University of Perpetual Help System Laguna
Dr. Jose G. Tamayo Medical University
Sto. Niño, Biñan, Laguna
COLLEGE OF NURSING
Pediatric Community-Acquired
Pneumonia (PCAP – C)
In Partial Fulfillment of the Requirements in NCM 107 B
A Case Presented By
Group 1 - 3/ N4X
Abellar, Justine A.
Acabado, Melanisol C.
Delfin, Gian Carlo D.
Fermindoza, Jenny Gay S.
Garcia, Leslie M.
Gutierrez, Joana G.
Olay, Nicole Neil N.
Regis, Melanie B.
Santos, Jeffrey M.
August 15, 2013
CONTENTS
I.
Introduction
II.
Patient’s Profile
III.
Physical Assessment
IV.
Anatomy and Physiology
V.
Pathophysiology
VI.
Medical Management
VII.
Laboratory and Diagnostic Tests
VIII.
Drug Study
IX.
Nursing Care Plan
INTRODUCTION
I. Introduction
Pediatric community-acquired pneumonia (PCAP)
Pneumonia is a general term that refers to an infection of the lungs, which can be
caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites.
Pneumonia is the infection of the pulmonary tissue, including the interstitial spaces, the
alveoli, and the bronchioles. Pneumonia can be community-acquired or hospitalacquired.
Community acquired pneumonia occurs either in the community setting or within the
first 48 hours after hospitalization or institutionalization.
Pneumonia is caused by a number of infectious agents, including viruses, bacteria and
fungi. The most common are: Streptococcus pneumoniae – the most common cause of
bacterial pneumonia in children; Haemophilusinfluenzae type b (Hib) – the second most
common cause of bacterial pneumonia; respiratory syncytial virus is the most common
viral cause of pneumonia.
Environmental Risk Factors include: indoor air pollution caused by cooking and
heating with biomass fuels (such as wood or dung), living in crowded homes, parental
smoking.
Signs and Symptoms vary depending on the age of the child and the cause of
the pneumonia, but common ones include: fever, chills, cough, nasal congestion,
unusually rapid breathing (in some cases, this is the only symptom), breathing with
grunting or wheezing sounds, labored breathing that makes the rib muscles retract
(when muscles under the ribcage or between ribs draw inward with each breath) and
causes nasal flaring, vomiting, chest pain, abdominal pain, loss of appetite (in older
kids) or poor feeding (in infants), which may lead to dehydration, in extreme cases,
bluish or gray color of the lips and fingernails.
Incidence:
Pneumonia is the single largest cause of death in children worldwide. Every year, it kills
an estimated 1.2 million children under the age of five years, accounting for 18% of all
deaths of children under five years old worldwide. Pneumonia affects children and
families everywhere, but is most prevalent in South Asia and sub-Saharan Africa.
PATIENT’S
PROFILE
Name
:
C.R.
Age
:
2 years old 9 months
Gender
:
Female
Status
:
Child
Nationality
:
Filipino
Religion
:
Roman Catholic
B-date
:
November 5, 2010
B-place
:
Binan,Laguna
Address
:
Cabuyao, Laguna
Admission date and time :
Attending Physician
Initial Diagnosis
:
August 4, 2013/ 9:42am
Dra. G.M.
:
PCAP-C
Final Diagnosis
:
NONE
Chief Complaint
Cough
History of present illness:
Two weeks prior to admission, patient experienced cough, productive, no fever
noted, no difficulty of breathing. Patient was given Cefexime 2.5 ml and cetirizine
2.5 ml which give temporary relief. One day prior to admission suddenly
experienced fever, temperature maximum of 39 degree Celsius, patient was given
Paracetamol suppository which gave temporary relief, associated with
appearance of petechial rashes on the periorbital area. Persistence of the
symptom, prompted to have the admission.
Maternal and obstetric history:
Patient was born to a 27 years old G2P2 (2002) mother who had regular prenatal
checkup and regular intake of vitamins. No history and exposure to radiation and
teratogenic drugs. Patient had history of UTI during the course of pregnancy and
asthma at 7 months.
Birth History:
Patient was delivered live, via Caesarian Section attended by obstetrician and
pediatrician with no noted complications. Routine newborn screening was done.
Neonatal History:
Patient has no history of jaundice and cyanosis. Meconium was passed out
within 24 hour of life.
Immunization History:
(+) BCG
(+) DPT 3 doses
(+) OPV 3 doses
(+) Hep B 3 doses
(+) Varicella Vaccine
(+) Pneumonia Vaccine
Past Medical History:
(+) Hospitalization = 2012 Aug ; cough, UPHS
(+) Seizure at 5 months
(+) Asthma, 2012, Montelukast and prednisone
Family History:
(+) HPN = Paternal
(+) DM = Paternal
(+) Seizure = Paternal
(+) Asthma = Both
(-) CVD
(-) PTB
Aug. 8, 2013 vital signs:
Temperature
:
36.1°C
Cardiac Rate
:
107 bpm
Respiratory Rate
:
35cpm
Blood pressure
:
90/60
Weight
:
14.1kg
Physical
assessment
Psychological and social examination
 she is conscious and coherent
Erik Erikson Stages of psychosocial development
 Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt
 Toilet Training-Children need to develop a sense of personal control over
physical skills and a sense of independence. Success leads to feelings of
autonomy, failure results in feelings of shame and doubt.
Freud’s Stages of Psychosexual Development
 Anal Stage: Age Range 1 to 3 years old
 The child begins to toilet train, which brings about the child's fascination in
the erogenous zone of the anus. The erogenous zone is focused on the
bowel and bladder control. Therefore, Freud believed that the libido was
mainly focused on controlling the bladder and bowel movements. The anal
stage coincides with the start of the child’s ability to control their anal
sphincter, and therefore their ability to give or withhold gifts at will. If the
children during this stage can overcome the conflict it will result in a sense
of accomplishment and independence.
PHYSICAL ASSESSMENT (Cephalo-caudal)
August 8, 2013
Body Parts
Technique
Normal
Findings
Actual Findings
Skin (General)
Inspection
Palpation
-light to dark
brown
- light to dark
brown
-no swelling
-no swelling
-good skin turgor
- with good skin
turgor.
-no lesion
-no lesion
Hair and scalp
Inspection
Head
Inspection
Neck
Inspection
Eyes
Inspection
Eye brows
Inspection
Eye lashes
Inspection
Eye lids
Sclera
- hair distribution, -color black
equal.
- Equal and
healthy hair and
distribution.
-face is
-face is
symmetrical
symmetrical
-no lesion
-no lesion
-no swelling
-symmetrically
align
-blinking
symmetrically
-Evenly
distributed
-no swelling
-symmetrically
align
-blinking
symmetrically
- Turned outward
eyelashes; hair
equally
distributed
-eyelashes are
short
Inspection
-eye lid margins
are moist
- Moist
Inspection
-white in color
-white in color
Analysis
Pupil
Inspection
-equally round
and reactive to
light and
accommodation
- Pupils equally
reactive to light
and
accommodation.
Ears
Palpation
-equal in size
-equal and
symmetrical
Inspection
-symmetrically
align
-no lesion
-no swelling
- no discharge
-no lesion
-no swelling
- no discharge
Nose
Inspection
-Symmetric and
straight; no
discharge or
flaring; Uniform
color
-Symmetric and
straight; no
discharge or
flaring; Uniform
color
Lips
Inspection
-pink, moist and
smooth in
texture.
-no lesion, no
sores.
Buccal mucosa
Inspection
-Pink in color,
soft, moist,
smooth texture,
asymmetry of
contour, ability to
purse lips
- Pink in color,
soft, moist,
smooth,
glistening, and
elastic texture.
- Pink color and
moist.
- no lesions and
sores noted
Tongue
Inspection
-no lesion
-no swelling
- moisten
-no lesion
-no swelling
-moist
- no sores noted
Gums
Inspection
-pink and moist
-pink and moist,
- healthy gums.
Teeth
Inspection
-symmetrically
aligned, no tooth
decay
-Good set of milk
teeth.
Nails
Capillary refill
Inspection
-Pink in color
<2 secs
-Pink in color
<2 secs
Upper
Extremities
Inspection
Palpation
-symmetrically
align
-no lesion
-no swelling
-light to dark
brown in color
-symmetrically
align
-no lesion
-no swelling
-light to dark
brown in color
- can do active
range of motion.
ANTERIOR
Inspection
-Quiet, rhythmic,
and effortless
respirations.
-Normal
breathing pattern
- no chest
indwelling
Auscultation Broncho
vesicular and
vesicular breath
sounds.
-Normal breath
sounds heard on
auscultation
Auscultation Vesicular and
broncho
vesicular breath
sounds
Crackles on both
lower lung fields
Inspection
Palpation
-smooth to touch
-no lesion
-no swelling
-warm to touch
-round and
symmetrical
-abdomen rises
THORAX
Breathing
patterns
Anterior Thorax
POSTERIOR
THORAX
Abdomen
-smooth to touch
-no lesion
-no swelling
-warm to touch
-round and
symmetrical
-abdomen rises
Crackles are
often associated
with inflammation
or infection of the
small bronchi,
bronchioles, and
alveoli.
with inspiration in with inspiration in
synchromy with
synchromy with
chest
chest.
Lower
Extremities
Posterior Lower
Extremities
Inspection
-bilaterally
symmetrical and
equal
-right foot has
complete fingers
-skin color is as
same as the
other parts of the
body
-bilaterally
symmetrical and
equal
-right foot has
complete fingers
-skin color is as
same as the
other parts of the
body
Inspection
and
palpation.
Normal skin
color.
-Normal skin
color
F. Functional Health Pattern Assessment
1.
Health Perception-Health Management Pattern
The child’s health is fair as describe by the mother but now it’s already poor. She
said that in maintaining the child’s health she provided the child with nutritious food as
much as possible and giving all the needs of the child like nice dress and proper
hygiene. She gave the child time to play with other kids. The child’s immunization was
complete.
The child was admitted to the hospital because of cough fever for 2 weeks. The
mother know the real cause of the illness because the ‘’yaya’’ has cough and cold. It
began on July 22, 2010 in the child was warm to touch. Patient was given Cefexime 2.5
ml and cetirizine 2.5 ml which give temporary relief. One day prior to admission
suddenly experienced fever, temperature maximum of 39 degree Celsius, patient was
given Paracetamol suppository which gave temporary relief, associated with
appearance of petechial rashes on the periorbital area. Persistence of the symptom,
prompted to have the admission.
The child was hospitalized last August 2012 because of cough as stated by her
grandmother. They expect that the child will get well soon as soon as possible so that
the child will not suffer from staying in the hospital.
During her pregnancy, the mother had her complete pre-natal check-up during
her pregnancy stage. She did not take any medications & no complications during
pregnancy.
2.
Nutritional and Metabolic Pattern
The child’s appetite is usually good but upon hospitalization the child’s appetite is
poor. She doesn’t like to eat fruits and vegetables. They were not fond of going to fast
food or restaurants.
3.
Elimination Pattern
The child defecates once a day, usually every morning with soft, brown, formed &
moderate in amount stool. She was toilet trained. The child doesn’t have any problems
in his urination. He doesn’t have any trouble in his skin.
4.
Sleep-Rest Pattern
The child usually sleeps 9pm & wakes at 8am. She sleeps 11 hours a day with
naps. The child’s usual sleep routine was singing with his parents and listening bedtime
stories. She had no usual sleep pattern problem.
5.
Activity-Exercise Pattern
Walks with steady gait, runs with few falls, walks on toes, stands on one foot,
jumps, kicks ball, throws ball overhand.
The child could eat using spoon and fork with assistance. She doesn’t want to
be helped. The child needs help in toileting since she doesn’t know where to defecate
and urinate. She defecates and urinates on their comfort room. The child needs help to
dress by herself, bath and brush his teeth.
The child watches TV for more than an hour she loves to watch cartoons. She
watches with his parents. She was prohibited watching action movies to avoid being
violent when he grows up.
6.
Cognitive-Perceptual Pattern
The child did not have any sensory perception deficits. She was 2 years old. She is a
smart child
7.
Self-Perception – Self-concept Pattern
The mother feels bad about her child’s illness and she was concerned about the
wellness of the child. The child verbalizes that he feels restless.
8.
Role Relationship Pattern
The child uses appropriate words for his age. Spoken language in their home is
Tagalog and English. The child has one sibling. She was the youngest. Both the child’s
parents do the decision making and in disciplining the child. There was no marital
problem and violence in the family.
9.
Sexuality-Reproductive Pattern
The child did not verbalize any sexual curiosity according to her mother.
10.
Coping Stress Tolerance Pattern
The child needs to learn to decide for himself and if greater decisions are to be
made she should ask approval from his parents. There were no losses for the past year.
When the child is stress he turns to her mother. When the child was frustrated he plays
with her toys. She was not afraid of her mother and always try things that she is not
familiar of.
11.
Value-Belief Pattern
The whole family was Roman Catholic as claimed by the mother. The mother just
likes to be prayed for her child’s wellness.
ANATOMY
AND
PHYSIOLOGY
Respiratory System
Nose or Nasal Cavity
As air passes through the nasal cavities it is warmed and humidified, so that air
that reaches the lungs is warmed and moist. The Nasal airways are lined with cilia and
kept moist by mucous secretions. The combination of cilia and mucous helps to filter out
solid particles from the air a Warm and moisten the air, which prevents damage to the
delicate tissues that form the Respiratory System. The moisture in the nose helps to
heat and humidify the air, increasing the amount of water vapour the air entering the
lungs contains. This helps to keep the air entering the nose from drying out the lungs
and other parts of our respiratory system. When air enters the respiratory system
through the mouth, much less filtering is done. It is generally better to take in air
through the nose.
To review: The nose does the following:
1.
Filters the air by the hairs and mucous in the nose
2.
Moistens the air
3.
Warms the air
Pharynx
The pharynx is also called the throat. As we saw in the digestive system,
the epiglottis closes off the trachea when we swallow. Below the epiglottis is
the larynx or voice box. This contains 2 vocal cords, which vibrate when air passes by
them. With our tongue and lips we convert these vibrations intospeech. The area at the
top of the trachea, which contains the larynx, is called the glottis.
Trachea
The trachea or windpipe is made of muscle and elastic fibres with rings of
cartilage. The cartilage prevents the tubes of the trachea from collapsing. The trachea is
divided or branched into bronchi and then into smaller bronchioles.
The bronchioles branch off into alveoli.
Bronchi
Similar to trachea with ciliated mucous membrane and hyaline cartilage. Lower
end of trachea divides into right and left this.
Bronchioles
Thinner walls of smooth muscle, lined with ciliated epithelium. Subdivision of
bronchi.At the end, alveolar duct and cluster of alveoli.
Lungs
The lungs are spongy structure where the exchange of gases takes place. Each
lung is surrounded by a pair of pleural membranes. Between the membranes is pleural
fluid, which reduces friction while breathing. The bronchi are divided into about a million
bronchioles. The ends of the bronchioles are hollow air sacs called alveoli. There are
over 700 million alveoli in the lungs. This greatly increases the surface area through
which gas exchange occurs. Surrounding the alveoli are capillaries. The lungs give up
their oxygen to the capillaries through the alveoli. Likewise, carbon dioxide is taken from
the capillaries and into the alveoli.
pathophysiology
MEDICAL
MANAGEMENT
Time
Doctors Order
Rationale
Nursing
Consideration
August 4, 2013
- Please admit to
- Patient has a right to
ROC under the service choose his/her medical
of Dr. Malayan
practitioner or
treatment
- Please secure
consent for this
admission and
management
- An informed consent
is a sign of patient
participation in medical
treatment in written
form.
- TPR q shift and
record pls
-TPR is used to create
baseline parameters.
- DAT
-DAT means that the
patient can eat any
meals as long as
he/she can tolerate.
- IVF D5 0.3 NaCl
500cc x 6hrs at 20 -21
gtts/min
- Temporary treatment
for shock if any plasma
expander is
unavailable and for
patient having
addison’s crisis. For
replacement or
maintenance of fluid
and electrolytes.
- Make sure there
is a witness when
patient signs an
informed consent.
- Observe proper
documentation.
- Carefully check
for regulation to
avoid fluid
overload or
underload.
-
-It is a diagnostic test
that gives information
about the cells in the
patient's blood.
Diagnostics:
a. CBC c platelet
count
b. Chest X-ray AP-L
- It is a radiograph
projection of the chest
used to diagnose
conditions affecting the
chest
- Paracetamol is an
anti-pyretic and
analgesic drug used to
treat fever and pain.
Therapeutics
- Paracetamol 150mg
IV every 4 hrs for temp
38 and above.
- Paracetamol
250mg/5ml, give 4ml
every 4 hrs for temp
37.8 and above
- Monitor I&O every
shift
- I &O is a parameter
that checks how much
fluids has been
consumed or excreted
in the patients body.
- Paracetamol is
given as a PRN
order if the
patient really
needs it.
- Vital signs are
monitored to know
- Always check
how the body functions
for fluid intake
proprerly.
including IVF
consumed
-History taking and
physical examination
are important tools to
know what are the
etiologic factors prior
to a disease.
- Monitor VS every
2hrs
mesuring the fluid and
electrolytes losses by
how manny times the
patient vomit througt
the use of cup method
- Always double
check VS
readings if there
is doubt.
- when doing PE
it should be from
head-toe.
-Do complete Hx and
PE c/o PCIC/PHC
-Replace volume per
volume losses with
PLR
-Dr. Malayan informed
with this condition
- It relieves
inflammation (swelling,
heat, redness, and
pain) and is used to
treat certain forms of
arthritis; skin, blood,
kidney, eye, thyroid,
and intestinal
disorders (e.g., colitis);
severe allergies; and
asthma.
-Refer
- It is used in inhibition
- Rotate sites of
of eosinophil
chemotaxis
IM repository
injections to avoid
local atrophy.
Meds:
- Start hydrocortisone
60mg/IV every 6 hrs
- For maintenance of
losses in fluids and
electrolytes.
- Montelukast is a
- This should be
leuokotreine receptor
given after the
antagonist (LTRA)
patient has eaten.
used for the
maintenance treatment
of asthma and to
relieve symptoms of
seasonal allergies.
- Start cetrizine +
phenylephrine (Alnix
plus) 2.5ml BID in full
stomach
- Replace losses
volume per volume as
ordered
-D5IMB is an IV
solution that consists
of 5% dextrose and
water level. It is
usually given to
patients in hospitals
that could potentially
become ill through
high sodium levels or
low blood sugar levels.
- Assess for drug
hypersensitivity.
- Replace patient
meds:
4 mg chewable tablet
or 4 mg granules orally
- Carefully check
for regulation to
1:30pm
once a day.
- IVF to follow D5IMB
500cc x 11hrs at
45cc/hr
avoid fluid
overload or
underload.
- It is a diagnostic test
that checks the
components of your
urine.
- NS1 (Nonstructural
Protein 1) is a test for
dengue which allows
rapid detection on the
first day of fever,
before antibodies
appear some 5 or
more days later.
- Hold D5IMB instead
IVF to follow
D5NSS 500cc at
4cc/hr
3:45pm
- For repeat cbc with
platelet tomorrow at
6am
- for urinalysis
- for dengue NS1 to
include to next blood
extraction
8:46pm
- cut present
management
August 5, 2013
5pm
7:45am
- IVF for follow D5NSS
500cc at 42cc/hr
- follow up CBC with
platelet result
- Dr. Malayan updated
9am
- for repeat cbc with
platelet tomorrow at
6am(8/6/13)
- Nebulize with
combivent 1 neb every
- For maintenance of
losses in fluids and
electrolytes.
- Carefully check
for regulation to
avoid fluid
overload or
underload.
6hrs via facemask
- rounds with Dr,
Malayan
- Combivent is a drug
used for treating
COPD through
inhalation from a
nebulizer.
- continue present
management
9:45am
- start cefuroxime
250mg n every 8
ANST()
- Cefuroxime is a
parenteral second
generation
cephalosphorin
antibiotic used to treat
infection.
- Assess for drug
hypersensitivity.
- IVF to follow D5NSS
500cc at 42cc/hr
- For maintenance of
losses in fluids and
electrolytes.
3:30pm
August 6, 2013
8:30am
2:30pm
- Continue with
present management
- for repeat cbc with
platelet tomorrow at
6am
- am present
management
- Carefully check
for regulation to
avoid fluid
overload or
underload.
12nn
- IVF to FF: D5NSS at
42cc/hr
- For maintenance of
losses in fluids and
electrolytes.
- Carefully check
for regulation to
avoid fluid
overload or
underload.
-Heraclene
(Dibencozide) Capsule
aids optimal
consumption of
nutritional protein
ingestion and helps in
the development and
restoration of body
tissues and kindles in
the body the desire for
food.
- Advise patient
to avoid products
that contain
caffeine.
August 7, 2013
7:50am
11:30am
- continue present
management
- rounds with Dr.
Malayan
- Heraclene 1mg/cap
OD c/o patient meds,
continue present
management
- Dr. Malayan updated
- for report cbc with
platelet tom at 6am
(8/8/13)
August 8, 2013
8:25am
- Continue present
management
- IVF to follow D5NSS
1 liter at 42cc/hr
1:20pm
- continue present
management
- For maintenance of
losses in fluids and
electrolytes.
- Carefully check
for regulation to
avoid fluid
overload or
underload.
LABORATORY
AND
DIAGNOSTIC
TESTS
COMPLETE BLOOD COUNT (CBC)
The complete blood count or CBC test is used as a broad screening test to check
for such disorders as anemia, infection, and many other diseases.
DATE REQUESTED: August 4, 2013
RESULT
NORMAL
VALUE
INTERPRETATION SIGNIFICANCE
Hemoglobin
132
110-140
NORMAL
Hematocrit
.406
0.37-0.47
NORMAL
RBC count
4.70
4.00-5.50
NORMAL
WBC count
6.50
5.0-10.0
NORMAL
Neutrophils
3.44
1.63-6.96
NORMAL
Lymphocytes
2.25
1.09-2.99
NORMAL
Monocytes
.739
0.240-0.790
NORMAL
Eosinophiles
.005
0.00-0.5%
NORMAL
Basophiles
.064
0.00-0.80
NORMAL
MCV
86.3
80-98
NORMAL
MCH
28.1
26-32
NORMAL
MCHC
325
320-360
NORMAL
RDW
10.2
10.2-14.5%
NORMAL
Platelet count
124
150-450
DECREASED
Indicate risk of
bleeding
DATE REQUESTED: August 6, 2013
RESULT
NORMAL
VALUE
INTERPRETATION SIGNIFICANCE
Hemoglobin
125
110-140
NORMAL
Hematocrit
.387
0.37-0.47
NORMAL
RBC count
4.51
4.00-5.50
NORMAL
WBC count
4.81
5.0-10.0
NORMAL
Neutrophils
2.45
1.63-6.96
NORMAL
Lymphocytes
2.02
1.09-2.99
NORMAL
Monocytes
.309
0.240-0.790
NORMAL
Eosinophiles
0.00
0.00-0.5%
NORMAL
Basophiles
.025
0.00-0.80
NORMAL
MCV
85.9
80-98
NORMAL
MCH
27.8
26-32
NORMAL
MCHC
323
320-360
NORMAL
RDW
10.3
10.2-14.5%
NORMAL
Platelet count
122
150-450
DECREASED
Indicate risk of
bleeding
DATE REQUESTED: August 7, 2013
RESULT
NORMAL
VALUE
INTERPRETATION SIGNIFICANCE
Hemoglobin
119
110-140
NORMAL
Hematocrit
.376
0.37-0.47
NORMAL
RBC count
4.41
4.00-5.50
NORMAL
WBC count
3.76
5.0-10.0
DECREASED
Neutrophils
2.03
1.63-6.96
NORMAL
Lymphocytes
1.41
1.09-2.99
NORMAL
Monocytes
.296
0.2400.790
NORMAL
Eosinophiles
0.00
0.00-0.5%
NORMAL
Basophiles
.024
0.00-.0.80
NORMAL
MCV
85.2
80-98
NORMAL
MCH
26.9
26-32
NORMAL
Decreased due to
inadequate
inflammatory
defenses to suppress
infection.
MCHC
316
320-360
DECREASED
RDW
10.0
10.214.5%
DECREASED
Indicate presence of
anemia.
Indicate presence of
anemia.
Platelet count
122
150-400
DECREASED
Indicate risk of
bleeding
DATE REQUESTED: August 8, 2013
RESULT
NORMAL
VALUE
INTERPRETATION SIGNIFICANCE
Hemoglobin
118
110-140
NORMAL
Hematocrit
.376
0.37-0.47
NORMAL
RBC count
4.41
4.00-5.50
NORMAL
WBC count
4.21
5.0-10.0
DECREASED
Neutrophils
1.42
1.63-6.96
DECREASED
Lymphocytes
2.42
1.09-2.99
NORMAL
Monocytes
.326
0.240-0.790
NORMAL
Eosinophiles
.001
0.00-0.5%
NORMAL
Basophiles
.018
0.00-.080
NORMAL
MCV
26.8
80-98
DECREASED
MCH
26.8
26-32
NORMAL
MCHC
315
320-360
DECREASED
RDW
10.1
10.2-14.5%
DECREASED
Platelet count
176
150-400
NORMAL
Decreased due to
inadequate
inflammatory
defenses to suppress
infection.
Decreased. May
indicate increase risk
of infection
Indicate presence of
anemia
Indicate presence of
anemia
Indicate presence of
anemia
CHEST X-RAY (CHEST RADIOGRAPHY)
The chest x-ray is the most commonly performed diagnostic x-ray examination. A
chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of
the spine and chest.
DATE REQUESTED: August 4, 2013
EXAMINATION DONE: Chest X –ray Posterior Anterior
Interpretation:
-
The interstitial lung markings are accentuated with fine reticulation in the
parihilar areas.
The heart is not enlarged
Diaphragm and sulci are normal
Visualized bones are intact
Impression: INTERSTITIAL PNEUMONITIS CONSIDERED
URINALYSIS
The urinalysis is used as a screening and/or diagnostic tool because it can help
detect substances or cellular material in the urine associated with different metabolic
and kidney disorders. It is ordered widely and routinely to detect any abnormalities that
require follow up.
DATE REQUESTED: August 4, 2013
RESULT
Color:
Light Yellow
Transparency:
Reaction (pH):
Glucose:
Protein
Ketones:
Specific
gravity:
Slightly Hazy
6.5
Negative
Negative
2.020
NORMAL
VALUE
Straw to Dark
Yellow
Clear-Hazy
5-8.5
Negative
Negative
Negative
1.003-1.029
INTERPRETATION SINIFICANT
Pus cells:
10-12/hpf
2-3/hpf
INCREASED
RBC
1-2/hpf
NORMAL
Epithelial
Cells
Few
Male: 0-3/hpf
Female: 05/hpf
Raremoderate
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
INCREASED
NORMAL
Indicate
presence of
dehydration
Indicate
presence of
infection
DENGUE NS1 Ag Assay Test
This test is use for early diagnosis of dengue virus infection
DATE REQUESTED: August 5, 2013
TEST NAME
RESULT
Negative
Dengue NS1Ag
: IgG Negative
: IgM Negative
Drug study
Drug Name
Generic Name:
Cefuroxime axetil
Brand Name:
Ceftin
Classification:
Cephalosporin 2nd
generation
Dosage:250mg/5
ml
Frequency:Q8
Mode of Action
-Secondgeneration
cephalosporin
that inhibits cellwall
synyhesis,promot
ing osmotic
instability;usually
bactericidal.
Indication
-Lower respiratory
infection
Interaction
-Amino
glycosides
-Loop diuretics
-Probenecid
Side Effect
Nursing Consideration
GI: nausea and vomiting
-Determine history of
hypersensitivity reactions to
drugs.
SKIN: rash,pruritus,
urticaria
-Check the IV site before
giving the medicartion.
Contraindication:
-Contraindicated in
patients
hypersensitivity to
cephalosporin
-Instruct the parent or
guardian of the patient to
Notify the prescriber about
rash or evidence of
superinfection.
-Administer medication with
meals to decrease GI upset
and enhance absorption.
Route: IV
-Advise the parent or
guardian of the patient to re
portloose stools or
diarrhea.
Drug Name
Mode of Action
Generic Name:
citirizine
+penylphrine
-A long-acting
nonsedating
antihistamine that
selective inhibits
pheripera H1
receptor.
Brand Name:
Alnix Plus
Classification:
Antihistamine
Dosage: 2.5ml
Frequency: BID
Route: P.O
Indication
-Seasonal allergic
rhinitis
-Perennial allergic
rhinitis,chronic
urticaria
Contraindication:
-Contraindicated in
patients
hypersensitivity to
drug.
-Use cautiously in
patients with renal
and hepatic
impairement.
Interaction
- CNS
depressant
-Theophylline
-Barbiyuates
-Hypnotics
-Opiod
analgesics
Side Effect
-somnelence,head
ache,
dizziness,fatigue.
-pharyngitis
-dry mouth,nausea,
vomiting,abdominal
distress.
-couhing,bronchospasm
Nursing Consideration
-Assess for allergy
symptoms: rhinitis, pruritus,
urticaria, watering eyes,
before and periodically
during treatment.
-Assess respiratory status
and increase in bronchial
secretions, wheezing, chest
tightness: provide fluids to
decrease viscosity or
thickness of secretion.
-Instruct the patient’s family
to take 1hr before or 2 hrs
after a meal to facilitate
absorption.
-Advise pts family to use
sugarless gum, candy,
frequent zip of water of
minimize dry mouth.
-Instruct pts family to inform
physician if dizziness
occurs or if symptoms
persist.
Drug Name
Mode of Action
Generic Name:
clarithromycin
-Inhibits protein
synthesis in
susceptible
bacteria, causing
cell death.
Brand Name:
Klaz
Classification:
Macrolide
Antibiotic
Dosage:250mg/5
ml
Frequency: BID
(on full stomach)
Route: PO
Indication
-Bacterial infection
(pneumonia)
Contraindication:
-Contraindicated in
patients
hypersensitivity to
clarithromycin,
erythromycin, or
any macrolide
antibiotic.
Interaction
-Alprozalam
Carbamazepine
-Cyclosporine
-Digoxin
-Ritonavir
-Thophylline
-Fluconazole
-Warfarin
Side Effect
Nursing Consideration
CNS:dizziness,
headache, vertigo,
fatigue
-Assess bowel
pattern,discontinue drug if
severe diarrhea occurs.
GI: diarrhea,
abdominal pain or
discomfort,nausea,vo
miting,
pseudomembranous
colitis.
-Assess patient’s infection
before therapy and regularly
thereafter.
-Take drug with food if GI effects
occur.Do not drink grapefruit
juice while taking this drugs.
SKIN: rash(pediatric)
HEMATOLOGIC:
leukopenia,coagulati
on abnormalities.
-Shake suspension before use:
do not refrigerate.
-Instruct the pts family to take all
medication prescribed for the
length of time ordered and to
continue drug therapy as
prescribed even he feels better.
-Instruct the pts family to report
persistent adverse reactions.
-Advise the pts family to report
diarrhea, rash or itching, mouth
sores.
Drug Name
Mode of Action
Generic Name:
dibencozide
-Dibencozide
increases the
protein efficiency
coefficient ie, the
percentage of
bound nitrogen
for protein buildup in the body
compared to
ingested nitrogen
with food intake.
BrandName:
Heraclene
Classification:
Appetite
Stimulants
Dosage:1mg
Frequency:OD
Route:
Indication
-Premature babies, low birth weight,
retarded growth,
poor appetite in
infants, children and
adults.
Contraindication:
- Hypersensitivity to
drugs or its
ingredients
Interaction
Side Effect
GI: Constipation,
Diarrhea, N/V.
Nursing Consideration
-Advise the parent of the
patient to avoid products
that contain caffeine.
CV: Tachycardia
CNS: Overstimulation,
Headache, Dizziness,
Insomnia
-Report any evidence of
excessive stimulation
Drug Name
Generic
Name:
hydrocortisone
sodium
succinate
Mode of Action
-Decreases
inflammation,mainl
y by stabilizing
leukocyte
lysosomalmembra
nes;suppresses
Brand Name:
immune
Solu-Cortef
response;stimulate
s bone
Classification: marrow;and
Corticosteroids/ influences
Antiprotein,fat,and
inflammatory
carbohydrate
metabolism.
Dosage:60mg
Frequency:
Q 6hrs
Route: IV
Indication
-Severe
inflammation,
-Adrenal
insufficiency
-Shock
Contraindication:
-contraindicated in
patients
hypersensitivity to
drug or its
ingredients,in
those receiving
immunosuppressiv
e
doses together
with live virus
vaccine,and in
premature infants.
Interactio
n
Side Effect
Nursing Consideration
-NSAID’s
Cyclospori
ne
-Oral
anticoagul
ants
Pottasiumdepleting
drugs
-Skin-test
antigen
-headache
nausea/vomi
ting
-easy
bruising
carbohydrate
intolerance
-GI irritation
-growth
suspension
in
children,mus
cle
weakness
-Assess the pt’s condition before
starting therapy and reassess
regularly.
-Tell the parents or guardian of
the patient not to stop drug
abruptly or without prescriber’s
consent.
-Warn the parents or guardian of
the patient on long-term therapy
about cushing effects (moon
face,buffalo hump) and need to
notify prescriber about sudden
weight gain or swelling,ang easy
bruising.
-Monitor the patient’s weight and
electrolyte level.
-Instruct the parents or guardian
of the patient to take Vit.D and
calcium supplement.
-Encourage the parents or
guardian of the patient to deep
breathing exercise.
-Teach the parents or guardian
of the patient sign and
symptoms of early adrenal
insufficiency:
fatigue,muscleweakness,jointpai
n,fever,anorexia,nausea,
Shortness of
breath,dizziness,and fainting.
Drug Name
Mode of Action
Generic Name:
paracetamol
- Unknown.
Thought to
produce
analgesia by
blocking pain
impulses by
inhibiting
synthesis of
prostaglandin in
the CNS or other
substances that
sensitize pain
receptors to
stimulation.The
drug may relieve
fever through
central action in
the hypothalamic
heat regulating
center.
Brand Name:
Tempra
Classification:
Analgesic/Antipyre
tic
Dosage:
250mg/5ml
T - >37.8
Frequency:Q4
Route: PO
Indication
-Mild pain or fever
Contraindication:
-Contraindicated in
patients
hypersensitivity to
drugs.
Interaction
- Barbiturates
- Carbamazepine
- Hydantoins
- Fifampin
- Sulfinpyrazone
Side Effect
- hemolytic
anemia
- neutropenia
- leukopenia
- pancytopenia
- jaundice
- rash
- urticaria
Nursing Consideration
-Assess pts fever: temperature,
diaphoresis.
-Give with food or milk to
decrease gastric symptoms;give
30mins before or 2hrs after
meals;absorption may be
slowed.
- Advise the parents to do tepid
sponge bath (TSB) to lower the
body temperature (if the pt. is
febrile 38 and above).
- Tell parents to consult
prescriber before giving drug to
children younger than age 2.
-Advise the parent of the patient
that the drug is only for shortterm used and to consult
prescriber if giving to children for
longer than 5 days.
-Tell parents to increase fluid
intake to prevent dehydration.
Drug Name
Mode of Action
Generic Name:
paracetamol
- Unknown.
Thought to
produce
analgesia by
blocking pain
impulses by
inhibiting
synthesis of
prostaglandin in
the CNS or other
substances that
sensitize pain
receptors to
stimulation.The
drug may relieve
fever through
central action in
the hypothalamic
heat regulating
center.
Brand Name:
Classification:
Analgesic/Antipyre
tic
Dosage:
150mg
T - >38
Frequency:Q4/pr
n
Route: IV
Indication
-Mild pain or fever
Contraindication:
-Contraindicated in
patients
hypersensitivity to
drugs.
Interaction
- Barbiturates
- Carbamazepine
- Hydantoins
- Fifampin
- Sulfinpyrazone
Side Effect
- hemolytic
anemia
- neutropenia
- leukopenia
- pancytopenia
- jaundice
- rash
- urticaria
Nursing Consideration
-Assess pts fever:
temperature, diaphoresis.
-Give with food or milk to
decrease gastric
symptoms;give 30mins
before or 2hrs after
meals;absorption may be
slowed.
-Assess the IV site before
giving medication.
- Advise the parents to do
tepid sponge bath (TSB) to
lower the body temperature
(if the pt. is febrile 38 and
above).
- Tell parents to consult
prescriber before giving
drug to children younger
than age 2.
-Advise the parent of the
patient that the drug is only
for short-term used and to
consult prescriber if giving
to children for longer than 5
days.
-Tell parents to increase
fluid intake to prevent
dehydration.
Drug Name
Mode of Action
Generic Name:
montelukast
sodium
Selective,competitive leukotriene
receptor antagonist
that reduces early
and late-phase
bronchoconstriction
from antigen
challenge.
Brand Name:
Singulair
Classification:
Bronchodilator
Indication
-asthma
-seasonal allergic
rhinitis
Interaction
Phenobarbital
-Rifampin
Side Effect
Nursing
Consideration
CNS:fever,headache,
dizziness,fatigue.
-Assess
patient’s
underlying
EENT:nasal
condition before
congestion,dental pain
therapy and
regularly
GI:dyspepsia,infectious
thereafter to
gastroenteritis,abdominal monitor drug
pain
effectiveness.
Contraindication:
Dosage:4mg
granules
Frequency:
ODHS
Route: PO
RESPIRATORY:cough
-Contraindicated in
patients
hypersensitivity to
drug.
-Use cautiously
and with
appropriate
monitoring in
patients whose
dosages of
systemic
corticosteroids are
reduced.
.
SKIN:rash
-Assess
respiration
ausculted
bilateral lung
fields:rate and
rhythm.
-Assess for
allergic
reactions: rash,
urticaria, and
pruritus.
-Take with or
without
food.May give
directly in
mouth or mixed
w/a spoon of
soft food
(carrots, apple
sauce, juice,
milk rice).
-Assess
patien’s and
family’s
knowledge of
drug therapy.
Nursing
Care
plan
CUES
Objective:
• Nasal
Flaring
• Abnormal
breath
sounds.
(crackles)
 Productive
cough
(transparent)
V/S taken as
follows:
RR-35
PROBLEM
Ineffective
airway
clearance
related to
increase
production of
mucus
secretion
SCIENTIFIC
REASON
Ineffective airway
clearance occurs
when an artificial
airway is used
because normal
mucociliary transport
mechanisms are
bypassed and
impaired.
DESIRED
OUTCOME
Short term goal:
After 6 hours of
Nursing
Intervention, the
Patient breathes
without using nasal
flaring.
Long term goal:
After 3 days of
nursing intervention
the patient breathes
normally.
INTERVENTION/
RATIONALE
Independent:
• Auscultate breath
sounds. Note
adventitious breath
sounds like wheezes,
crackles and rhonchi.
Rationale:
• Some degree of
bronchospasm is
present with
obstructions in airway
and may or may not be
manifested in
adventitious breath
sounds.
• Keep
environmental
pollution to a minimum
like dust, smoke and
feather pillows,
according to individual
situation.
Rationale:
• Precipitators of
allergic type of
respiratory reactions
EVALUATION
STANDARD
CRITERIA
The patient
will be able
to breathes
without nasal
flaring with
RR of 35bpm
to 28bpm
Outcomes
partially met,
the patient
was able to
demonstrate
behavior to
improved
airway
clearance
that can trigger or
exacerbate onset of
acute episode.
• Encourage or
assist with abdominal
or pursed lip breathing
exercises.
Rationale:
• Provides patient
with some means to
cope with or control
dyspnea and reduce
air tapping.
• Assist with
measures to improve
effectiveness of cough
effort.
Rationale:
 Coughing is most
effective in an
upright position
after chest
percussion.
 Position
appropriately and
discourage use of
oil-based products
around nose.
Rationale:
 To prevent vomiting
with aspiration into
lungs.
 Obtain sputum
specimen,
preferable
 before antimicrobial
therapy is initiated.
Rationale:
 To verify
appropriateness of
therapy.
COLLABORATIVE:
 Administered
analgesics.
Rationale:
 To improve cough
when pain is
inhibiting effort.
CUES
PROBLEM
SCIENTIFIC
REASON
DESIRED
OUTCOME
INTERVENTION/
RATIONALE
EVALUATION
STANDARD
Subjective:
Risk for further
infection
r/t
spread
of
pathogens
Objective:
Patient secondary to
is diagnosed identified
PCAP
with PCAP
Vital
Sign
RR: 35 cpm
HR:142 bpm
TEMP: 36.6
WT: 14.1 kg
Decrea
sed
WBC
level 4.21
The patient’s immune
system is not fully
activated
until
sometime after birth.
Limitation
in
the
patient’s inflammatory
response result in
failure to recognize,
localize, and destroy
invasive bacteria thus,
increasing risk for
infection
Short term goal:
INDEPENDENT
After 8 hrs of nursing
1. assess TPR,
intervention
auscultate
the patient will free
breath sounds
from further infection
- Assessments
provide
Long term goal:
information about
After several days of
the
spread
of
nursing intervention
infection,
infection
will
be
increased RR and
prevented.
HR, decreased BP
are
signs
of
sepsis. Spread of
infection
may
cause
resp.
distress
2. Ensure that all
people coming
in contact with
patient. wash
their
hands
well before &
after touching
the patient.
- Hand
washing
prevents
the
spread
of
pathogens coming
from the patient to
CRITERIA
The patient After 8 hrs of
will exhibit nursing
no signs of
intervention
infection
the patient are
Free
from
further
infection
-
-
the caregiver and
vice versa
3. Ensure that all
equipment
used for patient
is
sterile,
scrupulously
clean
&disposable.
Do not share
equipment with
other patient.
this would prevent
the
spread
of
pathogens to the
patient
from
equipment
4. Place patient
in
isolette/
isolation room
per
hospital
policy
placing the patient
in
an
isolette
allows
close
observation of the
ill
neonate
&
protects
other
patient
from
infection
5. maintain
neutral thermal
-
-
-
environment
A neutral thermal
environment
decreases
the
metabolic needs of
the patient. The
patient
has
difficulty
maintaining
a
stable temp
6. Provide
respiratory
support
(oxygen)
resp. support may
be needed during
the acute phase of
the infection to
prevent additional
physiological
stress
7. Monitor
lab
results
as
obtained.
Notify
care
giver/ physician
of
abnormal
findings
lab results provide
information about
the pathogen and
patient’s response
to
illness
and
-
-
treatment
8. administer IV
fluids
as
ordered
(D10IMB)
IV
fluids
help
maintain
fluid
balance
9. Administer
antibiotics as
ordered.
Antibiotics act to
inhibit the growth
of bacteria and
destruction
of
bacteria.
CUES
Subjective:
PROBLEM
Risk for
Deficient Fluid
”Anim na bases Volume may
na siyang
includeexcessi
nagsusuka.” As ve fluid loss
verbalized by
(fever, profuse
the patient’s
diaphoresis,
caregiver
mouth
breathing/hyp
erventilation,
Objective:
vomiting)
•Restlessness
•Vomiting (6x)
•Fatigue
•V/S taken as
follows:
RR: 35 cpm
HR:142 bpm
TEMP: 36.6
WT: 14.1 kg
SCIENTIFIC
REASON
DESIRED
OUTCOME
INTERVENTION/
RATIONALE
Fluid volume
deficit, or
hypovolemia,
occurs from a
loss of body fluid
or the shift of
fluids into the
third space, or
from a reduced
fluid intake.
Common
sources for fluid
loss are the
gastrointestinal
tract, polyuria,
and increased
perspiration.
Fluid volume
deficit may be an
acute or chronic
condition
managed in the
hospital
outpatient
center, or home
Short term
goal:After 8 hrs
of nursing
interventionthe
patient will
demonstrate fluid
balance
evidenced by
individually
appropriate
parameters, e.g.,
moist mucous
membranes,
good skin turgor,
prompt capillary
refill, stable vital
signs.
1. Assess vital
sign changes,
e.g.,
increased
temperature/p
rolonged
fever,
tachycardia,
orthostatic
hypotension.
Long term
goal:After
several days of
nursing
intervention the
patient will
experience fluid

Elevated
temperature/
prolonged
fever
increases
metabolic
rate and fluid
loss through
evaporation.
Orthostatic
BP changes
and
increasing
tachycardia
EVALUATION
STANDARD
The client will
remain show
no signs and
symptoms of
dehydration
Subjective:
”Anim na
bases na
siyang
nagsusuka.”
As verbalized
by the
patient’s
caregiver
Objective:
•Restlessness
•Vomiting (6x)
•Fatigue
•V/S taken as
follows:
RR: 35 cpm
HR:142 bpm
setting.
balance.
may indicate
TEMP: 36.6
WT: 14.1 kg
CUES
Subjective:
Objective:
•Use of
accessory
muscle.
•Productive
cough
(transparent)
•Restlessness
•Fatigue
•V/S taken as
follows:
RR: 35 cpm
HR:142 bpm
TEMP: 36.6
PROBLEM
Acute pain r/t
localized
inflammation
and persistent
cough.
SCIENTIFI
C REASON
Pneumonia
is
inflammatio
n of the
terminal
airways and
alveoli
caused by
acute
infection by
various
agents.
Pneumonia
can be
divided into
three
groups:
community
acquired,
hospital or
nursing
home
acquired(no
socomial),
and
pneumonia
DESIRED
OUTCOME
Short term
goal:
After 4hrs of
nursing
interventionthe
patient will relief
of pain and
demonstrate
relaxed manner,
resting/sleeping
and engaging in
activity
appropriately.
Long term
goal:
After several
days of nursing
intervention the
patient will
display patent
airway with
breath sounds
INTERVENTION/
RATIONALE
EVALUATION
STANDARD
CRITERIA
INDEPENDENT
The patient will
relief of pain
1. Elevate head of and
the bed, change
demonstrate
position
relaxed
frequently.
manner,
resting/sleepin
 Lowers
g and
diaphragm,
promoting chest engaging in
activity
expansion and
expectoration of appropriately
secretions.
2.Assist patient
with deep
breathing
exercises

Deep breathing
facilitates
maximum
expansion of
the lungs and
smaller
airways.
The patient will
free from pian
The patient
was relief on
pain and
demonstrated
relaxed
manner,
resting/sleepi
ng and
engaging in
activity
appropriately.
in an
immune
compromis
ed person.
Causes
include
bacteria
(Streptococ
cus,
Staphyloco
ccus
Haemophilu
sinfluenzae,
Klebsiella,L
egionella).
Community
Acquired
Pneumonia
(CAD) is a
disease in
which
individuals
who have
not recently
been
hospitalized
develop an
infection of
clearing
3. Demonstrate or
help patient learn
to perform activity
like splinting chest
and effective
coughing while in
upright position.

Coughing is a
natural selfcleaning
mechanism.
Splinting
reduces chest
discomfort, and
an upright
position favors
deeper, more
forceful cough
effort.
4. Force fluids to
at least 3000
ml per day and
offer warm,
rather than
cold fluids.

Fluids
especially warm
the lungs. It
is an acute
inflammator
y condition
that’s result
from
aspiration
of
oropharyng
eal
secretions
or stomach
contents in
the lungs.
liquid said in
mobilization
and
expectoration of
secretions
COLLABORATIVE
5. Administer
medications as
prescribe:
mucolytics or
expectorants.

Aids in
reduction of
bronchospasm
and
mobilization of
secretions.
6. Provide
supplemental
fluids.

Fluids are
required to
replace losses
and aid in
mobilization of
secretions.