Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

Comprehensive Clinical Case Analysis

Chapter I: Assessment
A. Nursing Health History

 Personal Data:
NAME: Bon, Luigi Matteo
AGE: 2 months
ADDRESS: Buhi, Camarines Sur

 Chief Complaint:
COUGH for 2 days
FEVER for 1 day
Vomiting x1 for 1 day

B. Physical Examination (Head to Toe)

GENERAL APPERANCE Lethargic and irritable.

HEAD Fontanels are normal, no signs of distress

EYES Protruding eyes, clear and no discharge or signs of infection

EARS - NO discharge or redness noted

NOSE Nasal congestion, nasal flaring

MOUTH AND THROAT Moist mucus membranes, cough observed

NECK NO lymphadenopathy noted

CHEST AND LUNGS Increased respiratory rate, chest retraction

HEART Tachycardia, no murmurs or abnormal sounds

ABDOMEN No distended, normal shape and bowel sounds, soft and non- tender

EXTREMITIES Normal, no signs of edema and no signs of peripheral cyanotic

 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

SKIN Warm to touch, no rashes and lesions noted

C. DEFINITION AND DESCRIPTION OF DISASE

Pneumonia is an infection that causes inflammation in the air sacs of one or both
lungs. It can be caused by bacteria, viruses, or fungi. Common symptoms include cough, fever,
chills, difficulty breathing, and chest pain. Treatment typically involves antibiotics for bacterial
pneumonia, rest, and supportive care such as pain relief and hydration. In severe cases,
hospitalization may be necessary, especially for infants, the elderly, or individuals with weakened
immune systems. It's important to seek medical attention if you're experiencing difficulty
breathing, especially if it's severe or persistent, as it could be a sign of a serious underlying
condition

D. Anatomy and Physiology (only the organ or system involve with drawing)

1. Lungs:
Pneumonia directly affects the lungs, causing inflammation of the
air sacs and leading to difficulty breathing.

2. Respiratory Airways:
The airways, including the bronchi and bronchioles, can
become inflamed and obstructed, contributing to respiratory distress.

3. Heart:
Increased respiratory effort and decreased oxygen levels can strain
the heart, leading to an increased heart rate or other cardiovascular
complications.
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

4. Brain:
Lack of oxygen due to respiratory distress can impact the brain,
potentially leading to neurological symptoms.

5. Kidneys:
Pneumonia and respiratory distress can affect
kidney function due to decreased oxygen delivery and the
body's response to infection.

6. Liver:
In severe cases or with certain infections, the liver
may be affected due to the systemic response to
inflammation and infection.

7. Blood: Pneumonia can lead to sepsis, a severe bloodstream

infection, affecting multiple organs throughout the body.

8. Muscles and Joints:

Increased respiratory effort and general illness can
lead to muscle fatigue and discomfort.
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

9. Gastrointestinal System:
Illness and decreased oxygenation
may impact feeding tolerance and digestive function.

10. Skin:
Changes in skin color or temperature can
indicate circulatory and respiratory distress.

E. Pathophysiology of the disease

Pneumonia usually happens when a pathogen enters the lungs. Common pathogens in
babies include Streptococcus pneumoniae, Haemophilus influenzae, and respiratory syncytial
virus (RSV). When the pathogen enters the lungs, it can infect the respiratory epithelium,
resulting in inflammation. This inflammatory reaction causes the release of cytokines and
chemokines, which recruit immune cells to the infection site. In pneumonia, the infection
predominantly affects the alveoli, which are small air sacs in the lungs that allow for gas
exchange. The pathogens enter the alveolar gaps, causing damage to the alveolar epithelial
cells and compromise of the alveolar-capillary membrane. As the infection improves,
inflammatory exudate (fluid comprising white blood cells, proteins, and debris) accumulates
in the alveoli, causing consolidation. This accumulation reduces lung compliance and impairs
gas exchange. Consolidation of lung tissue reduces the surface area accessible for gas
exchange. This causes hypoxemia, in which oxygen levels in the blood drop, and the newborn
may show signs of respiratory distress such as tachypnea (rapid breathing), grunting, nose
flaring, and cyanosis (bluish skin discoloration). Pneumonia can also cause systemic
consequences by releasing inflammatory mediators into the bloodstream. These consequences
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

in babies may include fever, lethargy, poor feeding, and irritability. In extreme cases,
pneumonia can cause pleural effusion (fluid accumulation in the pleural space), empyema
(pus buildup in the pleural space), sepsis (systemic infection), respiratory failure, and even
death if not addressed.

F. Diagnostic Procedures:

Name of the Diagnostic Procedure:

URINALYSIS

Definition/Description:
Urinalysis is a diagnostic procedure commonly used to assess the physical, chemical, and
microscopic properties of urine. It involves examining the urine sample for indicators of health or disease,
including its color, clarity, pH level, presence of proteins, glucose, ketones, blood cells, and bacteria.

Specific Indicator/s:
Urinalysis procedures often include testing for specific indicators such as the presence of glucose,
which can suggest diabetes or kidney dysfunction, and the detection of blood cells, which may indicate
urinary tract infections, kidney stones, or other renal conditions. By identifying these specific indicators,
urinalysis aids in diagnosing various medical conditions and monitoring overall urinary tract health.

Nursing Responsibility:
In nursing, conducting urinalysis involves the responsibility of properly collecting, labeling, and
transporting urine samples to the laboratory for analysis, ensuring accuracy and reliability of results.
Nurses also play a crucial role in educating patients about the importance of providing a clean catch
sample, following instructions for collection, and understanding the significance of the test outcomes in
their overall healthcare management.

Name of the Diagnostic Procedure

COMPLETE BLOOD COUNT (CBC)

Definition/Description
A Complete Blood Count (CBC) is a common blood test that provides important information
about the cellular components of the blood, including red blood cells, white blood cells, and platelets.
This comprehensive diagnostic procedure helps healthcare providers assess overall health, diagnose
various medical conditions such as anemia, infections, and blood disorders, and monitor responses to
treatments.

Specific Indicator/s:
CBC procedures typically include analyzing specific indicators such as hemoglobin and
hematocrit levels, which assess the oxygen-carrying capacity of the blood and the volume of red blood
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

cells, respectively. Additionally, CBCs measure the white blood cell count, aiding in the detection of
infections, inflammatory conditions, or immune system disorders.

Nursing Responsibility:
In nursing, performing CBC procedures involves ensuring proper venipuncture technique to
obtain blood samples and accurately labeling specimens for analysis. Nurses also play a critical role in
educating patients about the purpose of the CBC, potential discomfort during blood collection, and any
necessary preparations, contributing to patient understanding and cooperation during the procedure.

Name of the Diagnostic Procedure:

X-RAY

Definition/Description:
X-ray procedures involve the use of electromagnetic radiation to create images of the internal
structures of the body, including bones, organs, and tissues. These images, captured on film or digitally,
provide valuable diagnostic information to healthcare providers, aiding in the identification of fractures,
abnormalities, and diseases within the body.

Specific Indicator/s:
X-ray procedures often focus on specific indicators such as bone density and structure, revealing
fractures, dislocations, or signs of osteoporosis. Additionally, X-rays can detect abnormalities in soft
tissues or organs, such as lung infections or intestinal blockages, helping clinicians diagnose and treat
various medical conditions effectively

Nursing Responsibility:
In nursing, overseeing X-ray procedures involves preparing patients for the examination, ensuring
they understand safety protocols and positioning requirements. Nurses also play a crucial role in
monitoring patient comfort during the procedure, assisting with positioning adjustments as needed, and
communicating effectively with radiology staff to facilitate a smooth and efficient process.

Name of the Diagnostic Procedure:

ELECTROCARDIOGRAM (ECG)

Definition/Description:
An Electrocardiogram (ECG) procedure involves recording the electrical activity of the heart over
a period of time using electrodes placed on the skin. This diagnostic test provides valuable information
about the heart's rhythm, rate, and any abnormalities, aiding in the diagnosis of various cardiac conditions
such as arrhythmias, heart attacks, and other cardiovascular diseases.

Specific Indicator/s:
During an ECG procedure, specific indicators such as the presence of P waves, QRS complexes,
and T waves are analyzed to assess the heart's electrical activity. Abnormalities in these indicators can
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

indicate conditions like atrial fibrillation, ventricular hypertrophy, or myocardial infarction, aiding
healthcare providers in diagnosing and managing cardiac disorders effectively.

Nursing Responsibility:
In nursing, overseeing an ECG procedure involves preparing the patient by explaining the
process, ensuring they are comfortable, and positioning them correctly for electrode placement. Nurses
also monitor the ECG tracing during the procedure, recognizing and reporting any abnormalities promptly,
and providing support and reassurance to the patient throughout the test.

Chapter II: PLANNING

NURSING CARE PLAN:

ASSESSEMTN NURSING GOAL/ NURSING RATIONALE EXPECTED OUTCOME/

OR CUES DIAGNOSIS OBJECTIVE INTERVENTI EVALUATION
ONS

SUBJECTIVE: Ineffective LONG

Airway
TERM Dependent: -Oxygen > Assess the baby's
> Experienced Clearance
cough for 2 1. Improve Administered therapy helps respiratory status
related to
days; Fever for 1
excessive respiratory oxygen improve regularly, including
day; Vomiting
x1 for 1 day. mucus function and therapy as oxygenation oxygen saturation,
production
gas exchange. prescribed by and alleviate respiratory rate, and
OBJECTIVE: and the respiratory breath sounds.
inflammation 2.Prevent
>Productive complications healthcare distress.
as evidenced >Monitor for
cough
by such as provider.
> Initial VS
adventitious
improvements in gas
RR: 48 respiratory Independent: exchange, such as
PR: 186 lung sounds
and cough.
failure and Encourage -Adequate decreased respiratory
O2Sat: 99
Temp: 36.2 sepsis. breastfeeding nutrition and distress and improved
3.Promote or offer hydration oxygen saturation.
adequate small, support the
nutrition and frequent body's immune - Evaluate feeding
hydration. feedings of response and tolerance and hydration
4. Enhance formula to promote status.
caregiver maintain recovery.
knowledge - Adjust the plan of care
adequate
and as needed based on the
nutrition and
confidence in baby's response to
hydration.
managing the interventions.
baby's
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

condition.

SHORT Independent: -Upright

Position the positioning
TERM:
baby upright facilitates lung
or in a semi- expansion and
1. Promote
Fowler's improves
effective
position to ventilation-
airway
facilitate perfusion
clearance.
breathing matching.
and lung
expansion.

Collaborative:
Collaborate -Chest
with physiotherapy
respiratory and suctioning
therapy for help clear
chest secretions and
physiotherapy maintain
and airway
suctioning as patency.
needed.

Chapter III: Implementation

A. Medical Management
For pneumonia in an infant involves initiating prompt antibiotic therapy, often with
ampicillin or amoxicillin plus gentamicin, to target likely causative pathogens and prevent
complications. Supportive care is paramount and includes ensuring hydration, nutrition, and
comfort measures, while infants with respiratory distress may require supplemental oxygen to
maintain adequate oxygen saturation levels. Close monitoring of vital signs, respiratory status,
and fluid balance guides treatment adjustments, with consideration for respiratory support or
chest tube drainage in severe cases. Collaboration with caregivers for education and support is
integral to optimizing outcomes, emphasizing early recognition, prompt intervention, and
comprehensive management to reduce morbidity and mortality associated with infant pneumonia.
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

B. Surgical Management (if any)

N/A

C. Nursing Management ( general intervention related to disease process)

•Monitor vital signs, including respiratory rate, heart rate, temperature, and SpO2 levels •Assess
hydration status and provide fluids if needed.

•Provide supplemental oxygen when necessary.

•Measure oxygen saturation using pulse oximetry regularly.

•Initiate supplemental oxygen when oxygen saturations fall below 90%.

•Titrate oxygen delivery to keep oxygen saturations between 92% and 95%, unless
contraindicated by other factors.

•Administer antibiotics targeting common causative agents like Streptococcus pneumoniae,

Haemophilus influenzae, Moraxella catarrhalis, and Mycoplasma pneumoniae.

•Prevent complications by ensuring proper positioning, suctioning, and pain relief as needed

•Support the patient's recovery through rest, nutrition, and emotional support

•Educate parents about the disease process, prognosis, and treatment plan

•Perform ongoing nursing assessments to monitor progress and identify any changes that could
indicate worsening condition or complications

•Ensure timely follow-up appointments after discharge from the hospital. Administer 20mg of
Cefexime Tergecef twice daily to target common causative agents such as pneumoniae.
Administer 15mg of Ambroxol twice daily or Provide mucolytic therapy to help with mucus
clearance as needed for additional mucolytic effect and cough relief.
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

Administer intravenous therapy of 200mg of Cetriazome mixed with 90ml of normal saline
solution (PNSS) to run over 1 hour once daily. ensuring proper aseptic technique and
monitoring for adverse reactions. Meropenem 35mg +HO 90ml PNSS via Soluset:
Administer 35mg of Meropenem mixed with 90ml of PNSS via Soluset infusion. This broad-
spectrum antibiotic targets severe infections, including those caused by multidrug-resistant
organisms. Perform nebulization with a combination of Salbutamol and Ipratropium,
diluted in half a nebule with distilled water, three times a day to relieve bronchospasm and
improve airflow. - Monitor the pt. for any adverse side effects related to any medication;
document vital signs and symptoms - Educate on completing full medication course for best
results and prevention of recurrence

1. Drug Study

Date Brand Generic Frequency/mode/ Mechanism Adverse Nursing

Name/ Name route of of Action Reaction/ Responsibility
Trade administration Effects
Name

2. Treatment (IVF, BT, etc.)

Date Name Frequency/mode/ Regulation Expected Nursing
route of administration outcome Responsibilities

3. Diet
Date Kind of Route of Administration Frequency Nursing Responsibilities
Diet

(ngt, oral, parenteral) (How many

times a day)

4. Activity/Exercises
Date Definition Specific Date Date Clients’ Nursing
indication Ordered performed/Given reaction Responsibilities
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

Chapter IV: Evaluation

A. Discharge planning instruction (hypothetical if patient is still admitted and consult references)
M- Medication
-Ensure that the baby's caregiver understands the prescribed medications,
including dosage, frequency, and administration route.
- Provide written instructions and demonstrate proper administration techniques
if necessary.
- Emphasize the importance of completing the full course of antibiotics as
prescribed.

E - exercise
-Encourage gentle activities such as tummy time and supervised play to promote
lung expansion and respiratory function.
- Advise against strenuous activities that may cause fatigue or strain on the
respiratory system.

T - treatment
- Review any ongoing treatments or therapies prescribed by the healthcare
provider, such as oxygen therapy or chest physiotherapy.
- Instruct the caregiver on how to monitor the baby's response to treatment and
when to seek medical attention if symptoms worsen or new symptoms develop.

H - health teachings
- Provide education on signs and symptoms of pneumonia recurrence or
complications, such as persistent fever, increased respiratory distress, or worsening cough.
- Teach caregivers about preventive measures to reduce the risk of pneumonia,
including hand hygiene, vaccination, and avoiding exposure to smoke or air pollutants.
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

O - out patient department( schedule to come back)

- Schedule a follow-up appointment with the healthcare provider to monitor the
baby's recovery and assess for any lingering symptoms or complications.
- Provide information on how to contact the outpatient department and arrange
transportation if needed.
D - diet
- Discuss the importance of adequate nutrition and hydration for the baby's
recovery.
- Encourage breastfeeding if applicable, as breast milk provides antibodies and
nutrients that support the immune system.
- Provide guidance on appropriate feeding practices and offer resources for
breastfeeding support if needed.

S - spiritual counseling
- Acknowledge the emotional stress and anxiety that may accompany a baby's
illness, and offer support and reassurance to the caregivers.
- Offer spiritual counseling or connect the family with appropriate resources or
support groups if desired. It's important to tailor the discharge instructions to the
individual needs of the baby and their caregivers, taking into account any specific
medical conditions, cultural considerations, or social factors.
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

Prepared by: BSN 2G - GROUP 3

MEMBERS:

1. Abala, John Paul

2. Arbaja, Gina
3. Bilolo, Chrishea
4. Breboneria, Suzette
5. Deunida, Noemi Carmela Angel
6. Inson, Serge Anthony
7. Miranda, Rinnah
8. Noblefranca, Graciel Ann Pearl
9. Plotado, Nicole Anne
10. Sabularse, John Carlo