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Table of contents

I.

Introduction......2

II.

Objectives....4

III.

Patients Data..7

IV.

Health History..9
a. Genogram
b. Past Health History
c. Present Health History
d. Medication Reconciliation

V.

Development Data....13

VI.

Definition of Patients Diagnosis..16

VII.

Anatomy & Physiology.17

VIII.

Physical Assessment...26

IX.

Etiology30

X.

Symptomatology...33

XI.

Pathophysiology35

XII.

Doctors Order.66

XIII.

Diagnostic/ Laboratory Test....39

XIV. Drug Study.....51


XV.

Nursing Theory..64

XVI.

Drug Study...51

XVII. Nursing Care Plan..67


XVIII. Prognosis....75
XIX.

XXI.

Recommendation...77
a.

Patient & Family

b.

Nursing Education

c.

Nursing Practice

d.

Nursing Research

Bibliography.80

Chapter 1
Introduction
Paediatric Community Acquired Pneumonia (PCAP) refers to pneumonia in a
previously healthy person who acquired the infection outside a hospital. PCAP is a
common illness that affects infants and children. In children, the majority of deaths
occur in the newborn period, with over two million worldwide deaths a year. In fact, the
WHO estimates that one in a three newborn infant deaths are due to pneumonia. It
occurs because the areas of the lung which absorb oxygen (alveoli) from the
atmosphere become filled with fluid and cannot work effectively. (Smeltzer, et. al.
Medical-Surgical Nursing: 11th Edition. Lippincott Williams and Wilkins. 2008)
Children are very susceptible to acquire this illness especially when their immune
systems are low. They can get it anywhere like in school, for example,one of the
classmates has a cough. Then in house, if there is a poor environment. Then in
playground, wherein there are lots of other children playing.
PCAP is classified into four types. First is, PCAP A, which has a minimal risk, there is
no dehydration, with a respiratory rate of greater than 30-50/min.Second is, PCAP B,
which has a low risk, there is mild dehydration, with a respiratory rate of greater than
30-50/min. Third is, PCAP C, which has a moderate risk, with moderate dehydration,
with a respiratory rate of greater than35-60/min. Fourth is, PCAP D, which has a high
risk, with severe dehydration,with a respiratory rate of greater than 35-70/min.
The United Nations Children's Fund (UNICEF) estimates that 3 million children die
worldwide from pneumonia each year; these deaths almost exclusively occur in children
with underlying conditions, such as chronic lung disease of prematurity, congenital heart
disease, and immunosuppression. According to the WHOs Global Burden of Disease
2000 Project, lower respiratory infections were the second leading cause of death in
children younger than 5 years (about 2.1 million [19.6%]).

The chronology we have came from the Department of Healths Health statistics
which have been updated sometime last January 2014, documented that one of the
leading causes of mortality in the Philippines is Pneumonia either community acquired
or hospital acquired, Pneumonia is considered the 3rd leading cause of death and the
4th leading cause of morbidity in children (Department of Health, 2015 Health
Statistics). For the adults, this occurs mainly as a complication of other chronic diseases
like lung cancer, COPD, tuberculosis, and other debilitating illnesses that leave them
bedridden most of the time and for the children, this remains to be a major killer. In the
year 2004 it was recorded that in every 100,000 total population in the Philippines over
15,822 males died this year and 16,276 for the females. In the Philippines, there are
more than 40,000 cases of PCAP annually. More than 50% are admitted in the hospital.

In the statistics in Davao City on 2011 PCAP was rank second in the top common
disease in all age groups in the 16 health districts of Davao City between January and
February last three year based on statistics prepared by the City Health Office (CHO).
Since January that year , PCAP is also the most common disease among admitted
patients at the Community Health and Development Cooperative Hospital, Anda
Riverside, Davao City.
The group chose the case of PCAP C which is Paediatrics Community Acquired
Pneumonia C primarily because of having a prior knowledge on this type of paediatric
illness, thus requiring to apply this knowledge in the actual setting.This would serve as a
good avenue for the group to develop skills in relation to the facts and information that
have already learned in the university.
As student nurses and future registered nurses, the proponents want to understand
and appreciate more on what is happening to a patient with PCAP C, being one of the
most common illnesses affecting children, the group are in a pursuit for knowledge to be
able to impart it to others. Through this, the group are hoping that we will be able to find
the right plan of care and interventions, not forgetting the patients rights as a person. All
in all, these will help them become efficient and effective nurses in the future.

Chapter 2
Objectives
General Objective
Within the 4 days of duty in the Davao Medical School Foundation
Hospital. Our fundamental goal for the study is to be able to select a patient for
our case study and conduct a comprehensive case study of the illness, and most
especially, to provide a holistic and effective nursing care to the client by relating
and putting to use the knowledge that we have acquired.
Specific Objectives:

Cognitive:
Define the complete diagnosis of the patient
Conduct a cephalocaudal assessment of the patient and Identify
any abnormalities within the physical assessment.

Identify the developmental data of the patient


State a comprehensive prognosis
Text
Create efficient nursing care plan based on actual high-risk
health needs
Discuss the implications of the laboratory results of the
patient as well as the surgical procedure done
Review and discuss the human anatomy and physiology of
the respiratory system, focusing primarily on the affected
organ and organ systems

Locate and identify a genogram that could trace any disease


that could be hereditary to the patient which might contribute
to his present condition
Analyse the disease process of pneumonia by explaining its
pathophysiology
Formulate specific, measurable, attainable, realistic, and timebounded nursing care plans to outline the care to be provided for
the patient.
Recognise the relevance of drug to the patient by doing drug
studies.
State nursing theories to organise the framework of concepts for
our nursing practice.

Psychomotor
gather data and comprehend the patients data, family
background, health history and present health condition
Select a pediatric patient who will be the main subject of the
case presentation.

choose and apply the different and related nursing theories


that are appropriate to the present health condition of the
patient
present medications and its indications given to the patient
Conduct a thorough physical and acute assessment to the
patient by using this as basis for NCP.
Collect valid data regarding the past and present health
history of the patient
5

Perform the appropriate nursing care plan to achieve the


need of the patient
Conduct health teachings to the patient to promote health
and prevent disease that can be acquired.

Affective
establish good rapport with the patient to gain their trust
and cooperation
show respect, genuine concern, and empathy to the
patient by giving care and attention
provide the best quality of care along with the
principles of nurse-patient relationship
Give the best quality of care with integrity, honesty, love and
compassion by doing bedside care and regular visit.
Allow patient to express their feelings and thoughts through active
listening and have a good and open communication.

offer health teachings to the client to achieve optimum


wellness as well as other relevant discharge orders

CHAPTER 3
Patients Data
Name: C. V. B. B.

Sex: Female

Birthdate: November 24, 2013

Age: 2Y 9M 20D

Birth place: Davao City

Religion: Roman Catholic

Address: Iron Street, Mineral Village, Brgy 19-B Bajada, Davao City
Nationality: Filipino

Occupation: none

Status: Single
Name of Father: A. B. Jr
Name of Mother: C. M. B.

Clinical/Admission Data
Date of Admission: September 14, 2016
Chief Complaint: Fever and cough
Presenting Symptoms:

2 days PTA
- Onset of fever
-Productive cough (yellow phlegm around 10x a day)
-Runny nose

1 day PTA
-Fever
-Productive cough
-Onset of abdominal pain (bilateral lower abdomen; lasts for 2secs)

On the day of admission


7

-Fever
-Cough
-Abdominal pain (1ep)

Vital Signs upon admitting:


Temperature 37.6oC
Heart Rate 130 bpm
Respiration 45 cpm

Admitting Physician: Dr. Love Joy C. Mabano


Attending Physician: Dr. Marcelo Dahinog
Admitting Diagnosis: Bronchopneumonia
Final Diagnosis: Clinical Pathway on Paediatric Community-Acquired Pneumonia
Moderate Risk

CHAPTER 4
Health History
A. Genogram

B. Past Health History


1. Medical/Surgical History
The patient is currently 2 years, 9 months, and 20 days old. She has a family
history of cardiomyopathy, hypertension, tuberculosis, and asthma
a. Communicable Diseases: The patient has yet to experience any
communicable disease aside from the present acquisition of Pediatric
Community Acquired Pneumonia Moderate Risk (PCAP-C)
b. Serious or Chronic Illness: None
c. Childhood Illness: None
d. Family History: Asthma, Cardiomyopathy, Tuberculosis, Hypertension
e. Injuries/Accidents: None
f. Special Needs: None
g. Allergies and Reactions: None
h. Blood Transfusions: None
2. Immunizations

BCG 1x

DPT 3x

OPV 3x

Measles 1x

Hib 1x

Hepatitis 3x

3. Feeding History

Breastfeeding: 7 months

Vitamins: Tiki-tiki; Cilin syrup, 2.5mL, OD

4. Natal History

Type of Delivery: NSD

AOG: 38 weeks

G3P3

APGAR Score: 8.9

BW: 3.2kg
10

Anomalies: None

Complications: None

5. Past Illness

None

C. Present Health History


Chief Complaint: Fever with cough
Date of Admission: September 14, 2016

Ht 87cm

Wt 10.3kg

HC 49cm

T 37.6 degrees Celsius

P 130 bpm

R 45 cpm

Oxygen Sat 99%

1 week PTA, patient had onset of non-productive cough associated with colds.
This was not associated with fever, LBM or vomiting. No consult and no meds taken.
Cough gradually progressed to be productive with yellowish sputum until 2 days
PTA. Patient developed fever at 38.7 degrees Celsius, still with productive cough
and colds. Until the day of admission, symptoms persisted now with decrease in
appetite prompting consult hence admission.
2 days PTA, patient had onset of fever, undocumented hot to touch; intermittent,
given paracetamol syrup 250mg/5ml, 2.5ml (12MKD) associated with productive cough
yellow phlegm around 10x a day, rpm quantity; running nose, no consult done.
1 day PTA, patient had persistence of fever and productive cough. Patient had
new onset of abdominal pain, bilateral lower abdomen, 2-3x lasts for 2 seconds. No
medications given for pain.
11

On day of admission, patient had persistence of fever, cough, and abdominal


pain, 1 episode prompted consult. Hence, for admission.

a. Medication and Treatments

Paracetamol 250/5mL. 3mL q4 PRN for fever

Cefuroxime 375 mg IVTT q8 ANST

Salbutamol nebulization 1 neb q6

Zinc Sulfate syrup 5mL OD

b. Laboratories

CBC

UA

Chest X-ray PAL

12

Chapter 5
Development Data
Development is an increase in the complexity of function and skill progression.
Development is the behavioural aspect of growth. Growth and development are
continuous, orderly, sequential processes influenced by maturational, environmental
and genetic factors. Components of growth and development are generally categorised
as physiologic, psychosocial, cognitive, moral and spiritual. Normally, an individual
cannot have growth without development.
Many factors can influence growth and development. An example of which is,
genetic inheritance, which is already established at conception. Characteristics such as
gender and physical can be determined. Temperament refers to the way how individuals
respond to their external and internal environment. The role of the family is to provide
support and safety for the each member of the family. Since family is involved in an
individuals growth and development. Not only the family, but also environmental factors
such as socioeconomic status, climate and community, health and cultural customs.
Adequate nutrition can also affect an individuals growth and development. Different
nutritional practices may influence the rate of growth for infants.
Most importantly, only the person himself can contribute a lot in his own growth
and development. This highly includes the way how an individuals lifestyle, the way he
handles different life situations and also the way he manages life difficulties.
Psychosocial Theory of Development by Erik Erikson
Erikson enumerate eight stages though which healthily developing human should
pass from infancy to late adulthood. At each stage, there is a crisis to be resolved and a
virtue to be gained. According to the theory, failure to properly master each step leads to
problems in the future.

13

Stage

Description.

EARLY

-The child is developing Working on As verbalized by the

CHILDHOOD

physically and becoming

(1 to3)

Result

the process

more mobile. Between the


ages of 18 months and three,

Autonomy vs.

children begin to assert their

Shame

independence, picking which

Justification

mother, patient was able


to know what she wants.
she was able to do
things such as picking
her clothes after taking a
bath, and putting on her

toy to play with, and making

clothes with the

choices about what they like

assistance of the

(to wear, eat, etc.)

mother.

Robert Havighursts Developmental Milestones Theory


Havighurst defines a developmental task as one that arises as a certain period in
our lives, the successful achievement of which leads to happiness and success with
later tasks; while leads to unhappiness, social disapproval, and difficulty with later tasks.
He identifies three sources of developmental tasks (1972).
Tasks that arise from physical maturation
Tasks that arise from personal values
Tasks that have source in the pressures of society.
Our client belongs to the 1st stage which is the infancy.
The following are the developmental task that an infant must fulfil or achieve.

14

DEVELOPMEN RESULT
TAL TASK

JUSTIFICATION

Learning to walk

Achieved

Patient was able to walk by herself.

Learning to take
solid foods

Achieved

Patient was able to take solid food. Mother


verbalizes that she used to feed her child by
mashing vegetables like squash, or even rice.

Learning to talk

Achieved

Patient was able to verbalize what she wanted and


what she feel.

Learning to form Achieved


relationships with
family members

Patient was able to recognize her family, most


especially with her parents. She was able to
respond when they communicate with her.

Freuds Psychosexual Development Theory:


Freuds Stages of Psychosexual Development are, like other stage theories,
completed in a predetermined sequence and can result in either successful completion
or a healthy personality or can result in failure, leading to an unhealthy personality. This
theory is probably the best known as well as the most controversial; as Freud believed
that we develop through stages based upon a particular erogenous zone. During each
stage, an unsuccessful completion means that a child becomes fixated on that particular
erogenous zone and either over or under-indulges once he or she becomes an adult.
STAGE

RESULT

JUSTIFICATION

ANAL STAGE (1 to 3 year)

Working on the process

According to the mother,


the patient is still on
diapers. But then she
verbalizes that she used
teach her child to do toilet
training.

15

Chapter 6
Patients Diagnosis
Final Diagnosis: Paediatric Acquired Pneumonia Type C

Diagnosis

Rationale

Pediatric

Pediatrics is the branch of medicine dealing with the health


and medical care of infants, children, and adolescents from
birth up to the age of 18.

Community - Acquired Community-acquired pneumonia (CAP) occurs outside of


hospitals and other health care settings. Most people get
CAP by breathing in germs (especially while sleeping) that
live in the mouth, nose, or throat.
CAP is the most common type of pneumonia. Most cases
occur during the winter. About 4 million people get this form
of pneumonia each year. About 1 out of every 5 people who
has CAP needs to be treated in a hospital.

Pneumonia

Refers to the lung inflammation caused by bacterial or viral


infection, in which the air sacs fill with pus and may become
solid. Inflammation may affect both lungs ( double
pneumonia ), one lung ( single pneumonia), or only certain
lobes ( lobar pneumonia ).

Type C

Type of pneumonia which has a moderate risk, with


moderate dehydration, with a respiratory rate of greater
than35-60/min

16

Chapter 7
Anatomy and Physiology
RESPIRATORY SYSTEM

The Respiratory system consists of the external nose, the nasal cavity, the pharynx, the
larynx, the trachea, the bronchi and the lungs. Although air frequently passes through
the oral cavity, it is considered to be part of the digestive system instead of the
respiratory system. The upper respiratory tract refers to the external nose, nasal cavity,
pharynx, and associated structures; and the lower respiratory tract includes the larynx,
trachea, bronchi, and lungs.
17

"
Nose
The nose consists of the external nose and the nasal cavity. The external nose is
the visible structure that forms a prominent feature of the face. Most of the external
nose is composed of hyaline cartilage, although the bridge of the external nose consists
of bone. The bone and cartilage are covered by connective tissue and skin.
The nasal cavity extends from the nares to the choane. The nares or nostrils, are
the external openings of the nose and the choane are the openings into the pharynx.
The

nasal septum is a partition dividing the nasal cavity into left and right parts. A

deviated nasal septum occurs when the septum bulges to one side or the other. The
hard palate forms the floor of the nasal cavity, separating the nasal cavity from the oral
cavity. Air can flow through the nasal cavity when the mouth is closed or when the oral
cavity is full of food. Three prominent bony ridges called conchae are present on the
lateral walls on each side of the nasal cavity. The conchae increase the surface of the
nasal cavity.
Paranasal sinuses are air-filled spaces within bone. The maxillary, frontal,
ethmoidal and sphenoidal sinuses are named after the bones in which they are located.
The paranasal sinuses open into the nasal cavity and are lined with a mucous
membrane. They reduce the weight of the skull, produce mucus, and influence the
quality of the voice by acting as resonating chambers. The nasolacrimal ducts, which
18

carry tears from the eyes, also open into the nasal cavity. Sensory receptors for the
sense of smell are found in the superior part of the nasal cavity. Air enters the nasal
cavity through the nares. Just inside the nares the epithelial lining is composed of
stratified squamous epithelium containing coarse hairs. The hairs trap some of the large
particles of dust suspended in the air. The rest of the nasal cavity is lined with
pseudostratified columnar epithelial cells containing cilia and many mucus-producing
goblet cells. Mucus produced by the goblet cells also traps debris in the air. The cilia
sweep the mucus posteriorly to the pharynx, where it is swallowed. As air flows through
the nasal cavities, it is humidified by moisture from the mucous epithelium and is
warmed by blood flowing through the superficial capillary networks underlying the
mucous epithelium.

"

19

Pharynx
The pharynx is the common passageway of both respiratory and digestive
systems. It receives air from the nasal cavity and air, food, and water from the mouth.
Inferiorly, the pharynx leads to the rest of the respiratory system through the opening
into the larynx and to the digestive system through the opening into the larynx and to
the digestive system through the esophagus. The pharynx can be divided into three
regions: the nasopharynx, the oropharynx, and the laryngopharynx.
The nasopharynx is the superior part of the pharynx. It is located posterior to the
choaneae and superior to the soft palate, which is an incomplete muscle and connective
tissue partition separating the nasopharynx from the oropharynx. The uvula is the
posterior extension of the soft palate. The soft palate forms the floor of the
nasopharynx. The nasopharynx is lined with pseudostratified ciliated columnar
epithelium that is continuous with the nasal cavity. The auditory tubes extend form the
middle ears open into the nasopharynx. The posterior part of the nasopharynx contains
the pharyngeal tonsil, which aids in defending the body against infection.

The soft

palate is elevated during swallowing, this movement results in the closure of the
nasopharynx, which prevents food from passing from the oral cavity into the
nasopharynx.
The oropharynx extends from the uvula to the epiglottis, and the oral cavity
opens into the oropharynx. Food and drink all passes in the oropharynx. The
laryngopharynx passes posterior to the larynx and extends from the tip of the epiglottis
to the esophagus.The larynx (plural larynges), colloquially known as the voicebox, is an
organ in the neck of mammals involved in protection of the trachea and sound
production. The larynx houses the vocal folds, and is situated just below where the tract
of the pharynx splits into the trachea and the esophagus. Sound is generated in the
larynx, and that is where pitch and volume are manipulated. The strength of expiration
from the lungs also contributes to loudness.The trachea, or windpipe, is the bony tube
that connects the nose and mouth to the lungs, and is an important part of the
vertebrate respiratory system. When an individual breathes in, air flows into the lungs
for respiration through the windpipe. Because of its primary function, any damage
incurred to the trachea is potentially life-threatening.The bony skeletal trachea is
20

comprised of cartilage and ligaments, and is located at the front of the neck. The
trachea begins at the lower part of the larynx and continues to the lungs, where it
branches into the right and left bronchi. It measures 3.9 to 4.7 inches (10-12 cm) in
length, and .62 to .7 inches (16-18 mm) in diameter. The trachea is composed of 16 to
20 c shaped rings of cartilage connected by ligaments, with a ciliated-lined mucus
membrane. It is this structure that helps push objects out of the airway should
something become lodged.
Larynx
The larynx is the portion of the breathing, or respiratory, tract containing the
vocal cords which produce vocal sound. It is located between the pharynx and the
trachea. The larynx, also called the voice box, is a 2-inch-long, tube-shaped organ in
the neck.
We use the larynx when we breathe, talk, or swallow. Its outer wall of cartilage
forms the area of the front of the neck referred to as the "Adams apple". The vocal
cords, two bands of muscle, form a "V" inside the larynx.
Each time we inhale (breathe in), air goes into our nose or mouth, then through
the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air
goes the other way. When we breathe, the vocal cords are relaxed, and air moves
through the space between them without making any sound.
When we talk, the vocal cords tighten up and move closer together. Air from the
lungs is forced between them and makes them vibrate, producing the sound of our
voice. The tongue, lips, and teeth form this sound into words.
The esophagus, a tube that carries food from the mouth to the stomach, is just
behind the trachea and the larynx. The openings of the esophagus and the larynx are
very close together in the throat. When we swallow, a flap called the epiglottis moves
down over the larynx to keep food out of the windpipe.
Trachea
A tube-like portion of the breathing or "respiratory" tract that connects the "voice
box" (larynx) with the bronchial parts of the lungs.

21

Each time we inhale (breathe in), air goes into our nose or mouth, then through
the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air
goes out the other way.
The esophagus, the tube that carries food from the mouth to the stomach, is just
behind the trachea and the larynx. The openings of the esophagus and the larynx are
very close together in the throat. When we swallow, a flap called the epiglottis moves
down over the larynx to keep food out of the windpipe.
The trachea is also called the windpipe, weasand (sometimes written wesand or
wezand) or wesil. "Cut his weasand with thy knife." The Tempest, Shakespeare.

"
Bronchi
The trachea divides into left and right main (primary) bronchi. Each of which
connects to a lung. The left main bronchus is more horizontal than the right main
bronchus because of it is displaced by the heart. Foreign objects that enter the trachea
22

usually lodge in the right main bronchus, because it is more vertical than the left main
bronchus and threfore more in direct line with the trachea. The main bronchi extend
from the trachea to the lungs. Like the trachea, the main bronchi are lined with
pseudostratified ciliated columnar epithelium and are supported by C- shaped pieces of
cartilage.
The large air tubes leading from the trachea to the lungs that convey air to and
from the lungs. The bronchi have cartilage as part of their supporting wall structure. The
trachea divides to form the right and left main bronchi which, in turn, divide to form the
lobar, segmental, and finally the subsegmental bronchi.
Bronchi is the plural of bronchus from the Greek word bronchos, a conduit to the lungs.

23

Lungs
The lungs are the principal organs of respiration. Each lung is cone-shaped, with
its base resting on the diaphragm and its apex extending superiorly to a point about 2.5
cm above the clavicle. The right lung has three lobes called the superior, middle and
inferior lobes. The left lung has two lobes called the superior and inferior lobes. The
lobes of the lungs are separated by deep, prominent fissures on the surface of the lung.
Each lobe is divided into broncho-pulmonary segments separated from one another by
connective tissue septa, but these separations are not visible as surface fissures. There
are 9 broncho-pulmonary segments in the left lung and 10 in the right lung. The main
bronchi branch many times to form the tracheobronchial tree. Each main bronchus
divides into lobar bronchi as they enter their respective lungs. The lobar (secondary)
bronchi, two in the left and three in the right lung, conduct air to each lobe. The lobar
bronchi in turn give rise to segmental (tertiary) bronchi, which extends to the bronchopulmonary segments of the lungs. The bronchi continue to branch many times, finally
giving rise to bronchioles. The bronchioles also subdivide numerous times to give rise to
terminal bronchioles, which then subdivide into respiratory bronchioles. Each respiratory
bronchiole subdivides to form alveolar ducts, which are like long, branching hallways
with many open doorways. The doorways open into alveoli which are small air sacs
become so numerous that the alveolar duct wall is little more than a succession of
alveoli. The alveolar ducts end as two or three alveolar sacs, which are chambers
connected to two or more alveoli. There are about 300 million alveoli in the lungs. As the
air passageways of the lungs becomes smaller, the structure of their walls changes. The
amount of cartilage decreases and the amount of smooth muscle increases, until at the
terminal bronchioles, the walls have a prominent smooth muscle layer, but no cartilage.
Relaxation and contraction of the smooth muscle within the bronchi and bronchioles can
change the diameter of the air passageways. For example, during exercise the diameter
can increase, thus increasing the volume of air moved. During an asthma attack,
however, contraction of the smooth muscle in the terminal bronchioles can result in
greatly reduced air flow. In severe cases, air movement can be so restricted that death
results. As the air passageways of the lungs become smaller, the lining of their walls
also changes. The trachea and bronchi have pseudo stratified ciliated columnar
epithelium, the bronchioles have ciliated simple cuboidal epithelium. The ciliated
24

epithelium of the air passageways functions as mucus-cilia escalator, which traps debris
in the air and removes it from the respiratory system. The respiratory membrane of the
lungs is where gas exchange between the air and blood takes place. It is mainly of the
alveoli and surrounding capillaries but theres some contribution by the alveolar ducts
and respiratory bronchioles it is very thin to facilitate the diffusion of gases.

Pleural cavity

In human anatomy, the pleural cavity is the body cavity that surrounds the lungs.
The pleura are a serous membrane which folds back upon itself to form a two-layered,
membrane structure. The thin space between the two pleural layers is known as the
pleural cavity; it normally contains a small amount of pleural fluid. The outer pleura
(parietal pleura) is attached to the chest wall. The inner pleura (visceral pleura) covers
the lungs and adjoining structures, viz. blood vessels, bronchi and nerves.
The pleural cavity, with its associated pleurae, aids optimal functioning of the
lungs during respiration. The pleural cavity also contains pleural fluid, which allows the
pleurae to slide effortlessly against each other during ventilation. Surface tension of the
pleural fluid also leads to close apposition of the lung surfaces with the chest wall. This
physical relationship allows for optimal inflation of the alveoli during respiration. The
pleural cavity transmits movements of the chest wall to the lungs, particularly during
heavy breathing. This occurs because the closely opposed chest wall transmits
pressures to the visceral pleural surface and hence to the lung itself.

25

Chapter 9
Physical Assessment
General Assessment
Physical assessment done at Davao Medical School Foundation 3A Pediatric
Ward at around 9:30 AM of September 16, 2016 while patient was lying on bed, awake
and responsive. The patient is 2 years old, Female. Received patient with an IVF of
D5IMB 500mL at 480mL, infusing well at 60cc/hr at her left metacarpal vein. The stated
age is congruent with the apparent age. No physical deformities noted. Arms and legs
are proportionate to the body. Mobility and gait is normal for age. Patient is not yet
capable to walk. Patient appears neat and clean. She is wearing a sando and a pair of
shorts, which are appropriate for the environment. Crying and babbling noted for
speech.
Vital Signs
Temperature 37.1oC
Cardiac Rate 132 bpm
Respiratory Rate 30 cpm
Blood Pressure 70/40 mmHg
Pulse Rate 132 cpm
Skin, Hair and Nails Assessment
Skin color is fair. Lip membrane is pink. Nails are properly trimmed and clean.
Nail beds and palms are pink. Skin is warm to touch and sweating with temperature of
37.1oC. Normal skin turgor noted. Thin, smooth, black, minimal hair on head is noted
which is normal for age. Terminal hair is found in the eyebrows, eyelashes, and scalp.
Hair is evenly distributed throughout the body. No lesions, scars, tenderness, masses,
and infestations noted upon inspection and palpation. Capillary refill of 2 seconds noted.
Head, Neck and Regional Lymphatics Assessment

26

Head is normocephalic and symmetrical. Skull is smooth, non-tender, and


without masses or depressions. Scalp is shiny, intact, moist and lighter in color than
complexion. No scars, nits, dandruff, or infestations noted. No lesions, tenderness, nor
masses noted upon palpation. Shape of face is rounded and symmetrical. No lumps
and swelling, tenderness noted. Forehead is symmetrical, brown, and no rashes, scars,
pimples, tenderness, lumps, masses noted. Muscle of the neck is symmetrical with the
head in central position. Patient is able to move head without difficulty or pain. Trachea
is at midline. No enlargement or masses noted. Lymph nodes are neither visible nor
inflamed.
Eye Assessment
Eyes are symmetrical and inline with each other. Eyes are non-protruding and
with equal palpebral fissure. Eyebrows are symmetrically aligned and evenly distributed.
Equal eye movement noted. Eyelashes are black in color, equally distributed, and
slightly curled outward. The sclera appears white and moist. No lesions noted. Both
conjunctivas are smooth, shiny, and pink in color. No swelling noted or tenderness
noted. The corneal surface is moist, shiny and transparent with no abnormal discharges
or cloudiness noted. The irises are black in color. The pupils are black in color; appears
round, smooth, and of equal size. Pupils dilate at 3mm and constrict at 2mm. No
drooping, infections, tumors, lesions, and abnormal discharges noted in all areas of the
eyes.
Ears, Nose, Mouth and Throat Assessment
Both ears match the flesh color of the rest of the patients skin. Ears are
positioned centrally and in proportion to the head. The top of the ear crosses the
imaginary line drawn from the outer canthus of the eye to the occiput. There were no
foreign bodies, redness, drainage, deformities, nodules, tenderness or lesions noted.
Nose is located symmetrically in the midline of the face and is without swelling,
bleeding, lesions or masses. Sticky mucous noted on left nostril but she is able to
breathe through her nose. No tenderness noted upon palpation. Septum is at midline
and without perforation, lesions or bleeding noted. Minimal watery discharge noted
which is normal. No evidence of swelling noted around the eyes and nose.
27

Lip and membranes are pink, moist, and smooth with no evidence of lesions or
inflammation. Tongue is in the midline of the mouth. No swelling or bleeding found. No
teeth noted which is normal for her age. Gums are pink, moist, and firm with no signs of
bleeding or swelling. No tenderness, masses, or lesions noted. Uvula is at midline.
Tonsils are present and pink in color. No inflammation noted.
Thorax and Lungs Assessment
Patients shoulders are of the same height. The scapulae are at the same height
bilaterally. No masses, tenderness. Respiratory rate is 30 breaths per minute. Slightly
deep and irregular respirations noted. Patient inhales and exhales through the nose. No
chest indrawing noted. Wheezing is noted upon auscultation. Minimal crackling sounds
noted. Productive cough noted.

Abdomen Assessment
Abdomen contour is rounded and clean. Slight protruding appearance noted
which is normal. Diaphragm rises with inspiration and falls with expiration. Umbilicus is
depressed and beneath the abdominal surface. Skin immediately returns to normal
shape when slightly pinched, results to normal skin turgor. Bowel sounds are active with
10 per minute.
Musculoskeletal System Assessment
Patients head is at midline and is perpendicular to the shoulders and pelvis. The
shoulder and hips are at level, and the arms hand freely from the shoulders. Right and
left shoulders are of the same level. Ankle, hip, shoulder, and hand mobility is normal.
No pain, stiffness, masses, and inflammation noted. Patient is not able to fully ambulate
which is normal due to underdeveloped muscles. Babinski reflex is present which is
normal.
Mental Status
Patient is aware of her surroundings. She is responsive to the external stimuli
and irritable.
28

Genito-Urinary Assessment
Patient is wearing a diaper. Her labias are clean and smooth. No masses, and
tenderness noted upon palpation. Patient is able to urinate efficiently. Minimal rashes
noted around anus.

29

Chapter 10
Etiology
PRECIPITATING FACTORS

Factor

Pres

Rationale

Justification

ence
Environment

Respiratory diseases occur as a result of interactions The patients sister


between genotype and environment. Environmental had PCAP-C first and
influences include allergens, irritants, smoking, then after a few days,
environmental tobacco smoke (ETS), diet, nutrients, the patient herself
drugs, infections and injuries. Other diseases are acquired the disease.
triggered mainly by major environmental exposures;
examples include carbon monoxide poisoning, acute
lung injury and acute respiratory distress syndrome
(due to severe pneumonia or major trauma).
Source:http://www.erswhitebook.org/chapters/genetic-susceptibility/

Lifestyle

Smoking damages fragile lung tissue, making lungs The patient is only 2
more vulnerable to infection.
Source:http://www.knowpneumonia.com/causes-pneumococcal-

years old, still a child.


She cannot do things
like these at her age.

pneumonia

Smoking damages the tiny hairs in the lungs that help


remove germs and bacteria. Alcohol abuse can put you at
increased risk of aspiration pneumonia, a type of
pneumonia that develops after you inhale particles into your
lungs. This occurs most often when you vomit and small
particles enter your lungs because you are not strong
enough to cough the particles out. Alcohol abuse also
interferes with the way your white blood cells (which are
responsible for fighting infection) work.
Source:http://familydoctor.org/familydoctor/en/diseasesconditions/pneumonia/causes-risk-factors.html

30

PREDISPOSING FACTORS
Factor

Pres

Rationale

Justification

enc
e
Age

The World Health Organization (WHO) The patient is 2


estimates there are 156 million cases of years, 9 months,
pneumonia each year in children younger than and 20 days old.
five years, with as many as 20 million cases
severe enough to require hospital admission. In
the developed world, the annual incidence of
pneumonia is estimated to be 33 per 10,000 in
children younger than five years and 14.5 per
10,000 in children 0 to 16 years. Pneumonia is
considered as the largest killer of children.
Source: http://www.uptodate.com/contents/pneumonia-inchildren-epidemiology-pathogenesis-and-etiology

31

Genetic

Your inherited genetic makeup predisposes you T h e p a t i e n t s

s/Family

to having asthma. In fact, it's thought that three- m o t h e r

History

fifths of all asthma cases are hereditary. asthma, which is

has

According to a CDC report, if a person has a believed to be a


parent with asthma, he or she is three to six risk factor why the
times more likely to develop asthma than p a t i e n t

is

someone who does not have a parent with s u s c e p t i b l e t o


asthma.

pneumonia.

Source:http://www.webmd.com/asthma/guide/asthma-riskfactors

Certain children have a higher-than-normal risk


for pneumonia and recurrence. Conditions that
predispose infants and small children to
pneumonia include:
Abnormalities in muscle coordination of
the mouth and throat
Asthma
Certain genetic disorders such as sicklecell disease, cystic fibrosis, and
Kartagener's syndrome, which result in
poorly functioning cilia, the hair-like cells
lining the airways
Gastroesophageal reflux disorder
(GERD)
Impaired immune system
Inborn lung or heart defects
Infection with the respiratory syncytial
virus (RSV)
Source: http://www.nytimes.com/health/guides/disease/
pneumonia/risk-factors.html

32

Chapter 11
Symptomatology
SYMPTOMS

ACTUAL

RATIONALE

JUSTIFICATION

COUGH

Present

Cough is a common symptom in


pneumonia. It is caused by the
inflammation and irritation of the
passages in the lungs, which is
sensed by small nerve endings
which trigger the cough

The patient had a productive


cough 2 days prior to admission
around 10 x a day and is noted
during physical examination
upon admission.

CHEST PAIN

Absent

" P l e u r i t i c c h e s t p a i n " No chest pain noted nor


This pain often occurs when you documented in the patients
take a deep breath in or out, or charts/records
cough.

FEVER

Present

Increase in temperature because


of the infection. Inflammatory
response due to invading
organisms in the respiratory
tract.

Patient had onset of fever three


(3) prior to her admission. And,
on the day of admission, she
had a persistent fever. One of
the chief complaints of the
patient upon admission.

FATIGUE

Present

Loss of appetite and loss of


energy

Patient had decrease in appetite


upon admission documented in
the patients charts/records

SHORTNESS
OF BREATH

Present

With presence of mucus in the


Rapid, shallow, irregular
airway, it decreases the passage respirations noted during PA.
of air to pass,
making it hard to inhale since
small air comes in, which then
result to rapid breathing to
compensate with less air being
inhaled

33

With presence of mucus in the


airway, it decreases the passage of
air to pass,
making it hard to inhale since small
air comes in, which then result to
rapid breathing to compensate with
less air being inhaled

Upon admission, patient had RR of 45


cpm, rapid breathing was noted. During
the PA, patient had RR of 30 cpm. In
addition, it was endorsed to refer the
patient if RR is greater than 40 cpm.

RAPID
BREATHING

Present

CRACKLES

Present

Crackles are heard when an


Prior to admission of the patient, during
obstructed airway suddenly
physical assessment, positive bilateral
equilibrates resulting in transient,
mid-basal fine crackles are heard.
distinct vibrations in the airway wall.

WHEEZING

Present

Due to the presence of mucus


secretions as response to infection,
it blocks/obstructs the airway
making the passages narrow for air
to pass and result to frequent
vibrations creating a high-pitched
sound.

CHEST
RETRACTIO
NS:

Absent

>SUBCOSTA
L

Absent

>SUBSTERN
AL

Present

>INTERCOST
AL

These retractions are a sucking in


of the skin between or around the
bones of the chest while inhaling.
Retractions may occur in several
areas of the chest and are a sign of
increased use of the chest muscles
for breathing. This is usually a sign
of difficulty in breathing.

There were wheezing sounds were


noted upon auscultation during the
physical assessment.

>There is no Subcostal, substernal, and


supraclavicular retractions noted during
the physical examination of the pation
upon admission. However, there is a
positive bilateral intercostals retractions
noted.

Absent

>SUPRACLA
VICULAR
HYPOXIA

Absent

During an attack, airways are


narrowed, making it hard to get air
into lungs.

34

there was no Arterial Blood Gas (ABG)


test was ordered.

Chapter 12
Pathophysiology

35

Chapter 13
Doctors Order
DATE &

DOCTORS ORDER

RATIONALE /

TIME

JUSTIFICATION

ORDERED
9-14-16

5:00 pm

> Please admit under the service of Admission is required to assess and
Dr. Dahinog

observe the patient further.

> Secure consent to care

A secure consent form is given to the


parents since the patient is still 2 years
old, to be signed by indicating her
approval that she will be receiving
treatment from the institution.

> DAT; NPO if with RR greater than

To avoid aspiration.

40 cpm.
> VS q 4 and record please

To monitor and obtain baseline data.

> Labs
CBC

-Laboratory tests are primarily conducted

U/A

to determine baseline values and aid in

Chest X-ray

the diagnosis of the patient.


- X-rays will show where air sacs in the
lungs are filled with fluid and debris and
to look for other causes of your
symptoms.

36

> Meds
(1) Paracetamol 250, 3ml q 4
PRN
(2) Cefuroxime 375 mg IVTT
q8 ANST

-Paracetamol has good analgesic and


antipyretic properties.
-Cefuroxime is used to treat a wide
variety of bacterial infections. It works by
stopping the growth of bacteria.
-Bronchodilator. It relaxes smooth
muscles of the bronchioles allowing
maximun passage of air.

(3) Salbutamol Nebulization 1


neb q6
> Start IVF with D5 0.3 NaCl (bottle

For replacement or maintenance of fluids

#1) @ 45cc/hr

and electrolytes. Hypertonic saline has


also been shown to help in other
respiratory problems specifically
bronchiolitis.

> I & O q shift

To monitor and measure liquid intake and


output of patient.

>Hydration rounds q4

- Drinking fluids will help thin out the


congestion in the chest and make it
easier to expectorate, or cough up the
mucus in the chest. Without adequate
hydration, the cough will become dry and
breathing will become more difficult.

> Chest physiotherapy every after

-Breathing is improved by the indirect


removal of mucus from the breathing
passages of a patient. To mobilize or
loose secretions in the lungs and
respiratory tract.

nebulization

> Refer for unusualities; RR > 40

-Unreported unusualities may lead to

cpm, cyanosis, decrease sensorium, further complications.


grunting
>Will inform AP of this admission

>Add meds:
-Zinc sulfate syrup 5mL OD 37

Zinc has been used as a treatment for the


common cold. Zinc also has applications
in pneumonia. Supplement.

DATE & TIME


ORDERED

9-14-16

RATIONALE /
DOCTORS ORDER

JUSTIFICATION

>Patient seen and examined.


>Hx reviewed.

6:30 pm
> IVF TF: (bottle #2) D5 IMB 500 -For maintenance of fluid and electrolytes
@ 55cc/hr once with urine output. especially to patients who need calories
and hydration.

9-15-16

>Meds:
(1) Cefuroxime
(2) Salbutamol neb q6
(3) Zinc

- To continue treating the patient.

>IVF TF: (bottle #3) D5 IMB 500


@ 55cc/hr

>Continue meds and monitoring

-To continue treating the patient.

6 am
>Refer accordingly

38

Chapter 14
Diagnostic/ Laboratory Test
1) Chest X-ray
Chest x-rays (CXR) are
among the most frequently
performed radiologic studies and
yield a great deal of information
about the pulmonary and cardiac
systems. The lung fields, the
clavicle and ribs, the cardiac
border, the mediastinum, the
diaphragm, and the thoracic spine
can all be studied using CXRs.
Although only a single view is
obtained, critical problems such as
pneumonia, atelectasis,
pneumothorax, pulmonary edema, and pleural effusion can be identified. (Cavanaugh,
2003)
In the posterior-anterior (PA) view, the x- ray beam passes through the client from
back to front. This is a preferred view because it results in less magnification of the
heart than does the anterior-posterior (AP) view.13 The farther away from the x-ray film
an object is situated, such as the heart in the AP view, the more magnified and less
distinct will be its image. (Cavanaugh, 2003)
Patient was ordered to have a chest x-ray since her diagnosis was a pulmonary
infectious disorder, which is Pediatric Community-Acquired Pneumonia Type C

Date and Time ordered: 09-14-2016


Examination: CHEST APL
39

Physician: Dr. Dahinog


Reference Result:
Normal lung fields, cardiac size, mediastinal structures, and thoracic spine; no
masses, infiltrates, areas of collapse, pleural effusion, fractures of clavicles or ribs, or
abnormal elevation or flattening of the diaphragm
Patients Result:
There are hazy densities in both inner and middle ling zones. The heart is normal
in size. There are no other additional significant remarkable findings.
IMPRESSION: BRONCHOPNEUMONIA
Nursing Responsibilities
Explain to the client:
1. The location for the procedure and the fact that a technician or radiologist will
perform it.
2. That the procedure takes about 15 minutes.
3. That foods, fluids, and medications are not restricted before the procedure.
4. That no sedation or anesthetic is administered before the procedure.
5. That views may be taken with the client in various positions on the x-ray table or
in an x-ray chair.
6. That the area to be examined will be immobilized or the client will be asked to
remain still during the procedure.
7. That the procedure should not cause discomfort, except possibly from lying on
the hard table
Prepare for the procedure:
8. Obtain a history of known underlying medical conditions or trauma and (for
women) date of last menstrual period to determine the possibility of pregnancy.
9. Ensure that all dental prostheses, jewelry, eyeglasses, or other metal objects
such as hair clips are removed.
10.Provide a hospital gown, if needed.
11.Perform baseline neurological check and vital signs for later comparison
readings.

40

2) Complete Blood Count (CBC) + Platelet


A CBC includes (1) enumeration of the cellular elements of the blood, (2)
evaluation of RBC indices, and (3) determination of cell morphology by means of
stained smears. Counting is performed by automated electronic devices capable of
rapid analysis of blood samples with a measurement error of less than 2 percent.
Reference values for the CBC vary across the life cycle and between the genders.
(Cavanaugh, 2003)
Because the CBC provides much information about the overall health of the
individual, it is an essential component of a complete physical examination, especially
when performed on admission to a health-care facility or before surgery. Since patient
was suspected for an infection (local or systemic, acute or chronic) in her respiratory
tract, CBC is ought to be ordered as a screening test and to monitor the responses to
the drug therapy and progression of nonhematologic disorders such as chronic
obstructive pulmonary disease, and watch out for undesired reactions to drugs that may
cause blood dyscrasias. (Cavanaugh, 2003)
Date and Time Ordered: 09-14-16, 7:28 PM
Date/Time Released: 09-14-2016, 7:43 PM

TEST

CLINICAL SIGNIFICANCE

NORMAL VALUE

PATIENTS
RESULT

COMPLETE BLOOD COUNT

41

Hemoglobin

Normally, Hgb and Hct levels

120 150 g/L

L 99

0.36 0.45

L 0.30

parallel each other and are


commonly used together to
express the degree of anemia.
The combined values are also
useful in evaluating situations
involving blood loss and
related treatment. The Hct
level is normally three times
the Hgb level. If erythrocytes
are abnormal in shape or size
or if Hgb manufacture is
defective, the relationship
between Hgb and Hct is
disproportionate.
Hematocrit

Abnormalities in RBC size and


extremely elevated WBC
counts may produce false Hct
values. Elevated blood
glucose and sodium may
produce elevated Hct values
because of the resultant
swelling of the erythrocyte.
Normally, the Hct parallels the
RBC count. Thus, factors
influencing the RBC count
also affect the results of the
Hct.

42

Red Blood
Cells

The erythrocyte (RBC) count,


a component of the CBC, is
the determination of the
number of RBCs per cubic
millimeter. In international
units, this is expressed as the
number of RBCs per liter of
blood. The test is less
significant by itself than it is in
computing Hgb, Hct, and RBC
indices. Increases in the RBC
count are most commonly
seen in polycythemia vera,
chronic pulmonary disease
with hypoxia and secondary
polycythemia, and
dehydration with
hemoconcentration

43

4.00 6.00
x10^12/L

4.28

White Blood
Cells

The WBC count determines


the number of leukocytes per

5.00 10.00

6.89

x10^9/L

cubic millimeter of whole


blood. The counting is
performed very rapidly by
electronic devices. The WBC
may be performed as part of a
CBC, alone, or with differential
WBC count. If the WBC count
is low, a buffy coat smear can
be performed to identify
leukemia or solid tumor cells
in the blood. An alteration in
total WBC count indicates the
degree of response to a
pathological process but is not
specifically diagnostic for any
one disorder.
Mean
Corpuscular
Volume
Mean
Corpuscular
Hemoglobin
Mean

MCV indicates the volume of the

L 70.1

27.0 31.0 pg

L 23.1

320 360 g/L

330

Hgb in each RBC, MCH is the


weight of the Hgb in each RBC,
and MCHC is the proportion of
Hgb contained in each RBC.
MCHC is a valuable indicator of
Hgb deficiency and of the
oxygen-carrying capacity of the
individual erythrocyte. A cell of

Corpuscular

abnormal size, abnormal shape,

Hemoglobin

or both may contain an

Concentration

81.0 99.0 fL

inadequate proportion of Hgb.

RBC indices are used mainly


in identifying and classifying
types of anemias.

44

DIFFERENTIAL COUNT
Neutrophil

The differential WBC count

0.45 0.65

L 0.41

Lympochyte

indicates the percentage of

0.20 0.35

H 0.50

each type of leukocyte

0.02 0.06

H 0.08

present per cubic millimeter of

0.00 0.04

0.01

0.00 0.01

0.00

150 - 450

326

Monocyte
Eosinophil
Basophil

whole blood. An increase in


immature neutrophils
indicates the bodys attempt to
produce more neutrophils in
response to the pathological
process. A decreased
neutrophil count is fairly
common in children during
viral infections.

Platelet Count

The test reveals the size of


platelets important in the
diagnosis of disorders
affecting the hematologic
system. An increased volume
of platelets that are larger
than normal in diameter is
found in lupus erythematosus,
thrombocytopenic purpura,
B12-deficiency anemia,
hyperthyroidism, and
myelogenic and other
myeloproliferative diseases.

Nursing Responsibilities
Explain to the client:
45

1. The purpose of the test.


2. The procedure, including the site from which the blood sample is likely to be
obtained.
3. That momentary discomfort may be experienced when the skin is pierced.
4. That food, fluids, and drugs are to be withheld before to the test.

3) Urinalysis
Routine urinalysis, one of the most widely ordered laboratory procedures, is used
for basic screening purposes. It is a group of tests that evaluate the kidneys ability to
selectively excrete and reabsorb substances while maintaining proper water balance.
The results can provide valuable information regarding the overall health of the patient
and the patients response to disease and treatment. The urine dipstick has a number of
pads on it to indicate various biochemical markers. Urine pH is an indication of the
kidneys ability to help maintain balanced hydrogen ion concentration in the blood.
Specific gravity is a reflection of the concentration ability of the kidneys. (Cavanaugh,
2003)
The routine urinalysis is a screening technique that is an essential component of a
complete physical examination, especially when performed on admission to a healthcare facility or before surgery. It may also be performed when renal or systemic disease
is suspected. Note that the components of a UA may be performed separately, if
necessary. (Cavanaugh, 2003)
Patient needs urinalysis because its one of the initial protocols of the institution
and to check the acid-base balance status of her body or system. Since the patients
respiratory system is affected and it is one of the buffer systems of the body, her
condition might progress to metabolic acidosis.

Date/Time Ordered: 09-15-2016, 7:48 AM


Date/Time Released: 09-15-2016, 8:00 AM

46

PARAMETER
S

RESULTS

REFERENCE

SIGNIFICANCE

RANGE
PHYSICAL EXAMINATION

The color of urine is mainly a result


of the presence of the pigment
urochrome, which is produced
through endogenous metabolic
Color

processes. Because urochrome is

Light Yellow

normally produced at a fairly


constant rate, the intensity of the
yellow color may indirectly indicate
urine concentration and the clients
state of hydration.
Urine is normally clear or slightly
cloudy. In alkaline urine, cloudiness
may be caused by precipitation of
phosphates and carbonates. In acidic
urine, cloudiness may be caused by

Clarity

Clear

precipitation of urates, uric acid, or


calcium oxalate. The accumulation
of uroerythrin, a pink pigment
normally present in urine, may
produce a pinkish or reddish haze in
acidic urine.

47

CHEMICAL ANALYSIS
The pH of urine reflects the kidneys
ability to regulate the acidbase
balance of the body. In general, when
too much acid is present in the body
pH

6.0

5.0 9.0

(i.e., respiratory or metabolic acidosis),


acidic urine (low pH) is excreted.
Conversely, alkaline urine (high pH) is
excreted in states of respiratory or
metabolic alkalosis.
The specific gravity of urine is an
indication of the kidneys ability to

Specific
Gravity

reabsorb water and chemicals from the


1.025

1.001 1.029

glomerular filtrate. It also aids in


evaluating hydration status and in
detecting problems related to secretion
of antidiuretic hormone.
Normally, glucose is virtually absent
from the urine. Although nearly all
glucose passes into the glomerular
filtrate, most of it is reabsorbed by the

Glucose

Negative

Negative

proximal renal tubules through active


transport mechanisms. If plasma
glucose levels are very high, however,
such that carrier mechanisms are
overwhelmed, glucose will appear in
the urine.
Urine normally contains only a scant
amount of protein, which derives from
both the blood and the urinary tract

Protein

Negative

Negative

itself. The proteins normally filtered


through the glomerulus include small

48

amounts of low-molecular-weight
serum proteins such as albumin.

URINE FLOWCYTOMETRY
Normally, only a few white blood cells are found in urine.
Increased numbers of leukocytes in the urine generally indicate
either renal or genitourinary tract disease. As with red blood cells,
WBC

10

0-17/
uL

white blood cells may enter the urine either through the
glomerulus or through damaged genitourinary tissues. In addition,
white blood cells may migrate through undam- aged tissues to
sites of infection or inflammation. An excessive amount of white
blood cells in the urine is termed pyuria.
Red blood cells are too large to pass through the glomerulus; thus,
the finding of red blood cells in the urine (hematuria) is
considered abnormal. If red blood cells are present, damage to the

RBC

0-11/
uL

glomerular membrane or to the genitourinary tract is indicated.


For this test, the number of red blood cells is counted. The result
may indicate the nature and severity of the disorder causing the
hematuria. Red blood cells may also be seen with some nonrenal
disorders like acute systemic febrile and infectious diseases.
Epithelial cells found in urine samples are derived from three
major sources: (1) the linings of the male and female lower
urethras and the vagina (squamous epithelial cells); (2) the linings
of the renal pelvis, bladder, and upper urethra (transitional

Epith
Cells

0-17/

epithelial cells); and (3) the renal tubules themselves. Because it

uL

is normal for old epithelial cells to slough from their respective


areas, finding a few epithelial cells in a urine sample is not
necessarily abnormal. Presence of a large numbers of cells,
especially those of renal tubular origin, is considered a
pathological situation.

49

Casts are gel-like substances that form in the renal tubules and
collecting ducts. Healthy individuals may normally excrete a few
casts, especially if there is a low urinary pH, increased protein in
Cast

0-1/uL the urine, increased excretion of solutes, and decreased urine flow
rate. Otherwise, excretion of an excessive number of casts is
usually associated with wide-spread kidney disease that involves
the renal tubules.
Bacteria are not normally present but may be seen if UTI is
present or if the sample was contaminated externally. The number

Bacter
ia

28

0-278/
uL

of bacteria will increase if the specimen is allowed to stand at


room temperature for several hours. Bacteria in the urine are
generally not of major significance unless accompanied by
excessive numbers of white blood cells, which may indicate an
infectious or inflammatory process.

Nursing Responsibilities:
Explain to the client:
That results are most reliable if the specimen is obtained upon arising in the
morning, after urine has accumulated overnight in the bladder (Exception: Serial
urine samples for glucose should consist of fresh urine.)
The proper way to collect the sample, if the client is to do this independently.
The importance of the sample being received in the laboratory within 1 hour of
collection.
Prepare for the procedure:
The client should be provided with the proper specimen container.
For women, a clean-catch midstream kit should be provided.
For catheterized specimens, a catheterization tray is needed if an indwelling
catheter is not already present.

50

Chapter 15
Drug Study
Generic Name

Cefuroxime axetil

"

Brand Name

Ceftin, Cefuroxime axetil

Classification

Therapeutic classification: Antibiotic


Pharmacologic classification: Second-Generation
Cephalosporin
Pregnancy risk Category B

Dosage and
Frequency

375 mg IVTT q8 ANST

51

Mechanism of
action

Indications

Contraindication
s & Cautions

Cefuroxime is primarily bactericidal; it also may be


bacteriostatic. Activity depends on the organism, tissue
penetration, dosage, and rate of organism multiplication. It
acts by adhering to bacterial penicillin-binding proteins,
thereby inhibiting cell wall synthesis. Cefuroxime axetil
Inhibits bacterial cell wall synthesis, renders cell wall
osmotically unstable, leads to cell death by binding to cell
wall membrane
Gram-negative Bacterial Pathogen:
Haemophilus influenza
Escherichia coli
Neisseria
Proteus mirabilis
Klebsiella;
Gram-positive Bacterial Pathogen:
Streptococcus
Pneumonia
Streptococcus pyogenes,
Staphylococcus aureus
Treats infection of:
Serious Lower Respiratory Tract
Urinary Tract
Skin
Bone
Joint
GonococciInfections
Septicaemia
Meningitis
Antibiotic prophylaxis
Contraindicated in patients hypersensitive to
cefuroxime or other cephalosporins.
Use cautiously in breast-feeding women and in
patients with impaired renal function or penicillin
allergy.

52

Drug to Drug
Interactions

Aminoglycosides: Produces synergistic activity


against some organisms; increases risk of
nephrotoxicity. Monitor patient closely.
Diuretics: Increases risk of adverse effects. Monitor
patient closely.
Probenecid: Competitively inhibits renal tubular
secretion of cephalosporins, resulting in higher,
prolonged serum levels of these drugs. Sometimes
used for this effect.

Side effects

Hypersensitivity reactions
Nausea
Vomiting
Diarrhea
Vaginitis

Adverse effects

CNS: Dizziness, headache, fatigue, paresthesia,


fever,chills,confusion
GI: Diarrhea, nausea, vomiting, anorexia, dysgeusia,
glossitis,bleeding; increasedAST,ALT, bilirubin, LDH,
alkphos; abdominal pain, loose stools, flatulence,
heartburn, stomach cramps, colitis, jaundice,
pseudomembranous colitis
GU: Vaginitis,pruritus,candidiasis, increasedBUN,
nephrotoxicity, renal failure, pyuria,dysuria,reversible
interstitialnephritis
HEMA: Leukopenia, thrombocytopenia, agranulocytosis,
anemia, neutropenia, lymphocytosis, eosinophilia,
pancytopenia, hemolytic
anemia,
leukocytosis,
granulocytopenia
INTEG:
Rash, urticaria, dermatitis, Stevens-Johnson
syndrome
RESP: Dyspnea
SYST: Anaphylaxis, serum sickness, superinfection

53

Nursing
Considerations

1. Assess patient for signs and symptoms of infection


prior to and throughout therapy.
2. Before initiating therapy, obtain a history to
determine previous use of and reactions to
penicillins or cephalosporins. Persons with a
negative history of penicillin sensitivity may still have
an allergic response.
3. Observe patient for signs and symptoms of
anaphylaxis (rash, pruritus, laryngeal edema,
wheezing). Discontinue the drug and notify
physician or other health care professional
immediately if these symptoms occur.
4. Keep an antihistamine, and resuscitation equipment
close by in the event of an anaphylactic reaction.
5. Instruct patient to report signs of hypersensitivity.
6. Tell patient that drug should be taken with meals to
minimize GI effects; maximum absorption will occur
if drug is taken between meals.
7. Remind patient that Drug appears in breast milk;
use cautiously in breast-feeding women.
8. Ensure that patient will take the right amount of drug
in order to prevent overdose.
9. Encourage patient to eat a meal prior to drug intake
in order to minimize Gastrointestinal discomfort.
PATIENT TEACHING
10. Inform patient of potential adverse reactions.

54

Generic Name: Albuterol

"
Brand Name:

Salbutamol, Proventil, Ventolin, Accuneb, airet, NovoSalbutamol,


Proventil HFA, Gen-salbutamol, Ventodisk, Ventolin
HFA, Volmax, VoSpira ER

Classification:

Bronchodilator (therapeutic); adrenergics


(pharmacologic)

Dosages

1 neb q6

Mechanism Of Action

Causes bronchodilation by action on b2 (pulmonary)


receptors by increasing levels of cAMP, which relaxes
smooth muscle; produces bronchodila- tion, CNS,
cardiac stimulation as well as increased diuresis and
gastric acid secre- tion; longer acting than isoproterenol

Indications

Relief and prevention of bronchospasm in


patients with reversible obstructive airway disease
Inhalation: Treatment of acute attacks of
bronchospasm
Prevention of exercise-induced bronchospasm
Unlabeled use: Adjunct in treating serious
hyperkalemia in dialysis patients; seems to lower
potassium concentrations when inhaled by
patients on hemodialysis

55

Contraindications&
Cautions

Contraindicated with hypersensitivity to albuterol;


tachyarrhythmias, tachycardia caused by digitalis
intoxication; general anesthesia with halogenated
hydrocarbons or cyclopropane (these sensitize
the myocardium to catecholamines); unstable
vasomotor system disorders; hypertension;
coronary insufficiency, CAD; history of CVA;
COPD patients with degenerative heart disease.
Use cautiously with diabetes mellitus (large IV
doses can aggravate diabetes and ketoacidosis);
hyperthyroidism; history of seizure disorders;
psychoneurotic individuals; labor and delivery
(oral use has delayed second stage of labor;
parenteral use of beta2-adrenergic agonists can
accelerate fetal heart beat and cause
hypoglycemia, hypokalemia, pulmonary edema in
the mother and hypoglycemia in the neonate);
lactation; the elderly (more sensitive to CNS
effects).

Drug to Drug Interactions The pharmacologic effects of albuterol sulfate are


attributable to activation of beta2-adrenergic receptors on
airway smooth muscle. Activation of beta2-adrenergic
receptors leads to the activation of adenylcyclase and to
an increase in the intracellular concentration of cyclic-3',
5'-adenosine monophosphate (cyclic AMP).
Side effects

Nervousness, shaking (tremor), mouth/throat dryness or


irritation, cough, dizziness, headache, trouble sleeping,
or nausea may occur

56

Adverse effect

CNS: Restlessness, apprehension, anxiety, fear,


CNS stimulation, hyperkinesia, insomnia, tremor,
drowsiness, irritability, weakness, vertigo,
headache
CV: Cardiac arrhythmias, tachycardia,
palpitations, PVCs (rare), anginal pain
Dermatologic: Sweating, pallor, flushing
GI: Nausea, vomiting, heartburn, unusual or bad
taste in mouth
GU: Increased incidence of leiomyomas of uterus
when given in higher than human doses in
preclinical studies
Respiratory: Respiratory difficulties, pulmonary
edema, coughing, bronchospasm, paradoxical
airway resistance with repeated, excessive use of
inhalation preparations

57

Nursing Considerations

Assessment
Monitor therapeutic effectiveness which is
indicated by significant subjective improvement in
pulmonary function within 6090 min after drug
administration.
Monitor for: S&S of fine tremor in fingers, which
may interfere with precision handwork; CNS
stimulation, particularly in children 26 y,
(hyperactivity, excitement, nervousness,
insomnia), tachycardia, GI symptoms. Report
promptly to physician.
Lab tests: Periodic ABGs, pulmonary functions,
and pulse oximetry.
Consult physician about giving last albuterol dose
several hours before bedtime, if drug-induced
insomnia is a problem.
Patient & Family Education
Review directions for correct use of medication
and inhaler (see ADMINISTRATION).
Avoid contact of inhalation drug with eyes.
Do not increase number or frequency of
inhalations without advice of physician.
Notify physician if albuterol fails to provide relief
because this can signify worsening of pulmonary
function and a reevaluation of condition/therapy
may be indicated.
Note: Albuterol can cause dizziness or vertigo;
take necessary precautions.
Do not use OTC drugs without physician
approval. Many medications (e.g., cold remedies)
contain drugs that may intensify albuterol action.
Do not breast feed while taking this drug without
consulting physician.

58

Generic Name
Paracetamol,
Acetaminophen

"
Brand Name:

Biogesic, Panadol, Tylenol

Classification:

Non-narcotic analgesic, Antipyretic, Abenol (CA),


Acephen, Anadin Paracetamol (UK), ApoAcetaminophen (CA), Aspirin Free Anacin, Atasol (CA),
Calpol (UK), Cetaphen, Children's Tylenol Soft Chews,
Disprol (UK), Feverall, Galpamol (UK), Genapap, Little
Fevers, Mandanol (UK), Mapap, Nortemp, Nortemp
Children's, Novo-Gesic (CA), Pain Eze, Panadol (UK),
Pediatrix (CA), Silapap, Tempra (CA), Tycolene, Tylenol
8 Hour, Tylenol, Tylenol Arthritis, Tylenol Extra Strength,
Valorin

Dosages

3mL q4 PRN for fever

Mechanism Of Action

Pain relief may result from inhibition of prostaglandin


synthesis in CNS, with subsequent blockage of pain
impulses. Fever reduction may result from vasodilation
and increased peripheral blood flow in hypothalamus,
which dissipates heat and lowers body temperature.

59

Indications

Contraindications&
Cautions

Oral, IV: Edema associated with CHF, cirrhosis,


renal disease
IV: Acute pulmonary edema
Oral: Hypertension

Intravenous acetaminophen is contraindicated in


patients with severe hepatic impairment or
patients with a known hypersensitivity to
acetaminophen or its excipients (mannitol,
cysteine hydrochloride, dibasic sodium
phosphate, hydrochloric acid, or sodium
hydroxide). It should be used with caution in
patients with active hepatic disease, alcoholism,
chronic malnutrition, severe hypovolemia, or
severe renal impairment.

Drug to Drug Interactions Antihistamines, opioids, sedative-hypnotics: additive


CNS depression
Disopyramide, quinidine, tricyclic antidepressants:
increased anticholinergic effects
MAO inhibitors: intensified and prolonged anticholinergic
effects
Side effects

CNS: Drowsiness, dizziness, light-head- edness,


confusion, headache, sedation, euphoria, dysphoria,
weakness, halluci- nations, disorientation, mood
changes, dependence, seizures
CV: Palpitations, tachycardia, bradycar- dia, change in
B/P, circulatory depres- sion, syncope, cardiac arrest
(children) EENT: Tinnitus, blurred vision, miosis, diplopia
GI: Nausea, vomiting, anorexia, con- stipation, cramps,
dry mouth, ulcers GU: Increased urinary output, dysuria,
urinary retention
INTEG: Rash, urticaria, flushing, pruritus RESP:
Respiratory depression; pulmo- nary edema,
bronchopneumonia, respira- tory arrest (children)

Adverse effect

Hematologic: thrombocytopenia, hemolytic anemia,


neutropenia, leukopenia, pancytopenia Hepatic:
jaundice, hepatotoxicity Metabolic: hypoglycemic coma
Skin: rash, urticaria
Other: hypersensitivity reactions (such as fever)
60

Nursing Considerations

Assessment & Drug Effects

Monitor for S&S of: Hepatotoxicity, even with


moderate acetaminophen doses, especially in
individuals with poor nutrition or who have
ingested alcohol (3 or more alcoholic drinks daily)
over prolonged periods; poisoning, usually from
accidental ingestion or suicide attempts; potential
abuse from psychological dependence
(withdrawal has been associated with restless
and excited responses).
Patient & Family Education

Do not take other medications (e.g., cold


preparations) containing acetaminophen without
medical advice; overdosing and chronic use can
cause liver damage and other toxic effects.
Do not self-medicate adults for pain more than 10
days (5 days in children) without consulting a
prescriber.
Do not use this medication without medical
direction for: Fever persisting longer than 3 days,
fever over 39.5 C (103 F), or recurrent fever.
Do not give children more than 5 doses in 24 h
unless prescribed by prescriber.

61

Zinc Sulfate

Generic name

"
Brand Names

Zincate, Orazinc, E-zinc

Classification

Mineral and electrolyte replacement/supplement

Dosage and Frequency 5mL OD


Mechanism of action

Serves as a cofactor for many enzymatic reactions. Required


for normal growth and tissue repair, wound healing, and
sense of taste and smell.

Indication

Replacement and supplementation therapy in patients who


are at risk for zinc deficiency.

Contraindication

Contraindicated to patients with hypersensitivity or allergy to


any components in th formulation, patients who has renal
failure should use it cautiously, and direct injection of
undiluted solution into peripheral vein.

Side effects

Abdominal pain, dyspepsia, nausea, vomiting, diarrhea,


gastric irritation, gastritis, dizziness, headache

Adverse effects

Severe allergic reactions, severe vomiting, unusual


restlessness, very dry mouth, eyes, or skin.

62

Nursing responsibilities

Monitor progression of zinc deficiency symptoms


during therapy.

Encourage patient to comply with diet


recommendation.

Ask the paient to notify any of the healthcare team if


he/she feels nausea, severe vomiting, abdominal
pain, dehydration, or restlessness occurs.

Emphasize the importance of follow-up exams.

Identify food sources of zinc (e.g., seafood, organ


meats)

Inform patient that sense of taste and smell, skin


hydration, and wound healing should improve.

Instruct patient to follow RDA guidelines and


limitations in terms of vitamin and mineral
supplementation.

Tell patient to take with food if GI upset occurs but to


avoid foods high in calcium, phosphorus, and phytate.

Inform patient that bran, caffeine, and dairy products


may decrease absorption.

63

Chapter 16
Nursing Theories

Nightingales Environmental Theory


The Environmental Theory by Florence Nightingale defined Nursing as the act of
utilizing the environment of the patient to assist him in his recovery. It involves the
nurses initiative to configure environmental settings appropriate for the gradual
restoration of the patients health, and that external factors associated with the patients
surroundings affect life or biologic and physiologic processes, and his development.
Human beings are not defined by Nightingale specifically. They are defined in
relationship to their environment and the impact of the environment upon them.
Therefore, the Environmental Theory of Nursing is a patient-care theory. It focuses in
the alteration of the patients environment in order to affect change in his or her health.
Caring for the patient is of more importance rather than the nursing process, the
relationship between patient and nurse, or the individual nurse. In this way, the model
must be adapted to fit the needs of individual patients. The environmental factors affect
different patients unique to their situations and illnesses, and the nurse must address
these factors on a case-by-case basis in order to make sure the factors are altered in a
way that best cares for an individual patient and his or her needs.
Altering the environment with the participation of the client will provide an
environment and conducive to the health maintenance and personal development of the
client and clients family. The nurse wont do much without the client participating
because they would just go back to their old habits and forget anything that the nurse
tries to imply. Knowing that the problem is for life, the client must be cautious and avoid
factors that could worsen the problem. Environmental hazards can probably affect the
condition and the healthcare team should cooperate with the client and clients family to
avoid problems that may arise. The environment is an important and relevant part for
the betternment of the clients health and personal development. The theory will be just

64

the right theory to be taught and given importance by the client due to its relevance in
the development and personal health of the client.
Orems Self Care Deficit Theory
Orems self care deficit theory is based on the idea that people have the innate
ability, right, and responsibility to care for themselves. It reflects a concept of human
development that maturation is accompanied by self-reliance, a desire to be selfdirecting, and to encourage others to be so. Self-care is seen as a behavior learned
throughout a persons lifetime from childhood where it is learned and in adulthood
where it is maintained or perpetuated in the succeeding years. It contains those
activities one does and performs to maintain the optimum well being. The nurse role is
therefore, to assist the client with self-care activities and to maximize ones capability to
care for themselves. It specifies when nursing care is needed too. Nursing is needed
when the client cannot continuously maintain ones daily living pattern and activities to
sustain ones own life and health, to recover from a condition, or to cope with its effects.
There are instances wherein patients are encouraged to bring out the best in them
despite being ill for a period of time. This is very particular in rehabilitation settings, in
which patients are entitled to be more independent after being cared for by physicians
and nurses. Therefore the theory is used to identify when patients should receive help
to meet their heath care needs, to what degree the client needs help, and to allow the
patient to care for themselves.
Prevention is better than cure. Although there is already a presenting problem, it
may complicate and worsen into a more sophisticated and severe problem. In terms of
knowledge regarding the problem, the healthcare team or the nurses and doctors know
more about what is best for the client. Simple intervention and ways can decrease the
chance of complications arising. Cooperating with the parents of the client may very well
improve the overall health of the client. To also maximize the time in teaching the family
they will be taught the importance of caring oneself to open their minds and thus be
more aware of themselves for the betternment of their life. Orems theory can very well
be related to the problem as it identifies and is able to give guide to the care that should
be given to the client.

65

Penders Health Promotion Model


This model is based on the idea that human beings are rational, and
will seek their advantage in health. But the nature of this rationality is tightly
bounded by things like self-esteem, perceived advantages of healthy behaviors,
psychological states and previous behavior. As for the medical profession in general,
the main purpose here is not merely to cure disease, but to promote healthy lifestyles
and choices that affect the health of individuals. The central function of this theory
is to show the individual as self-determining, but as also determined by
personal history and general personal characteristics. Health is a dynamic process, not
a static state. Health, to put it differently, is a lifestyle conditioned by a number of
choices made by the individual to actually live a healthy lifestyle. The medical
profession itself is only a small part of this world. The individual is posited in this model
as "being" health, "living" it, rather than considering health a static state. Health is a
lifestyle. The main effect of Pender's model is that it puts the onus of
healthcare reform on the person, not on the profession. Health is up to the
person. The significance here is that the medical profession is really not the
main ingredient in living a healthy lifestyle. They might be an important part, but always
serve a secondary role to the basic rational choices of healthy living. The health
profession, in other words, is useless unless individuals reform their own lives and
perception of what is healthy.
Knowing that the existing problem is not curative though it can still be improved
through health promotion and disease prevention which mean that the progress or the
benign state can be delayed or prevented. The care to be given may be focused on
activities that improve the well-being of the client. It can easily carried out since it is
focused on a client that has a specific problem which in this case is the respiratory
functionality of the client. Having a good health is just a state but being and living.
Which means that the cooperation is a must with the medical orders and selfperception regarding the existing problem must exist. Basic daily life directly affects the
health of oneself.

66

Chapter 17
Nursing Care Plan
1.

Nursing Care Plan (Ineffective airway clearance)

2.

Nursing Care Plan (Impaired gas exchange)

3.

Nursing Care Plan (Ineffective breathing pattern)

4.

Nursing Care Plan (Activity Intolerance )

67

Nursing Care Plan (Ineffective airway clearance)


Date/

Cues

Need

Diagnosis

Objectives

Intervention

Evaluation

Time
1.) Monitor and record vital

Goal Partially

signs

Met

Septemb Objective:

Ineffective

After 3-4 hours

er 16,

airway

of nursing

Productiv

clearance

interventions,

e cough

related to

with

presence of

the patient will: 2.) Assist the patient to


Improve change position every 30

2016

phlegm

nursing
interventions,

secondary to

ons

effort

inflammatory

upon

process in

no

the alveoli

signs of R: This is to maintain a

and difficulty of

breathin patent airway

breathing was
slightly not

Have

R: This is to mobilize
secretions

the patient was


able to have

3.) Position patient in

improved

moderate high back rest

respirations

4.) Encourage to increase

Crackles

R: The

heard

inflammation

and

difficulty R: Hydration can help


;
liquefy viscous secretions

noted;

upon
auscultati

increased

Able to

and improve secretion

moderate high

clearance

back rest but

Nasal

oral fluid intake

repositioned in

secretions

expecto

brought

rate

about by

secretio R: To loosen the mucus


ns and mechanically

not able to

Maintai

6.) Auscultate breath

phlegm.

sounds and air movement

flaring

minutes

After 3 hours of

Exertional T

on

reference

respirati

baseline data and

secretions

expectora E
tion

R: This is to establish

noted

pneumonia

Mild

make it

5.) Encourage chest


physiotherapy

chest

difficult to

na

indrawing

maintain a

patent

noted

patent

airway

Shortnes

airway. This

symptoms of infection

s of

is due to the

R: To identify infectious

breath

decreased

process and promote timely

noted

ability to

Wheezing

expel the

noted

excessive

R: Strict compliance of

Rapid

mucus

medications will lessen the

breathing

produced that

chances of complications.

noted

will lead to

R: To ascertain status and


note progress
7.) Observe for signs and

interventions
8.) Administer medications
as prescribed

9. Assist with efforts to


cough such positioning.

extensive

R: to clear secretions.

obstruction of
the airway.

68

the patient is
expectorate

Nursing Care Plan (Impaired gas exchange)

Date/

Cues

Nee

Diagno

sis

Time

Objectives

Intervention

Evaluation

Septemb

Objective:

Impaire

Within the 2

1.Assess respiratory rate,

Goal Met.

er 15-16,

-Dyspnea,

d gas

day nursing

depth, and ease. R:

After the 2-

intervention

Manifestations of respiratory

day nursing

2016

-Tachycardia

exchan

distress are dependent on/

ge

the patient will

Restlessness

related

be able to:

to

-Demonstrate

alveolar

underlying general health

improved

status.

ventilation and 2. Observe color of skin,

improved

capillar

oxygenation of mucous membranes, and

ventilation

tissues by

membr

ABGs within

E
R
C

ane
change
s

patients
acceptable
range and

and indicative of the degree


of lung involvement and

intervention
the patient
was able to
demonstrate

nail beds, noting presence of

and

peripheral cyanosis (nail

oxygenation

beds) or central cyanosis

of tissues by

(circumoral). R: Cyanosis of

ABGs within

nail beds may represent


vasoconstriction or the

patients

absence of

bodys response to fever/

symptoms of

chills; however, cyanosis of

respiratory

earlobes, mucous

distress.

membranes, and skin

symptoms of

around the mouth (warm

respiratory

membranes) is indicative of

distress and

systemic hypoxemia.

participate in

3. Assess mental status. R:

participate in

actions to

Restlessness, irritation,

actions to

maximize

confusion, and somnolence

maximize

may reflect hypoxemia and

oxygenation.

decreased cerebral

P
A
T
T
E
R
N

-Patients care
giver will be
able to

oxygenation.
4. Monitor heart rate and
rhythm. R: Tachycardia is
usually present as a result of
fever and/or dehydration but
may represent a response to
hypoxemia.

69

acceptable
range and
absence of

oxygenation.

5. Monitor body temperature,


as indicated. R: High fever
greatly increases metabolic
demands and oxygen
consumption and alters
cellular oxygenation.
6. Maintain bedrest.
Encourage use of relaxation
techniques and diversional
activities. R: Prevents over
exhaustion and reduces
oxygen demands to facilitate
resolution of infection.
7. Elevate head and
encourage frequent position
changes, deep breathing,
and effective coughing. R:
These measures promote
maximum chest expansion,
mobilise secretions and
improve ventilation.
8. Monitor ABGs, pulse
oximetry. R: Follows
progress of disease process
and facilitates alterations in
pulmonary therapy.
9. Administer oxygen therapy
by appropriate means: nasal
prongs, mask, Venturi mask.
R: The purpose of oxygen
therapy is to maintain PaO2
above 60 mmHg.
10. Assess anxiety level and
encourage verbalisation of
feelings and concerns.
Anxiety is a manifestation of
psychological concerns and
physiological responses to
hypoxia.

70

Nursing Care Plan (Ineffective breathing pattern)


Date/

Cues

Nee

Time

Diagnosis

Objectives

Intervention
1.Establish rapport

Evaluation

Septem Objective:

Ineffective

Within the 2

ber

-Increase in

breathing

day nursing

15-16,

respiratory

pattern

intervention

2016

rate of 30

related to

the patient

cooperation.

cpm

presence of

will be able

-Shortness

tracheo-

to:

2. Instruct patient to met met


increase oral fluid

of

bronchial

-Be free of

breath(orth Y

secretions

opnea)

and nasal

cyanosis and Increased mucus and cyanosis but


sputum secretions has a dyspnea
establish

-Dyspnea

secretions

normal

-Use of

breathing

increased water

accessory

pattern

intake can help

breathing

muscles

dissolve secretions.

pattern.

with patient. R: o gain


patients
trust and

intake to
8-10glasses. R:

can lead to
dehydration;

3. Instruct patient to

inbreathing C

do deep breathing

-Increased

anterior-

demonstrating proper

posterior

technique. R: Deep

exercise after

breathing exercise

diameter
-Chest

increases oxygen

intake and can help

Retractions A

alleviate dyspnea.

T
T
E
R
N

71

After the
nursing
intervention:
Goal partially

-Patient was
free of

which is an
abnormal

4. Keep environment
allergen free (dust,
feather pillows,
smoke, pollen). R:
Presence may trigger
allergic response that
may cause further
increase in mucus
secretion5. Take vital
signs. R: To get baseline
data.
6. Suction naso, tracheal/
oral PRN. R: These may
compromise airway. A
distended abdomen can
interfere with normal
diaphragm expansion
7. Educate proper
hand washing. R: To
prevent infections such
as nosocomial
infections
8. Position the patient in
Semi-fowlers position.
R: To enable the body to
recuperate and repair.
9. Encourage patient
to eat nutritious foods
such as green leafy
vegetables and lean meat
10. Review clients chest
x-ray for severity
of acute/ chronic
condition. R: To prevent
allergic reactions that
can cause respiratory
distress

72

Nursing Care Plan (Activity Intolerance )


Dat

Cues

Nee

Diagno

sis

e/

Objectives

Intervention

Evaluation

Tim
e

Se

Objective:

pte -

Activity Within the 2 1.Establish rapport. R:

Intoler

mb Weakness, T
er
1516,
20
16

fatigue,
exhaustion
-Exertional
dyspnea,
tachypnea
Tachycardi

day nursing

ance

Determine patients response


to activity. R: Establishes

intervention patients capabilities and


related the patient needs and facilitates choice

to

will be able

2. Provide a quiet

imbala

to:

nce

Report/

betwee demonstrat
n
ea

of interventions.
environment and limit visitors

Goal
Partially
Met. After
the 2-day
nursing
intervention

during acute phase as

the patient

indicated. R: Promote rest.

was able to

3. Encourage use of stress

report/

management and diversional

a,

increases

oxygen measurable
activities as appropriate. R:
supply increase in Reduces stress and excess

on activity

and

deman activity with


increase in
treatment plan and necessity
d
tolerance to
absence of for balancing activities with

Temperatur C
e 37.1oC

-Cardiac S
Rate
132 bpm

tolerance to

dyspnea
and

Respirator P

vital signs

y Rate 30 A

within

- B l o o d T
Pressure
7 0 / 4 0
mmHg

measurable

rest. R: Bedrest is

activity but

maintained during acute

without the

phase to decrease metabolic

excessive

Explain importance of rest in

demands, thus conserving

fatigue, and energy for healing. Activity

cpm

stimulation.

demonstrate

absence of
dyspnea

restrictions thereafter are

and

determined by individual

excessive

patient response to activity

fatigue, and

patients

and resolution of respiratory

acceptable

insufficiency.

unusual vital

4. Assist patient to assume

signs for the

range.

comfortable position for rest and

sleep. R: Patient may be

- P u l s e N

comfortable with head of bed


elevated, sleeping in a chair, or

Rate

leaning forward on overbed table

132 cpm

with pillow support.

73

patients
age.

5. Assist with self-care activities


as necessary. Provide for
progressive increase in activities
during recovery phase and
demand. R: Minimizes
exhaustion and helps balance
oxygen supply and demand.
6. Assess the patients nutritional
status. R: Adequate energy
reserves are needed
during activity.
7. Observe and monitor the
patients sleep pattern and
the amount of sleep achieved
over the past few days. R: Sleep
deprivation and difficulties during
sleep can affect the activity level
of the patient
8. Use portable pulse oximetry
to assess for oxygen
desaturation during activity. R:
May determine the use of
supplemental oxygen to help
compensate for the increased
oxygen demands during physical
activity.
9. Observe and document
response to activity. R: close
monitoring will serve as a guide
for optimal progression of
activity.
10. Assess the patients
baseline cardiopulmonary status
before initiating activity. R: In
normal adults, HR should not
increase more than 20 to 30
beats/min above resting with
routine activities.

74

Chapter 18
Prognosis
Good Fair
Onset of
illness
"

Duration of
ilness
"

Poor Justification

Precipitating
Factors

Willingness
to take the
medication
"

"

Patient C experienced the symptoms of the


illness a week PTA, patient had onset of nonproductive cough associated with colds. This
was not associated with fever, LBM or vomiting.
No consult and no meds taken. Cough gradually
progressed to be productive with yellowish
sputum until 2 days PTA. Patient developed
fever at 38.7 degrees Celsius, still with
productive cough and colds. Until the day of
admission, symptoms persisted now with
decrease in appetite prompting consult hence
admission. 2 days PTA. She had onset fever,
productive bought (yellow phlegm around 10x a
day) and runny nose. 1 day PTA she had and
fever, productive cough and abdominal pain
(bilateral lower abdomen that lasted for 2 secs)
until
the day of admission.
During the experience of the symptoms, patient
C did not seek for medical help they waited a
week until they decided to seek medical help.

The patients sister had PCAP-C first and then


after a few days, the patient herself acquired the
disease.

Patient C was willing to submit herself to take


the medicines that was ordered with the help of
her guardian. She was well oriented with the
cautions and responsibilities to take into
consideration for recovery. The patient has the
positivity to continue.

75

Environment
al Factors
"

As the patient guardian stated, their home


environment is capable of therapeutic recovery.
In addition, it has minimal noise and suitable for
rest and comfort.

Family
Support
"

The patients family members such as her mum


was present to take care of her and they often
take turns in taking care of the patient.

Total

Poor: 2*3/6 = 1
Fair: 1*3/6 = 0.5
Good: 3*3/6 = 1.5
Total: 3
General Prognosis:
1-1.6 = Poor
1.7-2.3 = Fair
2.4-3.0 = Good

As shown in the calculated prognosis, it shows a good prognosis. This means that the
patient, through medical treatment has able to attain a good recovery. The factors
related to the prognosis shows that the patient is capable on therapeutic management
on her illness and was cooperating based on the data.

76

Chapter 20
Recommendations
Through the rationalisation of the information in this case presentation, the student
nurses would like to recommend the following:
Patient and Family
To patient C. B. and to her parents, we recommend continuing taking care of
patient C.B. To support her with her needs, to always have time for her. We recommend
the parents to help the patient comply with her medications.
Nursing Education
We recommend the nursing education to support us throughout our college life
as nursing students. May they provide us more knowledge and good skills in taking care
of our patients in the future. May they encourage us to be more studious so that we can
learn in our own ways through their guidance. May they continue to educate us with the
updated medical trends. Furthermore, may the nursing education help us in
disseminating and educating our patients, the community and the society regarding
health education. In this way, it would help not only us student nurses but also the
people around us.
Nursing Practice
We, the nursing students of the Ateneo de Davao University, make sure to
provide equal nursing quality care to all the people we encounter everyday, may they be
ill or not. We should be more flexible in learning and should fully understand the things
we deliver to our patients such us the health teachings, nursing interventions and such.
We should not limit ourselves in acquiring new information regarding health education.
To our clinical instructors, may they guide us in each and every clinical exposure, that
they may be able to fulfil our shortcomings. May they continue to educate us with more
knowledge and skills to prepare us in whatever examinations we will encounter in the

77

future. Furthermore, may they also be able to guide us not only in our studies, but also
in the different aspects of life.
Nursing Research
In this case study, we discovered and learned a lot of things from our patient
through analysing her case. In this way, it would improve our critical thinking, it would
give us more knowledge, it would enhance our learning, and so, we can make our future
case studies better through acquiring new knowledge. And through rationalisation of the
information of this case presentation, we will know what nursing quality care should we
deliver to our patient. Not only knowing and giving care to our patient but we also know
the rationale behind these interventions. Furthermore, this study taught us that being
flexible in finding sources helps us learn more.

78

Chapter 21
Bibliography
Lewis, S. (2014). Pneumonia. Medical-Surgical Nursing, Assessment and
Management of Clinical. Retrieve September 26, 2016. pp. 522-528
Bauman, R. (2015). Bacterial Pneumonia. Microbiology with Diseases by Body
System. Retrieve September 26, 2016. pp. 686-687
Cavanaugh, B. (2003). Nurses's Manual of Laboratory and Diagnostic Tests.
Retrieve September 26, 2016Tidy, C. (September 25, 2014) Mild-to-Moderate
Chronic Kidney Disease. Patient.info. Retrieve August 1, 2016. [Web Page] URL:
http://patient.info/health/mild-to-moderate-chronic-kidney-disease
Fundamentals of Nursing Concepts, Process and Practice 7thEdition
Authors: Barbaras Kozier, Glenora Erb, Aubrey Berman and Shirlee
SryderPublished by: Oearson Education Inc., Copyright 2004
Medical-Surgical Nursing 7th edition Authors: Brunner & Suddarth
2007 Lippincotts Nursing Drug Guide by Amy M. Karch Copyright Lippincot Williams
and Willkins
Nurses Pocket Guide Diagnoses, Prioritized Intervention and Rationales,10thEdtion
Authors: Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Murr
Published by: F.A. Davis Company, Philadephia, Pennsylvania Copyright
2006
Nursing Care Plans Guidelines for Individualizing Patient Care, 6th EditionAuthors:
Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. MurrPublisher: F.A.
Davis Company, Philadephia, Pennsylvania Copyright 2002
79

Medical-Surgical 5thEditionAuthors: Wilma J. Philips, Virginia Cassmeyer, Judith K.


Sands, Mary Kay Lehman Publisher: C and E Publishing Inc
http://www.rn.com/getpdf.php/607.pdf
http://www.merck.com/mmhe/sec14/ch173/ch173a.html
http://www.emedicine.com/ped/topic962.htm
http://www.wikipedia.com
http://www.news-medical.net/health/What-is-Pediatrics.aspx

80

"

ATENEO DE DAVAO UNIVERSITY


E. Jacinto St, Davao CIty
In Partial Fulfillment of the Requirements in NCM 103RLE
CASE PRESENTATION: PEDIATRIC COMMUNITY-ACQUIRED PNEUMONIA
TYPE C
SUBMITTED TO:
Mrs. Crescencio Roy Linao, RN, MN
Clinical Instructor
SUBMITTED BY:
Bianca Kateri Trish M. Abella
Ada Marie S. Basilio
Alyanna N. Cuaki
Nico Abel P. Dulay
Yves Angelo M. Espino
Dara Adrienne D. Llamas
Al-Amin S. Manebpel
BSN-3A, Group 1
Septembre 27, 2016