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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Introduction
This case presentation is about C. Guillermo ( Patient X )a 3 y.o. boy from La Torre, Talavera, Nueva Ecija which have been admitted last October 5, 2011 at San Jose District Hospital. The Patient was diagnosed with Bronchopneumonia, moderate risk. Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells cant work properly. Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs. Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most common. Other pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella) catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gramnegative bacilli. Major pulmonary pathogens in infants and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever). The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions from the upper airways. Other means include hematogenous or lymphatic dissemination and direct spread from contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility, immunocompromise (as in diabetes mellitus and chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissible agents. Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.

WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Bronchopneumonia or bronchial pneumonia or Bronchogenic pneumonia is the acute inflammation of the walls of the bronchioles. It is a type of pneumonia characterized by multi faci of isolated, acute consolidation, affecting one or more pulmonary lobules. And it is classified under Bacterial pneumonia. The bronchopneumonia pattern has been associated with hospital- acquired pneumonia, and with specific organisms such as Staphylococcus aureus, Klebsiella pneumonia, E.coli and Pseudomonas. It can also be secondary (complication of some other disease): Viral infection (influenza, measles); aspiration of food or vomiting; obstruction of bronchus with foreign body, neoplasm and others; inhalation of

poisonous gases; major surgery; sever chronic diseases (tuberculosis), malnutrition; and, hipostatics (long lying after suffering stroke). Hospital acquired pneumonia, also known as nosocomial pneumonia, is defined as the onset of pneumonia symptoms more than 48 hours after the admission in patients with no evidence of infection at the time of admission. Pneumonia is the most common cause of death among infectious diseases. They take the fifth place in the statistics of diseases causing death. Bacterial and viral lower respiratory tract infections are categorized into four groups: Acute Bronchitis, an acute inflammation of the tracheobronchial tree; Bronchiectasis is the permanent dilatation and subsequent destruction of sub segmental bronchi; Lung abscess is the parenchymal destruction caused by an indolent suppurative process; and, pneumonia is an infection of the distal portion of the lungs, involving the respiratory bronchioles, alveolar ducts, sacs and alveoli. Primary care providers frequently evaluate patients with cough, which is the single most common symptom of respiratory illness. The objective of this presentation is to gain more knowledge about the disease and to prevent the development of further complications. This study aims to: Conduct and evaluate an assessment for the client Render series of nursing interventions for the clients care

WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Provide and disseminate important information as teachings to the client and the significant others to boost the knowing and understanding of the nature of the said health condition. Improve skills and knowledge as health care providers in the clinical area

Demographic data
Name Hospital Number Sex Age Date of Birth Birthplace Address Citizenship Religion Status Weight Date of admission Name of Mother Physician : : : : : : : : : : : : : : Patient X 5994 male 3 years old April 9, 2008 Cabanatuan City Purok 1, La Torre, Talavera, Nueva Ecija Filipino Roman Catholic Single 14 kg. October 5, 2011 at 1:53 p.m. W. Guillermo Dr. De Guzman

Diagnosis
Bronchopneumonia, moderate risk

History of Present Illness


Last September 28, 2011, 1 week PTA, Patient X have productive cough associated with colds (watery) without other symptoms noted. The next day, he was brought to a Pedia and was given with home medications. After 6 days the parent doesnt noticed any improvement with the childs condition the patient is still with productive cough and associated with on and off fever.

WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Few hours prior to admission, the patient still have cough and fever, consulted once and then admitted. The patient shows decrease in appetite, tachypnea, and decrease in activity level.

History of Past Illness


The patient were fully immunized, (-) allergies and (-) surgeries PTA.

Family Medical History


Unremarkable

Physical Assessment:
Pertinent physical assessment findings upon admission Pulse rate Respiratory rate Temperature Weight HEENT Neuro Exam Chest and lungs Heart Abdomen Extremities Clinical Impression Recent Physical Assessment
BODY PARTS HAIR METHOD USED Inspection & Palpation *Color * Amount and distribution Fine None No signs of abnormality None NORMAL Varies Vary PATIENT FINDINGS Black thick

: 115 bpm : 42 bpm : 39.3*C : 14 kg. : PG AS, (-) NAD , (-) TOC : Conscious and coherent : SCE, (-) retraction, tachypneic, crackles (+) right : AP : Soft, flat, NABI, (-) tenderness : (-) edema : Bronchial pneumonia, moderate risk

WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
*Texture *Presence of parasites SCALP *Symmetry *Texture HEAD *Size *Shape *Consistency Inspection & Palpation Normal Symmetrical & Round Hard & Smooth Normal No signs of abnormality Inspection & Palpation Symmetrical Smooth, firm Symmetrical No signs of abnormality

FACE *Symmetry *Facial Features Symmetrical May vary, centered head position Symmetrical

TRACHEA, THYROID, LYMP NODE

EYES *Position & Appearance *Blinking Palpation Lids margins moist and pink; lashes short, evenly spaced, and curled outward *Shape Symmetrical, involuntary, at approximate 15 No signs of abnormality Black No lymph nodes noted

WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
blinks per min Round *Color of Iris EAR *Size & Shape Ears of equal size and similar LIPS *Color *Consistency ABDOMINAL *Color *Umbilicus SKIN *Generalized color Inspection Normally pallor No signs of abnormality Moist, smooth with no lesion * Color variations in the patches of the body *Texture Inspection Right Arm Left Arm Right Leg Left Leg Nails *color *Shape *Texture Inspection In Dark Skin; Light to dark brown in dark skin; Lighter colored palms, soles, nail beds and lips. Smooth, soft No signs of abnormality No signs of abnormality No signs of abnormality Sunken centrally No signs of abnormality Inspection Light to Dark Brown Tiny Red Spots(Skin rash caused by insect bites skin (normal) No signs of abnormality Pinkish Normal appearance Normal Uniform color Normal

WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Pinkish Round Nail Nail is round, mobile, hard

Pathophysiology
Normal flora invades the lower resp. tract: Escherichia Coli Pseudomonas aeruginosa

Lung Contamination

inflammation

Damage to bronchial tubes

Release of endotoxins

Antigen- antibody response

Consolidation of lung tissue

Chest X-ray: White patchy infiltrate

WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Diagnostic Tests
1. Hematology Ref. No.: 12/05/IP Date : October 5, 2011 Result Reference Values Male: 4.5- 6x 1012/ L Female: 4- 5.5 x 1012/L Male: 0.40-0.54 Female: 0.77- 0.47 Male: 120-170 g/ L Female: 110-150 g/ L 150- 450 x 109/ L Adult: 5-10 x 10 / L Children: 6.2- 11.2 x 109/ L 0.50 0.70 0.20- 0.40
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Time out: 2:20 p.m.

Component

Interpretation Decreased erythrocyte counts is associated with disorders such as malnutrition A decreased hematocrit indicate hemodilution Normal Normal Normal Normal Decreased as pneumonia is present Not a characteristic of specific disorders

RBC count

4.36

Hct

.36

Hgb Platelet count WBC count Segmenters Lymphocytes

123 390 9.1 0.51 0.43

Monocytes 2. Urinalysis Ref. No.: 17/05/IP Date Physical Color :

0.06

0- 0.07

Time out: 6:01 p.m.

: October 5, 2011 Albumin Yellow Slightly turbid Ketone Urobilinogen Nitrite Bilirubin Microscopic : negative RBC : 0-1/ HPF : : negative negative

Clarity :

: normal (0.2-1 EV/dl) : : negative negative

Specific gravity: 1.005 pH : 5.5

Chemical Glucose

WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Pus cells : 0-1/ HPF Rare/ LPF Few/ LPF Bacteria : Rare/ HPF few/ LP Epithelial cells : Mucous Threads: Amorphous urates:

Urinalysis shows normal findings and has no significant relevance with the disease.

Anatomy and Physiology (normal)


The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain. The Upper Airway and Trachea When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voicebox) and into the trachea (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs. The Lungs The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply. Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide. Blood Supply The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs.

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
The Pleurae The lungs are covered by smooth membranes that we call pleurae. The pleurae have two layers, a 'visceral' layer which sticks closely to the outside surface of your lungs, and a 'parietal' layer which lines the inside of your chest wall (ribcage). The pleurae are important because they help you breathe in and out smoothly, without any friction. They also make sure that when your ribcage expands on breathing in; your lungs expand as well to fill the extra space. The Diaphragm and Intercostal Muscles When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in, the diaphragm contracts and flatten out, expanding the space in your chest and drawing air into your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not normally require your muscles to work. This is because your lungs are very elastic, and when your muscles relax at the end of inspiration your lungs simply recoil back into their resting position, pushing the air out as they go. The Respiratory System and Ageing The normal process of ageing is associated with a number of changes in both the structure and function of the respiratory system. These include: Enlargement of the alveoli. The air spaces get bigger and lose their elasticity, meaning that there is less area for gases to be exchanged across. This change is sometimes referred to as 'senile emphysema'. The compliance (or springiness) of the chest wall decreases, so that it takes more effort to breathe in and out. The strength of the respiratory muscles (the diaphragm and intercostal muscles) decreases. This change is closely connected to the general health of the person. All of these changes mean that an older person might have more difficulty coping with increased stress on their respiratory system, such as with an infection like pneumonia, than a younger person would. Functions: Works closely with circulatory system, exchanging gases between air and blood:

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Takes up oxygen from air and supplies it to blood (for cellular respiration). Removal and disposal of carbon dioxide from blood (waste product from cellular respiration). Homeostatic Role: Regulates blood pH. Regulates blood oxygen and carbon dioxide levels.

Medical Management
GENERIC NAME cefuroxime axetil BRAND NAME Ceftin ACTION Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. INDICATION 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Serious lower respiratory tract infection, UTI , or secondary or skin-structure infections, Perioperative prevention. Bacterial exacerbation of chronic bronchitis or secondary bacterial infection of acute Acute bacterial maxillary sinusitis. Pharyngitis and tonsillitis. Otitis media. Uncomplicated skin and skin structure infection. Uncomplicated UTI. Uncomplicated gonorrhea. Early Lyne disease. Impetigo. CEREBROVASCULAR- phlebitis, thrombophlebitis GASTROINTESTINAL- diarrhea, pseudomembranous, colitis, nausea, anorexia, vomiting before or joint infection, septicemia, meningitis and gonorrhea.

bronchitis.

SIDE EFFECTS

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
HEMATOLOGIC- hemolytic anemia, thrombocytopenia, transient neutropenia, eosinophilia SKIN- maculopapular and erythematous rashes, urticarial, pain, induration, sterile abscess, temperature elevation, tissue sloughing at IM injection site OTHER- anaphylaxis, hypersensitivity reactions, serum sickness NURSING RESPONSIBILITIES 1. 2. 3. thigh. 4. 5. 6. Absorption of oral drug is enhanced by food. Alert: tablets and suspension arent bioequivalent and cant be substituted milligram-forMonitor patient for signs and symptoms of super infection. Before giving drug, ask patient if he is allergic to penicillins or cephalosporins. Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin For IM use, inject deep into a large muscle, such as the gluteus maximus or the side of the

while awaiting results.

milligram.

GENERIC NAME gentamicin sulfate BRAND NAME Cudomycin, Garamycin ACTION Inhibits protein synthesis by binding directly to the 30S ribosomal subunit; bactericidal. INDICATION Serious infections caused by sensitive strains of pseudomonas acruginosa, Escherichia coli, Proteus, Klebsiella, or Staphyloccocus. To prevent endocarditis before GI or GU procedure or surgery. SIDE EFFECTS CENTRAL NERVOUS SYSTEM- encephalopathy seizure, fever, headache, lethargy, confusion, dizziness, numbness, peripheral neuropathy, vertigo, ataxia, tingling CEREBROVASCULAR- hypotension EENT- ototoxicity, blurred vision, tinnitus GI- vomiting, nausea

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
GU- nephrotoxicity, possible increase in urinary exertion of casts, HEMATOLOGIC- agranulocytosis, leukopenia, thrombocytopenia, anemia, eosinophilia MUSCULOSKELETAL- muscle twitching, myasthenia gravis,-like syndrome RESPIRATORY- apnea SKIN- rash, urticarial, pruritus, injection site pain NURSING RESPONSIBILITIES 1. 2. 3. 4. 5. 6. Obtain specimen for culture and sensitivity test before giving. Begin therapy awaiting Evaluate patients hearing before and during therapy. Notify prescriber if patient complains Weigh patient and review renal function studies before therapy begins. Monitor renal function: urine output, specific gravity, UA, BUN and creatinine levels and Watch for signs and symptoms of super infection such as continued fever, chills and Therapy usually continues for 7 to 10 days. If no response occurs in 3 to 5 days, stop results. of tinnitus, vertigo or hearing loss.

creatinine clearance. Report to prescriber evidence of declining renal function. increased pulse rate. therapy and obtain new specimens for culture sensitivity testing. GENERIC NAME: ipratropium bromide BRAND NAME: Atrovent ACTION Inhibits vagally mediated reflexes by antagonizing acetylcholine at muscarinic receptors on bronchial smooth muscle. INDICATION Bronchospasm in chronic bronchitis and emphysema. Rhinorrhea caused by allergic and non-allergic perennial rhinitis. Rhinorrhea caused by the common cold. Rhinorrhea caused by seasonal allergic rhinitis. SIDE EFFECTS CNS- dizziness, pain, headache, nervousness CV- palpitations, hypertension, chest pain

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
EENT- blurred vision, rhinitis, pharyngitis, sinusitis, epistaxis GI- nausea, GI distress, dry mouth MUSCULOSKELETAL- back pain RESPIRATORY- URTI, bronchitis, bronchospasm, cough, dyspnea, increased sputum SKIN- rash OTHER- flulike symptoms, hypersensitivity reactions NURSING RESPONSIBILITIES 1. 2. 3. If patient uses a face mask for a nebulizer, take care to prevent leakage around the mask Safety and effectiveness of use beyond 4 days in patients with a common cold havent been Alert: patient with a severe peanut allergy could have an anaphylactic reaction after using because eye pain or temporary blurring of vision may occur. established. Atrovent inhalation aerosol metered-dose inhaler (MDI). Get a thorough allergy history from patient before giving any drug. 4. Look alike-sound alike: Dont confuse Atrovent with Alupent.

GENERIC NAME: acetaminophen BRAND NAME: Acetaminophen ACTION Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center. INDICATIONS Mild pain or fever SIDE EFFECTS HEMATOLOGIC- hemolytic anemia, leukopenia, neutropenia, pancytopenia HEPATIC- jaundice METABOLIC- hypoglycemia SKIN-rash urticarial NURSING RESPONSIBILITIES

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
1. 2. 3. Alert: Many OTC and prescription products contain acetaminophen; be aware of this when Use liquid form for children and patients who have difficulty swallowing. In children, dont exceed five doses in 24 hours. calculating total daily dose.

Management
(Medical Management) Antibiotics are prescribed based on Gram stain results and antibiotic guidelines Supportive treatment includes hydration, antypiretics, antihistamines, or nasal Bed rest is recommended Oxygen therapy is given for hypoxemia Assess clients for s/sx Note changes in temperature; pulse; amount, odor and color of secretions; and breath sounds Frequency and severity of cough Encourage hydration: fluid intake (2-3 L/day) to loosen secretions Provide appropriate method of oxygen therapy Place client in semi-fowlers position Educate the parents/guardian of the patient about the disease

decongestants

( Nursing management)

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Nursing Care Plan
Assessment

Subjective: Napansin ko na hirap sa paghinga yung anak ko, nag-iba yung parang hinahabol niya yung paghinga niya. Mas nahihirapan siya kaysa nung unang araw ng ubo niya as verbalized by the mother. Objective: CR= 110 RR= 35 Temp. = 38.6 Wt. = 14 kg. Adventitious breath sound (rales) Productive cough Dyspnea

Diagnosis Planning

Ineffective airway clearance related to secretions in the bronchi Short term: After 8 hour of nursing intervention the patient will be able to: Maintain airway patency Expectorate secretion readily Demonstrate reduction of congestion with clear breath sounds and the mother will be able to: Verbalize understanding of cause(s) and therapeutic management regimen of her son Identify potential complications and how to initiate appropriate preventive or corrective actions Long term (not applicable because of one day duty in the hospital) Independent: Assess clients respiration and breath sounds, noting rate and sounds Evaluate clients cough/gag reflex and swallowing ability Position client in semi fowlers position for maximum lung

Implementation

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
expansion Change position every 2 hours to decrease gravity pressure on the diaphragm and to enhance ventilation to lung segments Monitor clients feeding intolerance, and abdominal distention Keep environment allergen free Assist and teach the mother in nebulizing client accompanied with bronchial tapping if not contraindicated Increase fluid intake to loosen secretions Monitor clients vital signs Observe for signs of respiratory distress Assess client/SOs knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedure Provide information about the clients condition to the mother/ SO Demonstrate/assist SO in performing specific airway clearance techniques Dependent: Give expectorants/bronchodilators as ordered Administers analgesics as ordered Interdependent: Assist with appropriate testing to identify causative/precipitating factors Assist with procedures (bronchoscopy) to clear/maintain open airway Assist with use of respiratory devices and treatments Assist in obtaining sputum specimen
Evaluation

After 8 hour of nursing intervention the patient was able to: Maintain airway patency (partially met) Expectorate secretion readily (partially met) Demonstrate reduction of congestion with clear breath sounds(partially met) and the mother was able to:

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Verbalize understanding of cause(s) and therapeutic management regimen of her son (goal met) Identify potential complications and how to initiate appropriate preventive or corrective actions (goal met)

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Assessment

Subjective: Yung tatay niya ay naninigarilyo as verbalized by the mother Objective: Risk diagnosis is not evidenced by signs and symptoms

Diagnosis

Risk for infection related to insufficient knowledge to avoid exposure to pathogens secondary to bronchopneumonia After 4 hours of nursing intervention the mother/SO will be able to: Verbalize understanding of individual causative/risk factor(s) Identify interventions to prevent/reduce risk of infection Understand on how to promote safety environment on her child Independent: Assess client for any sign of infection and document initial finding Educate mother for the risk factors Stress proper hygiene by all caregivers to avoid infection Educated significant others close to the client about the effects of smoking to the client Monitor/assist with the use of adjuncts Review individual nutritional needs with the mother Instruct client/SO in techniques to prevent spread of infection Discuss the role of smoking in respiratory infections Dependent: Administer medication as ordered Interdependent: Obtain appropriate fluid specimen for observation and culture and sensitivity testing After 4 hours of nursing intervention the mother/SO was able to: Verbalize understanding of individual causative/risk factor(s) (goal met) Identify interventions to prevent/reduce risk of infection (goal met) Understand on how to promote safety environment on her child (goal met)

Planning

Implementation

Evaluation

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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Discharge Planning
Meds Instruct the mother about the medicine Evaluation Evaluate whether the mother understand the teaching. Evaluate the clients response to the treatment given in the ward Evaluate the mothers need for additional learning Treatment Refer patient for home care to facilitate adherence to therapeutic regimen Instruct mother about the follow-up care Health education Review principles of adequate nutrition and rest to the mother Advise mother to increase the activities of the client gradually after fever subsides Repeat instructions and explanations as needed to the mother Observe personal hygiene Instruct the mother to avoid smoking near the client which lower the resistance to pneumonia Include information about ways to reduce potential for infection Diet As for our client, Diet as tolerated Instruct the mother on what is nutritional foods that her child needs Spiritual Assist parents to learn effective coping, for them to understand that its not their fault but they can do something to prevent and help their child to avoid it.

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