PEDIATRIC WARD ROTATION

Activities Day 1

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further understand that if plagiarism is found in my paper, my professor will follow
the procedures on academic dishonesty set forth by Manila Doctors College of
Nursing.

Signed: ALCABAZA, MA. SOFIA ANDREI S.

Date: March 27, 2023
 LEARNER’S WORKSHEET

Name of the Student: Alcabaza, Ma. Sofia Andrei S.

Year and Section: BSN IV - 01
Date: March 27, 2023
Area: Pediatric Ward

Application of the Nursing Process

#1 Patient’s Identication
Patient’s Case: Pediatric Community
Acquired Pneumonia (PCAP-C)
Age: 3-year-old
Sex: Male
Room No: 1905
Attending Physician: Dr. Kua
Religion: Roman Catholic
Activity Restriction: Avoid participating
in vigorous activities.
Chief complaint: “Nilalagnat ang anak
ko na umabot na ng 38.8°C. At tatlong
araw na ang lumipas, siya ay umuubo
tsaka pabalik-balik ang kanyang lagnat
magmula nun. Kasama na rin dito ang
kanyang pagduduwal at pagsusuka.” as
verbalized by the mother of the client.

Admitting Diagnosis: PCAP-C Diet: DFA (Diet for Age)

Brief History
Present Illness: The client has cough that is followed by an on and off fever that
is also accompanied by nausea and vomiting.
Past Health Hx: N/A
Family Hx: The father of the client smokes 3 packs of cigarette per day in 10
years. Both of the client’s parents have hypertension.
OB-Gyne: N/A
Personal/Social Hx: N/A

#2 Assessment
General Generally, the client is well-developed and everything
applicable for the indicated age. The client is conscious of the
time, person, and place.
 However, the client exhibits signs of discomfort such as
difficulty breathing and employs supplementary muscles to
breathe via the mouth. The skin is also warmer than normal.
Skin The client’s skin remains intact, smooth, and odorless. There
were no rashes, bruises, or wounds found. The patient's skin is
pale in color with a dry surface, elastic, and recoils instantly
when pressure is released. No discoloration. When assessed,
the temperature of the skin is warm to touch at 38.8°C.
EENT Eyes: Pupils are symmetric and light receptive, and the
conjunctiva and eyelids are free of edema or abnormalities.
There is no swelling or pain in the lacrimal gland region, and
there is no drainage in the nasolacrimal gland when palpated.
The eyelashes are spread uniformly. The eyeballs are perfectly
aligned.

Ears: Auricle, tragus, and lobule are visible and bilaterally

symmetrical. The auricle is aligned with the lateral canthus of
each eye and bears a 10-degree vertical angle bilaterally. The
skin of the ears is smooth and free of lumps, lesions, or
nodules, and the color matches up with the rest of the skin on
the face.

Nose: The color of the nose is identical as the color of the face.
When palpated, the nose is soft and symmetrical, with no
swelling or pain. The nasal septum is in good condition free of
ulcers and perforations.

Throat: Moisture in the mouth cavity. Mucosa is pink, with no

discoloration, tumors, nodules, or swelling. Tonsils can be
seen but are not swollen.
Neck There are no tumors or masses in the neck. There are no bruit
noises in the thyroid region during auscultation. There was no
swelling or expansion of the lymph nodes, nor was there any
discomfort. There is no evidence of diminished ROM.
Breast There is no swelling, nodules, or ulcerations in the breast.
Areolas are brown and spherical in shape. Nipples are
bilaterally sized and located on the same area of both breasts.
Respiratory Abnormal findings were found during the respiratory
assessment. Respiratory rate above normal range at 44cpm,
irregular, shallow, breathes via mouth, makes use of accessory
muscle for breathing, cannot breathe in supine position,
 audible breath sounds within a few feet. Auscultation indicates
bilateral coarse crackles on the lower lobes, as well as
diminished breath sounds in the posterior region.
Cardiovascular The aortic and pulmonic regions had no apparent pulsations.
Heaves and lifts are not present. Normal heart sounds can be
heard. The client has a higher pulse rate than normal of 125
beats per minute and an SPO2 of 92%.
Gastrointestinal The skin of the abdomen is brown, but considerably lighter
than the rest of the body. The umbilicus is inverted and
midline, with no bulges. The abdomen is round and symmetric,
with no bulges or abnormalities.
Genitourinary External organs such as the penis, scrotum, and testicles are
normal. The presence of two scrotums, two testes, and an
intact foreskin. The skin is loose and smooth. There is no
discharge and the patient is not circumcised. Urination is not a
concern.
Musculoskeletal His posture is partially slouched, but it is appropriate for his
age. Gait weight is distributed appropriately and is capable of
balancing without falling. Despite experiencing weakness, the
patient was able to complete the tests throughout the physical
examination. Shoulders are symmetrical and sensitive,
although there is utilization of supplementary muscles and
uneven chest expansion during breathing.
Neurologic With regular speech, the patient is attentive and oriented to
person, place, and time. There were no motor impairments
discovered. Bilateral sensation is intact and bilateral reflexes
are 2+. Cranial nerves and cerebellar function are fully
functional. Memory and thinking processes are both natural.
Gait irregularities are not recognized.
 #3 Concept Mapping
Modifiable Risk Factors: Non-modifiable Risk Factors:

 Exposure to secondhand smoke  3-year-old (<5 years old)

Local inflammatory response: neutrophils Exposure to pathogen: inhalation,

recruited to the site of infection by epithelial hematogenous, direct, aspiration Systemic inflammatory response: Cytokine release
cytokine release (TNF and IL-1)
Susceptible host
Accumulation of plasma exudates Stimulation of increased WBC
Infection and proliferation of pathogen in
Irritation of airways and failure of ciliary the lower respiratory tract WBC: 14000/mm3
clearance to keep up with the fluid buildup

Pediatric Community Acquired Pneumonia - C Disruption of hypothalamic thermoregulation

Cough (3 days)

↑ Temperature: 37.9°C
(+) Crackles and ↓ breath sounds
Nausea and Vomiting
↓ efficiency of gas exchange
Weakness
Hypoxia
↑ respiratory drive
PR: 125 bpm RR: 44 cpm SPO2: 92%

Respiratory accessory muscle use

Fluid build-up in spaces between the alveoli

Bilateral coarse crackles on lower lobes with

decreased breath sounds

Chest X-ray reveals Pneumonia

Unable to breathe in supine position

 Paracetamol 5mL Q4H for Temp >37.8 and above; Pen-G 200,000U IV Q6H; Salbutamol neb 1respoule Q6H; Erceflora 1 sachet TID PO, Zinc sulfate 2mL OD PO

1. Ineffective Airway Clearance related to bronchial inflammation as evidenced by bilateral coarse crackles on lower lobes with decreased breath sounds at
posterior area
2. Impaired Gas Exchange related to fluid and mucus in the alveoli as evidenced by dyspnea and restlessness
3. Hyperthermia related to inflammation and infection in the respiratory tract as evidenced by body temperature above the normal range and hot, flushed skin

Short Term:

The patient will retain a patent airway as shown by the lack of respiratory distress symptoms such tachypnea, nasal flaring, or the employment of auxiliary muscles, as
well as by clear breath sounds and oxygen saturation levels that are within normal ranges of between 95 and 100%.

Long Term:

Clear breath sounds and regular, unlabored breathing are signs that the patient will expectorate residual secretions and maintain a patent airway.

Nursing Interventions:

1. Keep an eye on the respiratory wellness and vital indicators, particularly breath sounds.
2. Regularly check the oxygen saturation level.
3. Record intake and output strictly.
4. Keep the area clean and allergen-free.
5. Posture the bed's head higher and in a semi-Fowler posture. (30-45 degrees).
6. Encourage the client to use an incentive spirometer.
7. Make sure the client can get enough sleep, and consider nursing care to preserve the client’s strength.
8. If the client is kept in a mist tent, make regular changes of the client’s clothing and bedding to prevent chilling.
9. Maintain dental health and hydrate the oral mucosa.
10. According to the doctor's instructions, administer nebulization and oxygen therapy.
11. Administer antipyretics for the treatment of fever.
12. Suction the nose, mouth, and trachea as necessary.
13. As required and tolerated by the client, perform postural drainage, percussion, and vibration.
Watch out for complications such as acute respiratory distress, pleural effusion, pulmonary edema, sepsis, lung abscess,
bacteremia, and necrotizing pneumonia and many more.
14.
 #4 Drug Study

Drug(s) Dose, Frequency, Classification Mechanism of Nursing

Time, and Route Action Responsibilities

Erceflora Dose: Anti-diarrheal Bacillus clausii 1. Instruct that the

1 sachet (Erceflora) spores medicine is for oral
overcome the use only. Do not inject
Route: gastric acid barrier or administer in any
PO due to their high other way.
resistance to both 2. During treatment with
Frequency: chemical and antibiotics, the
TID physical agents, medicinal product
and reach the should be used during
intestinal tract the interval between 2
intact where they administrations of
are transformed antibiotics.
into metabolically 3. Mix the Erceflora with
active vegetative sweetened water or
cells. Hence, orange juice as
preventing indicated.
antibiotic 4. Health Teaching:
associated a. Educate to take 30
diarrhea. minutes before
meals.
b. WOF: Anaphylactic
shock.
c. Report
immediately if
rash, hives,
swelling in hands,
face, and feet
develops.

Paracetamol Dose: Antipyretics Appears to inhibit 1. Assess relief of fever.

5 mL prostaglandin 2. Assess for allergic
synthesis in the reaction.
Route: CNS 3. Monitor the client’s
N/A (Can be PO or (cyclooxygenase 1 vital signs, especially
intravenously) and 2 enzymes) the temperature.
leading to a 4. Health Teaching:
Frequency: decreased a. Educate the
Q4H for Temp synthesis of parents that the
>37.8 and above prostaglandins, medication can be
and to a lesser taken with or
extent, block pain without meals
 impulses through b. Educate the
peripheral action. parents to always
Acts centrally on use the
the hypothalamic appropriate
heat regulating dropper or
center, as measuring cup
prostaglandins provided when
sensitize neuronal administering to
pain receptors, children to prevent
inhibition of their overdosing of the
synthesis leads to drug.
analgesic and c. Discontinue drug if
inflammatory hypersensitivity
effects. occurs and report
immediately to
healthcare
practitioners.
d. Report rash,
unusual bleeding
or bruising,
yellowing of skin or
eyes, changes in
voiding patterns.

Pen-G Dose: Penicillins Penicillin G exerts 1. During administration,

200,000U a bactericidal keep a close eye on
action against the IV site for
Route: penicillin- extravasation.
IV susceptible 2. Assess and monitor
microorganisms for sign of allergic
Frequency: during the stage of reactions.
Q6H active 3. Monitor the
multiplication of temperature of the
binding to one or client.
more of the 4. Monitor laboratory
penicillin-binding values of the client
proteins. It acts such as the CBC and
through the WBC.
inhibition of 5. Health Teaching:
biosynthesis of a. Educate the
cell-wall parents of the
peptidoglycan, the client to report any
final sign of
transpeptidation hypersensitivity
step, rendering the such as rash,
cell wall urticaria, laryngeal
 osmotically edema, and
unstable. anaphylaxis and to
report any
discomfort at the
insertion site.
b. Advice the
caregiver or family
to not abruptly stop
the medication
unless told by the
physician.

Salbutamol Dose: Beta-2 Salbutamol acts as 1. Assess lung sounds,

1 respoule adrenergic a functional vital signs.
agonist antagonist to relax 2. Monitor rate, depth,
Route: the airway rhythm, type of
Nasal Cannula irrespective of the respiration;
spasmogen quality/rate of pulse,
Frequency: involved, thus B/P. Assess lungs for
Q6H protecting against wheezing, rales,
all rhonchi.
bronchoconstrictor 3. Periodically evaluate
challenges. It serum potassium
stimulates beta2- levels.
adrenergic 4. Keep the canister at
receptors in lungs, room temperature
resulting in (cold decreases
relaxation of effects).
bronchial smooth 5. Health Teaching:
muscle. a. Educate the
guardian to avoid
stopping the
medication or
exceeding
recommended
dosage.
b. Note chest pain,
dizziness.
c. Wait at least 1 full
minute before
second inhalation.

Zinc Sulfate Dose: Minerals and Zinc improves 1. May be taken with
2 mL Electrolytes regeneration of the food if GI upset
supplements intestinal occurs.
Route: epithelium, 2. Health Teaching:
PO increases the a. Educate the parent
levels of brush about food
Frequency: border enzymes, interactions that
OD and enhances the may inhibit the
immune response, absorption of Zinc
allowing for a such as cereals,
better clearance of whole grains,
the pathogens. bread)
Besides, this b. Report pain,
medication also trouble breathing
inhibits cAMP- and swallowing,
induced, chloride- and rashes.
dependent fluid
secretion by
inhibiting
basolateral
potassium (K)
channels. Thus, it
results in
improving the
absorption of water
and electrolytes.
#5 Nursing Care Plan(s)
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Subjective Data: Ineffective Short Term: Independent Independent Short Term:
“Nahihirapan Airway After 8 hours of 1. Assess the rate, 1. Changes in
huminga ang Clearance nursing rhythm, and depth breathing patterns Goal Met.
baby ko dahil sa related to interventions, the of breathing, as may occur in The client was able
kakaubo niya ng bronchial client will be able well as chest conjunction with to have a patent
kakaubo.” as inflammation to: movement and the accessory muscles airway with breath
verbalized by the as evidenced  Have a patent usage of in order to promote sounds clearing
mother of the by bilateral airway, with accessory chest excursion and has vital signs
patient. coarse breath sounds muscles. and hence of respiratory rate
crackles on clearing. facilitate at 26 cpm, pulse
Objective Data: lower lobes  Have vital successful rate at 85 bpm,
● Vital signs: with signs within the breathing. temperature of
o RR 44 decreased normal range 2. Auscultate the 2. In locations where 36.7, and spo2 of
cpm breath sounds such as the lung fields, noting fluid has collected, 100% after 8 hours.
o PR 125 at posterior respiratory rate areas of reduced airflow is reduced.
bpm area of 20-30 cpm, or absent airflow In these
o T 38.8°C pulse rate of as well as irregular consolidated
o SPO2 70-110 bpm, breath sounds regions, bronchial
92% temperature of such as crackles breath sounds can
● (+) bilateral 36.5°C-37.5°C, and wheezes. also occur. On
coarse and spo2% of inspiration and
crackles 97-100%. expiration,
● (+) Irregular crackles, rhonchi,
shallow Long Term: and wheezes are
breathing audible due to fluid Long Term:
After 1 week of
● (+) use of buildup, viscous
nursing
accessory
interventions, the secretions, and Goal Met.
muscles while
breathing client was able to airway spasms The client was able
● (+) decreased demonstrate and blockage. to demonstrate
breath sounds behaviors to 3. Elevate the head 3. Lowering the behaviors to
● Laboratory achieve airway of the bed and diaphragm would achieve airway
result: clearance such as shift positions enhance chest clearance such as
o Chest X- coughing often. expansion, coughing exercises
ray = exercises and aeration of lung and maintained a
Pneumon maintain a patent segments, patent airway as
ia airway as mobility, and evidenced by the
evidenced by the expectoration of absence of
absence of secretions. adventitious breath
adventitious breath 4. These allow for sounds after 1
sounds. 4. Teach and help maximal lung week.
the patient with expansion and
deep breathing lesser airway
techniques. expansion,
Demonstrate improving cough
correct chest production.
splinting and Splinting relieves
successful chest pain, and
coughing while being upright
standing upright. encourages a
Encourage the deeper and more
patient to do so on powerful cough,
a regular basis. making it more
effective.
5. Fluids, particularly
5. Maintain warm liquids, help
appropriate in the mobilization
hydration by and expectoration
encouraging fluids of secretions.
to at least 3000 Fluids aid in
mL/day, unless maintaining
contraindicated hydration and
(e.g., heart failure). increasing ciliary
Warm fluids are activity to eliminate
preferred over cold secretions and
fluids. decrease viscosity.
6. Helps mobilize
6. Encourage secretions and
ambulation. reduces
 atelectasis.
7. Vaccinations have
effectively reduced
7. Educate the family the incidence and
of the patient severity of
about the pneumonia in
importance of populations of
vaccination and children.
encourage them to
vaccinate their
children according
to recommended Dependent
guidelines. 8. Adequate oxygen
is necessary to
Dependent keep PaO2 at an
8. As directed by the appropriate level.
physician,
administer
supplementary
oxygen using a
nasal cannula at a 9. Nebulizer
rate of 1-2 liters treatments can
per minute. loosen secretions
9. Administer in the lungs while
nebulizer mucolytics and
treatments and expectorants can
other medications. help thin mucus
and make it easier
to cough up.
10. When heavy /
viscous secretions
are clogging the
10. Suction the nose, airway or the client
mouth, and is unable to
trachea with a swallow or cough
suitable size efficiently, the
 catheter, as airway must be
directed by the cleared.
physician.
Collaborative
11. This is for volume
Collaborative expansion
11. Refer to a protocols and
respiratory secretion
therapist. management
protocols.

Subjective Data: Impaired Gas Short Term: Independent Independent Short Term:
“Nararamdaman Exchange After 8 hours of 1. Assess lung 1. Assess breath
kong mabilis ang related to fluid nursing sounds and vital sounds, Goal Met.
tibok ng anak ko and mucus in interventions, the signs. respiratory rate The client was be
at the alveoli as client will be able and depth, sp02, able to demonstrate
nakakaramdam evidenced by to demonstrate blood pressure improved
siya nang dyspnea and improved and heart rate, and ventilation and
panghihina.” as restlessness ventilation and capillary refill to oxygenation of
verbalized by the oxygenation of monitor for signs tissues by ABGs
mother of the tissues by ABGs of hypoxia and within the
patient. within the patient’s changes in acceptable range at
acceptable range 2. Assess mental perfusion. SPO2 of 100%; and
Objective Data: and absence of status, 2. Restlessness, absence of
● (+) pale skin symptoms of restlessness, and irritation, symptoms of
● (+) dyspnea respiratory changes in the confusion, and respiratory distress
● (+) distress. level of somnolence may after 8 hours.
restlessness consciousness. reflect hypoxemia
● Tachycardia Long Term: and decreased
● SPO2 of 92% After 1 week of cerebral Long Term:
nursing oxygenation and
interventions, the require further Goal Met.
client will be able 3. Keep an eye on intervention. The client was be
to: the client's 3. High fever able to maintain
 Maintain temperature as (common in optimal gas
optimal gas suggested. Assist bacterial exchange; and
 exchange. with fever and cold pneumonia and participate in
 Participate in relief techniques, influenza) actions to maximize
actions to such as adding or significantly oxygenation such
maximize removing increases as breathing and
oxygenation bedcovers, metabolic coughing exercises,
such as maintaining a demands and mobilizing
breathing and suitable room oxygen secretions, and
coughing temperature, and consumption, as improving physical
exercises, taking a tepid or well as altering mobility after 1
mobilizing cool water sponge cellular week.
secretions, bath. oxygenation.
and improving 4. Maintain bedrest
physical by planning activity 4. It prevents over
mobility. and rest periods to exhaustion and
minimize energy reduces oxygen
use. Encourage demands to
the use of facilitate the
relaxation resolution of
techniques and infection.
diversional Relaxation
activities. techniques help
conserve energy
that can be used
for effective
breathing and
5. Elevate the head coughing efforts.
of the bed and 5. These approaches
promote regular encourage
position maximal chest
modifications, expansion,
deep breathing, secretion
and coughing that mobilization, and
is efficient. ventilation
improvement.
Dependent
6. Administer IV Dependent
 therapy as ordered 6. IV fluids are
by the physician. usually
administered for
the rehydration of
the client which
can further help in
7. Administer oxygen decreasing the
therapy as ordered body temperature.
by the physician. 7. Supplemental
oxygen may be
needed to support
oxygenation and to
8. As ordered and maintain sp02
tolerated by child, levels.
perform chest 8. To acquire and
physiotherapy maintain adequate
several times daily airways and also
such as chest improve
percussion, respiratory
vibration, and function and gas
postural drainage. exchange.

Collaborative
9. Refer to the
pulmonologist.
Collaborative
9. A pulmonologist is
a doctor who
specializes in
respiratory
diseases. As a
result, the client
will receive the
most appropriate
treatment.
Subjective Data: Hyperthermia Short Term: Independent Independent Short Term:
“Tumataas ng related to After 8 hours of 1. Every 4 hours, 1. As hyperthermia
sobra ang lagnat inflammation nursing check the patient's advances, the Goal Met.
ng anak ko at and infection interventions, the heart rate and heart rate rises. A The client was able
nararamdaman in the client will be able temperature, more precise to maintain his vital
ko na rin iyon pag respiratory to maintain his especially the indication of core signs within normal
hinahawakan ko tract as vitals signs within tympanic or rectal temperature is range, especially
ang balat niya evidenced by normal range, temperature. tympanic or rectal his body
dahil ito ay body especially his body temperature. temperature as
sobrang init.” as temperature temperature. 2. Identify the 2. Extremes of age or manifested by a
verbalized by the above the patient's age and weight increase respiratory rate of
mother of the normal range weight. the likelihood of 26 cpm, pulse rate
patient. and hot, being unable to of 85 bpm, and
flushed skin manage body temperature of
Objective Data: temperature. 36.7°C.
● Vital signs: 3. Monitor laboratory 3. To monitor illness
o RR 44 data (rbc, wbc, development, Long Term:
cpm Long Term: platelet count), identify early
o PR 125 After 3 days of diagnostic tests (x- indicators of Goal Met.
bpm nursing ray), and clinical infection, and give The client was able
o T 38.8°C interventions, the status trends. treatment. to manifest no
 (+) Hot, client will be able 4. Examine serum 4. Sodium losses signs of
flushed skin to remain free of electrolytes, occur as a result of complications such
 (+) Excessive complications such particularly serum excessive as diseases related
sweating as diseases sodium. perspiration and to infection after 3
 (+) weakness related to infection unintentional days.
 Laboratory from hyperthermia. overheating.
results: 5. Observe strict 5. To prevent
o WBC implementation of transmission of
transmission- pathogens spread
14000/mm
based precautions and infectious
3
and isolations, as agents.
indicated, to
prevent spread of
infection.
6. Adjust and monitor 6. Room temperature
environmental can be altered to
 elements such as be close to the
room temperature body's normal
and bed linens as temperature, and
advised. blankets and
linens can be
modified as
needed to manage
the patient's
7. Remove extra temperature.
garments and 7. Exposing skin to
coverings. room air reduces
Encourage the temperature,
patient to wear boosts evaporative
light clothing and cooling, and
maintain the room improves patient
at a reasonable comfort.
temperature.
8. When required,
provide lukewarm 8. Tepid sponge
sponge baths. baths can relieve
fever by bringing
down the patient's
body temperature
and enhancing
9. Encourage liquids comfort.
and nutritional 9. Hydration is
intake. essential for
preventing
dehydration and
maintaining
balance.
Encouragement of
oral fluids will help
to mobilize
respiratory
secretions. Proper
 eating increases
energy and
strengthens the
immune system.

Dependent Dependent
10. Administer 10. Antipyretic is used
antipyretic, to normalize the
antibiotic, and body temperature.
supplements as Antibiotics are
ordered by the used to treat
physician. bacterial
pneumonia.
Supplements help
support the
immune function of
the patient.
11. For severe 11. The need for
instances, metabolic oxygen
administer oxygen rises during
treatment which hyperthermia.
may include
mechanical
ventilation and
intubation.

Collaborative Collaborative
12. Refer to a dietitian 12. To provide enough
to meet the nutritional needs
patient's dietary and a diet plan,
demands, which since protein-rich
should include meals have anti-
high protein-rich inflammatory
meals. characteristics and
assist in increasing
the body's capacity
to repair and
regenerate
tissues.
 #6 F-D-A-R Charting
Focus Data Action Response
Ineffective The client was admitted Obtained vital signs; strict The client
Airway to the hospital due to implementation of droplet manifested no
Clearance cough, fever, precautions and kept signs of accessory
accompanied by nausea environment allergen free; muscle for
and vomiting. placed patient in semi-fowler’s breathing. Also, he
position and changed position was able to have
Assessment frequently; raised the bed side vital signs within
 (+) Irregular shallow rails and provided conducive the normal range
breathes through environment for rest; such as a decrease
mouth encouraged small frequent in respiratory rate
 (+) Uses accessory meals with foods that increases from 44 cpm to 26
muscle for breathing mucus excretion such as cpm, decrease
 (+) Unable to vegetables, fruits, and fish; abnormal breath
breathe in supine educated patient and guardian sounds, decrease
position on proper coughing, deep PR from 125 to 85
 (+) Audible breath breathing techniques, and bpm, decrease in
sounds within few splinting method such as the temperature from
feet use of incentive spirometer; 38.8°C to 36.7°C
 (+) bilateral coarse educated the family about the and improvement of
crackles on lower importance of vaccines; spO2 from 92% to
lobes with administered pharmacologic 100%. The client
decreased breath medication such as Salbutamol was also able to
sounds at posterior and supplemental oxygen via perform minimal but
area. nasal cannula as ordered by appropriate for his
the physician; assisted in age, deep
Vital Signs nebulization; suctioned the breathing
 RR 44 cpm nose and mouth as ordered; techniques.
 PR 125 bpm and performed chest
 T 38.8°C physiotherapy.
 SPO2 92%

#7 Critical Reasoning Questions

1. What possible COMPLICATIONS do you anticipate?

Generally, there are a lot of potential complications that is related to the

diagnosis of the client, including acute respiratory distress, pleural effusion,
pulmonary edema, sepsis, lung abscess, bacteremia, and necrotizing pneumonia
 and many more. Here are some of the possible complications and the factors
that may lead to it.

First complication could be respiratory distress syndrome (ARDS). This is

characterized by inflamed lungs caused by pneumonia, then there’s sepsis,
which causes fluid from adjacent blood vessels to seep into small air sacs,
making breathing difficult for the client. Besides, this might also aggravate the
client's respiratory condition. When the lungs become inflamed, vascular
permeability rises, allowing fluid to leak out to the vascular system and into the
small air sacs of the lungs, causing quick and severe trouble breathing or
coughing with crackles.

Also, the client could have pleural effusion as a complication wherein water
accumulates in the tissues that border the exterior of the lungs as well as inside
the chest. The presence of bacteria triggers a local inflammatory response, which
increases capillary microvascular permeability and resulting in a fast outflow of
inflammatory fluid into the pleural space.

Aside from that, the client might also experience pulmonary edema wherein
during assessment, the auscultation indicates bilateral coarse crackles on the
lower lobes and reduced breath sounds in the posterior region, indicating the
existence of fluid within the client's lung caused by community acquired
pneumonia. Fluid accumulation in the alveoli can exacerbate the retention of
water in the lungs, resulting in pulmonary edema.

2. What ASSESSMENT do you need to identify and respond to if this complication

develops?

In relation to general assessment and management for the mention

complications, the following are the appropriate assessment and nursing
interventions: assess the patient for weight changes, monitor the patient's blood
and laboratory findings, and look for symptoms of the client's infection if it's
getting worse. Monitoring vital signs, particularly respirations, and preparing for
probable airway trouble are also essential. Perform further physical tests, such
as auscultating the client's breath sounds and fremitus if they are decreased.

Also, ask the client whether he feels severe pain in his chest with deep inhaling
(pleuritic chest discomfort), and if percussion is (+) dull, this may suggest fluid in
the pleural area. Tracheal deviation can occur, therefore palpate the sternal
notch and note if the trachea is displaced to one side or in the midline. Chest X-
ray, CT-scan, and Thoracentesis can be used as diagnostic procedures to drain
 and see fluid collection in the pleural space. If bacteremia is suspected, blood
culture can be performed.

The nursing management that can be done are chest physiotherapy: vibration,
percussion, and postural drainage can be used in conjunction with frequent
rotating; maintain the patient's temperature and ensure that the client's
surroundings are clean and safe; pain management strategies such as deep
breathing exercises, guided visualization, administer the prescribed medications
on schedule and keep an eye out for any adverse reactions, and pain medicines
as prescribed. In the worst-case scenario, if the client's oxygen saturation is
dropping, supportive treatment, such as mechanical ventilation and intubation
can be offered.

3. Determine the applicable nursing theory for the implementation of care.

For me, the most applicable nursing theory that is also the most appropriate for
my client would be implementing the theory of Florence Nightingale which is the
Environmental theory. This theory is primarily based on five principles that she
considered were necessary for obtaining a healthy environment, such as fresh
air, pure water, basic sanitation, cleanliness, and light or direct sunlight, since
she believed that an optimal environment was needed for healing.

Besides, the Environmental Theory of Florence Nightingale is critically important

for ensuring the provision of healthcare to this type of patient. In fact, the
presence of secondhand smoking and other pollutants in the client's
surroundings is one of the key contributing factors to the client's community
acquired pneumonia. The presence of bacteria is the primary contributor of this
sort of diseases, which may lead to serious cases of different infection-related
diseases, which can also be prevented by maintaining cleanliness in the
surroundings.

ETHICO-MORAL RESPONSIBILITY
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?
Primarily, in this case, autonomy should be the most respected ethical principle.
However, autonomy refers to the right of capable individuals to make informed
medical care decisions. The patient has the right to refuse the vaccine or his
mother as a legal guardian because the client is not yet on his legal age, but it is
the nurse's responsibility to correct any misinformation about the vaccine. Health
education should be provided because it provides the mother with the necessary
information to make an informed decision about her child's health.
Chiefly, mothers are generally anxious about vaccines, especially for their
children. They may not be provided correct information because there has been
a lot of fake news that are spread in different social media sites. As a part of our
responsibilities, a trusting relationship is needed in order for the mother to feel
secure and share her worries openly. In lieu to that, the mother should be
educated about the benefits of the pneumococcal vaccination, such as its
capacity to prevent potentially deadly pneumococcal infections. There’s a need to
include the knowledge that delaying or failing to vaccinate children is particularly
risky since other illnesses, such as measles, continue to be widespread. Also
explain that there is no relationship between immunizations and autism, which is
primarily caused by genetic mutations or other environmental circumstances. The
advantages of taking the vaccination exceed the dangers; such as having minor
side effects that include redness, swelling, or soreness where the injection was
delivered, fever or chills. Critically, there is a need to educate the patient's family
members so that they are aware of what are the vaccinations and could be able
to participate in the patient's treatment. This also aids in the spread of accurate
information that can make a big impact in the patient's life.
One of our important characteristics that we need to bring with us as a nurse is
being an advocate for our patient's well-being and autonomy, that makes it
critical as the patient's family and health care providers have a thorough
awareness of its demands, particularly in terms of health. And so, to be able to
oppose the mother's vaccine hesitancy for her child, the nurse's ethical and
moral responsibility is also to demonstrate veracity, which is to provide the
mother with factual information about the said vaccine. The nurse should also
allow the mother to express her understanding about the said immunization and
provide insight into her concerns for her child. Soothe the mother so that she
may express her specific concern about the immunization and her child's general
status. This application is known as beneficence in the Ethico-Moral
Responsibility of the Nurse, and it involves the nurse delving further into the
mother's concerns and ensuring that the nurse is concerned about the patient's
health and recovery, which may create collaboration and especially build rapport
with the mother.