Case Study of a 1-year-old Infant with
Severe Pneumonia
Presented to
CHINESE GENERAL HOSPITAL COLLEGES
In Partial Fulfillment
of the Requirements for the Course
N-109 MCN 2 RLE
By:
Masangkay, Christine Darla V.
BSN-2C
Submitted to:
Ms. Ma. Cristabelle Denofra
MARCH 03, 2023
1. ASSESSMENT
A. CLIENT’S PROFILE
I. GENERAL INFORMATION
CLIENT’S INITIALS: JJSD
DATE OF ADMISSION: FEBRUARY 22, 2023
AGE: 1 Y.O.
HOSPITAL/INSTITUTION: CGHMC
SEX: MALE
WARD/AREA AND BED NUMBER: COP CHARI-PD04
Source of Information (if client is child): REPRESENTATIVE’S INITIALS: MJS
RELATIONSHIP TO CLIENT: MOTHER
FOR NEONATES/INFANTS:
BIRTH DATE: JULY 18, 2021
BIRTH PLACE: CALOOCAN
MANNER OF DELIVERY: CESAREAN DELIVERY
AGE OF GESTATION UPON BIRTH: 37 WEEKS AOG
BIRTH WEIGHT: 2.9 kg
FOR PEDIATRIC CLIENTS (18 YEARS OLD AND BELOW):
NUMBER OF SIBLINGS: 1
AGES OF EACH SIBLING: 3 Y.O. (MALE)
ORDINAL POSITION IN THE FAMILY: SECOND CHILD
IMMUNIZATION STATUS:
Vaccine
Dose
BCG
1
HEP B
1
DTWP/DTAP
3
OPV/IPV
3
HiB
3
PnCV
3
Measles
1
Influenza
1
IPV
1
OCCUPATION: N/A
CIVIL STATUS: SINGLE
II.
III.
IV.
V.
MEDICAL DIAGNOSIS
A 1-year-old male patient was diagnosed with Pediatric Community
Acquired Severe Pneumonia.
OPERATION (if any)
No medical operation was performed for health management.
CHIEF COMPLAINT
Chief Complaint: Cough
BRIEF HISTORY OF PRESENT HOSPITALIZATION
Apparently, the patient was well 3 days prior to hospitalization. Patient
was said to have undocumented low grade fever without other associated
symptoms noted such as vomiting, cough and colds, loss of appetite. The patient
was given Paracetamol drops at an unidentified dose and no consultation was
done.
2 days prior to hospitalization, the patient experienced resolved fever, but
was noted with a productive cough with cold associated with no other symptoms
such as vomiting, loss of appetite, and difficulty of breathing. Patient was given
self-medicated Carbocisteine (RobiKids) which provided no resolution, and no
consultation was done.
Few hours prior to client’s admission, persistent cough with notable
difficulty of breathing, subcostal retractions, pallor, and circumoral cyanosis was
present and observed. Patient was sent to the nearest hospital where
administration of Salbutamol nebulization was given every 15 minutes for 3 doses
offering no relief. Patient was advised to transfer to tertiary hospital, hence
admission.
B. NURSING HISTORY (narrative format per health pattern)
I. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN
Mrs. MJS, mother of Patient JJSD, stated that her son has never been
hospitalized before for any reason, thus this is his first hospitalization. She also
claimed that there was no history of illness in their family. Patient JJSD did not
have any illnesses or known allergies in the past 6 months. When asked what she
does to maintain her son’s health, Mrs. MJS said that her son takes vitamin
supplements, specifically Growee, Ceelin, and Tiki-Tiki. The use of cigarettes,
alcohol, and drugs were prohibited. Patient’s mother also affirmed that it is easy
for them to follow all of the doctor's suggestions and there were no beliefs and
practices followed when it comes to their health management.
II.
NUTRITION AND METABOLIC PATTERN
Milk, rice, bread, and biscuits make up Patient JJSD’s typical diet, which
he consumes 2 to 3 times a day. Patient JJSD also drinks yakult and chuckie. Mrs.
MJS also added that she supplements her son’s daily diet with vitamins like
Growee. She claimed that client JJSD consumed 1 to 2 glasses of water each day.
The patient’s appetite is noted to be good. Patient JJSD had no discomfort in
eating or drinking except now that he was ordered of NPO (Nothing by mouth)
due to endotracheal intubation. His weight is 8.5 kilograms and his height is 2’7
feet and 31.5 inches. Patient JJSD’s BMI is unidentified as the body mass index of
children below 2 years old cannot be calculated (CDC, 2022).
III.
ELIMINATION PATTERN
Patient JJSD defecates twice per day, depending on how much he ate for
that specific day. According to Mrs. MJS, her son’s feces has a paste-like
consistency, color green but most often occurs light brown. She also stated that
client JJSD did not have any discomfort or complaint about his usual pattern of
bowel movement. Prior to admission, the patient was able to regularly eliminate,
but during hospitalization he was not able to defecate since admission. Patient
JJSD saturates 8 to 10 diapers per day. His usual urine appears light yellow in
color. He did not have any discomfort when urinating as per his mother's
statement. Mrs. MJS also stated that her son experiences excess expiration.
Patient has no odor problems.
IV.
ACTIVITY-EXERCISE PATTERN
The patient’s daily routine activities include playing, running, and walking
around the house. Patient JJSD was active and had enough energy to complete
such activities. One of his leisure activities is to watch and play with his older
brother. These activities include social play and his favorite toys to play with are
stuffed toys and puzzles.
V.
SLEEP-REST PATTERN
According to Mrs. MJS, prior to confinement, patient JJDS sleeps at 12
midnight as he waits for his parents to finish work and wakes up at 9:00 in the
morning. His afternoon nap is at 2 pm. Patient has 9 hours of sleep and has no
nightmares; able to get enough rest. During hospitalization, client JJDS usual
pattern of sleep was disturbed because there were few procedures that needed to
be performed to monitor him from time to time. He is sometimes irritable so he
can only sleep every 2 hours.
VI.
VII.
COGNITIVE-PERCEPTUAL PATTERN
As per Mrs. MJS, patient JJDs has no deficit in hearing and vision.
Patient’s visual acuity was last checked around December to January according to
her mother’s statement.
SELF-PERCEPTION AND SELF-CONCEPT PATTERN
Mrs. MJS described patient JJDS as playful and active before
hospitalization. She also stated that her son recently experienced weight loss.
Client JJDS frequently feel angry, annoyed or frustrated when playing. Patient
JJDS had been inactive since admission due to intubation.
VIII.
ROLE-RELATIONSHIP PATTERN
Patient JJSD lives with his mother, father, brother, and his father’s sibling
(brother). According to Mrs. MJS statement, she doesn’t experience any difficulty
when handling family problems. If there are family problems, she and her partner
usually handle it by communicating effectively and thoroughly with each other.
When asked about how she feels about her son’s hospitalization, she stated that
she felt sad and hurt, but it doesn’t hinder her from trusting the doctors and the
nurses. Patient’s representative also stated that she has close friends to rely on.
IX.
HOME AND ENVIRONMENT
Patient JJSD lives in a two-storey house with two bedrooms, living room,
dining room and a business room. It is a mixed type of house composed of wood
and cement, moderate or medium in size. Patient JJSD lives in a neighborhood
beside a Christian church, so it is usually normal to have a busy and quite loud
environment especially on weekends.
X.
SEXUALITY-REPRODUCTIVE PATTERN
Sexuality-reproductive pattern is not applicable as the client is a
1-year-old pediatric patient.
XI.
COPING-STRESS TOLERANCE PATTERN
Mrs. MJS, patient JJSD’s representative, affirmed that there have been no
big and significant changes in their life in the past year since hospitalization.
During times of stress, coffee usually helps her. To be able to handle and solve
problems, she and her husband communicate.
XII.
XIII.
VALUE-BELIEF PATTERN
Mrs. MJS stated that the most important things in her life are her children.
Roman Catholicism is their religion and they go to church every weekend,
specifically Sunday, to attend mass and worship God which she said helps them
when difficulties arise.
OTHERS
Mrs. MJS, the mother of patient JJSD, stated that she hopes for her baby’s
fast recovery.
C. PHYSICAL EXAMINATION (narrative format per organ system)
I. VITAL SIGNS/ANTHROPOMETRIC MEASURES
Temperature
36.4 degrees Celsius
Respiratory Rate 36 breaths per minute
oral, axilla, rectal
regular, irregular
afebrile, febrile
Blood Pressure 100/70 mm Hg
Heart/Pulse Rate 124 beats per minute
right arm, left arm
regular, irregular
lying, sitting, standing
strong/bounding, weak/faint, absent
symmetrical, asymmetrical
warm to touch, cold to touch
Height (for infants, indicate length) = 80 cm; 2’7 feet; 31.5 inches
Weight = 8.5 kg
During physical examination, patient JJSD’s temperature is 36.4 degrees celsius. His
heart rate counts 124 beats per minute noted with regular, strong and bounding heart sounds. The
patient was observed to have a regular respiratory rate of 36 breaths per minute, and blood
pressure of 100/70 mm Hg obtained from his right arm in a supine lying position.
FOR CHILDREN:
Is height and weight appropriate for age? See growth chart.
Growth and Development milestones
THEORY
Physical
FINDINGS
The patient’s weight upon birth is 2.9 kg (normal) and
gained weight, which is currently 8.5 kg at the age of 1.
His height upon birth is 51 cm (normal) and his current
height is 80 cm. In head circumference, upon birth it is
35 cm and it is currently 46 cm. His chest
circumference upon birth is 34 cm, while the current
CC of DJJ is 50 cm. His abdominal circumference is 34
cm and now, it is 51 cm. DJJ usually sleeps 12 at
midnight and wakes up at 9 in the morning. He also
sleeps in the afternoon, usually 2 pm.
Psychosexual (Freud)
According to the mother of DJJ, he starts thumb
sucking at the age of 3 months. Sometimes, he puts
toys in his mouth or some things that he finds
interesting. He is usually in his diaper even in their
house. Sometimes, he gets irritable when wearing
diapers, especially when it is hot.
Psychosocial (Erikson)
The mother stated that the patient started to
demonstrate awareness or familiarity of faces at the age
of 4 months. He cries when someone he doesn’t know
tries to hold him. His first social smile was observed by
the mother at the age of 2 months. Sometimes, DJJ
cries or gets angry when someone takes away his toy.
He also cries when someone is mad. He smiles or
giggles when someone is talking to him in a playful
voice. At the age of 1 year old, he prefers to feed
himself than letting others do it for him. He is active
and very playful. He likes to play, run, and walk around
the house. He rarely gets mad or gets tantrums when
things don't go his way.
Cognitive (Piaget)
According to the mother, DJJ doesn’t throw his toys
when he throws a tantrum, which he rarely do
(tantrums). He likes to share his toys and play with his
brother.
Moral (Kohlberg)
The mother stated that DJJ often follows what his
parents tell him what to do. He knows what is good and
bad based on what his parents say. He didn’t adapt
some bad behaviors that his other playmates display,
such as hurting or getting mad with playmates.
II.
GENERAL APPEARANCE
Patient JJSD’s body frame is small. His head circumference measures 46 cm with
chest circumference of 50 cm and abdominal circumference of 51 cm. The patient’s
posture is upright with normal and coordinated gait. As for dress, grooming, and hygiene,
the patient is notably appropriately well-groomed with good body and breath odor. No
obvious physical deformities are noted.
III.
MENTAL STATUS
Upon examination, the patient is conscious and oriented especially with the
people around him. Patient JJSD’s emotional status is cooperative, irritable and resistive
from time to time. Language and communication was not applicable as no words were
noted, only mumbles.
IV.
SKIN
Upon examination, patient JJSD’s skin color is normally pinkish and symmetrical
all throughout his body. His skin was warm to touch, dry, intact and smooth in texture
with notable good skin turgor. Hair is thick and evenly distributed. No significant lesions
and edema was observed.
V.
HEAD AND FACE
Patient JJSD’s head is normocephalic and appears to be proportionate with his
body size. Upon inspection, there are no tenderness, lesions, visible or palpable masses,
depressions noted. The patient’s hair has normal texture, smooth, shiny and evenly
distributed. Facial symmetry and movement are observed symmetrical.
VI.
EYES
Upon examination of the eyes, the condition is straight normal. Eyebrows and
eyelashes appear to be intact, long and thick, and eyelids are symmetrical. There is no
edema or any discoloration observed in the periorbital region. Patient JJSD’s blink
response is spontaneous. Eyeballs are symmetrical, conjunctivae are pinkish and sclerae
are white. Pupils are symmetrical in size, and are reactive to light and accommodation
(PERRLA). Visual acuity and peripheral vision appears to be normal, and six ocular
movements are coordinated.
VII.
EARS
Patient JJSD’s ear color is the same as the facial skin, external pinnae are
symmetrical in position, mobile, firm, and non tender. External canal contains hair
follicles and there are no lesions, nor discharge. The client was able to hear normal voice
sounds symmetrically with both ears.
VIII.
NOSE
The patient’s nasolabial fold is symmetric, and septum appears to be intact and
located at the midline. Mucous membrane is pink and there are no lesions. The client was
able to smell and air moves patently as the client breathed through the left and right
nostril. No tenderness on the sinuses, no masses and pain was noted.
IX.
MOUTH
Patient JJSD’s lips appear to be soft but dry. The patient’s tongue is pink and is
located at the midline with no nodules and lumps. His teeth are intact and continue to
grow. Gums are pink with no swelling and lesions. The patient’s speech is noted to be
mumbling.
X.
PHARYNX
The patient’s uvula is located at the midline and is light pink in color. Hard and
soft palate appears to be soft, intact, and at the midline. Tonsils are moist and no
inflammation was observed. Upon assessment, gag reflex is present.
XI.
NECK
Patient JJSD’s head movement is coordinated with normal muscle strength.
Lymph nodes are non palpable and non tender. The trachea is located at the midline,
symmetrical with no visible masses or enlargement.
XII.
BREAST AND AXILLAE
The patient’s breast size and symmetry is equal, contour is flat, and there is no
redness or edema observed in the skin. Breast and axillae appear to be non tender. Nipple
and areola are symmetrical in size, shape and color which seems to be normal.
XIII.
CHEST AND LUNGS
Upon the assessment of the chest and lungs, the patient’s inspiration-expiration
ratio is 1:2. Breathing pattern is regular with respiration rate within the normal values.
Antero-posterior-lateral ratio is symmetrical, no bulges or tenderness was noted and
observed. Chest expansion is symmetrical upon inspiration and expiration. Upon
examination and auscultation, adventitious breath sounds are present, specifically
wheezes.
XIV.
HEART
The patient’s precordial area is flat. The point of maximal impulse, apical pulse, is
regular and strong, palpable and audible upon palpation and auscultation. Heart sounds
are strong and bounding with no extra heart sounds.
XV.
ABDOMEN
Upon inspection of patient JJSD’s abdomen, there are no scars, rashes or any
lesions observed. His abdomen is symmetrical in configuration. There are no palpable
masses or tenderness upon palpation and bowel sounds are normal upon percussion. The
umbilicus appears to be sunken.
XVI.
GENITALIA AND ANUS
No pubic hair is present, penis is not retracted and testes appear to be descended.
There are no tenderness, nodules, and masses in the rectum and anus upon examination.
XVII.
BACK AND EXTREMITIES
Patient JJSD’s peripheral pulses are symmetrical and regular. Joints are non
tender, and there is no swelling and redness observed. Nail plate shape is normal, nail bed
color is pink, and good capillary refill is notable. Muscle tone and strength of the upper
and lower extremities are equal in size, have normal tone and strength. No significant
lesions and deformities, pain in dorsiflexion, and phlebitis were observed. Spine is
located at the midline.
2. ANATOMY AND PHYSIOLOGY
Patient JJSD was diagnosed with pediatric community-acquired pneumonia. Pneumonia
has varieties of etiologies, as per this case, the etiological factor is environmental. Hence, the
anatomical and physiological scope primarily focuses on the respiratory system, particularly the
lower respiratory tract.
Countless cells in the body require vast and continuous oxygen supply to perform their
vital functions. A human cannot last without oxygen even for a short period of time as humans
can do without food or water. Hand in hand with the cardiovascular system, the respiratory
system works to supply the body with oxygen and dispose of carbon dioxide, a waste product
that the body must eliminate. The respiratory system oversees gas exchange between the blood
and the environment. Blood as the transporting vehicle, delivers respiratory gasses between the
lungs and the cells in the body. If failure occurs either of the systems mentioned, cells begin to
expire from oxygen deprivation and accumulation of carbon dioxide.
Nose, pharynx, larynx, trachea, bronchi and its smaller branches, and the lungs
containing alveoli or air sacs, are the organs of the respiratory system. Gas exchange mainly
occurs only in the alveoli of the lungs; other respiratory system structures act as passageways to
carry oxygen through the lungs. The passageways from the nose to the larynx are the upper
respiratory tract, and from the trachea to the alveoli are the lower respiratory tract (Marieb &
Keller, 2018). The lungs are the major organs of the respiratory system that occupy the thoracic
cavity. Each of these lungs houses the structure of conducting and respiratory zones. Each lung is
divided into lobes by fissures whereas the left has two lobes, and the right has three. As the gas
enters the lungs, the main bronchi subdivide into secondary and tertiary branches ending in the
smallest conducting passageways, the bronchioles. This branching and rebranching of respiratory
passageways within the lungs forms a network called the bronchial or respiratory tree that has
reinforcing cartilage in their walls. The terminal bronchioles lead to respiratory zone structures
including the bronchioles, alveolar ducts, alveolar sacs and alveoli where gas exchange occurs.
The surface of the alveoli is covered with pulmonary capillaries which makes up the respiratory
membrane where air and blood flows. Gas exchange happens by diffusion through the
respiratory membrane; oxygen enters capillary blood from the alveolar air, and carbon dioxide
exits the blood to the alveoli (Marieb & Keller, 2018). With the alveoli being infected by
pathogens, inflammation and filling up of fluid or pus occurs, a condition called Pneumonia.
3. PATHOPHYSIOLOGY
4. DIAGNOSTIC AND LABORATORY STUDY
Patient’s Initials: JJSD
Clinical Area: Pedia Charity Ward
Medical Diagnosis: Pediatric Community Acquired Pneumonia
(Severe)
Patient’s Age and Sex:1 Y.O. Male
Date of Test
Name of
Diagnostic/Laboratory
Test
Indication of Test
February 22, 2023
Molecular Pathology
Test
The most widely used
diagnostic technique for
severe acute respiratory
syndrome coronavirus 2
(SARS-CoV-2) infection
is
real-time
reverse
transcriptase-polymerase
chain reaction (RT-PCR).
Ribonucleic
acid
extraction is performed
using the RNA Extraction
Kit. Sars-Cov-2 viral N
Gene, ORF Gene or M
gene, S gene amplification
and detection were dont
with Real-Time PCR
machine with internal,
positive and negative
controls
included
to
confirm
validity
and
accuracy of the results.
SARS-CoV-2 RNA
(Ribonucleic Acid)
RT-PCR TEST
(CARTRIDGE-BASED)
This test is intended to be
used to achieve qualitative
detection of Sars-Cov 2
which is the causative
agent
of COVID-19,
Actual Findings or
Results of Test
ASSAY:
SARS-CoV-2
INTERPRETATION:
NEGATIVE (-)
Conclusion Based on
Findings/ Results
NEGATIVE (-)
The SARS-CoV-2 RNA
RT-PCR Test of the
patient was indicated
negative (-), meaning that
the patient has no
CoVid-19.
Nursing Implications
Health teaching to the parents
because patient JJSd is just 1 year
old, regarding the signs
and
symptoms of Covid-19 and the
importance of following health
protocols for Covid-19 such as
properly wearing masks and
avoiding going to places with many
people.
extracted
from
nasopharyngeal swabs or
oropharyngeal swabs or
of the patient.
February 22, 2023
Complete Blood Count
(CBC)
A Complete Blood Count
(CBC) is a common blood
test that is often a part of a
routine checkup which
measures
different
components of blood like:
Red Blood Cells (RBC),
White
Blood
Cells
(WBC),
Hemoglobin,
Hematocrit,
Platelets,
Mean
Corpuscular
Volume
(MCV), and
Mean Platelet Volume
(MPV).
CBC can help detect a
variety
of
disorders
including
infections,
anemia, diseases of the
immune
system, and
blood cancers.
February 22, 2023
Sodium (Na), Potassium
(K)
A sodium blood test, also
known as a serum sodium
test, is a routine test that
WBC – 11.6 (High)
RBC – 4.60
HGB – 124
HCT – 0.377
MCV – 81.9
MCH – 26.9
MCHC – 328
RDW – 15.4
PLATELET – 199
MPV – 9.33
DIFFERENTIAL
COUNT:
Segmenters – 0. 82 (High)
Lymphocytes – 0.12
(Low)
Monocytes – 0.05
Eosinophils – 0.01
Comments:
Machine Count only.
SODIUM:
138 mmol/L
HIGH
The patient's WBC count,
which is 11.6 compared to
the normal range of 6.0 to
11.0, is abnormal.
An increased number of
WBCs is one of the
indicators that a bacterial
infection,
including
Pneumonia,
may
be
present. (File, 2022)
High
WBC
and
decreased
neutrophil count are at high risk for
developing infection, the nurse
should carefully monitor WBC
count and assess for any signs of
infection.
Health teaching about how a proper
diet and getting enough rest and
sleep can regulate the levels of
white blood cells.
The patient's segmenters
(neutrophils) are high
(0.82),
and
his
lymphocytes are low
(0.12).
When there are high
neutrophils
and
low
lymphocytes, the NLR
(Neutrophil
to
Lymphocyte Ratio) is
high. An elevated NLR
ratio may be an indicator
of
severe
infection,
inflammatory
disorder,
chronic disease or cancer.
NORMAL
The sodium levels in the
Health teaching regarding the
importance of having normal
values of Sodium and Potassium
can be used to assess a
patient's overall health. It
enables the doctor to
determine the amount of
sodium in the patient's
blood. It can be used to
detect
and
monitor
conditions that affect the
body's fluid, electrolyte,
and acidity balance.
This test was also done to
check for hyponatremia
which
is
relatively
common
in
patients
admitted with pneumonia.
The potassium blood test
determines the level of
potassium in the blood.
Potassium is classified as
an electrolyte. Electrolytes
are electrically charged
minerals that help regulate
fluid levels and the
acid-base balance (pH
balance) in the body. They
also help to control
muscle and nerve activity,
among other things. Even
minor changes in the
amount of potassium in
the blood can cause
serious health problems.
This test is frequently part
of a group of routine
blood tests called an
electrolyte
panel
(including Na Test).
POTASSIUM:
3.9 mmol/L
blood were within the
normal range of 136 to
146 mmol/l. The patient's
sodium level is 138,
which means it is within
the usual range. His
potassium level, which
was 3.9, was also within
the usual range. Blood
potassium levels should
be between 3.5 and 5.1
mmol/L.
levels in the blood.
Eating more fresh vegetables and
fruits which are naturally high in
potassium and low in potassium are
good for the body avoiding
possible feelings of losing energy,
drowsiness and fatigue.
This test was ordered to
check for hyperkalemia
which is prevalent in
patients with Covid-19
pneumonia.
February 22, 2023
February 22, 2023
Ionized Calcium (iCa)
C-Reactive Protein
(CRP)
Calcium is a vital mineral
that the body utilizes in
numerous
ways.
It
strengthens the bones and
teeth and aids the function
of our muscles and nerves.
The total calcium in the
blood is measured by a
serum calcium blood test.
Ionized calcium is one of
several types of calcium
found in blood. The most
active form of calcium is
ionized calcium, also
known as free calcium.
Each of free calcium and
bound calcium accounts
for roughly half of your
body's total calcium. An
imbalance may indicate a
serious health problem.
Low free calcium levels
can cause your heart rate
to slow or speed up,
muscle spasms, and even
coma.
Result:
1.19 mmol/L
A
C-reactive protein
(CRP) test determines the
amount of c-reactive
Result:
0.3 mg/dL
NORMAL
The Ionized Calcium
normal value levels in
blood is 1.12 to 1.32
mmol/L. The patient’s iCa
result was 1.19 mmol/L
which indicates that it is
within the normal range.
NORMAL
The normal C-Reactive
Health teaching regarding why it is
important to maintain calcium
levels within a normal range.
Patient JJDS is still an infant so it
is vital to consume the right
amount of calcium which helps to
form and maintain healthy teeth
and bones. Having enough calcium
levels in the body over a lifetime
can help prevent osteoporosis.
Examine the client for
indications of an infection.
any
protein (CRP) in a blood
sample. CRP is a protein
produced by the liver.
Normally,
our
blood
contains low levels of
c-reactive protein. When
there is inflammation in
the body, the liver releases
more CRP into the
bloodstream. High CRP
levels may indicate a
serious health condition
that causes inflammation.
Protein (CRP) levels in
blood is less than 0.1
mg/dL. The patients\’s
CRP level is within the
normal range with the
value of 0.3 mg/dL.
Give the mother of patient JJDS a
health lesson on how to keep her
child healthy by ensuring that
client JJDS receives a balanced
meal as well as appropriate rest and
sleep. Having enough water is also
vital.
HIGH
Conduct a health teaching to the
mother of patient JJDS on how she
can keep her baby healthy by
having a proper diet and enough
rest and sleep.
A CRP test can determine
whether and how much
inflammation occurs in
the body and to monitor
inflammation in acute or
chronic
conditions
including lung diseases
such as pneumonia.
February 22, 2023
Complete Blood Count
(CBC) + Immature
Platelet Fraction (IPF)
The immature platelet
fraction (IPF) measures
the reticulated platelets
which are the platelets
containing mRNA in
peripheral blood.
IPF
reflects the bone marrow
thrombopoietic activity,
increasing when platelet
production
rises
and
decreasing
when
production falls.
According to Er et.al
(2020), immature platelet
Rapid ESR (Erythrocyte
Sedimentation Rate):
30 mm/hr
The normal value of
Rapid ESR for patient’s
under the age of 50 years
old is less than 15 mm/hr.
The patient’s age is 1 year
old and the result of his
Rapid ESR is 30 mm/hr
which is not within the
normal range.
A high or a faster ESR
rate may indicate higher
levels of inflammation.
Assess for any signs of infection
that the client may manifest.
fraction may have an early
predictive role in the
diagnosis of congenital
pneumonia.
5. DRUG ANALYSIS
Patient’s Initials: JJSD
Clinical Area: Pedia Charity Ward
Medical Diagnosis: Pediatric Community Acquired Pneumonia
(Severe)
Patient’s Age and Sex:1 Y.O. Male
Name of Drug
Generic Name:
Omeprazole
Brand Name:
Prilosec, PrilosecOTC
Desired Dosage,
Route, and
Frequency
Mechanism of
Action
General
Indications
Contraindications
General
Side/Adverse
Effects
Nursing
Responsibilities
15 mg, IV, OD
Reduce
stomach
acid production by
combining
with
hydrogen,
potassium,
and
adenosine
triphosphate
in
parietal cells of the
stomach to block
the last step in
gastric
acid
secretion.
Symptomatic
GERD
without
esophageal lesions
Contraindicated
in
patients hypertensive to
these drugs or their
components.
CNS:
asthenia,
dizziness,
headache
Use cautiously in patients
with hypokalemia and
respiratory alkalosis and in
patients on a low sodium
diet
Duodenal
(short-term
treatment)
ulcer
.
Short-term
treatment of active
benign gastric ulcer
GI:
abdominal
pain, constipation,
diarrhea,
flatulence, nausea,
vomiting,
acid
regurgitation
Musculoskeletal:
back
pain,
weaknesses
Dyspepsia
Respiratory:
cough, URI
Skin: rash
Specific
Indications
Client
to
Side/Adverse
Effects
Experienced
None
May increase risk of
osteoporosis-related bone
fractures and CDAD. Use
the lowest effective dose
for the shortest duration.
May increase risk of GI
infections,
hypomagnesemia and with
prolonged use, vitamin
B12 deficiency.
False-positive results in
diagnostic investigations
for neuroendocrine tumors
may
occur
due
to
increased CgA level.
Temporarily
stop
omeprazole treatment at
least 14 days before
assessing
CgA level and consider
repeating the test if initial
CgA level is high. If serial
tests are performed
(e.g., for monitoring), the
same commercial lab
should be used for testing,
as reference ranges
between tests may vary.
Long-term therapy may
cause
vitamin
B12
absorption
problems.
Assess patient for signs
and
symptoms
of
cyanocobalamin
deficiency
(weakness,
heart
palpitations,
dyspnea, paresthesia,
pale skin, smooth tongue,
CNS changes, loss of
appetite).
Because risk of fundic
gland polyps increases
with
long-term
use,
especially beyond 1 year,
use
drug for shortest duration
appropriate
to
the
condition being treated.
Periodically assess patient
for osteoporosis.
Monitor patient for signs
and symptoms of acute
interstitial nephritis. If
suspected, discontinue
drug and evaluate patient.
Drug increases its own
bioavailability
with
repeated doses. Drug is
unstable in gastric acid;
less
drug is lost to hydrolysis
because drug increases
gastric pH.
Gastrin level rises in most
patients during the first 2
weeks of therapy.
Alert: Prolonged use of
PPIs may cause low
magnesium
levels.
Monitor magnesium levels
before starting treatment
and periodically thereafter.
Alert: Monitor patients for
signs and symptoms of
low magnesium level,
such as abnormal
HR
or
rhythm,
palpitations,
muscle
spasms,
tremors,
or
seizures. In children, an
abnormal HR
may present as fatigue,
upset stomach, dizziness,
and
light-headedness.
Magnesium
supplementation or drug
discontinuation may be
required.
Look alike–sound alike:
Don’t confuse Prilosec
OTC
with
Plendil,
Prevacid, prednisone,
Pristiq, Prozac, prilocaine,
or Prinivil. Don’t confuse
omeprazole
with
aripiprazole,
esomeprazole,
or
fomepizole.
Generic Name:
Paracetamol
Brand Name:
Biogesic
140 mg, IV, Q6H
PRN for Fever ≥
37.8°C
Produce analgesia
by
inhibiting
prostaglandin and
other
substances
that sensitize pain
receptors.
Drugs
may relieve fever
through
central
action
in
the
hypothalamic
heat-regulating
center.
Mild pain or fever
Mild to moderate
pain;
mild
to
moderate pain with
adjunctive opioid
analgesics; fever
Contraindicated
in
patients hypersensitive
to drug. IV form is
contraindicated
in
patients with severe
hepatic impairment or
severe active liver
disease.
Use
cautiously
in
patients with any type
of liver disease, G6PD
deficiency, chronic
malnutrition,
severe
hypovolemia
(dehydration,
blood
loss), or severe renal
impairment (CrCl of
30 mL/minute or less).
Use
cautiously
in
patients with long-term
alcohol use because
therapeutic doses cause
hepatotoxicity in these
patients. Patients with
chronic
alcoholism
shouldn’t take more
than 2 g of
CNS:
agitation
(IV),
anxiety,
fatigue, headache,
insomnia, pyrexia.
CV:
HTN,
hypotension,
peripheral edema,
periorbital edema,
tachycardia (IV).
GI:
nausea,
vomiting,
abdominal pain,
diarrhea,
constipation (IV).
GU: oliguria (IV).
Hematologic:
hemolytic anemia,
leukopenia,
neutropenia,
pancytopenia,
anemia. Hepatic:
jaundice.
Metabolic:
hypoalbuminemia
(IV),
Use
caution
when
prescribing, preparing, and
administering IV
acetaminophen to avoid
dosing errors leading to
accidental overdose and
death. Be careful not to
confuse
dose
in
milliGRAMS and dose in
milliLITERS. Be sure to
base dose on weight for
patients weighing less than
50 kg, to properly program
infusion pump, and to
ensure that total
daily
dose
of
acetaminophen from all
sources doesn’t exceed
maximum daily limit.
Consider reducing total
daily dose and increasing
dosing intervals in patients
with hepatic or
renal impairment.
acetaminophen
24 hours.
every
hypoglycemia,
hypokalemia,
hypervolemia,
hypomagnesemia,
hypophosphatemia
(IV).
Musculoskeletal:
muscle
spasms,
extremity
pain
(IV).
Respiratory:
abnormal breath
sounds,
dyspnea, hypoxia,
atelectasis, pleural
effusion,
pulmonary edema,
stridor, wheezing
(IV). Skin:
rash,
urticaria;
infusion-site pain
(IV), pruritus.
Specific
Indications
Client
Side/Adverse
Effects
Experienced
to
None
PRN for fever ≥
37.8°C
Generic Name:
Amikacin
Brand Name:
270 mg, IV, OD
Aminoglycosides
are
bactericidal.
They bind directly
and irreversibly to
Septicemia;
postoperative,
pulmonary,
intra-abdominal,
Contraindicated
in
patients hypersensitive
to these drugs.
CNS:
neuromuscular
blockade.
Due to increased risk of
ototoxicity,
evaluate
patient’s hearing before
and during therapy if
Amikacide
30S
ribosomal
subunits,
inhibiting bacterial
protein synthesis.
They’re
active
against
many
aerobic
gram-negative and
some
aerobic
gram-positive
organisms and can
be used with other
antibiotics for short
courses of
therapy.
and urinary tract
infections;
skin,
soft-tissue,
bone, and joint
infections; aerobic
gram-negative
bacillary meningitis
not
susceptible to other
antibiotics; serious
staphylococcal,
Pseudomonas
aeruginosa,
Klebsiella,
and Acinetobacter
infections;
enterococcal
infections;
nosocomial
pneumonia;
TB;
initial
empirical therapy in
patients who are
febrile
and
leukopenic
Specific
Indications
Client
to
Severe Pneumonia
Aminoglycosides are
associated
with
significant
nephrotoxicity and
ototoxicity.
Toxicity
may develop even with
conventional
doses,
particularly in patients
with
prerenal azotemia or
impaired
renal
function. Evidence of
renal
function
impairment or
ototoxicity
requires
drug discontinuation or
appropriate
dosage
adjustments.
When
possible,
monitor
serum
drug
concentrations, renal
function, and eighth
nerve function. Avoid
use with
other
ototoxic,
neurotoxic,
or
nephrotoxic
drugs.
Aminoglycosides can
cause fetal harm when
given
during
pregnancy. Safety of
treatment lasting longer
than 14 days hasn’t
been established.
Use
cautiously
in
patients
with
neuromuscular
disorders and in those
EENT: ototoxicity.
GU:
azotemia,
nephrotoxicity,
increase in
urinary excretion
of casts.
Respiratory:
apnea.
patient will be receiving
the drug for longer than 2
weeks. Notify prescriber if
patient
has
tinnitus,
vertigo, or hearing loss.
Boxed Warning Weigh
patient and review renal
function studies before
and periodically
during therapy.
Correct
dehydration
before therapy because of
increased risk of toxicity.
Monitor serum amikacin
peak
and
trough
concentrations
periodically during
therapy. Peak drug levels
greater than 35 mcg/mL
and trough levels greater
than 10 mcg/mL may
be linked to a higher risk
of toxicity.
Side/Adverse
Effects
Experienced by
Client
None
Due to increased risk of
nephrotoxicity,
monitor
renal
function:
urine
output,
specific gravity, urinalysis,
BUN
and
creatinine
levels, and CrCl. Report
evidence of declining
renal
function
to
prescriber. Safe use for
longer than 14 days hasn’t
been established.
taking neuromuscular
blockers.
Use at lower dosages in
patients with renal
impairment.
Use cautiously during
pregnancy.
Safety
hasn’t been established
with breastfeeding. In
neonates and infants
born prematurely, the
half-life
of
aminoglycosides
is
prolonged because of
immature
renal
systems. In infants and
children,
dosage
adjustment may be
needed. Older adults
have an increased risk
of nephrotoxicity and
commonly need a
lower dose and longer
dosage
intervals; they’re also
susceptible
to
ototoxicity
and
superinfection.
Watch for signs and
symptoms
of
superinfection (especially
of upper respiratory tract),
such as
continued fever, chills,
and increased pulse rate.
Neuromuscular blockade
and respiratory paralysis
have been reported after
aminoglycoside
administration, especially
in
patients
receiving
anesthetics,
neuromuscular
blockers,
or
massive
transfusions
of
citrate-anticoagulated
blood. If blockade occurs,
calcium
salts may reverse these
phenomena,
but
mechanical
ventilation
may be necessary. Monitor
patient closely.
Therapy usually continues
for 7 to 10 days. If no
response occurs after 3 to
5 days, stop therapy
and obtain new specimens
for culture and sensitivity
testing.
Look alike–sound alike:
Don’t confuse amikacin
with anakinra.
Generic Name:
Ceftriaxone
Brand Name:
Numetrax
1800 mg + 30 cc
PNSS, IV, OD
Inhibits
cell-wall
synthesis,
promoting osmotic
instability; usually
bactericidal.
Adjust-a-dose (for
all indications): In
patients
with
significant
renal
disease and hepatic
dysfunction,
maximum dose is 2
g/day. In patients
receiving
intermittent
hemodialysis, no
dosage adjustment
is necessary as drug
is poorly dialyzed.
Uncomplicated
gonococcal
vulvovaginitis
UTI;
lower
respiratory
tract,
gynecologic, bone
or
joint,
intra-abdominal,
skin, or skinstructure infection;
septicemia
Complicated
infections
may
require
longer
treatment.
Meningitis
Perioperative
prophylaxis
Acute otitis media
Contraindicated
in
patients hypersensitive
to drug or other
cephalosporins.
• Use cautiously in
patients hypersensitive
to penicillin because of
possibility
of
cross-sensitivity
with other beta-lactam
antibiotics.
•
To
reduce
development
of
drug-resistant bacteria
and
maintain
effectiveness
of
antibacterial
drugs, use drug only to
treat
or
prevent
infections proven or
strongly suspected to
be caused by
bacteria.
Alert:
May
cause
superinfection and mild
to fatal CDAD. If
suspected,
manage
appropriately;
discontinue drug if
needed.
Alert:
May
cause
hemolytic
anemia,
which can be fatal. If
anemia
develops
during therapy,
stop drugs until cause
is determined.
• Use cautiously in
GI:
pseudomembranou
s colitis, diarrhea.
Hematologic:
eosinophilia,
thrombocytosis,
leukopenia. Skin:
pain, induration,
tenderness
at
injection site, rash.
Other:
hypersensitivity
reactions, serum
sickness,
anaphylaxis.
If large doses are given,
therapy is prolonged, or
patient is at high risk,
monitor patient for signs
and
symptoms
of
superinfection.
Monitor PT and INR in
patients with impaired
vitamin K synthesis or low
vitamin K stores.
Vitamin K therapy may be
needed.
Monitor
patients
for
superinfection, diarrhea,
and anemia and treat
appropriately.
Look alike–sound alike:
Don’t confuse drug with
other cephalosporins that
sound alike.
Specific
Indications
Client
to
patients with history of
colitis,
renal
insufficiency, or GI or
gallbladder
disease.
Dialyzable drug: No.
Side/Adverse
Effects
Experienced by
Client
Severe Pneumonia
None
Generic Name:
Salbutamol
Brand Name:
Ventolin
1 neb + 2 ml PNSS,
Q6H
Relaxes bronchial,
uterine,
and
vascular
smooth
muscle
by
stimulating beta2
receptors.
To prevent or treat
bronchospasm
in
patients
with
reversible
obstructive airway
disease
Regular use for
maintenance
therapy to control
asthma symptoms
isn’t recommended.
To
prevent
exercise-induced
bronchospasm
Adjuvant therapy
for acute treatment
of moderate to
severe
hyperkalemia
CNS:
tremor,
nervousness,
headache,
hyperactivity,
insomnia,
dizziness,
weakness, CNS
stimulation,
malaise.
CV:
tachycardia,
palpitations, HTN,
chest
pain,
lymphadenopathy,
edema.
EENT:
conjunctivitis,
otitis media, dry
and irritated nose
and throat (with
inhaled
form),
nasal
congestion,
epistaxis,
hoarseness,
pharyngitis,
rhinitis.
GI:
nausea, vomiting,
heartburn,
anorexia,
altered
taste,
•
Contraindicated
in
patients hypersensitive to
drug or its ingredients.
• Use cautiously in
patients with CV disorders
(including
coronary
insufficiency and HTN),
hyperthyroidism,
or
diabetes mellitus and in
those who are unusually
responsive to adrenergics.
• Use extended-release
tablets
cautiously
in
patients
with
GI
narrowing.
increased appetite.
GU:
UTI.
Metabolic:
hypokalemia.
Musculoskeletal:
muscle
cramps,
back
pain.
Respiratory:
bronchospasm,
cough, wheezing,
dyspnea,
bronchitis,
increased sputum.
Other:
hypersensitivity
reactions, flu like
syndrome,
cold
symptoms.
Specific
Indications to
Client
Side/Adverse
Effects
Experienced by
client
Severe Pneumonia
None
NURSING CARE PLAN PRIORITY 1
Student’s Name: Masangkay, Christine Darla V.
Year, Section, Group: 2C-3
Patient’s Initials: JJSD
Clinical Area: Pedia Charity Ward
Medical Diagnosis: Pediatric Community Acquired Pneumonia (Severe)
Patient’s Age and Sex:1 Y.O. Male
Assessment
Nursing Diagnosis
Inference
Goal and Objectives
Nursing
Interventions
Subjective:
“Napansin ko na hirap siya
huminga or parang naghahabol
ng hininga” as verbalized by the
patient’s mother
Impaired spontaneous
ventilation related to
endotracheal
intubation
Ineffective Airway
Clearance
Ineffective
airway
clearance is the inability to
maintain a clear airway
due to secretions or
obstructions
in
the
respiratory tract (NANDA
16th
Edition,
2022).
Breathing is spontaneous
and inherently comes to
everyone. Thus, a patent
airway is vital to life.
Cough, a natural airway
clearance
mechanism,
occurs to aid in removing
mobilize secretions when
airway is obstructed. In
the lower respiratory tract
involving bronchioles and
alveoli, mechanisms such
as the mucociliary system,
macrophages, and the
lymphatics take place for
patency of the airway
(Wayne, 2022). However,
risk for compromised
Goal:
Within 24 hours of
nursing
intervention,
the client will have and
maintain a patent and
clear airway free of
excessive
secretions
and obstructions.
Independent:
Monitor vital signs,
respiration and breath
sounds noting rate and
sounds (auscultate)
Objective:
(+) Wheezes
(+) Bilateral crackles
(+) Deep subcostal retraction
(+) Tachycardic rate
(+) Generalized pallor
(+) Cold extremities
Vital Signs as follows
T: 36.4 degrees celsius
SpO2: 99%
RR: 36 RPM
HR: 124 BPM
BP: 100/70 mm Hg
Dx
Severe Pneumonia
Objectives:
1. The client
will
demonstrate
absence or
reduction of
congestion
evidenced
by normal
breath
sounds and
improved
gas
exchange.
2. The client
will be free
Observe
signs of
respiratory distress
Rationale
Vital signs monitor and
detect health deviations or
problems. Assessment of
respiration,
SpO2
and
auscultation of breath sounds
indicates respiratory distress
and
accumulation
of
secretions (NANDA 16th
Edition, 2022). Changes of
these vital signs outside
normal ranges may indicate
respiratory
compromise.
Adventitious breath sounds
can be heard as both fluid
and
mucus
accumulate
indicating ineffective airway
clearance (Wayne, 2022).
Airway obstruction calls for
an increase in respiratory rate
and
rhythm,
cyanosis,
grunting, nasal flaring, chest
retraction,
etc.
as
compensatory
responses
(Wayne, 2022). Monitoring
signs of respiratory distress is
important
to
accurately
diagnose, intervene, and
manage for a positive
Evaluation
After 24 hours of nursing
intervention,
the
client/patient:
Goal Met:
The
patient
displays
improved gas exchange as
evidenced by normal
respiration rate and no
adventitious breath sounds.
Goal Met:
The patient was able to
maintain a patent airway
as evidenced by absence of
signs
of
respiratory
distress and compromise.
Goal Met:
The patient displays relief
of chest congestion as
evidenced by normal
breath
sounds
after
suctioning.
airway is present once
these mechanisms are
oppressed by increased
production of secretions in
conditions
such
as
pneumonia.
According to NANDA
16th Edition, Ineffective
Airway
Clearance
is
characterized
by
the
following:
● Adventitious
breath
sounds
(crackles
and
wheezes)
● Abnormal
respiratory rate,
rhythm
and
depth
● Excessive
secretions
● Hypoxemia/cyan
osis
● Cyanosis;
hypoxemia
● Subcostal
retraction
● Nasal flaring
● Difficulty
verbalizing
Endotracheal Intubation
Endotracheal intubation is
a medical procedure that
involves endotracheal tube
(ETT) insertion to provide
oxygenation
and
ventilation. Endotracheal
tube (ETT), a tube made
3.
of
aspiration.
The client
will
demonstrate
improved
air exchange
as
evidenced
by normal
vital signs
especially
oxygen
saturation
level
and
respiratory
rate.
outcome (Johns
Medicine, 2019).
Hopkins
Position
head
appropriately for age
and condition
Body, especially the head,
appropriately
positioned
allows open airway and
better lung expansion during
at-rest and for compromised
individuals (NANDA 16th
Edition, 2022). Positioning
mobilizes secretions and aids
in promoting drainage of
secretions, ventilation of lung
segments, thereby preventing
atelectasis, and improving
gas exchange (Wayne, 2022).
Dependent:
Administer
intravenous therapy
Hydration improves ciliary
action for the removal of
secretions and reduction of
its viscosity as coughing
thinner secretions is easier to
mobilize (Wayne, 2022).
Administer Amikacin
270 mg IV OD
Antibiotics are used to treat
bacterial infection such as
pneumonia (MIMS, 2020).
Administer
Ceftriaxone 1800 mg +
30 cc PNSS IV OD
Administer Salbutamol
1 nebule + 2 ml PNSS
Q6H
Antibiotics are used to treat
bacterial infection such as
pneumonia (MIMS, 2020).
Salbutamol
provides
short-acting bronchodilation
with an immediate onset in a
reversible
airways
obstruction
(Electronic
Medicines
Compendium,
n.d.).
of polyvinyl chloride, is
placed in the larynx or
vocal cords through the
trachea with an inflated
cuff.
Endotracheal
intubation secures a patent
airway allowing oxygen to
pass to and from the lungs
as indicated for inability to
maintain clear airway,
failure to ventilate and
oxygenate, and in such
case
of
deteriorating
condition which may lead
to
respiratory
failure
(Ahmed & Boyer, 2022).
Ineffective Cough
Cough is a spontaneous
airway clearance reflex
which mobilizes air and
particles out of the lungs.
Throat and lungs naturally
produce mucus to keep the
airway moist and acts as a
protective barrier against
irritants as inhaled. An
ineffective
cough
compromises patency of
the airway and prevents
secretions from being
expelled (American Lung
Association, n.d.).
Pneumonia
Pneumonia is an acute
respiratory infection that
inflames the alveoli or the
lungs’ air sacs. The lungs
have small sacs called
alveoli, which is filled
with air as a person
inhales. In pneumonia, the
alveoli are filled with fluid
Perform suction as
ordered
by
the
physician.
Suctioning is used to aspirate
retained
or
excessive
secretions
from
lower
respiratory airways. The
frequency of suctioning
should be in accordance with
the client’s clinical status,
and not a routine as over
suctioning stimulates vagus
nerves, hypoxia, and injury
to the tissues of the lungs and
bronchioles (Wayne, 2022).
or
pus resulting in
difficulty breathing and
limited oxygen intake
(World
Health
Organization,
2022).
According to the World
Health
Organization,
pneumonia is the leading
infectious cause of child
mortality worldwide.
NURSING CARE PLAN PRIORITY 2
Patient’s Initials: JJSD
Clinical Area: Pedia Charity Ward
Medical Diagnosis: Pediatric Community Acquired Pneumonia (Severe)
Patient’s Age and Sex:1 Y.O. Male
Assessment
Subjective:
3 days prior to admission
Patient
noted
to
have
undocumented low grade fever
2 days prior to admission
Fever was resolved, but patient
is noted to have productive
cough and colds
Few hours prior to admission
Patient noted to have persistent
cough with notable difficulty of
breathing, subcostal retractions
(indrawing of abdomen below
rib cage), pallor, circumoral
cyanosis (blue discoloration of
the mouth or lips)
Objective:
Endotracheal intubation and
suction
Vital Signs as follows
T: 36.4 degrees celsius
SpO2: 99%
RR: 36 RPM
HR: 124 BPM
BP: 100/70 mm Hg
Dx
Nursing Diagnosis
Risk for Infection
(secondary) related to
invasive procedure as
site for organism
invasion
Inference
Goal and Objectives
Nursing
Interventions
Infection
Infection is the invasion
and proliferation of
pathogenic
microorganisms
including
bacteria,
viruses,
fungi
or
parasites which enter
the body, grow and
multiply
interfering
with
the
normal
physiologic functions.
These microorganisms
may enter the body
anywhere and spread
through
causing
cellular,
immunological,
and
systemic
response
against these foreign
infective
microorganisms
(Harvard
Health
Publishing, 2021).
Goal:
Within 24 hours of nursing
intervention, the client will
remain
free
of
any
(secondary) infection upon
assessment.
Independent:
Encourage the client,
family members, and
staff to practice
proper hand washing
between activities
and handling of
clients.
Endotracheal
intubation
Endotracheal intubation
is a medical procedure
that
involves
endotracheal
tube
(ETT)
insertion to
provide
oxygenation
Objectives:
1. The client will
remain free of
infection
as
evidenced
by
normal
range
vital signs.
2. The client will
remain free of
signs
and
symptoms
of
Rationale
Handwashing is the
first-line defense
against infectious
diseases.
Monitor vital signs
Deviation of vital
signs outside normal
range signal early
signs of infection.
Observe for
signs/symptoms of
infection
Signs and symptoms,
often including fever,
are
indicative
of
infection
varying
depending on the
causative agent of the
infectious diseases.
Monitor/document
procedures such as
serial chest x-rays
Chest x-rays produce
images of
organs
including the heart,
lungs, and bones. The
condition of the lungs
can be revealed as
medical
conditions
such
as
infection
Evaluation
After 24 hours of nursing
intervention,
the
client/patient:
Goal Met:
The patient’s vital signs
remained stable and there
were no signs and
symptoms of infection
were observed.
Severe Pneumonia
and
ventilation.
Endotracheal
tube
(ETT), a tube made of
polyvinyl chloride, is
placed in the larynx or
vocal cords through the
trachea with an inflated
cuff.
Endotracheal
intubation secures a
patent airway allowing
oxygen to pass to and
from the lungs as
indicated for inability to
maintain clear airway,
failure to ventilate and
oxygenate, and in such
case of deteriorating
condition which may
lead to respiratory
failure
(Ahmed
&
Boyer, 2022).
Suction
Suction is known as the
mechanical aspiration
of retained or excessive
secretions from lower
respiratory
airways.
Suctioning is used to
aspirate
secretions
when
cough
mechanisms
are
ineffective or absent
and if there is increased
mucus production in
such conditions. A
suction
catheter is
inserted
via
endotracheal
or
tracheostomy tube to
the trachea to aspirate
the lower respiratory
tract, especially for
patients with artificial
infection such as
fever, and pain as
evidenced
by
zero
numeric
pain assessment.
manifesting lungs to
collapse
can
be
detected with
the
images it produces.
Dependent:
Administer
Paracetamol 140 mg
IV Q6H PRN for
fever ≥ 37.8°C
Collaborative:
Encourage early
removal of
endotracheal tube
Assist with weaning
from mechanical
ventilator as soon as
possible
Paracetamol is an
analgesic
and
antipyretic drug used
to relieve mild to
moderate pain and
reduce
high
temperature (fever).
Early termination of
endotracheal
intubation allows for
mobilization
of
respiratory secretions
and to prevent further
respiratory infections
and
aspiration
(NANDA
16th
Edition, 2022).
According to NANDA
(2022), Weaning of
oxygen reduces risk of
ventilator-associated
pneumonia,
destruction of lung
tissues and collapse
(atelectasis).
airway who cannot
spontaneously
expel
due
to
impaired
mechanisms.
NURSING CARE PLAN PRIORITY 3
Patient’s Initials: JJSD
Clinical Area: Pedia Charity Ward
Medical Diagnosis: Pediatric Community Acquired Pneumonia (Severe)
Patient’s Age and Sex:1 Y.O. Male
Assessment
Subjective:
“Baka mangayayat o mag
bawas ng timbang kasi nga
hindi
nakakakain”
as
verbalized by the patient’s
mother
Objective:
Endotracheal intubation
Vital Signs as follows
T: 36.4 degrees celsius
SpO2: 99%
RR: 36 RPM
HR: 124 BPM
BP: 100/70 mm Hg
Weight: 8.5 kg
Dx
Severe Pneumonia
Nursing Diagnosis
Imbalanced Nutrition:
Less than Body
requirements related to
altered ability to ingest
Inference
Goal and Objectives
Nursing
Interventions
Imbalanced nutrition
Imbalanced nutrition is
the intake of nutrients
that are deficient to
meet the metabolic
needs of the body
(NANDA 16th Edition,
2022). Nutrition is a
physiological process of
consuming and utilizing
nutrients needed by the
body
for
growth,
maintenance,
and
development.
Right
kind and adequate
amounts of nutrients
found in foods ingested
are essential to meet the
body’s
metabolic
demands.
Goal:
Within 24 hours of
nursing
intervention,
the client will meet the
body’s metabolic needs
and tolerate earlier
initiation of enteral
feeding
upon
termination
of
endotracheal intubation.
Independent:
Provide indicated or
ordered dietary and
nutritional
modifications such as
parenteral or tube
feeding.
Ingestion
The
process
of
digestion begins with
ingestion, the act of
taking food by mouth
where it is broken down
by mastication and
swallowing.
Endotracheal
intubation
Objectives:
1. The client
will
maintain a
normal
average
weight upon
assessment.
2. The client
will
promptly
tolerate
enteral
nutrition
(EN)
feeding
Dependent:
Administer
Omeprazole 15 mg IV
OD
Rationale
Parenteral
nutrition
is
supply
of
nutrients
intravenously, through an IV
catheter, bypassing the
digestive system. Enteral
nutrition is the use of the
gastrointestinal tract to
deliver nutrients either by
mouth or through a feeding
tube. Parenteral feeding and
enteral tube feeding are both
indicated for patients who
are unable to take food to
meet body metabolic needs
per orem.
Omeprazole is used to treat
gastric
or
duodenal
conditions
with
characterized
excess
stomach acid.
Evaluation
After 24 hours of nursing
intervention,
the
client/patient:
Goal Met:
The patient was able to
maintain
normal
body
weight.
Goal Met:
The patient was able to
tolerate
parenteral/enteral
tube feeding as a source of
nutrients to meet the body's
metabolic needs.
Endotracheal intubation
is a medical procedure
that
involves
endotracheal
tube
(ETT)
insertion to
provide
oxygenation
and
ventilation.
Endotracheal
tube
(ETT), a tube made of
polyvinyl chloride, is
placed in the larynx or
vocal cords through the
trachea with an inflated
cuff.
Endotracheal
intubation secures a
patent airway allowing
oxygen to pass to and
from the lungs as
indicated for inability to
maintain clear airway,
failure to ventilate and
oxygenate, and in such
case of deteriorating
condition which may
lead to respiratory
failure
(Ahmed
&
Boyer, 2022).
following
discontinuati
on
of
endotracheal
intubation.
References
Adeyinka, A., Rouster, A., & Valentine, M. (2022, November 4). Enteric Feedings.
StatPearls - NCBI. https://www.ncbi.nlm.nih.gov/books/NBK532876/
Ahmed, R., & Boyer, T. (2022, August 9). Endotracheal tube . StatPearls - NCBI
Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK539747/
Case-Lo, C. (2018, September 17). Ionized calcium test: Purpose, procedure & risks.
Healthline. https://www.healthline.com/health/calcium-ionized#uses
Edmonds, Z. V. (2012, April 7). Hyponatremia in Pneumonia. Journal of hospital
medicine.
https://pubmed.ncbi.nlm.nih.gov/22489080/#:~:text=Hyponatremia%20is%20rela
tively%20common%20in,to%20play%20a%20significant%20role
Er, İ., Cetin, C., Baydemir, C., & Günlemez, A. (2020, December 16). Can immature
platelet fraction be an early predictor for congenital pneumonia? Turk pediatri
arsivi.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750339/#:~:text=It%20was%20
determined%20that%20an,0.724%3B%20p%
Farrell, A. (n.d.). Suctioning. Physiopedia. https://www.physio-pedia.com/Suctioning
File, T. M. (2022, July 11). Patient education: Pneumonia in adults (Beyond the Basics).
UpToDate.
https://www.uptodate.com/contents/pneumonia-in-adults-beyond-the-basics/print#
:~:text=A%20CBC%20measures%20the%20number,including%20pneumonia%2
C%20may%20be%20present. https://www.healthline.com/health/sodium-blood
How to prevent Infections. Harvard Health Publishing. (2021, February 15).
https://www.health.harvard.edu/staying-healthy/how-to-prevent-infections
Learn about Cough. American Lung Association. (n.d.).
https://www.lung.org/lung-health-diseases/warning-signs-of-lung-disease/cough/l
earn-about-cough
Marieb, E., Keller, S. (2018). Essentials of Human Anatomy and Physiology Twelfth
Edition. Pearson Education South Asia PTE. ISBN: 987-981-31-3368-6
Mayo Foundation for Medical Education and Research. (2022, February 18). Infectious
Diseases. Mayo Clinic. Retrieved March 2, 2023, from
https://www.mayoclinic.org/diseases-conditions/infectious-diseases/symptoms-ca
uses/syc-20351173
Mayo Foundation for Medical Education and Research. (2022, March 5). Chest X-rays.
Mayo Clinic.
https://www.mayoclinic.org/tests-procedures/chest-x-rays/about/pac-20393494
Moreno-Pérez, O.,et al., (2020). Hypokalemia as a sensitive biomarker of disease severity
and the requirement for invasive mechanical ventilation requirement in
COVID-19 pneumonia: A case series of 306 mediterranean patients. International
Journal
of
Infectious
Diseases,
100,
449–454.
https://doi.org/10.1016/j.ijid.2020.09.033
Paracetamol. Tests & treatments | NHS inform. (2022, November 4).
https://www.nhsinform.scot/tests-and-treatments/medicines-and-medical-aids/type
s-of-medicine/paracetamol#:~:text=Introduction,such%20as%20colds%20and%2
0flu
Parenteral Nutrition: What it is, Uses & Types. Cleveland Clinic. (n.d.).
https://my.clevelandclinic.org/health/treatments/22802-parenteral-nutrition
RNlessons. (n.d.). Ineffective Airway Clearance Nursing Diagnosis & Care Plan.
https://rnlessons.com/ineffective-airway-clearance-nursing-diagnosis-care-plan/
Science Learning Hub. (2011, September 5). The Human Digestive System.
https://www.sciencelearn.org.nz/resources/1829-the-human-digestive-system
Torretta, S., Zuccotti, G., Cristofaro, V., Ettori, J., Solimeno, L., Battilocchi, L.,
D'Onghia, A., Bonsembiante, A., Pignataro, L., Marchisio, P., & Capaccio, P.
(2021, April). Diagnosis of SARS-COV-2 by RT-PCR using different sample
sources: Review of the literature. Ear, nose, & throat journal.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459180/
Underwood, C. (2021, September 20). Endotracheal Intubation: Purpose, Procedure &
Risks. Healthline. https://www.healthline.com/health/endotracheal-intubation
U.S. National Library of Medicine. (n.d.). C-Reactive Protein (CRP) Test. MedlinePlus.
https://medlineplus.gov/lab-tests/c-reactive-protein-crp-test/
U.S. National Library of Medicine. (n.d.). Erythrocyte sedimentation rate (ESR).
MedlinePlus. https://medlineplus.gov/lab-tests/erythrocyte-sedimentation-rate-esr/
U.S. National Library of Medicine. (n.d.). Potassium Blood Test. MedlinePlus.
https://medlineplus.gov/lab-tests/potassium-blood-test/
Wayne, G. (2022, March 19). Ineffective Airway Clearance. Nurseslabs.
https://nurseslabs.com/ineffective-airway-clearance/
Wayne, G. (2022, May 8). Imbalanced nutrition: Less than body requirements nursing
care plan. Nurseslabs.
https://nurseslabs.com/imbalanced-nutrition-less-body-requirements/
WebMD. (n.d.). Omeprazole oral: Uses, Side effects, Interactions, Pictures, Warnings &
Dosing. WebMD.
https://www.webmd.com/drugs/2/drug-3766-2250/omeprazole-oral/omeprazole-d
elayed-release-tablet-oral/details
Wolters, K. (2023). Nursing 2023 Drug Handbook. Wolters Kluwer Health, Inc.
ISBN-13: 9871975218867
World Health Organization. (2022, November 11). Pneumonia in Children. World Health
Organization. Retrieved March 2, 2023, from
https://www.who.int/news-room/fact-sheets/detail/pneumonia