Infant, toddler and older people can easily acquire this disease. As the
Group B5 rotated in the pedia ward in Bukidnon Provincial Hospita; - Talakag, I
was assigned into a 3 years old patient whose name is Ampoan, Alona Tayaotao
who was diagnosed with Bronchopneumonia. It’s my first time to handle a patient
with a case of bronchopneumonia and it seems to be challenging in my part as a
student nurse. Through this case study I share my knowledge and care to my
patient and at the same time I also gained knowledge from my patient.
b. Objective of the Study
At the end of 2-days (16 hrs) duty, I will be able to bring improvement to
my patient’s health status, impart health teachings and informations to the patient
and to her family, thus enhancing their naked mind regarding to the illness of
their daughter and poor health management. As a part of this objective, my aim
is to provide nursing interventions to the identified health problems affecting the
family and gain their cooperation towards the improvement of their daughter’s
health condition
The NCM501X was assigned in pedia ward of X. The study was directed
to X’s health. The information gather was only limited from the assessment to the
second day of our duty which is done last January 16-18, 2007. Any information
verbalized by the mother and father regarding to their daughter Ampoan, Alona
are included in this study.
In a period of time, the interventions are not to bring patient in a full
recovery but to improve the health status of the patient and to prevent
complications. For the parents are included in this study in the enhancement of
the patient’s health, health teaching is being done as a part of my interventions.
In this way, Dole-out system is being avoided.
Name : X
Has received blood in the past _____ Yes ___/__ No If yes list dates____
Reactions___ Yes ___ No
Name : X(Father)
Name : X
(Mother)
Health History
Roque, Ampoan
Has received blood in the past _____ Yes ___/__ No If yes list dates____
Reactions___ Yes ___ No
Last December 2006, Mrs. X experienced common cough and cold and
had taken Neozep to get rid of such illness. According to Mrs. X, she got this
illness due to the cold weather they have experienced last December 2006. As a
treatment, MsX had taken Neozep 550 mg twice a day.
d. Chief Complain
X fourth child of MrX and Mrs. X who was admitted last January 16, 2007
with a chief complain of cough and dry and experienced cold, fever, and
diarrhea, five days prior to admission.
Infancy
According to Erickson, the central crisis at this stage is trust vs. mistrust.
Resolution at this stage determines how the person approaches subsequent
developmental stages. During the first year of life, infant depend on their parents
for physiologic needs. Fulfillment for this need is required for the infant to develop
a basic sense of trust.
As for my patient, according to her mother during her infancy period she
always demand for an attention, she would really cry whenever she is being held
by other person. She also manifest sucking reflex.
Early childhood
According to Freud’s theory this age represents the anal phase of
development when rectum and anus are the especially significant areas of the
body. This is the toilet training stage.
Aside from her mother, Alona is being trained by her father, older brothers
and sister on when and where to defecate. Based on my interview to the client’s
mother, my patient is not properly trained. Though Alona give signs to her
parents that she wants to defecate and able to identify where is the proper place
to defecate but still she sometimes can’t help to defecate in her underwear.
IV. MEDICAL MANAGEMENT
Generic name Brand Date Classification Dose/ Mechanism Specific Contra- Side Nursing
of Ordered Name Ordered Frequency/ of Action Indication indication Effects/ Precautions
Drug Route Toxic
Effects
Paracetamol Biogesi 1/16/07 Anti-pyretic Drop 1.2 ml Inhibits the Reduction Contraindicate Skin: -assess
c QID P.O. synthesis of of fever/ d in patients rash, patient
the body hypersensitive urticari temperature
prostaglandin temperatur to drug a before and
s that may e during
serve as GI: therapy
mediators of Hepatic -be alert for
pain and failure adverse
fever primarily reactions
in the CNS. GU: and drug
Renal interaction
failure -give liquid
form to
children
-warn pt.
that high
doses or
unsupervise
d long-term
use can
cause liver
damage.
DRUG STUDY
Name of Patient: Ampoan, Alona
Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Nursing
name of Name Ordered Frequency/ of Action Indication indication Effects/ Precautions
Ordered Route Toxic
Drug Effects
Cefuroxime _____ 1/16/07 Cephalospori 250 mg Inhibits cell Serious Contraindicate CV: Obtain
ns every 8 hrs wall synthesis infections d in patient Phlebiti specimen for
IVTT ANST promoting of the lower hypersensitive s, culture and
(-) osmotic respiratory drug or other Throm sensitivity
instability tract. cephalosporins bophle test before
usually . bitis giving first
bactericidal. dose.
GI:
colitis,
nausea
,
anorexi
a,
vomitin
g,
diarrhe
a
SKIN:
urticari
a, pain,
indurati
on
Other:
Serum
sicknes
s
DRUG STUDY
Name of Patient: Ampoan, Alona
Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Nursing
name of Name Ordered Frequency/ of Action Indication indication Effects/ Precautions
Ordered Route Toxic
Drug Effects
Salbutamol Salbuta 1-16-07 Therapeutic 1 neb every Relax Inhalation Hypersensitivity CNS: Use
mol broncho – 6 hrs bronchial, used as to adrenergic Nervou cautiously in
proventil dilators uterine, quick amines. sness, cardiac
pharmacologi vascular relief restles disease
c adrenergics smooth agent for sness, hypertension
muscle by acute tremors ,
stimulating bronchos , hyperthyroidi
beta 2 pasm and headac sm,
receptors for he, diabetes,
preventio insomn glaucoma.
n of ia
exercise
induced CV:
bronchitis chest
spasm pain,
palpitat
ions
GI:
Nause
a,
vomitin
g
V. PATHOPHYSIOLOGY W/ ANATOMY AND PHYSIOLOGY
5. Treatment of
5. Administer choice penicillin
cephalosporin. resistant
streptococcal
After 2-days of care that was being imparted to the patient, my objectives
were fully met. As what is being said, I was able to managed the condition of my
client and seen some improvement on her health in just few days. Careful
assessment of the client’s health status was done. And from such examination,
the client’s problems were identified. Interventions were then planned carefully
and were properly addressed to her health problems. After which, her response
and reaction were evaluated and important health teachings for her recovery
were imparted to her mother and father and especially to my patient.
During the second day of our duty, my client was able to display some
improvement regarding to her actions and especially to her breathing. Diarrhea
and fever were no longer present during the last day of my duty. This implies that
the intervention done was effective.
BIBLIOGRAPHY
Smeltzer.Bare. Textbook on Medical-Surgical Nursing (10th edition) Lippincott-
Raven Publisher.Copyright 1996
Wilson, Billie Ann Nurse’s Drug Guide (vol. 1 & 2) Pearson Education
Inc.,Copyright 2000
Mosby’s Pocket Dictionary of Medicine, Nursing and Allied Health (4th edition)
Elsevier(Singapore) PTE LTD> Copyright 2002
NCM501202
A Care Study
X
Name of Client
Submitted to:
______________________________
Name of Faculty
Submitted by:
_______________________________
Name of Student
Rating Scale
A. Written WEIGHT RATING
I. INTRODUCTION
a. Overview of the case
b. Objective of the case 5
c. Scope and limitation of the study