UNIVERSITY OF THE CORDILLERAS ODC Form 1A

College of Nursing ACTUAL DELIVERY

Governor Pack Road, Baguio City, Philippines 2600 FORM
(+6374) 442-3316, 442-2564, 442-8219, 442-8256
E-mail: [email protected]
Website: www.bcf.edu.ph

Pediatric Community Acquired Pneumonia Type C among Infants

A Case Presented to the

College of Nursing

In Partial Fulfillment of the requirements in the Course

( MOTHER AND CHILD NURSING )

Submitted By:

Agayam, Alpha Rose Y.

Cabigon, Jayrose

Guyao , kesilda B.

Juan, Vanessa A.

Lambatan , Tzar R.

Marzan, Kurt O.

Mostoles, Al Jarreau

Pilipina, rizen anjel B.

Tuguinay , Ma. Theresa B.

Velasco, Menard Jun T.

(NOVEMBER 18, 2019 )

Noted and Approved for Presentation:

Name of Case Presentation Adviser or Panel/s

________________________
Signature of Adviser / Date

ABSTRACT

TITLE: Pediatric Community Acquired Pneumonia Type C among Infants

AUTHOR INFORMATION:
Agayam, Alpha Rose Y.,Cabigon, Jayrose,Guyao , kesilda B.,Juan, Vanessa A.,Lambatan , Tzar R., Marzan,
Kurt O.,Mostoles, Al Jarreau ,Pilipina, rizen anjel B.,Tuguinay , Ma. Theresa B.,Velasco, Menard Jun T.
BACKGROUND:

The patient is a 5 month old who was diagnosed with pediatric community acquired pneumonia type C . PCAP
type C has a moderate risk, with moderate dehydration with a respiratory rate greater than 35-60/min.
Pneumonia is an inflammation of the lung parenchyma that is caused by a microbial agent. Virus is known as
the most common cause of pneumonia among infants-(Brunner &Saddarth’s textbook of medical- surgical
nursing, vol.1). According to DOH 2010, pneumonia was number 5 cause of mortality. This case study is
reported to enhance the knowledge and understanding of nursing students in managing patient with
.pneumonia.

CASE DESCRIPTION:

Patient X seek consultation at BGHMC with a chief complain of cough and fever that prompted it for
admission. Upon admission patient x was diagnosed by Pediatric Community Acquired Pneumonia type C.
The patient undergone laboratory examination the blood test showed that the hemoglobin of the patient was
205, Hematocrit 0.62, WBC count 10.31 which are found to be above normal, neutrophil was 31 which below
normal. The chest X-ray result was reticular density are noted in both lung parenchyma with an impression of
pneumonia, crackles are present also upon auscultation. Patient loaf prescribed to take Pen G sodium,
ceftriaxone, clindamycin, paracetamol as needed and salbutamol neb to relieved signs and symptoms. The
patient undergoes nebulization every 9 hours for breathing treatment. Nursing interventions are also presented
in this case study for the management of the condition.

CONCLUSION:
Pneumonia is a preventable disease which greatly affects people at young age and the older one’s but not the
general population as a whole. Observance of proper hygiene such as proper hand washing helps prevent the
transfer of microorganisms to and from a person. If invasion of such bacteria or Virus is already there, then
strict compliance for medication intake should be done to stop the spread of such bacteria or virus. Nursing
intervention should also be carried out such as proper prioritizing of patient to promote comfort for breathing
and isolation of a patient who is immunocompromised, to contain the microorganisms, to prevent spread to
others.

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 TABLE OF CONTENTS

I. Introduction.............................................................................................................................................３
II. Statement of Objectives..........................................................................................................................３
A. General Objectives..................................................................................................................................３
B. Specific Objectives..................................................................................................................................３
III. Patient’s Profile.......................................................................................................................................３
IV. Chief Complaint......................................................................................................................................３
V. Present History of Illness.......................................................................................................................３
VI. Past History of Illness.............................................................................................................................４
VII. Family Health History............................................................................................................................４
VIII. Developmental History...........................................................................................................................４
IX. Social and Environmental History........................................................................................................４
X. Lifestyle and Health Practices.................................................................................................................4
XI. Health Assessment..................................................................................................................................５
A. General Survey........................................................................................................................................５
B. Head to Toe Assessment...........................................................................................................................5
C. 13 Areas of Assessment............................................................................................................................6
XII. Diagnostics.................................................................................................................................................8
XIII. Comprehensive Pathophysiology..........................................................................................................11
XIV. Treatment/Management........................................................................................................................12
A. Drugs....................................................................................................................................................12
B. IV Fluids..............................................................................................................................................17
XV. Nursing Care Plans.................................................................................................................................15
A. Prioritization of Problems....................................................................................................................15
a.1. List of Problems..............................................................................................................................15
a.2. Basis for Prioritization....................................................................................................................15
B. Nursing Care Plans...............................................................................................................................19
NCP 1...........................................................................................................................................................20
NCP 2...........................................................................................................................................................21
NCP 3...........................................................................................................................................................22
NCP 4...........................................................................................................................................................23
NCP 5...........................................................................................................................................................24
C. Discharged Plan......................................................................................................................................25
XVI. Learning Insights....................................................................................................................................26
XVII. List of References...................................................................................................................................29
XVIII. Appendices..............................................................................................................................................30
Appendix A: Approval/ Request Letter........................................................................................................31
Appendix B: Interview Guides......................................................................................................................32

I. Introduction

Pneumonia is an inflammation of the lung parenchyma that is caused by a microbial pose a patient to or
place a patient at risk for microbial invasion.

2
II. Statement of Objectives
A. General Objectives
-This case analysis aims to increase the knowledge and understanding of nursing student
in managing patient with PNEUMONIA.

B. Specific Objectives
1. Define PNEUMONIA,
2. Illustrate the pathophysiology of PNEUMONIAin relation to signs and symptoms
specifically observed in the patient.
3. Describe and identify the common signs and symptoms of PNEUMONIA
4. Discuss medical and nursing interventions in managing patient with PNEUMONIA.
5. Formulate appropriate nursing care plan suited to the patient based on assessment
findings.
6. Identify care measures to be given to patient and family to promote continuity of
care after discharge.

III. Patient’s Profile

Name : Patient X
Ethnic Background : Tagalog
Civil Status : N/A
Religion : Roman Catholic
Occupation : N/A

Admitting Diagnosis : Pediatrics Community Acquired Pneumonia –Type C

Final/Principal Diagnosis :
Date and Time Admitted : October 30, 2019 8:50 A.M

IV. Chief Complaint

- COUGH AND FEVER

V. Present History of Illness

-1 week prior to admission patient was noted to have cough, productive with no other
associated signs and symptoms. Consultation was done with private physician and was
prescribed with Ambroxol and PPA PITTSBURGH PNEUMONIA AGENT + PARACETAMOL as home
medication. However, there’s no relief from signs and symptoms.
-5 days prior to admission, patient was noted to have persistence of cough now
associated with fever. The patient still taking prescribed medications however, there was no
relief of cough.
-3 days prior to admission, patient noted to have persistence cough and fever now
associated with rapid breathing and alar flashing. No consult done. Few hours prior to admission
persistence of the condition prompted the parents to seek consultation at our institution and
subsequently admitted.

VI. Past History of Illness

The patient had no serious illness, just usual cough and colds and was remedied with ambroxol and
amoxicillin given free in the health. Had received vitamin K,BCG,Hepatitis B immediately after birth had
completed (3) three of pentavalent vaccine, pneumonococcal conjugate vaccine, oral polio vaccine and
inactivated polio vaccine. No noted allergies and no past hospitalization.

VII. Family Health History

. Both the parents of the patient claims to have hypertension only. No other physical and mental
problems stated. On the mother’s side have history of stoke while in the fathers side, they have history of
arthritis and hypertension.
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VIII. Developmental History

The patient is an only child, 5 months old male. Patient has good head control, reaches for objects and
turns to sound, appropriate for his age.

IX. Social and Environmental History

The patient is 5 months old, stays in the house however, exposed to noxious fumes such as vehicle and
cigarrete fumes for their house is located near the main road where vehicles and passing by smokers frequently
pass. They live in a rental house made up of permanent and semipermanent materials such as wood and
cement. Mother verbalized that she maintains cleanliness in house by sweeping and dusting. Water used daily
is being supplied by the city water district while the source of drinking water is from the water refilling stations
nearby.

X. Lifestyle and Health Practices

The mother of the patient are aware of the potential health threats with lifestyle related to vices and
environmental factors. Thus parents do not smoke, drink alcohol and most especially,they do not engage their
issues in any illegal drugs.Both parents ensurs that the pamily eats fruits, vegetables and sometimes meat. As
for the mother, she increase her fluid intake for the baby to get adequate and breastfeeds her baby as per
demand.

XI. Health Assessment

A. General Survey

The patients was received awake weak looking, crying cuddled by mother. Patients has changing
ongoing D5LRS 500 cc x 14 gtts/hr infusing well on the left hand. The mother tries to breastfeed the infant but
the infant seems to be irritable, in distress while crying. Patient weighs 6.8 kg, height=69 cm. Head
circumference = 4.5 cm, chest circumference = 43.2 cm, abdominal circumference = 45 cm. all are normal
range.

B. Head to Toe Assessment

1. Head Normocephalic,has no alopecia, with some minimal hair growth. No

areas of pain or tenderness during palpation.
2. Eyes Pupils are equally round and sensitive to light; pale conjunctiva and
the sclera appeared slightly red. Extra-ocular muscle is intact. Eyes
are slightly sunken. Well distribution of hair on eyebrow and
eyelashes.
3. Ears Ears are symmetrical and in line with the outer canthus of eyes. With
minimal cerumen build up in the ear canal, intact tympanic
membrane. No nodules, swelling or tenderness in the mastoid area.
4. Nose and sinuses Nose is patent, septum is located midline, alar flaring is positive, no
episodes of epistaxis and sinuses are not tender on palpation.
5. Mouth Oral mucosa and lips are dry, pink color, no lesions, tonsils are not
inflamed, uvula is located midline.
6. Neck Able to change direction of head slowly, carotid pulse is bilaterally
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 symmetrical. Jugular vein is not distended; superficial cervical lymph
nodes are palpated but not tender.
7. Chest Shape of the chest is normal, symmetrical chest wall expansion, with
positive subcostal retractions, positive crackles.
8. Cardiac Abnormal; tachycardia

9. Breast/Chest Similar color with the rest of the body , nipple is brownish.

10. Abdomen Full and rounded, with normoactive bowels sounds heard in all the
quadrants.
11. Genitals Size and shape, testicles, meatus, tanner stage are in normal status.

12. Musculoskeletal Limited movement

13. Integumentary Slightly dry, intact, no rashes, warm to touch,.

C. 13 Areas of Assessment

1. Psychosocial and Psychological Status

- He is on pure breastfeeding. His parents are the one providing for his needs. His parents sometimes
go back back from their house . They sometimes visit their relatives foe his to play with his cousins.They
regularly go to the church every Sunday to attend the mass. Patient X weighs 6.8 kg, length is 69 cm, head
circumference is 41.5 cm, chest circumference is 43.2 cm, abdominal circumference is 45 cm which are
normal for his age.
- Eriksons stages of psychosociall development theory state dthat we are motivated by the need to
adhere in certain competence in certain areas of lour lives. According to psychosocial theory , we experience
stages of development from infant to late adulthood. In infant stage, infants learn that adults can be trusted.
This occurs when adults meet the basic needs of a child for survival.
2. Mental and Emotional Status
- The patient is conscious and alert. He is very resoponsive to any sounds or noise, light, touch or pain
stimuli. The patient get startled or jumps to any loud noise. The patients cries whenever drug is administered
through IV line.
3. Environmental Status
-Patient is admitted at Baguio General Hospital and Medical center at Pedia Ward located at the 2 nd
Floor. The ward is well lighted but not well ventilated because there are no windows. There is a minimal space
for movement for visitors. Side tables are also provided for organization of things . The ward is also cleaned as
necessary. The needs of the patient are placed on the side table of the patient . The mother stated that they are
exposed to vehicle and cigarrete fumes because their house is located near the main road where vehicles and
passingby smokers pass. Mother verbalized that she maintains cleanliness in the house.
-Florence nightingale environmental theory. She believed that the environment had a strong influence
on patients outcome she proposed to the aspects of the theory .
4. Sensor Status
a. Visual Status
-Patients pupils eye responds normally to light. Pupils are equally round. Pale conjunctiva and the
sclera appearance slightly red. Extra ocular musles is intact, eyes are slightly sulky, eyebrows are well
distributed the same with his eyelashes.

b. Auditory
-His hearing ability is normal when he responded to sound heard. For example when you clapped, he
will look where the sound came from. His ears are symmetrical and also aligned with the canthus of
the eyes.
c. Olfactory Status
-Patient experiences nasal flaring due to abnormal breathing pattern. The patient shows a keen sense
of smell. He can determine his parents with his sense of smell by knowing the characteristics of smell
of his mother.
d. Gustatory Status
-The patient shows a strong preference for breastmilk and breast feeding.
e. Tactile Status
5
 -Patient X shows a secure behavior when held by the parent.
5. Motor Status
-The patients movement is not restricted but movement is monitored. It is due to his condition and his
breathing pattern. The patient appears also weak and is usually held by his mother.
6. Thermoregulatory Status

Date Time Temperature

3 pm 37.0°C
October 30, 2019 6 pm 36.8 °C
8 pm 37.2 °C
3 pm 37.6 °C
November 1, 2019 6 pm 36.4 °C
8 pm 36.5 °C
3 pm 37.2 °C
November 2, 2019 6 pm 37.5 °C
8 pm 37.5 °C

7. Respiratory Status

Date Time RR SPO2

3pm 71 cpm 95 %
October 30, 2019 6pm 70 cpm 95 %
8pm 70 cpm 98 %
3pm 65 cpm 92 %
November 1, 2019 6pm 63 cpm 96 %
8pm 65 cpm 97 %
3pm 58 cpm 94 %
November 2, 2019 6pm 58 cpm 95 %
8pm 58 cpm 98 %

8. Circulatory Status

Date Time CR Capillary

October 30, 2019 3 pm 151 bpm
6 pm 153 bpm 2-3 seconds
8 pm 153 bpm
3 pm 150 bpm
November 1, 2019 6 pm 151 bpm 2-3 seconds
8 pm 151 bpm
3 pm 147 bpm
November 2, 2019 6 pm 150 bpm 2-3 seconds
8 pm 149 bpm

9. Nutritional Status

10. Elimination Status

-The patient frequently changes diapers 3 times withing the 3-11 shift due to urination. The patients was
also observed to defecate one a day.
11. Sleep, Rest and Comfort Status
-Pstient is irritable, the patients mother verbalize that “lagi syang nagigising pag nakatulog sa ubo”.
The patient wakes from sleep because of discomfort caused by his illness.
12. Fluids and Electrolytes Status
-“egdede met isuna mga 10-15 minutes, tas agrerest isuna nga agdede kala agdede tas agrest santo na
manen ituloy”
13. Integumentary Status
During episodes of airway obstruction, the patient’s capillary refill is 2-3 seconds.
However, when managed, he appears to be pinkish in color and with good skin turgor.

6
XII. Diagnostics

Diagnostic Date of
Description of the Procedure Significance/Purpose of the Procedure Findings & Implications
Procedure Procedure
Chest X-ray Chest radiography is a primary Used for determining the severity of the October 30, 2019
investigation to be performed for patients pneumonothorax . Also used to - Reticular densities are noted in both lung parenchyma
assessing pneumonothorax, however, it determine the progress of his medical and - Heart is normal in size and configuration
is much less sensitive than chest ct for surgical management. - Pulmonary vascular marking are within normal
detecting a small pneumonothorax , - Visaulized osseous and soft tissues are structures and
blbes, and bullae. unremarkable.
Impression: Pneumonia

Diagnostic procedure and Description of procedure Significance/ Purpose of the procedure Significant findings Nursing Implications
date done

Complete Blood Count This procedure is done when an individual For getting the health status , screen, Hemoglobin – 205 -Indicate a related condition such as COPD,
October 30, 2019 shows several signs and symptoms that diagnose, or monitor any of a variety of dehydration
was related to the disorder that also affects diseases and condition s that affetct
the clients blood cells. If an individual blood cells, such as anemia, infection, -Indicate dehydration that causes body to
Hematocrit – 0.62
suffers from infection, inflammation, inflammation. Bleeding disorder or produce too many RBC
bruising or bleeding, the doctor might cancer
order a CBC to help in diagnosing the
severity of the clients illness. WBC count – 10.31 -Indicate an acute virus infection.

Differential count

Neutro – 31 -Indicate increase rsik of infection

7
 Lympho – 61 -Indication of lymphocytosis which is
associated with inflammatory . Lymphocytes
counts above normal range can be a harmless
and temporary situation due to bodys normal
response to an infection or inflammatory
condition.

-Typically indicates the presence of different

Mono – 7 circulatory anemia. This also indicates there
are low amount of hemoglobin present per
red blood cell

Eosino – 0

Baso – 1

Total – 100

RBC count – 8.02

Platelet count - 192

Diagnostic Date of
Description of the Procedure Significance/Purpose of the Procedure Findings & Implications
Procedure Procedure
Red Blood Cells Count October 30, 2019 MCV – 77.80
MCH – 25.60

8
MCHC – 329.00
RDW-CV – 15.70
RDW-SD – 42.80
MPV – 9.10

9
XIII. Comprehensive Pathophysiology
Predisposing Factor Precipitating Factor

Exposure for Aspiration of microbes

Failure of defense mechanism

Invasion of Lower Respiratory Tract

Activation of B- cells

Antigen-antibody Reaction

Antigen- antibody complex Hyperthermia or

adhere to the Mucosal Lining Fever
of the Lower Respiratory
Tract

Obstruction of Air
Accumulation of mucus
Passageway

Productive cough Ineffective breathing

pattern

Barrier of breastfeeding
Impaired Gas
Exchange

Risk for Imbalanced Risk for Skin

Risk for Infection
Nutrition Integrity

10
XIV. Treatment/Management

A. Drugs

DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES

CONTRAINDICATION
TRADE NAME: INDICATIONS : CNS : BEFORE:
GENERIC INTERFERES WITH -ANTHRAX -LETHARGY DX:
NAME : BACTERIAL CELL WALL -ACTINOMYCOSIS -HALLUCINATIONS MONITOR VITAL SIGNS
PENICILLIN G SYNTHESIS DURING -BOTULISM -SEIZURES ASSESS FOR HYPERSENSITIVITY
SODIUM ACTIVE -DIPHTHERIA GI: TX:
DOSAGE: MULTIPLICATIONS, ERYSIPELOTHIRX -GLOSSITIS PERFORM PHYSICAL ASSESSMENT
136,000 UNITS CAUSING CELL WALL ENDOCARDITIS -STOMTITIS THOROUGHLY
EVERY 12 DEATH -LISTERIA INFECTIONS -GASTRITIS EDX:
HOURS -HAVERHILL FEVER -SORE MOUTH EDUCATE PATIENT ON POSSIBLE SIDE
-RAT-BITE FEVER -FURRY TONGUE EFFECTS OF DRUGS
-PNEUMONIA -NAUSEA
-SYPHILIS -VOMITING
CONTAINDICATIONS: DIARRHEA
-HYPERSENSITIVITY TO DRUGS -ABDOMINAL PAIN
-WITH HISTORY OF -NON-SPECIFIC HEPATITIS
HYPERSENSITIVITY GU:
-IF PATIET HAVE CDAP -NEPHRITIS
OTHERS:
-RASH
-FEVER
-WHEEZING
-ANAPHYLAXIS
-PAIN
DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION
TRADE NAME: INDICATIONS: -FINE TREMOR OF SKELETAL MUSCLE BEFORE
SALBUTAMOL IN LOW DOSES, ACTS -RELIEF AND PREVENTION OF -FEELINGS OF TENSION DX:
NEB RELATIVELY BRONCHOPASM IN PATIENTS -PERIPHERAL VASSODILATION -CHECK AND VERIFY DOCTORS ORDER

11
 GENERIC SELECTIVELY AT BETA 2 – WITH REVERSIBLE - A COMPENSATORY SMALL INREASE IN AND KARDEX
NAME : ADRENERGIC RECEPTORS OBSTRUCTIVE AIRWAY DISEASE HEART RATE -OBERSERVE 10 R’S
ALBUTEROL TO CAUSE -INHALATION: TREATMENT OF -HEADACHE, TRANSIENT MUSCLE CRAMPS TX:
SULFATE BRONCHODILATION AND ACUTE ATTACKS OF - HYPERSENSITIVITY REACTIONS -MONITOR ECG, SERUM ELECTROLYTES
DOSAGE: 2-4 VASODILATION; AT BROCHOSPASM -POTENTIALLY SERIOUS HYPOKALEMIA AND THYROID FUNCTION TEST
mg 3-4 mg/DAY HIGHER DOSES, BETA 2 -PREVENTION OF EXERCISE - HYPERACTIVITY IN CHILDREN RESULTS
SELECTIVITY IS LOST, AND INDUCED BROCHOSPASM - PARADOXICAL BRONCHOSPASM -ASSESS PULSE FOR RHYTHM
THE DRUGS ACT AT BETA -UNLABELLED USE: ADJUNCT IN -NOUTH AND THROAT IRRITATION EDX:
2 RECEPTORS TO CAUSE TREATING SERIOUS (INHALERS) -INSTRUCT CLIENT TO RISE SLOWLY
TYPICAL HYPERKALEMIA IN DIALYSIS -TACHYCARDIA FROM BED OR WHEN CHANGING
SYMPATHOMIMETIC PATIENTS; SEEMS TO LOWER -PALPITATION. POSITIONS FROM LYING TO SITTING TO
CARDIAC EFFECT POTASSIUM CONCENTRATION STANDING
WHEN INHALED BY PATIENTS
ON HEMODIALYSIS DURING
CONTRAINDICATIONS: DX:
-CONTRAINDICATED WITH -INSPECT CLIENTS NAIL BED AND ORAL
HYPERSENSITIVITY TO MUCOSA FOR PALLOR
ALBUTEROL;TACHYARRHYTHMI TX;
AS, TACHYCARDIA CAUSE BY -ADMINISTER ACCURATELY BEAUSE
DIGITALIS INTOXICATION ADVERSE REACTION AND TOLERANCE
-USE CAUTIOUSLY WITH MIGHT OCCUR
DIABETES MELLITUS; EDX:
HYPERTHYROIDISM, HISTORY EMPHASIZE WITH THE FAMILY AND
OF SEIZURE DISORDERS. THE CLIENT THE IMPORTANCE OF
WIPING OFF SWEAT TO AVOID EASY
BREAKDOWN OF SKIN INTEGRITY

AFTER
DX:
-AUSCULTATE LUNGS FOR PRESENCE
OF AD VENTIOUS BREATH SOUNDS
THAT MAY SIGNAL PULMONARY
EDEMA, AIRWAY RESISTANCE OR
BRONCHOSPASM.
TX:
12
 -PROVIDE ORAL CARE OR LET PATIENT
GURGLE AFTER INHALATION TO GET
RID OF THE UNPLEASANT AFTERTASTE
OF THE INHALATION.
-RAISE SIDE RAILS BECAUSE CLIENT
MIGHT BE RESTLESS AND DROWSY
BECAUSE OF THE DRUG.
EDX:
ADVICE CLIENT TO SEEK ASSISTANCE
WHEN PERFORMING ADL OR GETTING
DROWSY.
DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION
TRADE NAME: WORKS BY INHIBITING INDICATIONS: -PAIN BEFORE
GENERIC THE MUCOPEPTIDE INDICATED IN PATIENTS WITH -INDURATION DX:
NAME : SYNTHESIS IN THE NEUROLOGIC COMPLICATIONS, -PHLEBITIS -ASSESS PATIENTS PREVIOUS
CEFTRIAXONE BACTERIAL CELL WALL. CARDITIS AND ARTHRITIS. IT IS -RASH SENSITIVITY REACTION TO PENICILIN
DOSAGE: 450 THE BETA-LACTAM ALSOE EFFECTIVE IN GRAM -DIARRHEA OR OTHER CEPHALOS PORINS.
mg TIV q/2 MOIETY OF CEFTRIAXONE NEGATIVE -THROMBOCYTOSIS -ASSESS PATIENTS FOR SIGNS AND
BINDS TO INFECTIONS;MENINGITIS, -LEUCOPENIA SYMPTOMS OF INFECTION BEFORE AND
CARBOXYPEPTIDASES GONORRHEA. IT IS ALSO FOR -GLOSSITIS DURING TREATMENT.
AND ENDOPEPTIDASES BONE AND JOINT INFECTIONS, -MONITOR HEMATOLOGIC,
AND TRANSPEPTIDASES IN MIDDLE EAR INFECTION, PID, CNS: ELECTROLYTES, RENAL AND HEPATIC
THE BACTERIAL SEPTICEMIA AND URINARY HEADACHE,DIZZINESS,LETHARGY FUNCTION.
CYTOPLASMICMEMBRANE TRACT INFECTIONS. GI: TX:
. THESE ENZYMES ARE NAUSEA,VOMITING,DIARRHEA,ANOREXIA, ASSISST FOR POSSIBLE UPPER
INVOLVED IN CELL WALL CONTRAINDICATIONS: PSEUDOMEMBRANUS COLITIS INFECTION, ITCHING, FEVER,
SYNTHESIS AND CELL CONTRAINDICATE WITH HEMATOLOGIC: MALAISE,REDNESS.
DIVISION. BY BINDING TO ALLERGY TO BONE MARROW DEPPRESSION, WBC, EDX:
THESE ENZYMES, CEPHALOSPHORINS OR PLATELETS, HCT INSTRUCT THE CLIENT TO REPORT
CEFTRIAXONE RESULTS IN PENICILLIN. USE CAUTIOUSLY LOCAL: ONLY SIGN SUCH AS
THE FORMATION OF WITH RENAL FAILURE, PAIN, INFLAMMATION OF IV SITE. PETECHIAE,ECCHYMOTIC
DEFECTIVE CELL WALL LACTATION, PREGNANCY. OTHER: AREAS,EPISTAXIS OR OTHER FORMS OF
AND CELL DEATH. SUPERINFECTIONS DISULFRAM LIKE UNEXPLAINED BLEEDING.
REACTION WITH ALCOHOL.
13
 DURING
DX:
-USE A SEPARATE SYRINGE WHEN
GIVING THIS DRUG.
TX:
HAVE VITAMIN K AVAILABLE IN CASE
OF HYPOTHROMBINEMIA OCCURS.
EDX:
INSTRUCT THE CLIENT REPORT ANY
CONCERNS.

AFTER
DX:
MONITOR BLOOD LEVELS IN PATIENTS
TAKINHG THIS BLOOD
TX:
-ASSISST THE REACTION, DISCONTINUE
IF HYPERSENSITIVITY OCCURS.
EDX:
-INSTRUCT PATIENTS TO PROMPTLY
SIGN OF REACTION
DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION
TRADE NAME: INHIBITS PROTEIN INDICATION:  GASTROINTISTINAL BEFORE
GENERIC SYNTHESIS IN -INFECTIONS CAUSED BY DISTURBANCES- DX:
NAME: SUSCEPTIBLE BACTERIA, SENSITIVE STAPHYLOCOCCI, NAUSEA,VOMITING, AND -CHECK DOCTORS ORDER
CLINDAMYSIN CAUSING CELL DEATH. STREPTOCOCCI,PNEUMOCOCCI,B DIARRHEA TX:
DOSAGE: ARTEROIDES,CLOSTRIDIUM  ORAL OR VAGINAL CANDIDIASIS ASSESS FOR ALLERGY TO
FREQUENCY : PERFURINGENS AND OTHER  DOSE-RELATED CLINDAMYSIN, HISTORY OF ASTHMA
SENSITIVE AEROBIC AND REVERSIBLESUPPRESSION OF RED OR OTHER ALLERGIES.
ANAEROBIC ORGANISMS. CELL PRODUCTION EXCEEDING 50 EDX:
-ENDOCARDITIS PRPHYLAXIS mg/kg/d AFTER 1-2 WEEKS. -INFORM PATIENT FOR THE
FOR DENTAL PROCEDURES IN  APLASTIC ANEMIA- PROCEDURES TO BE DONE
PATIENTS ALLERGIC TO IDIONSYNCRATIC REACTION
PENICILIN. UNRELATED TO DOSE. DURING
14
 -PNEUMOCYTIS SIROVICCI DX:
PNEUMONIA -VERIFY PATIENTS IDENTITY
-TOXOPLASMOSIS TX:
-ADMINISTER THE RIGHT DRUG WITH
CONTRAINDICATION: THE RIGHT DOSE
-CONTRAINDICATED IN EDX:
PATIENTS WITH -STATE TO THE PATIENT THE
HYPERSENSITIVE TO DRUG OR IMPORTANT PURPOSE OF THE DRUG
ANY LINCOMYCIN
-USE CAUTIOUSLY IN PATIENTS AFTER
WITH RENAL OR HEAPTIC DX:
DISEASE, ASTHMA, HISTORY OF -MONITOR LFT’S AND RENAL
GI DISEASE AND SIGNIFICANT FUNCTION TESTS, AND BLOOD COUNTS
ALLERGIES. TX:
-TAKE FULL PRESCRIBED COURSE OF
ORAL DRUG. DO NOT STOP TAKING
WITHOUT NOTIFYING YOUR HEALTH
CARE PROVIDER.
EDX:
-ADVICE CLIENT TO REPORT FOR ANY
DISCOMFORT

B. IV Fluids

Name Classification Component/s Use & Effects Nursing Responsibilities

NAME: -HYPERTONIC  ELECTROLYTES USED FOR REPLACEMENT OF BEFORE
D5LRS -NONPYROGENIC -1000ml EXTRACELLULAR LOSSES OF FLUID DX:
-PARENTAL FLUID  SODIUM AND ELECTROLYTES, WITH OR -CHECK FOR ALLERGIES
-ELECTROLYTE -130 mmol WITHOUT MINIMAL -PROPERLY LABEL IV FLUID
-NUTRIENT  POTASSIUM CARBOHYDRATE COLINIES. TX:
REPLENISHER -4mmol -CAUTION MUST EXERCISED IN THE
 CALCIUM EFFECTS: ADMINISTRATION OF PARENTAL FLUIDS

15
 -1.4mmol  BODY ACHES OR PAIN ESPECIALLY THOSE CONTAINING IONS TO
 CHLORIDE  CHILLS PATIENTS RECEIVING
109mmol  CONFUSION CORTICOSTEROIDS/CORTOTROSPIN
 LACTATE  DIZZINESS, FAINTNESS, OR -OBSERVE ASEPTIC TECHNIQUE WHEN
-28mmol LIGHTHEADEDNESS WHEN CHANGING IV FLUID.
 OSMOLALITY GETTING UP SUDDENLY EDX:
-406mosm FROM LYING. -DISCARD UNUSED PORTION
 DRY MOUTH -INSTRUCT THE CLIENT TO REPORT ANY
 UNUSUAL TIREDNESS OR CONCERN
WEAKNESS
DURING
DX:
-CHECK FOR DRUG INTERACTION
-MONITOR FOR ADVERSE EFFECTS
TX:
-SOLUTION CONTAINING ACETALE SHOULD BE
USED WITH CAUTION AS EXCESS
ADMINISTRATION MAY RESULT IN METABOIC
ALKALOSIS.
-SOLUTION CONTAINING DEXTROSE SHOULD BE
USED WITH CAUTION IN PATIENTS WITH KNOWN
SUBCLINICAL OR OVERT DIABETES MELLITUS.
AFTER
DX:
-MONITOR EFFECTIVENESS OF IV FLUIDS
-MONITOR SIDE EFFECTS
TX:
IN VERY LOW BIRTH WEIGHT INFANTS,
EXCESSIVE OR RAPID ADMINISTRATION
DEXTROSE INJECTION MAY RESULT IN
INCREASED SERUM OSMOLALITY AND POSSIBLE
16
INTRACEBRAL HEMORRHAGE

17
XV. Nursing Care Plans

A. Prioritization of Problems

a.1. List of Problems

1.Ineffective airway clearance related to presence of exudates in the tracheobronchial tract as manifested by
crackles upon circulation

2.ineffective breathing pattern related to copious and tenacious tracheobronchial tree as manifested bt
increased respiratory rate.

3.Impaired gas exchange related to altered oxygen supply as manifested by subsostal retractions.
4.risk for infection related to lack of knowledge on the different microorganisms which causes infection.

5.Risk for nutritional imbalance to decrease breastfeeding

a.2. Basis for Prioritization

NURSING DIAGNOSES JUSTIFICATION
1.Ineffective airway clearance related Airway must be given the first attention as based on the
to presence of exudates in the rule of ABC which is airways, breathing and circulations,
tracheobronchial tree as manifested therefore the one that needs the most education and
by crackles upon auscultation attention. Oxygenation is vital need for every cell, if there
are any problems related to it, it can easily affect the
functioning of the individual.

2.Ineffective breathing pattern this is one of the most priority to attend and demands
related to coppious and tenacious immediate treatment care and subsequent medical
tranchibronchial secretions as attention, as they can result in ineffective breathing
manifested by increased respiratory pattern. This also needs prioritization based on ABC. The
rate. ssoner the problem gets resolved the lesser the
complications that lead to crisis.

3..Impaired gas exchange related to Impaired gas exchange is the excessss or deficit in
altered oxygen supply as manifested oxygenation and or carbon dioxide elimination at the
by subcoastalretraction. alveolar-capillary membrane. This condition needs to be
addressed immediately for the patient to be able to
manifest a good gas exchange and to prevent further
complications.

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 B. Nursing Care Plans

NCP 1: PES Format as stated in your list of problem

Assessment Explanation of the problem Objective Nursing Intervention Rationale Evaluation
Subj: Inhales microorganisms STO: -establish rapport with the infant and -To gain client’s and relatives trust STO:
“adda oras nga marigatan ↓ Within 30 mins – 1 hour of the infants guardian -To obtain baseline data (Goal partially met)
suna nga aganges” effective nursing intervention -Monitored vital signs -to identify factors that compromises After 30 minutes -1 hour of
Transmitted to alveoli the patient will be able to: Monitored infant for feeding airway effective nursing
Obj: ↓ -Maintain airway patency and intolerance and emotional stressor intervention the patient is
 SpO2 94% have clear breath sounds. -positioned head midline with flexion -To identify infectious process or able to:
 Crackels Less function(impaired gas appropriate for age or condition promote timing intervention - Maintained open
exchange) LTO: To maintain open airway in at rest or airway
adventitious
↓ Within 1 day of effective -auscultated breath sounds and assess compromised individual - There is still the
sound upon nursing intervention to the air movement -To ascertain status and make progress
auscultation on presence of breath
Mucus patient he will be able to: -elevated head of the bed or change -To take advantage of gravity decreasing
both lungs. production(inflammatory -Expectorate retained position every 2 hours and as needed pressure on the diaphragm and sounds upon
 Cough, sputum reaction) secretions enhancing drainage or ventilation to auscultation
 Chsngesin ↓ -maintain normal breathing different lung segments
within normal range . -encouraged deep breathing and -to maximize effort LTO:
respiratory rate (Goal Met)
Phagocyte produce coughing exercise;splint chest
and rhythm. ↓ -provided information about the -to examine and report changes in color After 1 day of effective
necessity of raising and expertorating and amount of secretion nursing intervention the
Increase Accumulation of secretions versus swallowing them patient is able to:
Nursing diagnosis: exudates in alveoli -Encouraged mother/provided - Expectorated
Ineffective airway ↓ opportunities for rest; limit activities to -To prevent or lessen fatigue retained secretion
clearance related to level of respiratory tolerance - Maintained normal
presence of exudates in Ineffective airway clearance
the trachiobronchial tree breathing within
as manifested by crackles normal range
upon auscultation. which is 58

19
NCP 2: PES Format as stated in your list of problem
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
Sub: Ineffective breathing pattern: STO: -determine the presence of factors -To evaluate the presence and
“paspas diyay panag- inspiration or expiration that -Within 2-3 hours of effective /physical conditions characteristics of breath sounds and
anges ken adda rarek na” does not provide adequate nursing intervention the patient -Assess for concomitant pain secretions.
Ob: ventilzation will be able to: -auscultate the chest -To facilitate fast recovery
 Tachypnea -decrease respiratory rate from -Suction airway as needed -as baseline for medication
 Nasal flaring The patient was hospitalized 71 to 50 -Elevate the head of the bed administration.
 RR- 71 with a chief complaint of -Monitor pulse oximitry and the
 0xygen cough and admitted with LTO: respiratory rate.
Saturation-94 diagnosis PCAP C or pediatric -after 2-3 days of effective
community acquired nursing intervention the patient
pneumonia. will establish normal breathing
pattern.
It is an inflammation of the
parenchyma of the lungs by
typical bacterial pathogens
that cause CAP include
Nursing diagnosis: streptococcus
Ineffective breastfeeding pneumonia,haemophilus
pattern related to a influenza, and Moraxella
copious and tenacious catarrhallis. This inhibit lung
tracheobronchial tree as function, causing
manifested by increased dyspnea,fever,chest pains and
respiratory rate cough.

NCP 3: PES Format as stated in your list of problem

Assessment Explanation of the problem Objectives Nursing intervensions Rationale evaluation
Subjective: Entry of noxious particles of STO: -Note respiratory rate, depth, -This provide insight into the STO:
“paspas diyay panag-anges ken gases to the lungs After effective nursing use of accessory muscle, pursed work of breathing and (Goal Met)
adda rarek na” ↓ intervention with 2-4 hours the lip breathing, nasal flaring adequacy of alveolar After 2-4 hours the patient is
Release of mediators patient will be able to: -patient -Monitor VS and cardiac ventilation. able to:
Objective: ↓ respirations at 30-50 bpm and rhythm -In this nursing diagnosis, -attained normal range of
20
-Restlesness, irritability Abnormal Inflammation of the oximetry result within normal ventilator effort is insufficient oximetry result at 97%.
-Nasal Flaring Lungs range which is 95-100-by to deliver enough oxygen or to Respiratory rate at 58/min
-Abnormal rate and rhythm of ↓ WHO get rid of sufficient amount of
breathing with RR of 71 Chronic Inflammation LTO: CO2 LTO:
↓ After effective nursing -Provide airway adjuncts and -All VS are impacted by (Goal met)
Nursing diagnosis: Scar tissue formation intervention with 1-3 days there suction as indicated changes in oxygenation After 2 days there is:
Impaired Gas Exchange related ↓ would be: -Elevate head of the bed and -To clear or maintain open - No signs of respiratory
to altered oxygen supply as Narrowing of airway lumen - Absence of symptoms of position airway, when client is unable to distress.
manifested by Sub costal ↓ respiratory distress clear secretions - Attained normal
retractions Airflow limitations -Elevation fascilitates breathing pattern
↓ respiratory function by gravity
Impaired Gas Exchange
↓
Abnormal breath sound

NCP 4: PES Format as stated in your list of problem

Assessment Explanation of the problem Objectives Nursing intervensions Rationale evaluation
Risk for infection related to -Presence of underlying STO: -Stress proper handwashing -First-line of defence against
lack of knowledge on the diseases which suppress the -be able for the parents of the techniques by all caregivers nosocomial infections or cross
different microorganisms which immune function of the body. infant to acknowledge the -Involve in appropriate contamination.
cause infection -WBC level patient is importance of proper community education program -To increase awareness of
decreased or below normal handwashing. -Instruct client / significant spread / prevention of
range. LTO: others in techniques to protect communicable diseases
Be able to practice proper the integrity of skin, care for -Prevention of spread of
handwashing in their everyday lesions. infection
life. -Emhasize necessity of taking -Inappropriate use can lead to
antibiotics / using “left over” development of drug-resistant
drugs unless specifically strains/ secondary infections.
instructed by health care
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 provides.

NCP 5: PES Format as stated in your list of problem

Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
NURSING Malnutrition is the condition STO: -Assissted the px in demonstrating -For education of the px for appropriate
DIAGNOSIS: that results from taking During the extent of effective behavior to regain appropriate weight recovery from nutritional imbalance
Risk for imbalanced imbalanced diet in which nursing intervention; the -ascertained understanding of the px
nutrition related to certain nutrients are lacking in patient will be able to need -determine informational needs of the px.
decreased appetite excess (too high intake) or in demonstrate behavior changes
the wrong proportions. It is a to regain appropriate weight.
broad term which refers to
both under nutrition and over
nutrition. Individuals are
malnourished LTO or
suffering from under nutrition
if their diet does not provide
them with adequate calcium
and protein for maintenance
growth or they cannot fully
utilize the food they eat due to
illness.

22
 C. Discharged Plan
Health Teaching
Diet/Nutrition 1. Informed mother to breastfeed the patient per demand
2. Answered mother about proper breastfeeding technique
3. Encouraged mother to increase fluid intake and intake of
nutritious food like vegetable, fruits, and take vitamins. Also
minotor foods she intake.

Activity 1. Educated the mother to clean and disinfect possible sites of

microorganisms to grow to prevent cross contaminiation or
acquiring them.
2. Encouraged mother and significant others to obsrve and
practice proper handwashing specially when cuddling the
infant to prevent cross-contamination of microorganisms.
3. Disouraged mother not to engage in strenuous activities in
order for her to save energy to take care of her infant.
4.

Medication 1. Instruct mother to continue the medication prescribed by the

physician and not to stop it until nedication is finished.
2. Instructed mother to observe signs and symptoms of advrse
effect of medication and to report it immediately to the
physician.

Other 1. Duscuss the importance of breastfeeding for the mother and

the baby
2. Discuss the continues breastfeeding after six minutes and
introduction of other foods in addition to breast milk.

XVI. Learning Insights

23
 A. AGAYAM, Alpha Rose
Our case is about PCAP Type C which means Pediatric Community Acquired Pneumonia
Type C. The process of doing the case study helps me to acquire more knowledge about it. I
learned how to prioritize nursing diagnosis for having a nursing intervention to decrease
chances of further complication. Pneumonia is one of the most cause of mortality and
morbidity, so I learned that proper management of the problem would help decrease the
mortality and morbidity of the problem. Factors causing pneumonia also helps me learn that
to be able to decrease pneumonia we should prevent these factors to occur. I leaned also that
teamwork is a important factor to be able to make this case study possible.
B. CABIGON, Jayrose
During our duty, I was able to see the 5 months old infants patient which diagnosed by PCAP
C. In this case it needs accurate information or data when getting vital signs. Observed oxygen
saturation and auscultated the breathing, heart rate for abnormalities. That it needs treatment such as
giving antibiotic medication and nebulizer for breathing therapy.
C. Guyao , kesilda B.
Pneumonia is a serious illness that an infant can acquire. Pneumonia can effectively affect the
activities of daily living of a man. As a student nurse, we must learn techiniques on how to prevent
this illness that we can also use for our clients health.

D. Juan, Vanessa A.
We tackled about pneumonia in our case presentation. As a student nurse,I must be aware
about this illness that can affect the breathing pattern of a person . And we know that breathing is the
main source of our oxygen. As a student nurse, I should be one of the health advocate s for preventing
these kind of illness

E. Lambatan , Tzar R.
I have learned that Pneumonia is a curable condition. That being a responsible parent for an
infant or baby plays a vital role to prevent such condition to happen. Proper hand washing and maintaining a
clean environment also continues to a healthy condition.
Proper positioning of a patient with pneumonia helps him/her promote effective breathing to
prevent distress and discomfort and to strictly follow medication as prescribed by the physician.
F. Marzan, Kurt O.
Our case is about pneumonia. Infants or children ranging from age 12 above are mostly
affected by these illness. Having these kind of illness can affect the way of living of an individual in a
way that it could create different restrictions for him/her . As a student nurse, we must be able to
prevent further complications for our patients who suffers from pneumonia. We should should also be
able to provide accurate informations for our client to avoid this illness to happen again.

G. Mostoles, Al Jarreau
Our case study is about Pneumonia. This Pneumonia is an illness that critically affects
pediatric patients and is also community acquired illness. A person with pneumonia has an impaired
breathing which affects the exchange of gas inside his/her body.

H. Pilipina, rizen anjel B.

This was my first case study of studying nursing. Therefore I didn’t have much experience
in writing this type of assignment. As I look back on our case study and the preparation, I am amazed
to find that I learned a lot from this case study. Our case study started on November 16, 2019, we got

24
 the chance to select any patient we want from anywhere we choose, so we have chosen the patient
from same ward we were assigned.
Our schedule was too hectic to finish our case study on time, so for further improvement we should
learn how to manage our time. Also, my skills on making a Nursing Care Plan was enhanced and my
communication skills as a nursing student were used during the assessment. I learned a lot from this
case study it helped me to improve and use my skills and also it was a great experience.

I. Tuguinay , Ma. Theresa B.

Learning and experiencing to look after patients with pnemonia was a great experience for
me. It is indeed hard to be sick but I guess it is harder to be sick without any form of help. I am
greatful that even just for a while I was able to be of help to those patients having this case. Having
pneumonia is not just being sick with cough/colds and fever but it has risk factors that can even
worsen ones condition and lead to another illness. Giving proper nursing interventions is the outmost
learning I gained from this case. I also learned and thankful to have experienced teamwork with my
groupmates because it's not all the time that I get to see us work as a group. This case has help me a
lot to value the importance of health and help me grow as a student nurse specially with my
knowledge and skills.

J. Velasco, Menard Jun T.

Our case is about pneumonia , specifically pediatric community acquired pneumonia type c
where in it is an infection that has been acquired outside the hospital, i’ve got lots of new learning
about pneumonia. though I didn’t handle this patient but i have a patient that have been diagnosed also
with PCAP -type C , so I learned how to give proper interventions like elevating the head to have a
better lung expansion and better breathing pattern to promote balance gas exchange; on how to
position client to have a patent airway , I also learned the importance of establishing rapport which
helps me in my interventions to be done easier and accurate. I learned how to communicate to my
group mates for us to have a better team work and for our job to be done beneficently , And lastly , I
learned how to apply my knowledge , skills and attitude that College of nursing taught .

25
XVII. List of References

Patricia M. Dillon (2007). Nursing health assessment: a Culical thinking case studies approach.International
edition.

Kummor, Abbas, Faesto.(2010). Robbins and cotran:Pathogenic Basic of disease. Eight edition.

D’Amico,Barbanto(2007).An introduction to health and physical assessment in Nursing.

Marylinn. F Doenges. Mary Frances Moonhouse. Alice C. murr.(2014). Nurses pocket guide . Diagnoses,
prioritized, Interventions, and rationale. Edition B.

Wolter Klover. (2018). Nursing 2018:Drug Hand book.

Amy M. Karen(2009). Lippineotts: Nursing Drug Guide.

Who. Retieved from WHO.int/patient safety/safesurgery/pulse-oximetry-trainings-manual-en.pdf
DOH Hand Manual Guide.Retrieved from https://doh.gov/
Brunner &Saddarth’s textbook of medical- surgical nursing, vol.1

26
XVIII. Appendices

27
 Appendix A
Approval/Request Letter

28
 Appendix B
Interview Guides

1. When does the cough started?

Answer:

2. What are the medications given without consultation?

Answer:

3. Did you have consultation before because of the cough?

4. Answer:

5. Are you breastfeeding you child’s per demand?

Answer:

6. Do you observe anything to your child that worries you?

Answer:

29