PINES CITY COLLEGES

COLLEGE OF NURSING

CASE ANALYSIS- PEDIATRICS

(NCM 104 & 107 RLE)
1 Semester, A.Y. 2021-2022
ST

GROUP 4:
PONADON, PAUL KHYLE
ANSIBEY, FELIZE
CALIXTO, CORNELYN
DEPPAS, MARLA
GUDAREN, SARAHLYN
MONTERO, STEPHANIE
ORATE, JUMIA PAULEINE
RAMIREZ, SHIRLENE
SOTERO, LJ KLEINE

SECTION 1

OCTOBER 15, 2021

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1. PROFILE OF THE PATIENT

NAME: Chang Sheng Chen AGE: 27 months old SEX: Male

Patient presented with a history breathing difficulty, cough and fever for two days. His physical examination
revealed the past case history of grunting, very severe chest wall indrawing and hypoxemia (SpO2 (peripheral
capillary oxygen saturation) 82% without O2) and head nodding.
He was clinically diagnosed with PCAP-B. On admission, his temperature was 38.4 °C, RR 74 breaths/min,
PR 176 beats/min, and SpO2 was 82% without O2. Patient was dyspneic and irritated. On Auscultation,
crepitation was present in both lung fields (right upper zone and left lower zone) and rhonchi was present on
upper and middle side of left lung field. He was admitted in the Pediatric Ward- BPN ROOM and treated as a
PCAP-C patient immediately under the care of Dr. Judith So.
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2. PATHOPHYSIOLOGY of PCAP
 Additional findings in
pediatric pneumonia may
EXPOSURE TO PATHOGEN: include nausea, otitis,
headache
Inhalation, hematogenous, direct, aspiration
 Viral pathogens most
common in children.
SUSCEPTIBLE HOST AND/OR <2yrs; bacterial pathogens
VIRULENT PATHOGEN most common in children
>2yrs
 Interstitial pattern: suspect
Infection and proliferation of pathogen in Mycoplasma pneumoniae,
lower respiratory tract/ parenchyma
Influenza A + B,
Parainfluenza
PCAP  Lobar pattern: suspect S.
pneumonia, H. influenzae,
(Pediatric Community Moraxella, S. aureus
Acquired Pneumonia)

Local Inflammatory Response: Systemic Inflammatory Response:

neutrophils recruited to site of infection Cytokine Release
(LOBAR or INTERSTITIAL PATTERN,
depending on pathogen) by epithelial cytokine
release Respiratory Disruption of
drive hypothalamic
thermoregulation
Irritation of contiguous Accumulation of plasma exudate
structures and/or referred (from capillary leakage at sites of Tachypnea
pain. (mechanism inflammation), cell-debris, serous Fever/
unclear) fluid, bacteria, fibrin Chills

Irritation of Fluid buildup in efficiency of gas exchange

spaces between Fluid buildup in (↑ diffusion distance in
airways and alveoli (LOBAR
Acute failure of ciliary alveoli INTERSTITIAL, surface
(INTERSTITIAL PATTERN) area in LOBAR)
abdominal pain clearance to
keep up with PATTERN)
fluid buildup
Interstitial Hypoxemia
opacity on Lobar
Cough CXR Consolidation
oon CXR
Crackles, low
breath sounds
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3. NURSING DIAGNOSIS & PRIORITIZATION

CLASSIFICATION OF IDENTIFIED NURSING PROBLEMS
Nursing Problems Actual Problem Potential Problem
Ineffective Airway clearance r/t presence of retained secretions

in the tracheobronchial tree
Impaired Gas exchange r/t Altered oxygen-carrying capacity of

blood
Ineffective Breathing Pattern r/t very severe chest wall

Indrawing and hypoxemia
Hyperthermia 
Risk for Deficient Fluid Volume 

PRIORITIZATION
Rank Nursing Problems Justification
1 Impaired Gas This problem is prioritized first because based on Maslow’s hierarchy
exchange r/t Altered of needs, air or oxygenation is a physiologic need and also based on
oxygen-carrying the ABC principle, airway is the primary area that needs to be
capacity of blood addressed in the patient because deficit in oxygenation and/or problem
in elimination of carbon dioxide due to pneumonia could affect the
distribution of oxygen to the different tissues and could also alter cell
metabolism.

Ineffective airway clearance, with lung secretions as another

Ineffective Airway characteristic of pneumonia, goes hand in hand with Impaired gas
clearance r/t presence exchange, also being an airway problem. Although the patient is able
of retained secretions to cough, it is not effective because she only coughs and not able to
in the tracheobronchial expectorate secretions in the lungs. This alters airway patency causing
tree alteration in the exchange of oxygen and carbon dioxide in the alveoli.
2 Ineffective Breathing Ineffective Breathing Pattern, goes hand in hand with Impaired Gas
Pattern r/t very severe exchange, also being an airway problem. This demands immediate
chest wall treatment/care and subsequent medical attention, as they can result to
Indrawing and a more serious complication. This also needs attention as based on the
hypoxemia rule of ABC which is Airway, Breathing and Circulation. This is an
actual problem that needs to be addressed.

3 Hyperthermia
4 Risk for Deficient
Fluid Volume
This is next priority because the increase in the body temperature is
just in response to the illness experienced by the body. However,
many complications may arise if it is left untreated. Hyperthermia
may result to fluid loss, hemodynamic alterations, serum enzyme
abnormalities and other symptoms of variable severity. It can also
cause neurologic symptoms including nausea, confusion,
disorientation, apathy, delirium, stupor or coma
This problem is related to hyperthermia wherein the fever of the
patient may result to fluid loss which leads to Deficient Fluid Volume
if left untreated.
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4. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE Impaired gas Short term 1. Note respiratory rate, This provides insight After 8 hours of
DATA: exchange objectives: depth, use of accessory into the work of nursing
related to muscles, pursed-lip breathing and intervention
-Difficulty in
altered oxygen breathing; areas of adequacy of alveolar
breathing
carrying After 8 hours pallor/cyanosis, such as ventilation. Tachypnea
-cough and fever capacity of of nursing peripheral (nailbeds) is usually present to Goal was fully
for 2 days blood. intervention: versus central some degree during met
(circumoral) or general illness (especially with
duskiness. fever or upper -If the patient
respiratory infections), will
- The patient
but if tachypnea is demonstrate
will
OBJECTIVE accompanied by use of improved
demonstrate
DATA: Day of accessory muscles of ventilation and
improved
Admission inspiration (e.g., adequate
ventilation
(6am) external intercostals), oxygenation
and adequate
the client may have evidence by
- Temp=39.4ºC oxygenation
insufficient muscle normal blood
of tissues by
- RR=74 strength to sustain the oxygen
ABGs within
breath/min - work of breathing. saturation.
usual
PR= 176 parameters
beats/min - and absence 2. Auscultate breath - Mother will
SpO2=82% of symptoms 2. Abnormal breath
sounds, note areas of verbalize
without O2 of respiratory sounds are indicative
decreased/ adventitious understanding of
distress. of numerous problems
- dyspneic and breath sounds as well causative factors
and must be evaluated
irritated as fremitus. and appropriate
for further
- crepitation was intervention. interventions.
- The mother
present in both will verbalize
lung fields understandin
g of causative 3. Assess level of 3. A decreased level of
- Ronchi was
factors and consciousness and consciousness can be
present on upper
appropriate mentation changes. an indirect
and middle side
interventions. measurement of - Goal unmet if
of left lung
impaired oxygenation, the child cannot
fields.
but it also impairs expectorate
one’s ability to protect phlegm by
the airway, potentially coughing.
Day of Receive - The child further adversely
(7am) will affecting oxygenation.
- fast breathing successfully
excrete
- tachycardia phlegm 4. Imaging can often
through 4. Review chest x - provide information
- chest wall
effective rays. about the etiology of
indrawing
coughing. the impaired gas
- not able to exchange and monitor
expectorate a trend of the disease
phlegm process
-crepitation was
present in both 5. Check Hemoglobin
lung fields (Hbg) levels 5. Hemoglobin carries
oxygen within the
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- Ronchi was blood. If Hbg levels
present on upper are low, there is a
and middle side decreased capacity to
of left lung carry oxygen to the
tissues.
- Temp=36.8°C,
-RR=44 6. Maintain bedrest by
breaths/min - planning activity and 6. It prevents over
SpO2=97% with rest period to minimize exhaustion and
O2 energy use. Encourage reduces oxygen
the use of relaxation demands to facilitate
- PR= 157
techniques and the resolution of
beats/min
diversional activities. infection. Relaxation
techniques hep
conserve energy that
At 10:00 AM can be used for
-Temp= 36.2° C effective breathing and
coughing efforts.
-
RR=50breaths/
min - SpO2= 7. Elevate the head of 7. Elevation or upright
95% with O2 the bed and position the position facilitates
client appropriately. respiratory function by
- PR= 136
beats/min gravity; however, a
client in severe
distress will seek a
position of comfort.
At 12:00 NN
Temp= 36.3° C
8. Impaired small
RR= 62 8. Encourage the airways experience
breaths/min patient to cough to impaired gas exchange
expectorate thick primarily due to thick,
SpO2= 98%
sputum. Suction as tenacious mucoid
with O2 PR=
needed secretions.
132 beats/min.

At 2:00 PM 9. All vital signs are

9. Monitor vital signs impacted by changes
-Temp= 36.5° C in saturation.
and cardiac rhythm.
RR=
40breaths/min
10. To determine
PR =134 oxygenation and levels
beats/min 10. Evaluate pulse of carbon dioxide
SpO2= 99% oximetry, capnography, retention and to assess
with O2 lung volumes and lung mechanics,
forced vital capacity. capacities and
function.

Assessment Diagnosis Planning Implementation Rationale Evaluation

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S> Ineffective >Patient will 1. Assess the rate, 1. Tachypnea, shallow After 8 hours of
Airway identify/dem rhythm, and depth of respirations and nursing
- difficulty in
clearance onstrate respiration, chest asymmetric chest intervention
breathing
related to behaviors to movement, and use of movement are
Goal was fully
-cough and fever presence of achieve accessory muscles. frequently present
met
for 2 days. retained airway because of the
secretions in clearance. discomfort of moving > patient was
O> the chest wall and/or fluid able to
>Patient will
Day of tracheobronch in the lung due to a demonstrate
display/maint
Admission ial tree compensatory behaviors
ain patent
response to airway achieving airway
(6AM) airway with
obstruction. Altered clearance.
breath sounds
breathing patterns may
Temp.= 39.4oC clearing; > Chang Sheng
occur together with
absence of Chen maintained
RR= 74 accessory muscles to
dyspnea, patent airway
breath/min. increase chest
cyanosis, as with breath
excursion to facilitate
PR= 176 beats/ evidenced by sounds clearing;
effective breathing.
min keeping a absence of
patent airway dyspnea,
SpO2=82% and 2. Assess cough cyanosis, as
without O2 2. Coughing is the
effectively effectiveness and evidenced by
most effective way to
-dyspneic and clearing productivity keeping a patent
remove secretions.
irritated secretions. airway and
Pneumonia may cause
effectively
-crepitation was thick and tenacious
clearing
present in both secretions in patients.
secretions.
lung fields
-Ronchi was 3. Auscultate lung 3. Decreased airflow
present on upper fields, noting areas of occurs in areas with
and middle side decreased or absent consolidated fluid.
of left lung airflow and Bronchial breath
fields. adventitious breath sounds can also occur
sounds: crackles, in these consolidated
Day received
wheezes. areas. Crackles,
(7 AM) rhonchi, and wheezes
are heard on
-Temp.= 36.8oC
inspiration and/or
RR= 44 expiration due to fluid
breath/min. accumulation, thick
secretions, and airway
PR= 157 beats/ spasms and
min obstruction.
SpO2=97% with
O2
4. Observe the sputum 4. Changes in sputum
- fast breathing color, viscosity, and characteristics may
odor. Report changes. indicate infection.
- tachycardia
Sputum that is
- chest wall discolored, tenacious,
indrawing or has an odor may
- not able to increase airway
expectorate resistance and warrant
phlegm
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- crepitation was further intervention.
present in both
5. Airway clearance is
lung fields
hindered with
5. Assess the patient’s
- Ronchi was inadequate hydration
hydration status.
present on upper and thickening of
and middle side secretions.
of left lung

6. Doing so would
At 10:00 AM lower the diaphragm
6. Elevate the head of and promote chest
Temp.= 36.2oC the bed, change expansion, aeration of
position frequently. lung segments,
RR= 62
breath/min. mobilization, and
expectoration of
PR= 132 beats/ secretions.
min
SpO2=98% with
O2 7. These measures are
needed to correct the
7. Anticipate the need
hypoxemia. Intubation
for supplemental
At 12:00 NN is needed for deep
oxygen or intubation if
suctioning efforts and
the patient’s condition
Temp.= 36.3oC provides a source for
deteriorates.
augmenting
RR= 62
oxygenation.
breath/min.
PR= 132 beats/
min 8. Stimulates cough or
mechanically clears
SpO2=98% with 8. Suction as indicated: airway in a patient
O2 frequent coughing, who cannot do so
adventitious breath because of ineffective
sounds, desaturation cough or decreased
At 2:00 PM related to airway level of consciousness.
secretions. Note: Suctioning can
Temp.= 36.5oC
cause increased
RR= 40 hypoxemia; hyper
breath/min. oxygenate before,
during, and after
PR= 134 beats/
suctioning.
min
SpO2=99% with
O2 9. Fluids help maintain
9. Maintain adequate hydration and
hydration by forcing increases ciliary action
fluids. to remove secretions,
and reduces the
viscosity of secretions.
Thinner secretions are
easier to cough out.

10. Nebulizers
10. Assist and monitor humidify the airway to
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effects of nebulizer
treatment and another
respiratory
physiotherapy:
incentive spirometer,
IPPB, percussion,
postural drainage.
Perform treatments
between meals and
limit fluids when
appropriate.
thin secretions and
facilitates liquefaction
and expectoration of
secretions.
> Postural drainage
may not be as
effective in interstitial
pneumonias or those
causing alveolar
exudate or destruction.
> Incentive spirometry
serves to improve deep
breathing and helps
prevent atelectasis.
>Chest percussion
helps loosen and
mobilize secretions in
smaller airways that
cannot be removed by
coughing or
suctioning.

5. DRUG STUDY
Doctor’s Order/ Mode of Action Indication Contra- Adverse Nursing
Generic Name/ indication Effects Responsibilities
Classification
A. Doctor’s Order: Normal saline solution Replace -Heart failure Irritation or BEFORE:
 PNSS 1L X 8 has an osmolality of 308 Extracellular -Pulmonary swelling *Obtain history
hours now! (at mOsm/L. Because the Fluid edema where the shot of the patient’s
right arm) osmolality is entirely -Renal was given. fluid and
contributed by Hyponatremia impairment electrolyte status
B. Generic Name: electrolytes, the solution -Sodium Pain where the before therapy
 PNSS remains within the ECF, Hypochloremia retention shot was and reassess
does not cause red blood given. regularly.
C. Classification: cells to shrink or swell. Water overload *Before giving
 Isotonic Isotonic fluids expand the the bottle,check
ECF volume. Mild metabolic for the correct
acidocis patient to be
administer ed.
Medication *Check for the
diluent correct fluid to be
given
IV irrigant
DURING:
Compatible with *Upon inserting
blood the chamber to
another, make
sure that it is
inserted well.
*Be alert of fluid
overload
*Check for the
patients comfort
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AFTER:
*Infuse the IV
well to its
prescribed rate
*Check for the
presence of
bubbles in the IV
tube
*Evaluate
patient’s
knowledge of
therapy

Doctor’s Order/ Mode of Action Indication Contra- Adverse Nursing

Generic Name/ indication Effects Responsibilities
Classification
A. Doctor’s Order: Oxygen therapy increases Oxygen therapy Oxygen Drying effect Monitor oxygen
 Oxygen the arterial pressure of in clinical treatment is on the nasal concentration
Inhalation: oxygen and is effective in settings is used contraindicat passages; skin hourly.
2L/min - NOW improving gas exchange across diverse ed in all irritation, skin Check frequently
and maintain on and oxygen delivery to specialties, patients with breakdown for loose
02 via ped. tissues, provided that including unfavorable and nasal connections in
mask there are functional various types of ventilation dryness. the circuit.
alveolar units. Oxygen anoxia, hypoxia response to Ensure position
B. Generic name: plays a critical role as an or dyspnea and oxygen of oxygen
 Oxygen electron acceptor during any other treatment. analyzer sensor is
oxidative phosphorylation disease states close to infant’s
C. Classification: in the electron transport and conditions nose and not in
 Medical gasses chain through activation that reduce the mainstream of
of cytochrome c oxidase efficiency of gas the oxygen hose.
(terminal enzyme of the exchange and Maintain the
electron transport chain). oxygen infants head
This process achieves consumption inside the
successful aerobic such as headbox.
respiration in organisms respiratory Fill humidifier to
to generate ATP illnesses, appropriate level
molecules as an energy trauma, with distilled
source in many tissues. poisonings and water PRN.
Oxygen supplementation drug overdoses. Maintain inspired
acts to restore normal Oxygen therapy gas temperature.
cellular activity at the tries to achieve
mitochondrial level and hyperoxia to
reduce metabolic reduce the
acidosis. There is also extent of
evidence that oxygen may hypoxia-
interact with O2-sensitive induced tissue
voltage-gated potassium damage and
channels in glomus cells malfunction.
and cause
hyperpolarization of
mitochondrial membrane.

Doctor’s order / Generic Mode of Action Indication Contra- Adverse Nursing

Name / Classification indication Effects Responsibilities

A. Doctor’s Order: Salbutamol is a Salbutamol Salbutamol CNS: Check and verify

selective β2- Nebulizer sulfate is Restlessness, with doctor’s
 SALBUTAMOL neb 1 agonist providing Solution is contraindicated in apprehension, order and
amp every 6 hours
short-acting (4-6 indicated for patients with anxiety, fear, Kardex.
B. Generic Name:
hour) use in the hypersensitivity CNS
Observe rights in
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  SALBUTAMOL bronchodilation routine (allergy) to any stimulation, medication
with a fast onset management of the active vertigo, administration
C. Classification: (within 5 of chronic substances or the headache, such as giving the
 BRONCHODILATOR minutes) in bronchospasm excipients weakness, right drug to the
reversible airways unresponsive (Sodium tremors, right patient
obstruction. At to chloride, drowsiness, using the right
therapeutic doses conventional insomnia, route and at the
Water for
it acts on the β2- therapy and hyperactivity, right time.
injections,
adrenoceptors of the treatment malaise
Monitor ECG,
bronchial muscle. of acute Sulfuric acid for
CV: Cardiac serum
With its fast onset severe pH adjustment).
arrhythmias, electrolytes and
of action, it is asthma.
. palpitations, thyroid function
particularly
tachycardia, test results.
suitable for the
chest pain,
management and Administer
hypertension
prevention of accurately
attack in asthma. EENT: dry because adverse
and irritated reactions and
nose and tolerance might
throat with occur.
inhaled form,
Raise side rails
nasal
up because client
congestion,
might be restless
epistaxis,
and drowsy
hoarseness
because of this
Dermatologic drug.
: Sweating,
Keep room well-
pallor,
lit and see to it
flushing
that client has a
GI: Nausea, person with him
vomiting, closely in case of
heartburn, vertigo.
unusual or bad
Assess lung
taste in the
sounds, PR and
mouth
BP before drug
Metabolic: hy administration
pokalemia and during peak
of medication.
Musculoskele
tal: muscle Assess pulse for
cramps rhythm.
Respiratory: Provide oral care
Respiratory or let patient
difficulties, gurgle after
pulmonary inhalation to get
edema, rid of the
coughing, unpleasant
bronchospasm aftertaste of the
, paradoxical inhalation.
airway
Auscultate lungs
resistance
for presence of
with repeated,
adventitious
excessive use
breath sounds
of inhalation
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preparations, that may signal
increased pulmonary
sputum edema, airway
production, resistance or
dyspnea bronchospasm.
bronchitis
Inspect client’s
nail bed and oral
mucosa for
pallor.
 Place client in
position of
comfort to
facilitate
optimum rest and
sleep.
Client and
Family Teaching
Warn patient
about risk of
paradoxical
bronchospasm
and to stop drug
immediately if it
occurs.
Teach patent to
perform oral
inhalation
correctly. Give
the following
instructions for
using MDI:
Shake the inhaler
Clear nasal
passages and
throat
Breath out,
expelling as
much air from
lungs as possible
Place mouthpiece
well into mouth,
seal lips around
the mouthpiece,
and inhale deeply
as you release a
dose from the
inhaler. Or hold
inhaler about 1
inch (two-finger
widths) from
open mouth;
inhale while dose
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is released.
Hold breath for
several seconds,
remove
mouthpiece and
exhale slowly.
If prescriber
order more than 1
inhalation, tell
patient to wait at
least 2 minutes
before repeating
procedure.
Tell patient that
use of a spacer
device may
improve drug
delivery to lungs
If patient is also
using
corticosteroid
inhaler, instruct
him to use the
bronchodilators
first then wait
about 5 minutes
before using
corticosteroids
open air passages
for maximum
effectiveness of
the
corticosteroids
Tell patient to
remove canister
and wash inhaler
with warm, soapy
water at least
once a week
Advise patient
not to chew or
crush extended-
release tablets or
mix them with
food.
Advise patient to
seek assistance in
performing
activities of daily
living because
the risk of feeling
weak as well as
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having vertigo,
drowsiness, and
headache is
possible.
Educate client
about avoiding
stimulus that
might precipitate
vertigo such as
too much light
and too much
noise both in
forms of talking
and loud music
and television.
Instruct client to
rise slowly from
bed or when
changing
positions from
lying to sitting to
standing.
Advise client to
have small
frequent feedings
to avoid
increasing risk of
vomiting and
heartburn.
Emphasize with
the family and
the client the
importance of
wiping off sweat
to avoid easy
breakdown of
skin integrity.
Instruct client to
report
palpitations and
increasing
difficulty of
breathing.
Encourage family
to provide
opportunity for
the client to
express his or her
feelings as
apprehension and
anxiety are
common side
effects of the
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drug.
Instruct client to
increase oral
fluid intake to
facilitate drug
excretion.
Instruct client to
avoid spicy and
oily foods to
prevent risk of
developing
heartburn.
Emphasize with
the client the
importance of
gurgling after
inhalation to
prevent dry
mouth.
Extended-release
tablet should be
swallowed-
whole. It should
not be crushed or
chewed
Inform the
patient
that Albuterol ma
y cause an
unusual or bad
taste

Doctor’s order / Generic Mode of Action Indication Contraindication Adverse Nursing

Name / Classification Effects Responsibilities

A. Doctor’s Order: Paracetamol has a Paracetamol Paracetamol is Paracetamol Check that the
central analgesic is a mild contraindicated for children is patient is not
PARACETAMOL: 5 ml effect that is analgesic and for use in patients not associated taking any other
P/O q 8 hours (for fever mediated through antipyretic, with known with many medication
more than or equal to activation of and is hypersensitivity side effects containing
38° C) descending recommended or idiosyncratic and most paracetamol.
B. Generic Name: serotonergic for the reaction to children can
For children who
pathways. Debate treatment of paracetamol (or take
PARACETAMOL may refuse
exists about its most painful any of the other paracetamol to
medicine off a
primary site of and febrile ingredients in the relieve pain or
C. Classification: spoon try using a
action, which conditions, for product). reduce fever
medicine syringe
ANALGESIC and may be inhibition example, without
to squirt liquid
ANTIPYRETIC of prostaglandin headache experiencing
slowly into the
(PG) synthesis or including significant
side of the child’s
through an active migraine, side effects.
mouth or use
metabolite toothache, Rarely, side
soluble
influencing neuralgia, effects such as
paracetamol
cannabinoid colds and a rash, allergic
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receptors. influenza, reaction, drug mixed with a
sore throat, fever, low drink.
backache, levels of cells
Some children
rheumatic in the blood,
may be happy to
pain and or
take one
dysmenorrhea inflammation
paracetamol
of the liver
product but
may occur.
dislike the taste
of another.
There are no
known harmful
effects when used
during
pregnancy.
Small amounts
may pass into
breast milk.
However, there
are no known
harmful effects
when used by
breastfeeding
mothers.
Alcohol increases
the risk of liver
damage that can
occur if an
overdose of
paracetamol is
taken. The
hazards of
paracetamol
overdose are
greater in
persistent heavy
drinkers and in
people with
alcoholic liver
disease.
Evaluate
therapeutic
response.
Patient teaching
If symptoms
persist for more
than three days,
patients should
consult the
prescribing
practitioner.
Patients should
be cautioned not
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to take any other
products
containing
paracetamol and
they should read
the label of all
other medication
carefully to
ensure that it
does not contain
paracetamol.
Make sure
patients are
aware they must
not exceed the
recommended
dose.
Immediate
medical advice
should be sought
in the event of an
overdose, even if
patients feel well,
because of the
risk of delayed,
serious liver
damage.
Paracetamol for
children comes in
different
strengths. Parents
should take care
they give their
child the correct
dose.
Paracetamol can
be taken on an
empty stomach.
Do not drink
excessive
quantities of
alcohol while
taking
paracetamol.
Keep all
paracetamol well
out of the reach
of children.
Nurses should
refer to
manufacturer’s
summary of
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product
characteristics
and to
appropriate local
guidelines

Doctor’s order / Generic Mode of Action Indication Contraindication Adverse Nursing

Name / Classification Effects Responsibilities

A. Doctor’s Order Ceftriaxone Ceftriaxone is Ceftriaxone is Body Whole: Determine the

works by used for the contraindicated in Pruritus, history of
Ceftriaxone: 1gm IV inhibiting the treatment of patients with fever, chills, hypersensitivity
once daily for 5 days mucopeptide the infections known pain, reactions to
B. Generic Name: synthesis in the (respiratory, hypersensitivity induration at cephalosporin
bacterial cell skin, soft to Ceftriaxone, IM injection and penicillin and
CEFTRIAXONE wall. The beta- tissue, UTI, any of its site; phlebitis history of other
lactam moiety of ENT) caused excipients or to (IV site). allergies,
C. CLASSIFICATION:
ceftriaxone binds by susceptible any other GI: Diarrhea, particularly to
Third-generation to organisms. cephalosporin. abdominal drugs, before
Cephalosporin carboxypeptidase Organisms Patients with cramps, therapy is
antibiotics s, endopeptidases, that are previous pseudomembr initiated.
and generally hypersensitivity anous colitis,
 Lab tests:
transpeptidases in susceptible to reactions to biliary sludge.
Perform culture
the bacterial ceftriaxone penicillin and Urogenital:
and sensitivity
cytoplasmic include S. other beta lactam Genital
tests before
membrane. These pneumoniae, antibacterial pruritus;
initiation of
enzymes are S. pyogenes agents may be at moniliasis.
therapy and
involved in cell- (group A greater risk of
periodically
wall synthesis beta- hypersensitivity
during therapy.
and cell division. hemolytic to Ceftriaxone.
Dosage may be
Binding of streptococci),
started pending
ceftriaxone to coagulase-
test results.
these enzymes negative
Periodic
causes the staphylococci,
coagulation
enzyme to lose Some
studies (PT and
activity; Enterobacter
INR) should be
therefore, the spp, H.
done.
bacteria produce influenzae, N.
defective cell gonorrhoeae,  Inspect injection
walls, causing P. mirabilis, sites for
cell death. E. coli, induration and
Klebsiella inflammation.
spp, M. Rotate sites. Note
catarrhalis, B. IV injection sites
burgdorferi, for signs of
and some oral phlebitis
anaerobes. (redness,
swelling, pain).
Monitor for
manifestations of
hypersensitivity.
Report their
appearance
promptly and
discontinue drug.
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Watch for and
report signs:
petechiae,
ecchymotic areas,
epistaxis, or any
unexplained
bleeding.
Ceftriaxone
appears to alter
vitamin K-
producing gut
bacteria;
therefore,
hypoprothrombin
emic bleeding
may occur.
Check for fever if
diarrhea occurs:
Report both
promptly. The
incidence of
antibiotic-
produced
pseudomembrano
us colitis is
higher than with
most
cephalosporins.
Most vulnerable
patients:
chronically ill or
debilitated older
adult patients
undergoing
abdominal
surgery.
Patient &
Family
Education
Report any signs
of bleeding.
Report loose
stools or diarrhea
promptly.
Do not breastfeed
while taking this
drug without
consulting a
physician.

6. HOSPITAL FORMS
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MONITORING SHEET
PATIENT’S NAME: AGE SEX
Chang Sheng Chen
27 mos. Male
PHYSICIAN: HOSPITAL ROOM
DR. Judith So NUMBER
BPN

DATE / TEM PR/CR RR BP O2 URIN STOOL ADDITIONAL PARAMETERS

TIME P SAT E AS ORDERED

11/9/20 38.4 176 74 82%

6:00am
7:00am 36.8 157 44 97%
10:00am 36.2 136 50 95%
12:00nn 36.3 132 62 98% 150ml
2:00pm 36.4 134 40 99% 100ml Semi-
formed
yellowish

INTAKE AND OUTPUT SHEET

PATIENT’S NAME: HOSPITAL NUMBER
Chang Sheng Chen
INTAKE OUTPUT

DATE / KIND OF FLUID AMOUNT DATE / KIND OF FLUID AMOUNT

TIME TIME

7:00am PNSS IVF 900ml

11/9/20 10:00am water 100ml 11/9/20 12:00nn urine 150ml
7-3 12:00nn juice 150ml 7-3 2:00pm urine 100ml
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TOTAL 1150ml TOTAL 250ml

TOTAL TOTAL

TOTAL TOTAL

TOTAL FOR 24 HOURS TOTAL FOR 24 HOURS

Blood transfusion SHEET

PATIENT’S NAME: AGE SEX

HOSPITAL ROOM
NUMBER

NO. BLOOD BLOOD SERIAL NO. VOLUME & DATE & NURSE DATE & TIME NURSE ON
COMPONENT TYPE DURATION TIME ON DUTY CONSUMED/ DUTY
STARTED DISCONTINUED
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PARENTERAL FLUID SHEET

PATIENT’S NAME: Chang Sheng Chen AGE SEX

27 months old Male

HOSPITAL ROOM
NUMBER
Pediatric
Ward- BPN
Room

NO. DATE & IVF FLUID NURSE ON DUTY DATE & NURSE ON DUTY
TIME TIME
(Name & Sig.) (Name & Sig.)
STARTED ENDED

1 11/9/2020 PNSS 1L X 8 hours infusing well MD 11/9/2020 MD

on the right arm @ 900 ml
7:00 am 3:00 pm

2 3:00 pm PNSS 1L X 8 hours infusing well MD

on the right arm @ 900 ml
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MEDICATION SHEET

PATIENT’S NAME: Chang Sheng Chen AGE: SEX:

27 months old Male

HOSPITAL ROOM:
NUMBER Pediatric Ward-BPN
Room
MEDICATION / DATE 11/8-9/2020 11/9-10/2020
TREATMENT /
IMMUNIZATION /
PROCEDURE DONE
SHIF 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7
T/
TIME
Oxygen inhalation 6:00
am

Ceftriaxone 6:00
am

Salbutamol 6:00 12:00
am pm
 

Paracetamol 6:00
am

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KARDEX
PATIENT’S NAME: AGE SEX
Chang Sheng Chen 27 months old Male
HOSPITAL NUMBER ROOM
BPN
DATE SPECIAL ENDORSEMENT DATE REMARKS DATE DIET
ORDERE (Ordered Procedure, Monitoring, (Patient’s status upon
D Referrals, etc) receiving)
11/9/2020 PNSS 1 LX 8 hrs at right arm at 11/9/2020 Upon assessment, there
900 ml was age specific fast
breathing, tachycardia
and chest wall in
drawing. With cough and
colds, patient is not able
to expectorate phlegm.
On Auscultation,
crepitation was present
in both lung fields (right
upper zone and left
lower zone) and rhonchi
was present on upper and
middle side of left lung
field.
V/S: Temp. 36.8° C,
RR 44 bpm, SpO2: 97%
with O2  , PR: 157 bpm.

DATE MEDICATION / TREATMENT DATE MEDICATION / TREATMENT

ORDERE (Indicate to start, on hold,
D revised, discontinued, etc)
11/9/2020 Start Ceftriaxone: 1gm IV once
daily for 5 days
11/9/2020 Paracetamol: 5 ml P/O q 8 hours
(for fever more than or equal to 38°
C)
ORDERE (Indicate to start, on hold, revised, discontinued,
D etc)
11/9/2020 Start Salbutamol neb 1 amp every 6 hours
11/9/2020 Oxygen inhalation: 2L/min – NOW! And maintain
on O2 via ped. mask

DATE NO. INTRAVENOUS FLUID DATE NO. INTRAVENOUS FLUID (Side Drip)
ORDERE (Main Line) ORDERE
D D
11/9/2020 1 PNSS 1 LX 8 hrs

DATE NO. BLOOD TRANSFUSION

ORDERE
D
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NURSE’S NOTES
PATIENT’S NAME: Chang Sheng AGE 27 months SEX Male
Chen
HOSPITAL NUMBER 1 ROOM
Pediatric Ward- BPN
Room

DATE & FOCUS

TIME
11/9/2020 PCAP-C Admission Received patient at the Emergency Department presented
6:00 am with a history breathing difficulty, cough and fever for two
days ------------------------------------------------------------------------------SBM
D > Physical examination with: past case history of grunting,
very severe chest wall in drawing and hypoxemia (SpO2
(peripheral capillary oxygen saturation) 82% without O2) and,
head nodding clinically diagnosed with PCAP-B, with latest
vital signs of: Temp:38.4C, RR: 74bpm, PR: 176 bpm, and SpO2:
82% without O2, patient was dyspneic and irritated, --------- SBM
crepitation was present in both lung fields (right upper zone
and left lower zone), rhonchi was present on upper and
middle side of the left lung field --------------------------------------SBM
A > Vital signs taken, recorded, and monitored -----------------SBM
R > admitted in the Pediatric Ward- BPN ROOM ----------------SBM
R > treated as a PCAP-C -------------------------------------------------SBM
patient immediately under the care of Dr. Judith So ----------SBM
7:00 am Shifting R> Endorsed-------------------------------------------------------------------SBM

Stephanie B. Montero

7:00 am Airway Received patient cuddled by mother, with an ongoing IVF  of

PNSS 1L X 8 hours infusing well on the right arm @ 900 ml
D > age specific fast breathing, tachycardia, and chest wall
in drawing is present, with cough and colds, patient is not able,
to expectorate phlegm, crepitation is present in both lung
fields ronchi is present on upper and middle side of left lung
field, with latest vital signs of Temp: 36.8C, RR: 44 bpm, SpO2:
97 with O2 & PR:157 bpm ------------------------------------------------JPO
A > checked the medication and administered: ---------------JPO
Salbutamol neb- 1amp every 6 hours medication, oxygen
inhalation- 2L/min and maintain O2 via ped. mask,
Ceftriaxone- 1gm IV once daily for 5 days ------------------------JPO
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A > made a drug study of Salbutamol before giving to the
patient--------------------------------------------------------------------------JPO
A > recorded vital signs as ordered ---------------------------------JPO
A > checked the doctor’s order --------------------------------------JPO
A > computed and regulated patient IVF ------------------------JPO
A > reported any abnormal findings --------------------------------JPO
A > monitored input and output -------------------------------------JPO
A> Instructed patient to report for any untoward signs and
symptoms----------------------------------------------------------------------JPO
R> Patient understood the given instructions---------------------JPO
R > Patient has an abnormal respiratory rate and pulse rate
9:00 am Vital Sign Checking A > Vital signs taken, recorded, and monitored as ordered
as ordered R > vital sign of: Temp: 36.2° C, RR: 50 bpm, SpO2: 95% with O2
and PR: 136 bpm
R > patient has an abnormal respiratory rate and pulse rate
10:00 am Airway D > With latest vital sign of: Temp: 36.2° C, RR: 50 bpm, SpO2:
95% with O2 and PR: 136 bpm -----------------------------------------JPO
A > the mother offered water to the patient --------------------JPO
R > the patient drank around 100 ml --------------------------------JPO
R> patient has an abnormal respiratory rate and pulse rate
11:00 am Vital Sign Checking A>Vital signs taken, recorded, and monitored as ordered
as ordered R > vital signs of Temp: 36.3° C, RR: 62 bpm, SpO2: 98% with O2,
& PR: 132 bpm ---------------------------------------------------------------JPO
R > patient has an abnormal respiratory rate and pulse rate
12:00 NN Airway D > With latest vital signs of Temp: 36.3° C, RR: 62 bpm, SpO2
: 98% with O2, & PR: 132 bpm -----------------------------------------JPO
A>Vital signs taken, recorded, and monitored-------------------JPO
A>the patient drank another 150 ml of juice ---------------------JPO
after eating his favorite meal -------------------------------------------JPO
A> Monitored Input and Output --------------------------------------JPO
R> the patient urinated at around 150 ml, as estimated by the
Mother --------------------------------------------------------------------------JPO
R> patient has an abnormal respiratory rate and pulse rate
1:00 pm Administration of A> 1 amp of Salbutamol neb was given after 6 hours
Medications taken A > Vital signs taken, recorded, and monitored as ordered
every 6 hours and Vital R > vital signs of Temp: 36.5° C, RR: 40 bpm, SpO2 with O2: 99%,
signs checking as & PR: 134 bpm ----------------------------------------------------------------JPO
ordered R > patient has an abnormal respiratory rate and pulse rate
2:00 pm Airway D> With latest vital signs of Temp: 36.5° C, RR: 40 bpm, SpO2
with O2: 99%, & PR: 134 bpm --------------------------------------------JPO
A> Vital signs taken, recorded, and monitored ------------------JPO
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A> Monitored Input and Output ---------------------------------------JPO
R> The mother reported that the patient passed a semi-formed
yellowish stool and urinated again around 100 ml -------------JPO
R> patient has an abnormal respiratory rate and pulse rate
3:00 pm PNSS Replacement D> The patient’s IVF is changed to a new PNSS 1L x 8 hours
infusing well on the right arm @ 900 ml ------------------------------JPO
A > PNSS was replaced aseptically -----------------------------------JPO
A > Administered a new PNSS 1L X 8hours -------------------------JPO
R > Patient has a newly administered PNSS 1L X 8 hours as
ordered -------------------------------------------------------------------------JPO
Shifting R > Endorsed ------------------------------------------------------------------JPO

Jumia Pauleine D. Orate

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7. HEALTH TEACHING
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REFERENCES:
 https://rnspeak.com/salbutamol-drug-study/?fbclid=IwAR17JlVpi7Ph3-
CljvwnicYSiq8kM7SGi0kvmlmx4HbluAGpdnGvOyZ2iwA#:~:text=Nursing%20Responsibilities%3A
%201%20Check%20and%20verify%20with%20doctor%E2%80%99s,reactions%20and%20tolerance%20might
%20occur.%20More%20items...%20
 https://www.medicines.org.uk/emc/product/3214/smpc#EXCIPIENTS
 https://www.medicines.org.uk/emc/product/5164/smpc#:~:text=Paracetamol%20is%20a%20mild
%20analgesic,backache%2C%20rheumatic%20pain%20and%20dysmenorrhoea.
 https://go.drugbank.com/drugs/DB01212
 https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139004956
 https://rnspeak.com/ceftriaxone-drug-study/?fbclid=IwAR27juUsUzrFD1kHpQP1OQ4Dgx3F9FhV-
JueU9GwfC4nKMpJxzNddUfSZe0
 Doenges, M., Moorhouse, M., & Murr, A. (2010). Nursing care plans. F.A. Davis Company
 RNlessons. (n.d).Impaired gas exchange nursing diagnosis & care Retrieved from https://mlessons.com/impaired-
gas-exchange/plan
 RNlessons. (n.d). Ineffective breathing pattern nursing diagnosis & care plan. Retrieved from
https://rnlessons.com/ineffective-breathing-pattern nursing-diagnosis-care-plan/
 RNlessons. (n.d). Deficient fluid volume nursing diagnosis & care Retrieved https://mlessons.com/deficient-fluid-
volume/plan.
 Wayne, G. (2019). Ineffective airway clearance nursing care plan. Retrieved from
https://nurseslabs.com/ineffective-airway-clearance/