Professional Documents
Culture Documents
Institute of Nursing
Case Presentation
Submitted by:
Maningding, Marvic
Mislang, Angel Marie
BSN 122/ group 87
Submitted to:
Mr. Oliver Sanidad
I. Biographic Data
Name: S.A.G
Address: Marilao, Bulacan
Age: 6 years old
Gender: Male
Religious Affiliation: Catholic
Marital Status: single
Room & Bed no.: 214
Chief complaint: Fever
Provisional diagnosis: to consider acute
tonsilopharyngitis pneumonia
Attending physician: Dra. Alveza
II. Nursing History
A. past health history
Childhood illness:
opigesic
salbutamol tablet
penicillin G Na
Gentamicin
R.A
V.G. I.A
R.G (DM)
Son, 35
Son, 37
(asthma)
Daught
Son, 35 er, 29
Son, 33 Daught
er 33
Son, 31
Daught
Son, 29 er, 27
Daught
Daught er, 24
er, 25
Patient – 6
Daught y/o
er, (Asthma)
Legends
(asthm
a
Male Female
D. developmental history
2 months old- the incisor teeth are the first teeth
appeared
- the mother said that his child know them
- the first word to say was “tata”
6 months – the child started to eat celerac as his food
7 months – the patient started to crawl
- celerac is still the food that he eats
11 months – started to walk with guide
1 years old – started to eat solid foods
- say the word “mama” and can identify his
mom
- started to walk fast and run
2 years old – started to know his father
3 years old – the child can identify pictures
4 years old – started to go to school
5 years old – started to read word by word
6 years old – still reading word by word
- the mother said that she is still the one
who feeds her child though the child knows
how to eat
Patterns of functioning
A. Psychosocial
The patient has a good relationship with his parents. When
their family has problems, first they talk about it and decide what
action should be done. The child tells his parents what he wants but
sometimes he can’t get what he wants so he is “nagdadabog”. He
was able to express his feelings to others whether he is happy,
angry, or sad. As a family, they watch TV; go to mall, church
together. They have time to bond with each other. The child says
that he is a cheerful person. According to the mother of our client
“lageng nasa labas yan nakikipaglaro kay echo”. The client
verbalized that” si echo kalaro ko sa labas bestfriends kame forever
e tpos si shekaila un boss namin”. His closest friends are echo and
shekaila. He always plays with them, and he doesn’t have any
problems in school. The child doesn’t feel isolated in their place
because he has many playmates. When asked about the activity
when inside the house the client verbalized “ naglalaro lang ng
gameboy tska kumakaen”.
Analysis:
Six year old children play in groups, but when they are
tired or under added stress, they prefer one-to-one contact.
In a first grade classroom, students compete actively for a
few minutes of special time with the teacher. At the end of
the day, they enjoy time spent individually with parents. You
may have to remind the parents this is not babyish behavior
but of a typical 6 year old.
(Maternal and Child Health Nursing 5th Edition Vol. 2 page 919)
Interpretation:
The child’s behavior in his age is appropriate.
B. Elimination:
The mother of the patient said that the child doesn’t have
any problems with regard to his urinary and bowel
elimination. The mother said, “Umiihi siya ng 5- 6 beses sa
isang araw tska wala naman siyang nararamdaman na sakit.”
When asked about the odor of his urine. The child said,
“mapanghe po yung amoy..” his mother is the one who
cleans him after he defecates. She said that his son
defecates once a day and his stool is formed. “Pero simula
nung inadmit siya dito sa hospital, hindi pa siya
nakakadumi.” The mother said. The child doesn’t experience
excess perspiration and odor problems.
Analysis:
The school age child’s elimination system reaches
maturity during this period. The kidneys double in size
between age 5 and 10 years. During this period, the child
urinates 6-8 times a day. About 10% of all 6-year-old
experience difficulty in controlling the bladder. Bed-wetting
should not be considered a problem until after the age of 6.
(Fundamentals of nursing 8th edition Vol. 2 page 1288)
School age children and adolescent have bowel habits similar
to those of adults. Patterns of defecation vary in frequency,
quantity, and consistency. Some school age children may
delay defecation because of an activity such as play.
Interpretation:
The child doesn’t have problems with regards to his elimination
except on the time when he is admitted to the hospital
C. Rest and sleep
The child sleeps at 11:00 in the evening together with his
parents, “lage yang sumasabay sa amin sa oras ng pagtulog.
Hapon pa naman pasok niya kaya ayos lang.” the mother
said. But before the child sleeps, he eats his midnight snacks
which are milk and bread. The mother said, “pag natulog
nayan, hindi nay an gumigising sa madaling araw.
dirediretso na.” The child wakes up at 9:00 in the morning
and doesn’t take an afternoon nap because he is in school.
But when the child is admitted in the hospital, the child
needs to sleep earlier, “para makapagpahinga siya at
gumaling agad.” Verbalized by the mother.
Analysis:
Sleep needs vary among individual children. Younger school
age children require 10-12 hours of sleep each night., and
older school age children require about 8-10 hours. Most 6
year olds are too old for naps but do require a quiet time
after school to get them through the remainder of the day.
During school years, many children enjoy a quiet talk or a
reading time at bedtime.
(Maternal and child health nursing 5th edition Vol. 2 page 923)
Interpretation:
The child has a good sleeping pattern and doesn’t have a problem with
regards to sleep.
D. Sexuality
The patient doesn’t have any problems in expressing his
sexuality. As a boy, he said that he plays his toys like cars and “baril-
barilan” just like what other boys do. His mother said that he is not
yet circumcised. The child doesn’t talk too much regarding his
genital organ, as his mother said,”puro laro naman yan eh”
Analysis:
Age 6-12, sexual development includes:
has strong identification with parent of same gender
tends to have friends of the same gender
has increasing awareness of self
increased modesty, desire for privacy
continues self stimulating behavior
learns the role and self concepts of own gender as part of the
total self concept
E. Oxygenation:
The child has asthma and there are times that he can’t
breathe normally. The mother said that when this happens,
she consults their doctor and nebulize the child. “nung new
year nagpaputok yan sa labas kasama yun daddy niya eh ang
usok-usok sa labas buti hindi siya hinika.” the mother said.
Analysis:
Asthma is another chronic disease often identified in
childhood. The airways of the asthmatic child react to stimuli
such as allergens, exercise, or cold air by constricting,
becoming edematous, and producing excessive mucus.
Airflow is impaired, the child may wheeze as air moves
through narrowed airpassages.
F. Nutrition
The child said that he like fried foods. The mother said,
“nakaka 5 baso ng tubig yan sa isang araw”. The child
doesn’t have an idea when it regards to proper nutrition. His
favorite foods are hotdog, bread, foods in jollibee. Our Client
verbalized that” paborito kong pagkaen ung sa jollibee
hotdog pati chicken”. According to the mother of the client”
Kumakaen yan tatlong beses sa isang araw ang takaw nga
nyan e”.our client verbalized that” paborito ko din kumaen ng
candy kasi masarap”. He doesn’t like to eat vegetables, as
he said, “mapait eh...” he eats in the dining room together
with his parents. Before hospitalization the mother stated
that” malakas kumaen ng ulam yan di siya gano mahilig sa
kanin” When the child is admitted to the hospital, he is in a
soft diet. When the child has wound, his mother said that it
heals fast. The child doesn’t have any skin problems but he
has dental problems. The tooth of the client is yellowish and
has 26 teeth. The mother verbalized that “hindi siya
nagpapachek-up sa dentista”.
3 Day Diet Recall
01/09/2010
Breakfast: bread, 2 bottle of mineral water, half bottle of
Gatorade
Lunch: spaghetti, 2 bottle of mineral water
01/11/2010
2 bottles of mineral water
On a soft diet
Analysis:
School age children need breakfast to provide enough energy to
get them through active morning at school. Many children qualify
for a free or reduced price school lunch and breakfast. A
government –regulated school lunch (type A) provides milk (8 oz),
protein (2 oz), one starch serving, and vegetable (¾ cup). Servings
vary according to age to provide one third of a child’s nutrition
requirements for a day. Whether they take lunch or buy it in
school, school age children should know some elementary facts of
nutrition so they do not trade a sandwich for a cake or choose only
deserts in the cafeteria. Health care personnel should play an
active role in nutrition education at health maintenance visits. Most
children are hungry after school and enjoy a snack when they
arrive at home. Because sugary foods may dull a child’s appetite
for dinner, urge parents to make the snack nutritious: fruit, cheese
or milk rather than cookies and soft drinks.
(Maternal and child health nursing 5th edition Vol. 2 page 921-922)
Interpretation:
The child’s nutrition is not good because he is not eating nutritious
foods and loves to eat candies that’s why he has dental carries.
Activity of daily living
ADL Before After Interpretation
hospitalization hospitalization & analysis
1. Nutrition mother stated that” the client will now Analysis:
malakas kumaen ng ulam Most school age children
yan di xa gano mahilig sa
eat nutritious foods
have good appetite,
kanin” He doesn’t like to and avoid eating although any meal is
eat vegetables, as he too much candies influenced by the day’s
said, “mapait eh...” he activity. Help children who
eats in the dining room
as much as
are hospitalized to select
outside their house with possible. a diet that is enjoyable as
his parents. Our Client well as nutritious.
verbalized that” paborito (Maternal and child health
kong pagkaen ung sa nursing by Pilliteri 5th
jollibee hotdog pati edition vol. 2 page 921 &
chicken”. According to the 938 )
mother of the client”
Kumakaen yan tatlong Interpretation:
beses sa isang araw ang The client don’t like to eat
takaw nga nyan e”.our nutritious foods like
client verbalized that” vegetables, instead he
paborito ko din kumaen loves candies that's why
he has dental carries
ng candy kasi masarap”.
ADL Before After Interpretation &
hospitalization. hospitalization analysis
2. Elimination The mother said, The client will still Analysis:
School age children
“Umiihi siya ng 5- not experience and adolescent have bowel
6 beses sa isang problems in his habits similar to those of
elimination adults. Patterns of
araw tska wala defecation vary in
naman siyang frequency, quantity, and
nararamdaman consistency.
Circumstances of diet, fluid
na sakit.” intake and output, activity,
psychologic factors,
His mother is the lifestyle, medications,
one who cleans medical procedure and
disease affect defecation.
him after he (fundamentals of nursing
defecates. She by kozier and erbs 8th
edition vol. 2 page 1326)
said that his son Interpretation:
defecates once a The client has a good
day and his stool elimination pattern
is formed.
ADL Before After Interpretation &
hosp[italization hospita;ization analysis
Height: 107 cm
Age: 6 y/o
Weight: 24 kg
Vital signs:
BMI: 20.9
Blood Pressure: N/A
assessmen Normal Actual analysis
t findings findings
Proportionate,
Body built,
varies with lifestyle
His weight is Normal
height, and and age
proportion to
weight in (Fundamentals of
his height
relation to nursing by kozier
client’s age, and erbs 8th edition
p.572)
Normal
Highly vascular and pink in
Fingernail and light-skinned clients; dark-
His bed color is
toenail bed color skinned clients may have pink in color and
brown or black pigmentation
in longitudinal it is highly
steaks(Fundamentals of
nursing by kozier and erbs
vascular
8th edition p.584)
Tissues Intact
epidermis(Fundamentals
The tissues Normal
surrounding nails of nursing by kozier and surrounding his
erbs 8th edition p.583) nails are intact to
his epidermis.
Blanch test of Prompt return His blanch test Normal
capillary refill of pink or usual return in its
color(Fundame original color in
ntals of nursing 1 second
by kozier and
erbs 8th edition
p.584)
skull
Skull for size, Rounded
(Normocephalic and
His skull is Normal
shape, and symmetrical, with
rounded (norm
symmetry frontal, parietal and cephalic and
occipital symmetrical with
prominences); smooththe bone
skull contour
prominences)
(Fundamentals of
nursing by kozier and
and has a smooth
erbs 8th edition skull contour.
p.585)
Symmetry of facial movements and Symmetric facial He has symmetrical facial Normal
functions of facial nerve movements(Fundamentals of movements
nursing by kozier and erbs 8th
edition p.585)
eyes
Eyebrows for hair Hair evenly distributed; his hair in the eyebrows Normal
distribution and skin intact(Fundamentals are evenly distributed,
alignment and skin of nursing by kozier and skin intact, it is
quality and movement erbs 8th edition p.588) symmetrically aligned
Eyelashes for evenness Equally distributed; His hair in the eyelashes Normal
of distribution and curled slightly is equally distributed and
direction of curl outward(Fundamentals it is slightly outward
of nursing by kozier and
erbs 8th edition p.588)
Eyelids for surface Skin intact; no discharge;His skin is intact in the Normal
characteristics, no discolorationLids eyelids and there are no
position in relation to close discharge, no
the cornea, ability symmetricallyApproxima discoloration, it closes
to blink, and frequency tely 15-20 involuntary symmetrically, no visible
of blinking and blinks per minute, above corneas and the
functions of trigeminal bilateral blinkingWhen upper lower area of the
nerve lids open, no visceral cornea is slightly
sclera above corneas, covered. Approximately
and upper and lower 10-15 blinks/min.
borders of cornea are
slightly
covered(Fundamentals
of nursing by kozier and
erbs 8th edition p.588)
Peripheral visual When looking He can see Normal Six ocular Both eyes Both eyes Normal
fields to straight ahead, objects in movements to coordinated, coordinated,
determine client can see periphery determine eye move in unison, move in unison,
function of retina objects in alignment and with parallel with parallel
and neuronial periphery coordination and alignment alignment
visual pathways (Fundamentals of functions of (Fundamentals of
to brain and nursing by kozier oculomotor, nursing by kozier
optic cranial and erbs 8th trochlear and and erbs 8th
nerve edition p.591) abducens nerve edition p.592)
Ears
Auricles
Color, Symmetry of size, and Color same as facial -his auricle is the same as his Normal
position skinSymmetricalAuricle aligned facial skin.- it symmetrical to his
with outer canthus of eye, face.- his auricle is aligned with
about 10 degrees from the other canthus of the eye
vertical(Fundamentals of
nursing by kozier and erbs 8th
edition p.596)
Texture, elasticity, and areas of Mobile, firm, and not tender; His ear is firm and not tender Normal
tenderness pinna recoils after it is and after being folded it recoils
folded(Fundamentals of nursing
by kozier and erbs 8th edition
p.596)
External ear canal Distal ends contains hair his eardrum have a dry Normal
follicles and glands; Dry cerumen, the distal has some
cerumen, grayish-tan color; or hair follicles and glands.- No
sticky wet cerumen in various lesions, pus or blood In his
shades of brown eardrum.
Hearing Acuity Test
Response to normal voice tones Normal voice tones He can hear normal voice tones Normal
audible(Fundamentals of
nursing by kozier and erbs 8th
edition p.597)
Watch tick test Able to hear ticking in both He is able to hear the ticking of Normal
ears(Fundamentals of nursing the watch in both ears
by kozier and erbs 8th edition
p.597)
Weber’s test Sound is heard in both ears or isHe can hear the sound in both Normal
localized at center of the ears
head(Fundamentals of nursing
by kozier and erbs 8th edition
p.597)
Palpate external nose to Not tender; no His nose is not tender and no Normal
determine any areas of lesions(Fundamentals of presence of lesions
tenderness, masses, and nursing by kozier and erbs 8th
displacements of bone and edition p.600)
cartilage.
Patency of both nasal cavities Air move freely as the client The air moves freely as he Normal
breathes through the breath through the nares
nares(Fundamentals of nursing
by kozier and erbs 8th edition
p.600)
Nasal Cavity and Facial
Sinuses
Observe for any presence of Mucosa pink, clear, watery His nasal cavities are pink in Normal
redness, swelling, growths, and discharge, no lesions, color, clear, watery discharge
discharge. (Fundamentals of nursing by
kozier and erbs 8th edition
p.600)
Nasal Septum Nasal septum intact and in His nasal septum is intact and Normal
midline(Fundamentals of in the midline.
nursing by kozier and erbs 8th
edition p.600)
Palpate the Maxillary and No tenderness, not There are no tenderness in Normal
Frontal sinuses for tenderness palpable(Fundamentals of maxilla and frontal sinuses
and functions of olfactory nerve Nursing, 8th Ed.by Barbara
Kozier Pp.600)
MOUTH
Outer lips for symmetry of Uniform pink color; soft; moist; His lips is uniform, pink in color, Normal
contour, color and texture smooth texture; symmetry of moist, smooth in texture, has
contour; ability to purse symmetric contour and his lips
lips(Fundamentals of nursing by has the ability to purse.
kozier and erbs 8th edition p.602)
Inner lips and buccal mucosa for Uniform pink color; moist; His buccal mucosa is uniform in
color, moisture, texture, and the smooth; soft; glistening, and pink color, moist, soft, glistening
presence elastic texture(Fundamentals of and elastic in texture and has no
nursing by kozier and erbs 8th lesions
edition p.602)
Tongue Movement and Moves freely; no tenderness His tongue moves freely and Normal
functions of hypoglossal nerve (Fundamentals of nursing by there is no tenderness
kozier and erbs 8th edition
p.602)
Base of the Tongue, the mouth Smooth tongue base with His tongue is pink in color, Normal
floor, and the frenulum prominent veins smooth tongue base with
(Fundamentals of nursing by prominent veins.
kozier and erbs 8th edition
p.602)
Palpate the tongue and floor of Smooth with no palpable The tongue is smooth and there Normal
the mouth for any modules, nodules are no palpable nodules
lumps, or excoriated areas and (Fundamentals of nursing by
functions of glosopharyngeal kozier and erbs 8th edition
nerve p.603)
PALATES and UVULA
Hard and Soft Palate, its color, Light pink, smooth, soft palate, His soft palate light pink in color Normal
shape, texture, and the lighter pink hard palate, more and it is smooth while the hard
presence of bony prominences irregular texture palate is lighter pink in color
(Fundamentals of nursing by and it is irregular in texture
kozier and erbs 8th edition
p.603)
Uvula, its positioning, and Positioned in midline of soft -his uvula is positioned midline. Normal
mobility while examining the palate -it appears in pink and smooth
palates (Fundamentals of nursing by and no discharge.
kozier and erbs 8th edition
p.603)
OROPHARYNX and TONSILS
The Oropharynx, its texture and Pink and smooth posterior wall The color of his oropharynx is Normal
color (Fundamentals of nursing by pink and it is smooth on
kozier and erbs 8th edition posterior wall
p.603)
The Tonsils, its color, any Pink and smooth; no discharge; The tonsils is pink and it is Normal
discharges and size of normal size smooth and there are no
(Fundamentals of nursing by discharge; Grade 1
kozier and erbs 8th edition
p.603)
Thyroid Gland; observe Not visible on inspection The thyroid gland is not Normal
lower half of the neck (Fundamentals of nursing by visible on inspection
overlying the thyroid gland kozier and erbs 8th edition
for symmetry and visible p.608)
masses.
Palpate the Thyroid gland for Lobes may not be palpated; The lobes are not palbable Normal
smoothness and areas of if palpated, lobes are small, and it rise freely when he
enlargement, masses or smooth, centrally located, swallows
nodules painless, and rise freely with
swallowing
(Fundamentals of nursing by
kozier and erbs 8th edition
p.608)
Posterior thorax
Shape, Symmetry, size and Anteroposterior to transverse Anteroposterior to transverse Normal
diameter of anteriorposterior diameter in ratio 1:2; Chest diameter in ratio 1:2; Chest
thorax to transverse diameter symmetric symmetric
Spine alignment Spine vertically aligned; Spinal His spine is vertically aligned, Normal
column is straight, right and left straight shoulders and hips are
shoulders and hips are at same the same as the height.
height
Palpate the posterior thorax; for Skin intact, uniform His thorax skin is intact, it Normal
clients who have no respiratory temperature; chest wall intact; uniform in temperature and
complaints, rapidly assess the no tenderness; no masses there are no masses or lesions
temperature and integrity of all were seen in the thorax of the
chest skin client.
Palpate the posterior chest for Full symmetric chest expansion; It is Full and symmetric chest Normal
respiratory excursion normally the thumbs separate expansion.
3-5 cm(1.5-2 in.) during deep
inspiration
Palpate the chest for vocal Bilaterally symmetry of vocal The vocal fremetus is bilaterally Normal
fremitus fremitus; fremitus is heard most symmetrical and it is heard
clearly at the apex of the lungs more clearly at the apex of the
lungs
Percuss the posterior thorax Percussion notes resonate, His posterior resonant sound Normal
except over scapula; lower will be heard during percussion.
point of resonance is at the
diaphragm
Auscultate the posterior thorax Vesicular and Bronchiovesicular During his auscultation on his Normal
breath sounds thorax, there is a wheezing
sound
ANTERIOR THORAX
Breathing patterns Quiet, rhythmic and effortless Quiet sound and effortless Normal
Palpate for temperature, Uniformly warm, no tenderness, His Anteriror thorax has uniform Normal
tenderness, masses no masses temperature, no tenderness
and masses
Palpate the anterior chest for Full symmetric excursion; he has a full symmetric chest Normal
respiratory excursion thumbs normally separate 3-5 expansion.
cm (1.5-2 in)
Palpate the vocal fremitus Same as the posterior vocal He has bilateral symmetry of Normal
femitus; fremitus is normally vocal fremetus.
decreased over heart and
breast tissue
Percuss the anterior thorax Percussion notes resonate downIn percussing his thorax, there Normal
to the sixth rib at the level of is a resonate down to the sixth
the diaphragm but are flat over rib at the level of the
areas of heavy muscles and diaphragm but flat over the
bone, dull on areas over the heavy muscle and bone, dull on
heart and the liver, and the areas over the heart at the
tympanic over the underlying liver, tympanic over the
underlying stomach.
Auscultate the Trachea Bronchial and tubular breath There is a bronchial and breath Normal
sounds sound on his trachea.
Auscultate the anterior thorax Bronchiovesicular and vesicular During his auscultation on his The child has an asthma
breath sounds thorax, there is a wheezing
sound
CARDIOVASCULAR
Inspect and palpate the aortic No masses, no pulsations, no liftNo pulsation on his aortic Normal
and pulmonic areas or heave(Fundamentals of area.No pulsation and no lift or
nursing by kozier and erbs 8th heave.
edition p.621)
Inspect and palpate the No pulsations and no heaves or No pulsations and no lift or Normal
tricuspid areas lift heaves
Inspect and palpate the apical Pulsation visible 50% of adults Pulsation is palpable Normal
area and palpable in most PMI in fifth
LICS at or medial to MCL
Diameter of 1 to 2 cm (1/3 to ½
in.) No lift or heave
Auscultate the aortic, pulmonic, S1:usually heard at all In auscultating his thorax, S1 is Normal
tricuspid and apical valves sitesUsually louder at apical usually heard at all sites, S2
areS2: usually heard at all usually heard at all sites
sitesUsually louder at the base
of the heartSystole: silent
interval; slightly shorter
duration than diastole at normal
heart rateDiastole: silent
interval; slightly longer duration
than systole at normal heart
rates
Carotid artery and Jugular
Vein
Carotid Artery Symmetric pulse volumes; it has a full thrusting quality. Normal
pulse volumes; full pulsation, there is no sound heard
thrusting quality; quality
remains same when client
breaths; turns head, and
changes from sitting to supine
position; Elastic arterial wall; no
sound heard on
auscultation(Fundamentals of
nursing by kozier and erbs 8th
edition p.622)
Jugular Vein Veins not visible(Fundamentals His veins are not visible Normal
of nursing by kozier and erbs
8th edition p.623)
Breast and Axillae
Breast size; symmetry; and Males: Round, slightly unequal his breasts are rounded in Normal
contour or shape in size shape slightly unequal in size;
generally symmetric.-his
breasts skin uniform in color.
His skin is intact and smooth
Inspect the skin of the breast Skin uniform in color; skin his breasts skin uniform in Normal
for discolorations or hyper smooth and intact; diffuse color. His skin is intact and
pigmentation, retraction or symmetric horizontal or vertical smooth
dimpling, localized hyper vascular pattern in light-
vascular areas, swelling or skinned people; striae; moles
edema and nevi
Inspect the Areola for size, Round or oval and bilaterally His areola is round and Normal
shape, symmetry, color, surface the same; Color varies widely, bilaterally the same. The color
characteristics, and any masses from light to pink to dark of his areola is brownish. He has
or lesions brown; Irregular placement of an irregular placement of the
sebaceous gland on the surface sebaceous glands on the
of the areola surface of the area.
Inspect the Nipples for size, Round everted, and equal in His nipples are round in shape Normal
shape, position, color, dischargesize; similar in color; soft and everted and equal in
and lesions smooth; both nipples point in size.similar in color. Both nipple
same direction; no discharge, point in the same direction
except from pregnant or breast -it has no discharge
feeding females; inversion of - his breasts nipples have no
one or both nipples that is tenderness, masses or nodules.
present from puberty
Palpate the axillary, No tenderness, masses or There is no tenderness, masses Normal
subclavicular and nodules or nodules on the axillary.
supraclavicular lymph nodes
Palpate breasts for masses and No tenderness, masses, nodules There is no tenderness or Normal
tenderness masses around his breast
Palpate the nipples for No tenderness, masses, There is no tenderness masses, Normal
tenderness and discharge nodules, or nipple discharge nodules or nipple discharge
(Fundamentals of Nursing by
Barbara Kozier,8th Ed. Pp.628-
630)
ABDOMEN
Inspect the abdomen for skin Unblemished skin; Uniform His abdomen In skin is Normal
integrity Color; Silver white striae or Unblemished in skin,has
surgical scars uniform in color,silver with
striae or surgical scars
Inspect for an enlarged liver or no evidence of enlargement of Not done Not done
spleen liver or spleen;
Auscultate the abdomen for Audible bowel sounds; Absence Audible bowel sounds are heard Normal
bowel sounds, vascular sounds, of Arterial bruits and absence of Arterial bruits
and peritoneal friction rubs Absence of friction rub and
(Fundamentals of nursing by friction rub
kozier and erbs 8th edition
p.634)
Percuss several areas in each of Tympany over the stomach and Tympany over the stomach and Normal
the four quadrants to determine gas-filled bowels; dullness, gas-filled bowels
presence of tympany and especially overt the liver and
dullness. spleen, or a full bladder
Palpate muscle tonicity Normally firm His muscles are firm Normal
Test muscle strength (Neck) Equal strength on each body Cannot rotate his head on the (+) torticollis
part left side, only in the right side
(Fundamentals of Nursing by
Barbara Kozier,8th Ed. P. 640)
Test for muscle strength (Upper Equal strength on each body Equal strength on each body Normal
extremities) part part
(Fundamentals of Nursing by
Barbara Kozier,8th Ed. P. 640)
Test for muscle strength (Lower Equal strength on each body Equal strength on each body Normal
extremities) part part
(Fundamentals of Nursing by
Barbara Kozier,8th Ed. P. 640)
Bones and Joints
Inspect for normal bone No deformities No deformities Normal
structure and deformities (Fundamentals of Nursing by
Barbara Kozier,8th Ed. P. 641)
Palpate the bones to locate any No tenderness or swelling No tenderness or swelling Normal
areas of edema or tenderness
Inspect the joints for swelling, No swelling; no tenderness, There are no swelling of joints Normal
palpate each joint for swelling, or nodules; Joints and it moves smoothly and
tenderness, smoothness of move smoothly there is no tenderness
movements, swelling,
crepitation, Snodules
Range of Motion
Upper Extremities Can perform the range of He can perform the range of Normal
(shoulder and motion in the shoulder and motion in the shoulder and
scapula Reference: scapula
Scapula)
(Fundamentals of nursing 8th
edition Vol. 2 page 1108-1111)
Upper extremities Can perform the range of He can perform the range of Normal
(elbows) motion in the elbows motion in the elbows
Upper Extremities Can perform the range of He can perform the range of Normal
(hands) motion in the hands motion in the hands
Lower Extremities Can perform the range of He can perform the range of Normal
(acetabulum/ motion in the inguinal motion in the inguinal
inguinal area)
Lower Extremities Can perform the range of He can perform the range of Normal
(popliteal) motion in the popliteal motion in the popliteal
Lower Extremities Can perform the range of He can perform the range of Normal
(ankles) motion in the ankles motion in the ankles
Laboratory and Diagnostic
Examination
Urinalysis
Bacteria: occasional
Hematology
Test N.M units results
Hemoglobi M = 140- g/dl 120
n 170
F120-150
Hematocrit M = 0.41- Vol% 0.36
0.54F =
0.37-0.47
Leucocytes 5-10 X 10 g/l 8.3 N
Erythrocyt M = 4.1-
es 5.4F =
4.3-5.5
Drug study
Generic/Trade Dosage/Frequ Classification Indication Contraindicati Side effects
ency on Nursing Responsibilities
name
Generic T neb every 6 Bronchodilator Salbutamol is Hypersensitivt Headache,tremo -Assess pulse, respiration,
name: used in cases ty to agents r, tachycardia lung sounds, and character
Salbutamol hours of -avoid use in hypertension, of secretions before and
bronchospasm uncontrolled anxiety. Rarely throughout the therapy.
Trade name: in patients nausea,
arrythmias
Ventolin, with reversible vomiting, and
airway skin rash can be
obstruction: observed.
Albuterol
mild and
moderate
attacks of
dyspnea in
patients
suffering from
bronchial
asthma; mild
and moderate
bronchoobstru
ction in
patients with
chronic
bronchitis and
lung
emphysema.
Generic Name: 250 mg per Anti-pyretics Symptomatic Nephropathy. Hematological -Assess fever (note
Opigesic(supp rectum relief of fever reactions, rashes presence of
ository) associated w/ & other allergic associated
common reactions. symptoms
childhood diaphoresis,
infections. tachycardia and
Relief of minor malaise)
pains eg
headache,
headache,
toothache &
earache.
earache.
Paracetamol 240 mg TIV Anti-pyretics Mild to Contraindicate GI:hepatic -Assess fever (note
Generic Name: EVERY 4 moderate pain d in previous necrosis(overdose presence of
Acetaminophe HOURS and fever. hypersensitivit )Derm: Rashes associated
y products symptoms
n
containing diaphoresis,
Trade Name: alcohol,asparta tachycardia and
Tempra, me,saccharin, malaise)
Tylenol sugar or
tartrazine
should be
avoided in
patients who
have
hypersensitivit
y or
intolerance in
these
compounds.
Salbutamol(ta PO( 6-14 yrs BronchodilatorSalbutamol
BronchodilatorSalbutamol Hypersensitivity to CNS: -Assess pulse,
blets) old) 2 mg 3-4 tablets may adrenergic amines. nervousness,restl respiration, lung
Albuterol times daily. be used in Contraindicated essness.EENT: sounds, and character
asthma, to during broncho- eye irritation, of secretions before
relieve the spasm. blurred and throughout the
narrowing of vision.RESP: therapy.
the airways. Pulmonary
chronic edema(tocolytic
bronchitis. use of
emphysema terbutaline).GI:
Nausea and
vomitingEndo:
Hyperglycemia.
Hypoglycemia.F
and E:
hypokalemia
Penicillin G 800,000iu/IV Antibiotics Treatment of Contraindicated Severe allergic -Assess fever (note
sodium severe with allergy to reactions, presence of
infections penicillins, tightness in the associated symptoms
caused by cephalosporins, chest, swelling of diaphoresis,
sensitive beta lactamase the mouth, face, tachycardia and
organisms, inhibitors and other lips, or tongue, malaise)
treatment of allergens chills,convulsions,
syphilis and decreased
gonococcal urination
infections
Combivent Two sprays of Bronchodilator Management of Hypersensitivit Nervousness, -Assess pulse,
Generic name: Combivent four reversible y to adrenergic restlessness, respiration, lung
ipratropium times a day. airway disease amines, use pulmonary edema, sounds, and
(inhalation) due to asthma cautiously in hypertension, character of
cardiac tachycardia. secretions before
Trade name:
Combivent, disesase, and throughout the
diabetes, therapy
Duoneb
bronchospasm
(www.colgate.com )
Nursing problem analysis Goal/objectives Nursing interventions rationale evaluation
cues
Risk for infection Hemoglobin is the After 2 hours of Monitor vital signs Reflective of Patient was able
related to protein molecule nursing Especially inflammatory process/ to minimize the
decreased in red blood cells intervention, the temperature infection requiring sign of infection
hemoglobin that carries client will evaluation & treatment
production oxygen from the minimize sign of Demonstrate to the client
lungs to the infection and significant other
Prevents cross
body's tissues and Thorough
Cues: contamination/ bacterial
returns carbon Hand washing
colonization
dioxide from the
Hematology: tissues to the Encourage frequent
Hemoglobin = 120 lungs. position changes/ Promotes ventilation of
Hematocrit = 0.36 Hemoglobin also ambulation, all lung segments and
plays an coughing, & deep aids in mobilizing
Leucocytes = 8.3 secretions to prevent
important role in breathing exercises
maintaining the pneumonia
vital signs: shape of the red Promote adequate
T = 36.1˚C blood cells. fluid intake
PR = 93bpm
Assist in liquefying
Abnormal respiratory secretions to
RR = 21cpm Hemoglobin Obtain specimen facilitate expectoration
structure can, For & prevents stasis of
therefore, disrupt culture/ sensitivity
Body fluids
the shape of red as indicated
blood cells and
impede its (http://nursingdepart Verifies presence of
function and its ent.blogspot.com/200 infection, identifies
flow through /08/nursing-care-plan specific pathogens&
blood vessels risk-for-infection.html) influences choice of
treatment
(http://www.medi
cinenet.com/heog
lobin/article.h
m).
Anatomy and physiology
The lungs constitute the largest organ in the respiratory system.
They play an important role in respiration, or the process of
providing the body with oxygen and releasing carbon dioxide. The
lungs expand and contract up to 20 times per minute taking in and
disposing of those gases.
Air that is breathed in is filled with oxygen and goes to the trachea,
which branches off into one of two bronchi. Each bronchus enters a
lung. There are two lungs, one on each side of the breastbone and
protected by the ribs. Each lung is made up of lobes, or sections.
There are three lobes in the right lung and two lobes in the left
one. The lungs are cone shaped and made of elastic, spongy
tissue. Within the lungs, the bronchi branch out into minute
pathways that go through the lung tissue. The pathways are called
bronchioles, and they end at microscopic air sacs called alveoli.
The alveoli are surrounded by capillaries and provide oxygen for
the blood in these vessels. The oxygenated blood is then pumped
by the heart throughout the body. The alveoli also take in carbon
dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles
between the ribs. Exhaling results from relaxation of those
muscles. Each lung is surrounded by a two-layered membrane, or
the pleura, that under normal circumstances has a very, very small
amount of fluid between the layers. The fluid allows the
membranes to easily slide over each other during breathing.
Respiratory system
Pathophysiology of Pneumonia
Droplets S. Pneumoniae aspirated into
the lungs
Inflammatory response
initiated
Pnemonia
Drink lots of fluids, especially water. Liquids will keep patient from becoming
dehydrated and help loosen mucus in the lungs.
Health Teaching:
Tell guardians to avoid exposing the patient to an environment with too much
pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses
against respiratory infections.
Protect others from infection. Try to stay away from anyone with
a compromised immune system. When that isn’t possible, a
person can help protect others by wearing a face mask and
always coughing into a tissue.
Diet:
Eat nutritious foods like fruits and vegetables to recover well.