from a water
utility company, and whenever they have left-
over foods they store it in a refrigerator and
heat it up using a microwave oven before
consuming. The family does not practice
the proper waste disposal and the separation
of biodegradable from non-biodegradable
materials. "dili mi mag segregate sa amo basura
depende lang ug maka dumdum mi" as
verbalized by the grandmother. The apartment
has sanitary sewage with a manhole cover for
the wastes and a septic tank is also used for the
storage of human excreta. There are no traffics
or disturbances in their area since the barangay
officials control the peace and order in the
community.
II. PHYSICAL ASSESSMENT During the physical assessment, the skin is
intact with no rashes and abrasions. Upon
examining his eyes, ears, nose, throat and mouth
using a penlight, his eyes are normal, conjunctiva is
pinkish in color and pupils are equal, round, and
are reactive to light and accomodation. His ears
are symmetrical, hearing is not impaired, does
not have any discharges and both ears are
not in pain. He experiences nasal flaring due
to a runny nose caused by colds. However,
no epistaxis is observed. Zakk experiences
colds due to the change of environmental
temperature. In assessing the mouth, there are no
tonsilitis present, no gum bleeding but there is a
tooth decay one from the lower right molar due
to poor dental hygiene. “Usahay rani siya maka
toothbrush, kung dili nimo ingnon dili lang pud.
Kasagara kas-a or kaduha ra gyud sa isa ka
adlaw” as verbalized by his grandmother. He
seldomly eats sweet foods such as chocolates,
candies and ice cream but when he does, he
will not brush his teeth. There is a yellowish
discoloration of teeth but there were no plaques
seen upon assessment. No pain and there are no
limitations of movement in his neck. No
enlargement of chest seen, he has frequent
colds due to change of environmental temperature,
he is not cyanotic, but he experiences fatigue
on exertion due to lack of exercise. “Dali ra kaayo
na siya kapuyon bisag mag hike lang, tapulan
man gud kaayo mag exercise. Di pud hilig
magdula sa gawas kay naa ra pirmi sa balay
ga dula ug computer” as verbalized by his
grandmother. His heart rhythm is auscultated
and there were no abnormalities heard. His
pulse rate is in normal range with 72 beats
per minute. He has not undergone any
laboratory tests. However, he normally
urinates in a day since he drinks water more
than the average daily intake. His testes are
descended. Zakk usually eats too much, he eats
snacks between meals even at night. He mostly
eats vegetables, his favorite is broccoli. He
seldomly eats fish and dislikes meat fat. “Mosugot
 rani siya mag sud an ug law-uy paborito kaayo na
niya mao iya gina request nga ipaluto. Dili
lang siya mokaon ug isda, galonggong ra gyud
iya kaunon. Sauna ganahan kaayo siya ug taba
sa karne, karon lud on na daw siya. Kung sa
prutas pod kada gabii gyud ni siya mangita ug
apple. Orange ug apple na iyang paborito” as
verbalized by his grandmother. He usually
defecates right after eating too much. “Sige
ra gyud ni siya mangita ug kaon bisag gabiing
dako gutomon, taman sa iyang makita nga
pagkaon iya gyud nang ipaluto bisag ting katulog
na” as verbalized by the grandmother. He does not
have any bone fractures and deformities. “Basta
magkiat ni siya, gamay nga takilpo mabikil
dayun iyang tiil. Natumba siyag scooter sauna
kay nabug atan siguro to sa lawas unya nabikil
iyang tiil maong amo gipahilot kay nalisa” as
verbalized by the grandmother. His head does not
have any lesions, nor enlargement, and any
abnormalities. He is well oriented with the time,
day and can identify numbers and letters well.

III. BIRTH HISTORY AND IMMUNIZATION Due to the patient’s family situation,
the student-nurse gathered only some
information through the patient’s grandmother and
according to her, the mother experiences nausea
and vomiting, and morning sickness during the
pregnancy. The patient was delivered through
C-section. The grandmother does not have
information regarding the child’s APGAR score.
Zakk is fully immunized such as Hepatitis B,
Vitamin K, vaccine for measles, and BCG.
He does not receive any COVID-19 vaccine
yet because they would have to consult a doctor
first. “wala pa siya na vaccine-an kay ipa consult
pa namo sa doctor kong pwede naba siya ma
vaccine-an sa Covid” as verbalized by the
grandmother.
IV. DEVELOPMENTAL LEVEL
Freud’s Psychosexual Development
Erikson’s Psychosocial Development
Piaget’s Cognitive Development
Kohlberg’s Moral Development
Zakk is in the latency stage. During this stage the
libido is dormant and no further psychosexual
development takes place. He is channeled into
developing new skills and acquiring new
knowledge, and his play becomes largely confined
to other children of the same gender. Zakk loves to
interact with the people around him, ask questions
and play with his cousin of the same gender.
Zakk belongs to stage 4 which is Industry vs
Inferiority. In this stage, children become
capable of performing increasingly complex
tasks. As a result, he strives to master new skills.
When he is encouraged and commended by his
family and teachers he develops a feeling of
competence and belief in his abilities.
He belongs to the Concrete Operational Stage
in which children begin to think logically
about concrete events. They begin to
understand the concept of conservation. Their
thinking becomes more logical and organized, but
still very concrete. Zakk began using inductive
logic, or reasoning from specific information to
a general principle. Also, he becomes less
egocentric and begins to think about how other
people might think and feel. He begins to
understand that his thoughts are unique and
that not everyone else necessarily shares their
thoughts, feelings, and opinions.
Zakk belongs to the Preconventional
Morality level. Children at this level, according to
Kohlberg, regard regulations as fixed and
unchangeable. He is frightened of punishment,
and this stage is all about obedience and
punishment. He follows the rules and understands
what is right and wrong. He obediently follows
what his grandmother tells him.
V. FUNCTIONAL HEALTH PATTERNS
A. Health Perception-Health Management Pattern
· from the hospital. The medicines administered
B. Nutritional and Metabolic Pattern
Zakk has been admitted once due to an intermittent
fever accompanied by cough and colds. He
was able to recover and was discharged
as recalled by the grandmother were
paracetamol biogesic to help reduce fever
caused by illnesses and neozep used for the
relief of clogged nose, runny nose or fever
accompanied by common cold. And at home,
whenever he has a runny nose he takes neozep as
his medicine and is administered every 4 hours. He
takes his medicine using a spoon or a medicine cup
since it is in a liquid form. He has trouble
taking medications since he experiences
choking or vomiting whenever he takes it. And
Zakk does not have any allergies to medications.
The Laroya family usually eat breakfast together at
7:30 in the morning, have lunch at 12 noon,
and dinner at 6 in the evening. Zakk’s favorite
foods are vegetable soup, chopsuey and
calamares. For snacks he likes to eat pancakes,
fries, toasted bread and orange juice for the
beverage. He is a hearty eater who usually
consumes large amounts of food within a day.
“Wala jud ni siyay control sa iyang kaon,
makahurot siya ug 2 to 3 cups of rice samot na
kung paborito niya ang sud an. Paghuman pa
jud ug kaon mangita napod na siya ug e snack” as
verbalized by the grandmother. He does not
like meat fat, and usually seafood. He dislikes
drinking fresh fruit juice and or buko juice. He
likes his food served to be warm. When he is
sick, his grandmother always encourages him to
eat more so he does, that is why he does not
have problems with his appetite. However, Zakk
has difficulty eating whenever his tooth aches,
his grandmother would advise him to chew slowly.
Elimination Pattern Zakk is very independent when it comes to his
toilet habits. He usually defecates in a regular toilet
2-3 times daily especially when he eats too much.
“Modiritso raman ni siya sa CR basta daghan
kaayo siya ug kaunon. Kaloy an sa Ginoo wala ra
pud biya na siya kasulay ug kalibanga” as
verbalized by his grandmother.

Sleep-Rest Pattern Zakk usually sleeps around 11:00 to 12:00 in

the evening because he tends to always be on his
phone watching YouTube or playing online games.
He does not want to sleep in the afternoon.
"Di makatulog ug udto kay saba ang mga
motor ug sakyanan nga manglabay sa gawas sa
amoa" as verbalized by the grandmother. He
wakes up at 7:00 in the morning. Before going to
bed he usually eats 3 slices of apple and
watches television. He sleeps with his
grandmother in a queen size bed and has his
favorite blanket he calls it “mamu blanket”. He
sleeps in a supine position or on his back clutching
a cushion while facing one side. He has no
trouble waking up and getting ready in the
morning.
Activity-Exercise Pattern
· Note: Use the following code to assess
functional self-care level for feeding,
bathing/hygiene, dressing/grooming,
toileting:
à 0 – full self-care
à 1 – requires use if equipment or
device
à 2 – requires assistance or
supervision from another person
à 3 - Is dependent and does not
participate
Cognitive-Perceptual Pattern
During the day, he attends his online synchronous
classes at Misamis University via Microsoft
Teams. His favorite activity is playing
online games daily which consumes 4-5 hours
and his favorite toy is a nerf gun. Zakk has
unlimited time in watching television and using his
phone as well. His favorite programs are “Ang
Probinsyano” and Disney. He does not have any
illness that limits his activity. He typically takes
a bath early in the morning. “Usahay dili na
siya ganahan maligo bisag unsaon ug pugos
maong manimaho siyang ilok” as verbalized by
his grandmother. He brushes his teeth only when he
is told. He is independent in dressing and
grooming. He usually refuses to take a bath
whenever he does not like to. His
grandmother would rather convince him to sponge
bath.
Functional self-care:
● Feeding - 0
● Bathing/Hygiene - 2
● Dressing/Grooming - 0
● Toileting - 0
Zakk is in 4th grade he does not have difficulty in
hearing thus, he does not use any hearing aid.
He does not have any visual problems
hence, eyeglasses or lenses are not applicable.
Zakk has difficulty in learning since he dislikes
doing his school activities. He lacks motivation
to do his homework.
Self-Perception-Self-Concept Pattern Zakk is a very friendly and talkative child. He
mingles with everyone even with those older than
him, he knows how to interact and is easy
going. However, he is a short-tempered child,
he easily gets irritated when he can’t do what he
wants most especially when he is restricted to
play online games. He gets sad when he cannot
sleep with his grandmother, and when he is
annoyed he does not want to talk at all and will
ignore everyone at home. “Dili gyud ni siya
mo sugot nga dili mi magtapad ug tulog kay
mingawon daw siya nako. Kung molakaw lang
gani ko unya dugay ko makauli, mangita
dayun siya” as verbalized by his grandmother.
Zakk is afraid to fail at school, that's why his
grandmother always pushes him to study harder.
He is not afraid of animals. He is also afraid of
being circumcised even though he is now a 10-year
old child.
Role Relationship Pattern
Sexuality-Reproductive Pattern
He is fine being called “Zakkoy” or “Zakk”. Zakk
lives with his grandmother Myrna and his
uncle which he calls “Tito Joffy”. Grandmother
Myrna is the only one looking after Zakk the whole
day. His Tito Joffy works in the administrative
office at the Department of Education-Ozamiz
during the day from 8:00 AM to 5:00 PM.
Zakk’s parents separated when he was 6 years old,
his father Jeffy works abroad and has a fiance
while Zakk’s mother Margill works as a nurse in a
private hospital at the province of Batangas and
is living with Zakk’s younger brother Zion, his
half sister Olivia and Margill’s fiance. “Basta
ma mention namo ang ngalan sa fiance sa iyang
mama kay masuko jud na siya. Ug kung amo pud
siya pangutan on kung mo uban ba siya sa iyang
mama, dili pud siya mosugot kay naa ang fiance
sa iyang mama. Naka isturya gani siya nako
nga tungod atong lakiha naguba iyahang family”
as verbalized by his grandmother. Zakk loves to
play with his cousins in the neighborhood
and he usually hangs out with his closest aunt
which he calls “Ate May”. When handling
discipline problems, usually he gets scolded
by his grandmother and teaches him the right
way and it has been always effective since he is
very obedient.
Zakk is curious about those things, he tends to ask
questions about his genitals. His grandmother and
the elder people around him explained it according
to his level of understanding. He usually socializes
with everyone around him and is not hesitant
to ask questions. His closest friends are his
cousins, he usually spends time with them
every weekend watching television and playing
online games.

Coping Stress Tolerance Pattern
When Zakk is tired or upset he usually stays at the
room alone watching videos from youtube and he
isolates himself and does not want to talk to
everyone. He usually opens up his worries to
his closest aunt Ate May. “Basta wa nana siya
ganahi, magyawyaw gyud na siya. Usahay basta
wala sya kasabot mohilak siya'' as verbalized
by his grandmother. Zakk knows well about
what to do and not what to do, if he is
curious about something he asks first before doing
it.

The Laroya family is Roman Catholic and goes to

Value-Belief Pattern church every Sunday. It is very important in order
to strengthen the child’s faith and that he should be
always grateful for the things that God has blessed
his family with despite their situation. Their family
prays before meal time and prays the rosary
with the whole family every night.

Other Significant Findings:

Assessment Performed by: Marianne Thea O. Albiso & Veinz Ryan C. Gravino

Name/s of Student/s who Performed the Assessment

Clinical Instructor/s: Mr. Erwin Cubillan

Course/Subject: NCM109L Pediatrics

Dates of Assessment: April 14, 2022

Methods/Techniques of Assessment Used: Observation, Interview, Physical Assessment

Sources of Information: Patient and Patient’s Grandmother

References:

Pillitteri, A. (2017). Maternal & child health nursing: Care of the childbearing & childrearing family. 8th
edition. Lippincott Williams and Wilkins.

All Answers Ltd. (November 2018). Gordon’s Functional Health Patterns Assessment. Retrieved from
https://nursinganswers.net/essays/gordons-functional-health-patterns-1222.php?vref=1

Direction:
List and rank ten (10) identified priority nursing diagnoses.

Problem Etiology Signs and Symptoms

(Diagnostic Label – NANDA)
1. Imbalanced nutrition: more
than body requirement
2. Ineffective airway clearance
3. Impaired dentition
4. Poor home/environment
sanitation
5. Activity intolerance
6.Impaired parenting
7. Impaired swallowing
8. Sleep deprivation
(Related Factors)
Uncontrolled food intake
Nasal secretions
Poor oral hygiene
Unsanitary waste disposal and lack
of importance to proper
hygiene and sanitation
lack of exercise
Lack of parental cohesiveness
Behavioral feeding problem
Related to prolonged periods without Sleeping 11:00 to 12:00 in the evening because of
sleep
(Defining Characteristics)
 A body mass index of 26.1 more than the
normal value
 BMI category: Obesity
Rhinorrhea or “runny nose”
 Tooth decay
“Usahay rani siya maka toothbrush, kung dili nimo
ingnon dili lang pud. Kasagara kas-a or kaduha ra
gyud sa isa ka adlaw” as verbalized by his
grandmother.
"dili mi mag segregate sa amo basura
depende lang ug maka dumdum mi" as
verbalized by the grandmother
 Fatigue upon exertion
 “Dali ra kaayo na siya kapuyon bisag
mag hike lang, tapulan man gud kaayo
mag exercise. Di pud hilig magdula sa
gawas kay naa ra pirmi
sa balay ga dula ug computer” as
verbalized by his grandmother.
Separation of parents
Choking when drinking solid medications like
capsules or tablets
mobile games and watching Youtube videos

9.Risk for injury Related to falls and accidents from
excessive physical movements
10. Risk for infection Viral illness
“Basta magkiat ni siya, gamay nga takilpo
mabikil dayun iyang tiil. Natumba siyag
scooter sauna kay nabug atan siguro to sa
lawas unya nabikil iyang tiil maong amo
gipahilot kay nalisa” as verbalized by the
grandmother.
"wala pa siya na vaccine-an kay ipa consult pa
namo sa doctor kong pwede naba siya ma
vaccine-an sa Covid" as verbalized by the
grandmother.
 References:
Pillitteri, A. (2017). Maternal & child health nursing: Care of the childbearing & childrearing family. 8th edition.
Lippincott Williams and Wilkins.
All Answers Ltd. (November 2018). Gordon’s Functional Health Patterns Assessment. Retrieved from
https://nursinganswers.net/essays/gordons-functional-health-patterns-1222.php?vref=1

Nursing Diagnosis: Imbalanced nutrition: more than body requirement related to uncontrolled food intake as evidenced by a
body mass index of 26.1 more than the normal value.

Defining Outcome Criteria Nursing Rat Evaluation

Characteristics Interventions ion
ale
Subjective: At the end of the 4 weeks After 4 weeks of nursing
nursing intervention, the  Note weight,  Exact weight needs intervention, the patient
 “Wala jud ni patient will be able to: waist to be documented, is able to:
siyay control sa circumferenc as patient may have
iyang kaon,  Verbalize accurate e, and been estimating over  Verbalize
makahurot siya information about calculate time. BMI is the accurate
ug 2 to 3 cups benefits of weight body mass patient’s weight in information
of rice samot loss. index (BMI). kilograms divided about benefits
na kung by the square of his of weight loss.
paborito niya  Organize relevant or her height in
ang sud an. activities requiring meters. BMIs  Organize
Paghuman pa energy expenditure greater than 25 are relevant
jud ug kaon into associated with activities
mangita napod daily life. increased morbidity requiring
na siya ug e and mortality. energy
snack” as  Understand the expenditure into
verbalized by complications of daily life.
the being obese at a  Obtain a  So that we can
grandmother. young age. thorough assess lifestyle  Understand the
 A hearty eater nutritional choices and factors complications
who usually history the patient has. It of being obese
 State related
consumes may also help us in at a young age.
factors
large amounts developing an
contributing to
of food within individualized plan
weight gain.  State related
a day. based on the his
factors
 Assess current state.
 Demonstrates contributing
Objective: dietary intake to weight
appropriate through 24-  Data may not be
selection and gain.
Height: 54 hour recall or fully accurate.
control of questions Permits appraisal of
consuming regarding the patient’s knowledge  Demonstrate
inches amounts of food. s appropriate
usual intake about diet also.
Weight: 47.3 kg of food selection and
Body Mass Index: groups. control of
26.1 BMI Category: consuming
amounts of
Obesity
food.
 Advise  Measuring food
patient and/or alerts patient to
parent to normal portion
measure food sizes. Estimating
 regularly. amounts can be
extremely
inaccurate.

 Observ  To assess if patient

e for is consuming an
overuse excessive amount of
of food, like excessive
particul amount of rice for
ar age and weight, and
nutrient junk food.
s.

 Perform  A physically
health conditioned person
teaching uses more fat for
importance of energy at rest and
exercise in a with exercise than
weight control a sedentary person
program. does.

 Educate on  To elicit
exercises that cooperation
are easy and because kids love
fun for the playing games.
child such as Exercises like
playing running, game of
games. tag and other
games appropriate
for age.
 Nursing Diagnosis: Ineffective airway clearance related to nasal secretions as evidenced by rhinorrhea or “runny nose”

Defining Outcome Criteria Nursing Rati Evaluation

Characteristics Interventions onal
e
After three weeks of  Assess respiratory  Changes may vary After three weeks of
Objective: nursing intervention, status for rate, from minimal to nursing intervention, the
the patient will be able depth, ease, use of extreme caused by patient is able to:
to: accessory muscles, bronchial swelling,
 Nasal flaring and work of increased mucus  Express feelings of
 Use of  Express breathing secretions caused by comfort in
accessory feelings of over secretion of maintaining air
muscle comfort in goblet cells and exchange.
maintaining tracheobronchial
 Runny nose
air exchange. infection, narrowing  States experience
 Shortn of air passageways, of no further
ess of  States and presence of other signs or
breath experience of disease states that symptoms of
no further complicates the infection.
 Nasal
signs or current condition.
secretions
symptoms of  Perform proper
infection.  Instruct patient on  Promotes full lung hand washing
deep- breathing expansion and frequently
exercises. decreases anxiety.
 Perform
proper hand  Achieve and
washing  Encourage fluids,  Provides hydration maintain a
frequently. up to 3-4 L/day and helps to thin patent airway.
unless secretions for easier
 Achieve and contraindicated. mobilization and
maintain a removal.
patent airway.
 Prevents possible
 Instruct transmission of
patient/family to infection to the
avoid crowds and patient who already
persons with upper is
respiratory immunocompromise
infections when d
possible.
 NURSING PROCESS-FOCUSED DRUG STUDIES

Nursing Process Focus: Care for Patients Receiving Phenylephrine

Name: Gravino and Albiso BLOCK: B

Classification of the Drug: Decongestant

Common Indications of the Drug: Relief of clogged nose, runny nose, postnasal drip, headache, body aches and fever associated with
common cold, allergic rhinitis, sinusitis
Common Brand Names: Neozep

Assessment Possible Nursing Diagnoses

Prior to administration:
- Monitor cardiac output, central venous pressure, pulmonary - Deficient Knowledge, related to drug administration and
artery wedge pressure, standard vital signs and urinary effects related to newly prescribed drug
output. - Decreased Cardiac Output, related to effect of drug on heart
- Monitor vital signs and observe the nasal mucosa for muscle
changes such as excoriation or bleeding. - Ineffective Tissue Perfusion, related to drug effect
- Obtain complete health history including cardiac, visual, - Ineffective Breathing Pattern, related to nasal congestion
pulmonary, GI, urinary disorders including blood studies:
CBC, electrolytes, cardiac enzymes, BUN, creatinine. May
include EKG, pulmonary functions, and x-rays of the chest
or nasal sinuses.
- Obtain patient’s drug history to determine possible drug
interactions and allergies.

Planning: Patient Outcomes

The patient will:

- Demonstrate understanding of the drug's action.
- Return demonstrate proper nasal medication instillation technique.
- Demonstrate effective nasal airway clearance.
- Maintain vital signs within normal range.
- Maintain effective tissue perfusion.
Implementation
Interventions with Rationales Patient Education/Discharge Planning

- Monitor breathing patterns and observe for shortness of Inform patients:

breath and/or audible wheezing. (Phenylephrine may trigger
asthma.)
- Observe the patient's responsiveness to light.
(Phenylephrine causes photosensitivity by affecting the
pupillary light accommodation/response.)
- Monitor patient's eyes for redness, excessive lacrimation, or
other signs of a local reaction. (Phenylephrine can lower
intra-ocular pressure, affecting open (wide)-angle
glaucoma.)
- Observe the patient's nasal cavity. Monitor for
rhinorrhea/epistaxis.
- Assess all systems in order to decrease possible
complications because body systems are not fully
developed.
- to immediately report shortness of breath, palpitations,
dizziness, chest/arm pain or pressure or other "angina-like"
symptoms.
- to consult their health care provider before attempting to use
phenylephrine to treat nasal stuffiness or eye irritation.
- to monitor blood pressure, pulse and temperature ensuring
proper use of home equipment.
Instruct patient:
- to report change in heart rate and rhythm, or chest pain.
- to report elevated temperature, increased heart rate, and
behavioral changes to the health care provider.

Evaluation of Outcome Criteria (Met, Partially met, Not met)

The patient outcomes was met.
- The patient was able to demonstrate understanding of the drug's action.
- The patient was able to demonstrate proper nasal medication instillation technique.
 - The patient was able to demonstrate effective nasal airway clearance.
- The patient was able to maintain vital signs within normal range.
- The patien was able to maintain effective tissue perfusion.

Reference:
● McCuisition, Linda. DiMaggio, Kathleen., Winton, Mary., & Yeager, Jennifer. (2021). Pharmacology: A Patient-Centered
Nursing Process Approach 10th Edition

NPF Drug Study No. 1

 Nursing Process Focus: Care for Patients Receiving Paracetamol
Name: Gravino and Albiso BLOCK: B

Classification of the Drug: Analgesic & Anti-pyretic

Common Indications of the Drug: Control of pain due to headache, Reduce fever in viral and bacterial infections,
Common Brand Names: Biogesic

Assessment Possible Nursing Diagnoses

Prior to administration: - Risk for Injury (hepatic toxicity), related to adverse effects
- Obtain complete health history including allergies, drug of drug
history and possible drug interactions . - Deficient Knowledge (parents), related to drug action and
- Obtain history of liver disease. side effects
- Assess history of pain or fever.
- Obtain concurrent use of anticoagulants .
- Obtain intolerance to ASA.

Planning: Patient Outcomes

The patient will:
- Take medication as ordered .
The caregiver will:
- Demonstrate an understanding of safe self-administration of medication.
- Report no side effects or adverse reaction of the drug to the infant.

Implementation
Interventions with Rationales
- Monitor renal function tests and intake and output (due to Advise patient:
the ability of acetaminophen to impair renal function as a
result of toxic levels.)
- Monitor concurrent medication use. (Be alert to all other
medications that contain acetaminophen especially in
combination with narcotic pain reliever to avoid toxic
levels. Contraindicated for use with warfarin due to the
mechanism of inhibition of warfarin metabolism, which
causes warfarin to accumulate at high levels.)
- Observe for intolerance to ASA for possible cross-
hypersensitivity to acetaminophen
Patient Education/Discharge Planning
- that lab tests to assess renal function maybe necessary to
prevent renal tubular necrosis .
- to notify health care provider if changes in urinary output
occurs.
- to avoid taking any other OTC medication unless ordered
by health care provider.
- to read directions carefully when using acetaminophen
suspension and drops.
- not to exceed recommended daily dose of medication.
Instruct patient:
- to report any itching, skin rash or difficulty breathing.
- Instruct patient to report signs of infection, generalized
mild muscular pain, and headache.
- Instruct patient to report changes in pain level to health
care provider.
- Advise patient that this medication may cause
hypoglycemia.

Evaluation of Outcome Criteria (Met, Partially met, Not met)

All outcomes are met:
- The patient takes the medication as ordered.
- The caregiver reports no side effects or adverse reaction of the drug to the infant.
- The caregiver demonstrates an understanding of safe self-administration of medication.

Reference:
● 2018 Nursing Drug Handbook (2018) Jones & Bartlett Learning
NPF Drug Study No.2