LYCEUM OF THE PHILIPPINES UNIVERSITY- BATANGAS

College of Nursing
Capitol Site, Batangas City
 Presented By:
Alcaraz, Christine Gale
Acosta, Mary Anne

Atienza, Julius
Balmes, Jeneth
Bonado, Milagros
BSN 3-5

Presented To:
Mrs. Consuelo A. Cena RN
(clinical Instructor)

February 16 – 20, 2009 & March 2 – 6, 2009

3:00 pm – 11:00 pm
 
BATANGAS REGIONAL HOSPITAL
 INTRODUCTION
Pneumonia is an inflammatory illness of the lung.
Frequently, it is described as lung parenchyma/alveolar
inflammation and abnormal alveolar filling with fluid (
consolidation and exudation). The alveoli are microscopic air-
filled sacs in the lungs responsible for absorbing oxygen.
Pneumonia can result from a variety of causes, including
infection with bacteria, viruses, fungi, or parasites, and chemical
or physical injury to the lungs. Its cause may also be officially
described as idiopathic—that is, unknown—when infectious
causes have been excluded. Primary pneumonia is caused by
the client’s inhaling or aspirating a pathogen. Secondary
pneumonia ensues from lung damage caused by the spread of
bacteria from an infection elsewhere in the body. Likely causes
include various infections agents (bacterial, viral, or fungal),
chemical irritants (including gastric reflux/aspiration, smoke
inhalation), and radiation therapy.
 Pneumonia is a common illness which occurs in all age
groups, and is a leading cause of death among the elderly and
people who are chronically and terminally ill. Vaccines to
prevent certain types of pneumonia are available. The
prognosis depends on the type of pneumonia, the appropriate
treatment, any complications, and the person's underlying
health.
Pneumonia may be community acquired (including
during the first 2 days of hospitalization) or nosocomial (hospital
acquired occurring 48 hours or longer after admission). Viral
pneumonia accounts for approximately half of all cases of
community acquired pneumonia with common causative
organisms including respiratory syncytial virus (RSV) and
influenza. Bacterial pneumonias are divided into typical and
atypical types. Gram – positive Streptococcus pneumoniae,
Haemophilus and Staphylococcus are the most common
bacterial causes. The most common causes of fungal
pneumoniae are Histoplasma capsulatum, and Coccidioides
immitis. Pneumocystis carinii and cytomegalovirus often occur
in immunocompromised persons. Nosocomial pneumonias are
often caused by different pathogens, including Staphylococcus
aureus and Klebseilla. Other atypical pneumonias can be
caused by Mycoplasma, Mycobacterium tuberculosis, Coxeilla
burnetii, Chlamydia, Legionella, and others.
Pneumonia varies in the signs and symptoms defending
on the organisms and patient’s underlying disease. Usually, a
sudden onset of shaking, chills and rapidly rising fever, and
plouritic chest pain that is aggreviated by deep breathing and
coughing. The patient is severely ill, with marked tachypnea
accompanied by other signs of respiratory distress like
shortness of breath and use of accessory muscles in
respirations. The pulse is rapid and bounding. Others exhibit
upper respiratory tract infections. Diagnostic tools include x-rays
and examination of the sputum. Treatment depends on the
cause of pneumonia; bacterial pneumonia is treated with
antibiotics.
 In the Philippines, pneumonococcal disease and its
manifestations, which includes pneumonia, is a significant
health threat particularly for young children and elderly. In 2007,
pneumonia was recorded as the number one most common
cause of death in children in the Philippines. Internationally,
24,000 children per day are affected by pneumonia, and almost
10 million cases in children a year. Also in year 2007, the case
of Pneumonia here in Batangas accounts to as 9400 who
suspected to have this kind of disease with the rate of 620.16
with the population of 100,000. In addition to this, it is monitored
that 565 are died because of Pneumonia with the rate of 37.28.

Also important to note that growing incidence of antibiotic

resistance as an increase concern, complicates treatment
options for patients.
 Meanwhile, this study is chosen due to various reasons.
This study wouldn’t be chosen without its significance.
Pneumonia, a disease entity, is a common cause of morbidity
and mortality in the country. Due to increasing prevalence, there
exists the necessity to be knowledgeable of such disease.
Pneumonia having its own complexities, classification,
distinctive signs and symptoms, diagnostic exams, treatment
modalities, and prevention measures, is not a disease to be
taken for granted. It has been chosen also as our case so that
we can understand more the process involved with the case of
PNEUMONIA. The fact that pneumonia is the leading cause of
death among children in the Philippines. It is better for us to be
educated with its causative factors as well as the prevention
and management to decrease the mortality and morbidity of the
patient whenever PNEUMONIA occurs. As student nurses, we
should provide suitable nursing plans for patients with this kind
of disease.
 OBJECTIVES
General Objective:

Upon the completion of this case study, we aim to

acquire knowledge, skills and right attitude in the care of an
individual with PNEUMONIA – facts about its nature that will
enhance our comprehension that is very imperative to
provide a good nursing management to our client.
Specific Objective
At the end of the study, the student nurses will be able to:

1.Introduce and understand PNEUMONIA; its description and

definition.

2.Unfold and analyze the patient’s profile, past medical history,

as well as the family history, personal history, social history,
psychological history and the patient’s history of present illness
for further understanding his condition.
3. Assess the patient using Inspection, Palpation, Percussion
and Auscultation method that may help in determining the
clinical manifestation presented by the disease.

4. Identify, interpret and analyze the laboratory and diagnostic

examination and its significant findings to justify the presence
of the disease.
5. Identify and enumerate the anatomical part of the body that
is involved and affected by the disease and its respective
functions.

6. Explain and identify the causes and predisposing factors

that contribute to the development of the disease.

7. Formulate and apply Nursing Care Plan for better delivery

of care based on the client’s needs and concerns.
8. Determine the drugs that were administered to the patient
and analyze its relevance in the treatment of the disease.

9. Note changes in the condition of the patient and the degree

of development of his condition

10. Discuss with the patient the discharge planning.

 PATIENT’S PROFILE
NAME: Baby X
AGE: 5 months old
SEX: Male
DATE OF BIRTH: September 16, 2008
CIVIL STATUS: Child
FATHER’S OCCUPATION: Tricycle driver
MOTHER’S OCCUPATION: Laundry woman
ADDRESS: Sinisian West Lemery, Batangas
NATIONALITY: Filipino
RELIGION: Roman Catholic
DATE OF ADMITTED: February 8, 2008
TIME ADMITTED: 12:40 pm
DATE DISCHARGED: Febrbuary 19, 2009
TIME DISCHARGED: 9:50 am
ATTENDING PHYSICIANS: Dr. Macalindong
CHIEF COMPLAINT: cough associated with seizure disorder
ADMITTING DIAGNOSIS: Pneumonia
FINAL DIAGNOSIS: Pneumonia
 CLINICAL APPRAISAL
Past Health History
Baby X, a 5 month old baby boy, has been hospitalized for
the first time in Batangas Regional Hospital. He was first
hospitalized in Our Lady of Caysasay Medical Center. She didn’t
complete yet his childhood immunization due to his age. He
already have 1 BCG, 2 DPT, 2 OPV and 2 Hepa B vaccinations.
His common illnesses are cough, fever and convulsion. Mrs. G,
mother of Baby X, mentioned that Baby X doesn’t have any
allergies. Baby X did not take any medication, over – the – counter
drugs nor prescribed, not until his confinement to the hospital.
Family History
Baby X is the only child of Mr. and Mrs. G. Her mother is
Mrs. G., a 20 year old, and her father is Mr. G., a 20 year old who
smokes and drinks alcoholic beverages occasionally. Her father, as
the head of the family, is the one who provides for the financial
needs of the family while her mother is a plain housewife who also
attends to their needs. Mr. G stated that he and his brother are
smokers and sometimes they smoke inside the house. Their family
and other relatives are in good mental condition. They have no
known family history of cancer, hypertension, tuberculosis and
diabetes mellitus. They only have history of asthma, heart disease
and epilepsy.
Personal history

Because of his age, Baby X spends most of the time

sleeping and lying in bed or in her mother’s lap or arm. He
usually sleeps 15 – 18 hours a day. Her mother always
breastfeeds Baby X every 2 – 3 hours or when Baby X
expresses hunger through crying. When he is 4 months of
age, his mother introduce in his diet rice, vegetables and
fruits.
Social History
Baby X, together with her mother and father, lives with their
extended family at her grandmother’s house. Their house is in the farm and it
is made with cement but mostly wood. Their house is located near an open
drainage. Baby X belongs to a lower class family. His father earns money by
working part time job in a construction site or driving with other’s tricycle. His
mother accepts laundries.
According to Mrs. G, Mr. G’s monthly income is Php 2,000 which is
not enough to meet their daily needs. They live in a community where health
programs and services are implemented and are very accessible. Mrs. G
brings her son in their Community Health Center for consultation and when
there is a health problem. And his mother added that, their family is a typical
Filipino family who had different cultural beliefs in regarding their way of living.
They believe in the negative power like bad karmas and those unseen things
in this world that could hurt and cure them.
Psychological History
Baby X communicates in expressing hunger and irritability
through crying. He also expresses difficulty of breathing
through a facial grimace. Whenever he’s crying, her mother
taps lightly in her back which makes her feel relaxed and
comfortable. The noise around the environment and the
people around her add up to her stressor.
History of Present Illness
History of present illness started 5 days prior to admission
when patient noted to have undocumented fever assisted with
cough and colds. Patient was self medicated by his relatives with
Paracetamol 0.6 ml q4.
4 days prior to admission, patient still with fever and cough.
No other signs and symptoms noted. Patient again was given
Paracetamol.
3 days prior to admission, patient still with fever but this time
assisted with chills. Patient then was brought to Our Lady of
Caysasay Medical Center last February 5, 2009 where CBC was
done and revealed thrombocytopenia. Patient was then admitted
and managed as a case of Dengue Hemorrhagic Fever grade II.
Medications were given such as Cefuroxime, Paracetamol and
Amikacin. Repeat CBC was done to Baby X and revealed again
thrombocytopenia. Fresh frozen plasma was transfused to Baby X
with a level of 100 cc but it was not totally consumed then after 4
hours, PRBC was now transfused to Baby X with a level of 80 cc.
these blood transfusions were done last February 6, 2009. Until 1
day prior to admission, patient noted to seizures as upward rolling
of the eyeball and shaking of his extremities which lasted for 5
minutes.
On the day of his admission ate Bataangas Regional Hospital,
patient was again noted to have recurrence of seizure. The doctor
advised the relatives of Baby X for CT scan. Patient was then admit
for neuro – evaluations and management then was transferred to
BRH. Upon assessment, Baby X’s vital signs are BP – 90/60
mmHg, T – 37.4 o C, HR – 160 beats per minute and RR – 67
breaths per minute. Their initial intervention is to administer
oxygen administered at 2 – 3 Liters per minute to aid his
breathing. The resident on duty notified the attending
physician, Dr. Macalindong, and made the admitting diagnosis
which is Pneumonia to consider CNS infection probably
bacterial meningitis
 PHYSICAL
ASSESSMENT
 February 16, 2009
7:40 pm

GENERAL APPEARANCE

Baby X looked pale, weak in appearance, febrile with

ongoing D5IMB IV fluid in his left hand regulated at 34 – 35
gtts per minute, was sleeping, lying in bed and experiencing
difficulty of breathing when I met her. He shows facial
grimace and uses accessory muscle when breathing.

For his psychological presence, I noticed that he is

clean and neat.
VITAL SIGNS
Temperature - 38.3 oC
Heart rate - 190 beats per minute
Respiratory rate - 58 breaths per minute

ANTHROPOMETRIC MEASUREMENTS
Head Circumference – 44.5 cm
Chest Circumference – 44.5 cm
Abdominal Circumference – 42.5 cm
Length – 66 cm
Weight – 3.2 kg
BODY PART METHOD FINDINGS ANALYSIS
Skin
General Inspection  No lesions Normal
Appearance
Color Inspection  Pale Abnormal. Due to
decreased hemoglobin
level - 103.2 g/dL.

Texture Palpation  Hot to touch with temperature Abnormal. Elevated

of 38.3 oC body temperature
above normal range
indicates infection.
Edema Palpation  No edema; skin rebounds and Normal
does not remain indented
when pressure is released.
 No tenderness

Turgor Palpation  With good skin turgor; pinches Normal

easily and immediately returns
to its original position
 Head
General Inspection  Head is still and Normal
Appearance upright and without
lesions.
 Rounded
 Symmetrical
Fontanelle Palpation  Not yet fully close
Diamond – Normal
shaped anterior
fontanelle
Triangular Palpation
posterior Closed already Normal
fontanelle

Hair Inspection  Evenly distributed Normal

 No infestation.
Palpation  Silky and strong. Normal
 Resilient
Scalp Inspection  Smooth and without Normal
lesion
Palpation  Absence of
masses. Normal
 Not tender
 No seborrhea
 Face
General Inspection  Round Normal
Appearance  Facial features
and facial
movements
are
symmetrical

 Cyanotic Abnormal. Due to

inability of the
lungs to maintain
adequate
oxygenation of
blood.
Facial Palpation  Normal facial Normal
Muscles muscle tone
 Eyes
Eyebrows Inspection  Hair evenly
distributed. Normal
 Not meet at midline.
 Symmetrically
aligned
 Equal movement

Eyelashes Inspection  Equally distributed, Normal

curled slightly
outward.
Sclera Inspection  With normal color Normal
Pupil Inspection  PERRLA Normal
 Upward rolling Abnormal. Due to his
seizure attack.
Eyelids Inspection  No abnormal
discharges Normal
 Lids close
symmetrically
Conjunctiva Inspection  Pale palpebral Abnormal. Due to
conjunctiva inability of the lungs to
maintain adequate
oxygenation of blood.
 Ears
General Inspection  No lesions Normal
Appearance  Color is the
same as the
face
Auricles Inspection  Symmetrically Normal
aligned
Palpation  Firm Normal
 Not tender
Pinna Palpation  It recoils after it Normal
is being folded
External Ear Inspection  No abnormal Normal
Canal discharges
 Dry cerumen
(Grayish – tan)
 Nose
External Inspection  Symmetrically
Nose aligned Normal
 No discharge
 Nasal flaring Abnormal. It is
seen with the
labored
respirations and it
indicates hypoxia.
Nasal Cavity Palpation  No tenderness Normal

Sinus Palpation  No tenderness Normal

 Mouth
Muscle Tone Inspection  Able to open mouth Normal

Speech Inspection  Still can’t able to Normal. Because of his age.

speak

Lips Inspection  Dry Abnormal. This is due to

inadequate fluid intake.
 Bluish in color Abnormal. Due to inability of
the lungs to maintain
adequate oxygenation of
blood.
 Without lesions or Normal
swelling
Teeth Inspection  Absence of upper and Normal. Because of his
lower teeth. young age.
Tongue Inspection  Pink in color and normal
moist
 Moves freely
 At midline
 No lesion

Gums Inspection  Pink in color Normal

Uvula Inspection  Positioned at midline Normal
 Hangs freely
 Neck
General Inspection  Symmetrically Normal
Appearance aligned with
head centered

Muscles Inspection  Equal in size Normal

Lymph Palpation  No Normal

Nodes enlargement.

Thyroid Palpation  No Normal

Gland enlargement.

Trachea Palpation  Centered Normal

placement in
midline of
neck.
 Posterior Thorax
Shoulder Inspection  Symmetrical Normal.
and Back
Anterior Thorax
Chest and Inspection  Tachypneic with RR =58 Abnormal. Frequently present in
Lungs breaths per minute hypermetabolic and hypoxic states. By
increase respiratory rate the body id
trying to supply additional oxygen to meet
the body’s demand
 Non – productive cough Abnormal. Continuous coughs are
usually associated with acute infections.
 Use of accessory muscles Abnormal. Sternum or shoulder muscles
when breathing. are used to facilitate inspiration in case of
pneumonia.
 Difficulty of breathing Abnormal. Gradual onset of dyspnea is
usually indicative of lung changes such as
pneumonia, whereas sudden onset is
associated with bacterial infections.
Palpation  No tenderness is palpated
over the lung area with
respirations Normal
 No unusual surface masses
or lesions are palpated

Auscultation  Crackles heard upon Abnormal. Any condition where air

auscultation hunger exists has the potential to create
audible and noisy breathing. The body is
attempting to meet its oxygen demands.
Heart Inspection  No lift or heave. Normal

Auscultation  Within normal Abnormal. Due to

rate HR= 190 difficulty of breathing,
beats per minute heart is needed to
pump blood rapidly to
compensate the
oxygen requirements of
tissue and organs.
 No murmurs Normal
heard

Breast Inspection  Breast even with

the chest wall Normal
 Uniform in color
 No discharge
Palpation  No tenderness, Normal
masses or
nodules
Axillae Inspection  Not hairy Normal.
 Abdomen
General Inspection  Uniform in Normal
Appearance color
 Flat rounded
Bowel Auscultation  Active bowel Normal
Sounds sounds
Abdomen / Percussion  Presence of Abnormal.
Internal colic was Common in babies,
Structure noted upon due to wind in the
percussion. intestine
associated with
feeding difficulties.

Palpation  Soft and not Normal

tender
 Right and Left Upper Extremity
Muscles Inspection &  Firm Normal
Palpation  in size
Strength Testing or  Able to grip Normal
Inspection
Hands (Left Inspection  Presence of IV Abnormal. Fluids
Hand) - D5IMB IV are regulated to
fluid regulated replace losses.
at 34 – 35 gtts
per minute,
 Finger
Nails Inspection  Convex curvature Normal
 Dirty, long nails Abnormal. Fingernails
seen are result from poor
hygiene practices.
Palpation  Hard and immobile
 Smooth and firm
 Nail plate is Normal
attached to the nail
bed.

Color Inspection  Bluish color Abnormal. Due to

inability of the lungs to
maintain adequate
oxygenation of blood.
Capillary Refill Inspection &  Prolonged capillary Abnormal. Due to
Palpation refill; Capillary refill inability of the lungs to
is 4 seconds; pink maintain adequate
tone returns slowly oxygenation of blood.
to blanch nail beds
when pressure is
released.
 Right and Left Lower Extremity

Muscles Inspection  Firm Normal

& Palpation  in size

Strength Inspection /  Able to move Normal

Testing

Circulation Palpation  With distal Normal

pulse
 Genitalia
Penis and Urinary Inspection  No lesions
Meatus  Foreskin is retractable Normal
 Urinary meatus is at
tip of glans penis and
has no discharge and
redness

Scrotum and Inspection  Free of lesions Normal

Testes
Palpation  Testes are palpable in
scrotum with the left Normal
testicle usually lower
than the right
 Testes are mobile and
smooth
Inguinal Area Inspection and  No inguinal hernias
Palpation are present Normal

Anus and Rectum

Anus Inspection  Anal opening is visible
 Perianal skin is Normal
smooth and free of
lesions
 Neurologic System
Protective Inspection/  Positive blink reflex
Reflexes testing  Positive Gag reflex Normal

Feeding Reflex Inspection/  Negative rooting reflex Normal. Rooting reflex

Testing disappears by 3 to 4 months.

 Positive sucking reflex

 Positive swallow reflex
Normal
Muscle Tone Inspection/  Negative Moro reflex
reflexes Testing  Positive tonic neck reflex
 Positive Palmar grasp Normal
reflex
 Positive Plantar grasp

Distress Inspection  Seizure activity Abnormal. Because it is

occurring 30 minutes caused by abnormal activity
in brain cells, seizures can
affect any process your brain
coordinates.
SUMMARY OF PHYSICAL ASSESSMENT
Baby X, the subject of the study, is diagnosed with Pneumonia Physical
Appearance of the patient was assessed through inspection, palpation, percussion
and auscultation. This will serve as a baseline guide to recognize the signs and
symptoms of the disease. There were abnormalities found on him.

Upon admission Baby X’s Vital Signs was not stable, he had fever that
indicates infection, and he was tachypneic and tachycardic. Tachypneic is
frequently present in hypermetabolic and hypoxic states. By increase respiratory
rate the body is trying to supply additional oxygen to meet the body’s demand.
Tachycardic is due to difficulty of breathing, heart is needed to pump blood rapidly
to compensate the oxygen requirements of tissue and organs.

Pale skin was seen to Baby X which is due to decreased hemoglobin

level - 103.2 g/dL. Cyanotic face was also seen. This is due to inability of the lungs
to maintain adequate oxygenation of blood. We seen that his eyes is rolling
upward and this is due to his seizure attack. Pale palpebral conjunctiva was pale
also. This is due to inability of the lungs to maintain adequate oxygenation of
blood.
Nasal flaring was noted. It is seen with the labored respirations and it
indicates hypoxia. Upon inspecting the lips of Baby X, I noticed that her lips were
dry and bluish in color. Dry lips indicate mouth breathing and dehydration. Bluish
discoloration of the lips is due to inability of the lungs to maintain adequate
oxygenation of blood. The face was also cyanotic and it is also due to inability of
the lungs to maintain adequate oxygenation of blood.

Use of accessory muscles when breathing was also noticed. Sternum or

shoulder muscles are used to facilitate inspiration in case of pneumonia. Non -
productive cough noted and is often associated with acute infections. Difficulty of
breathing was seen. Gradual onset of dyspnea is usually indicative of lung
changes such as pneumonia, whereas sudden onset is associated with bacterial
infections.

Crackles were heard on lung fields because there is sudden opening of

small airways that contain fluid. Any condition where air hunger exists has the
potential to create audible and noisy breathing. The body is attempting to meet its
oxygen demands.

Colic was noted upon percussion of Baby X’s abdomen. This is an

abnormal finding because colic are common in babies, due to wind in the intestine
associated with feeding difficulties.Presence of D5 0.3 NaCl regulated at 30 mcgtts
per minute was also noted to replace losses.

Lastly, upon observing of the nail bed, it was pale and this is due to
inability of the lungs to maintain adequate oxygenation of blood.
 DIAGNOSTIC
AND
LABORATORY RESULTS
 SUMMARY OF DIAGNOSTIC
AND LABORATORY RESULTS
(Results in Our Lady of Caysasay Medical Center)
February 5, 2009 at exactly 9:47 in the morning, laboratory exam for the
hematology was released. We found some abnormalities in the result. The white blood cells
and neutrophil levels were increased which indicates viral infections; lymphocyte level was
increased which indicates viral infections; monocyte was also decreased which may indicate
that Baby X is suffering from aplastic anemia; eosinophil level was decreased too which may
indicate that Baby X is in stress; RBC was decreased which indicates anemia; hematocrit and
hemoglobin levels were decreased which may indicate that Baby X is suffering from anemia;
MCV was decreased which may indicate iron – deficiency anemia and thalassemia; MCH
level which may indicate possible hypo chromic anemia; and platelet count which may
indicate anemia.

February 5, 2009 11:58 pm, laboratory exam for the hematology was again
released. We found some abnormalities again in the result. The white blood cells level was
increased which indicates viral infections; lymphocyte level was increased which indicates
viral infections; eosinophil level was decreased too which may indicate that Baby X is in
stress; RBC was decreased which indicates anemia; hematocrit and hemoglobin levels were
decreased which may indicate that Baby X is suffering from anemia; MCV was decreased
which may indicate iron – deficiency anemia and thalassemia; MCH level which may indicate
possible hypo chromic anemia; and platelet count which may indicate anemia.
 February 5, 2009 8:26 am, laboratory exam for the
hematology was again released. We found some
abnormalities again in the result. The white blood cells level
was increased which indicates viral infections; RBC was
decreased which indicates anemia; hematocrit and
hemoglobin levels were decreased which may indicate that
Baby X is suffering from anemia; MCV was decreased which
may indicate iron – deficiency anemia and thalassemia; MCH
level which may indicate possible hypo chromic anemia; and
platelet count which may indicate anemia.

Chest X – ray was also done to Baby X last February 7,

2009 7:53 pm and it reveals that Baby X there is hazy filtrates
noted on the left lower lobe of his lung.

Other findings were all normal.

(Results in Batangas Regional Hospital)

February 8, 2009, laboratory exam for the hematology was released. We

found some abnormalities in the result. The erythrocyte, hemoglobin and
hematocrit level were all decreased which indicate that Baby X is suffering from
anemia; leukocyte and neutrophil levels were increased which indicates viral
infections; lymphocyte was decreased which may indicate that Baby X is suffering
from aplastic anemia; MCH level which may indicate possible hypo chromic
anemia; and MCV was decreased which may indicate iron – deficiency anemia and
thalassemia.

Blood chemistry was also done to Baby X on the same day, February 8,
2009. It revealed that glucose level was elevated which indicates renal failure and
the sodium level was decreased which indicates low sodium intake.

February 9, 2009 7:15 am, hematology was done to Baby X. The

erythrocyte, hemoglobin and hematocrit level were all decreased which indicate
that Baby X is suffering from anemia; leukocyte was increased which indicates viral
infections; lymphocyte was decreased which may indicate that Baby X is suffering
from aplastic anemia; MCH level which may indicate possible hypo chromic
anemia; MCV was decreased which may indicate iron – deficiency anemia and
thalassemia; and RDW was also elevated which indicates that Baby X is suffering
from iron - deficiency anemia.
 At 5:45 pm on the same day, February 9, 2009, hematology
was again done to Baby X. The erythrocyte, hemoglobin and
hematocrit level were all decreased which indicate that Baby X is
suffering from anemia; leukocyte was increased which indicates
viral infections; monocyte was decreased which indicates viral
diseases; MCH level which may indicate possible hypo chromic
anemia; MCV was decreased which may indicate iron – deficiency
anemia and thalassemia; and RDW was elevated which indicates
that Baby X is suffering from iron - deficiency anemia.

February 10 and 11, 2009, hematology was once again

done to Baby X. and it revealed that the erythrocyte, hemoglobin
and hematocrit level were all decreased which indicate that Baby X
is suffering from anemia; leukocyte level was increased which
indicates viral infections; lymphocyte was decreased which may
indicate that Baby X is suffering from aplastic anemia; MCH level
which may indicate possible hypo chromic anemia; and MCV was
decreased which may indicate iron – deficiency anemia and
thalassemia.
 February 10, 2009, blood chemistry was again done to Baby
X. It revealed that the BUN level was decreased which may indicate
a possible malnutrition and dehydration.
February 12, 2009, blood chemistry was again done to Baby X and
it revealed that the sodium level was decreased which indicates low
sodium intake.

February 13 and 14, 2009, hematology was again done to

Baby X. The erythrocyte, hemoglobin and hematocrit level were all
decreased which indicate that Baby X is suffering from anemia;
leukocyte level was increased which indicates viral infections;
monocytes was decreased which indicates viral diseases; and RDW
was elevated which indicates that Baby X is suffering from iron -
deficiency anemia.

Chest X – ray was also done to Baby X last February 8,

2009 and it reveals that Baby X there is hazy filtrates noted on the
left lower lobe of his lung.

Other findings were all normal.

 ANATOMY
AND
PHYSIOLOGY
 This chart of the respiratory system shows the apparatus for breathing.
Breathing is the process by which oxygen from the air is brought into the lungs and
circulated throughout the body in the blood. At the same time, the blood gives up
waste matter, also called carbon dioxide, which is transported out of the lungs as we
breathe out.
NORMAL CHEST X – RAY
PNEUMONIA
 The Respiratory System

Why do you need to breathe? All of the cells in the body require oxygen.
Without it, they couldn't move, build, reproduce, and turn food into energy. Your
body gets oxygen from breathing in air which circulates to all parts of the body.

Nasal cavity (nose): the preferred entrance for outside air into the respiratory
system
Oral cavity (mouth): air also enters the body here
Adenoids: lymph tissue at the top of the throat that helps resist body infection
Tonsils: lymph nodes in the wall of the pharynx that are often removed when
infected
Pharynx (throat): catches incoming air from the nose and passes it downward to
the windpipe
Epiglottis: a flap of tissue that guards the entrance to the trachea
Larynx (voice box): contains the vocal cords
Esophagus: the passage leading form the mouth and throat to the stomach
Trachea (windpipe): the passage leading from the pharynx to the lungs
Ribs: bones supporting and protecting the chest cavity

Bronchi (tubes): trachea divides into these two main tubes, one
for each lung

Cilia: the bronchial tubes are lined with these very small hairs that
have a wave- like motion

Mucus: the movement of the cilia carries mucus upward into the
throat where it is coughed up or swallowed

Diaphragm: wall of muscle that separates the chest cavity from the
abdominal cavity

Alveoli: small sacs where air goes when breathed in

Capillaries: blood vessels

Pulmonary Artery / Vein: blood is carried to the capillaries by the

pulmonary artery and taken away by the pulmonary vein
pathophysiology
 Non - Modifiable Factors Modifiable Factors

GENDER: MALE
INCOMPLETE IMMUNIZATION

AGE: 5 months OLD

AT VERY YOUNG AGE, THE PATIENT IS PRONE FOR
HAVING BPN BECAUSE OF LUNG IMMATURITY. EXPOSURE TO SECOND HAND SMOKE

INDEMENT WEATHER CONDITION

ENVIRONMENT
LOWER CLASS

Previous illness: ASPIRATION/ INSPIRATION OF ALTERED LUNG DEFENSE MECHANISM

DHF II PATHOGENIC AGENT

EASY ACCESS OF
MICROORGANISMS THAT MAY INFECTION OCCURS IN BOTH LUNGS
CAUSE INFECTION SUCH AS:
>STAPHYLOSCOCCUS AUREUS AND
KLEBSIELLA LUNG MUCOSA BECOMES SWOLLEN WITH
INCREASE MUCUS SECRETION

BRONCHIOLES ARE PLUGGED

ALVEOLI ARE BLOCKED WITH AIR

PATCHY CONSOLIDATION OF PERIBRONCHIAL LUNG TISSUE

FACIAL PALLOR TACHYCARDIC DIFFICULTY NON – PRODUCTIVE

FEVER NASAL FLARRING
OF COUGH
BREATHING
ERIPHERAL CYANOSIS USE OF ACCESSORY CRACKLES SOUND
TACHYPNEIC MUSCLE
HEARD

PNEUMONIA
 SUMMARY OF PATHOPHYSIOLOGY

Incomplete immunization and exposure to second hand

smoke is under the modifiable factor that altered the lung defense
mechanism of the patient. The patient is 5 months old and is prone to
have Pneumonia because of lung immaturity, indement weather
condition and also because of poverty and previous illness which is
DHF II are in non-modifiable factor that allows an easy access of
microorganisms which may cause the infection. Aspiration or
inspiration of pathogenic agent such as STAPHYLOSCOCCUS
AUREUS and KLEBSIELLA, and infection occurs in both lungs that
causes fever of the patient. Lung mucosa is being swollen with
increase mucous secretion. Bronchioles are then plugged with
secretions. Alveoli are blocked with air and then patchy consolidation
of peribronchial lung tissue occurs. The client experiences facial
pallor that causes peripheral cyanosis, nasal flaring with the use of
accessory muscles, tachyycardic, tachypneic, difficulty of breathing
and crackles are heard in the lung fields.
NURSING CARE
PROCESS
 ASSESSMENT NURSING SCIENTIFIC PLANNING
DIAGNOSIS EXPLANATION

Subjective cue: Ineffective airway The inflammatory After 2 hours of

“ Inuubo pa rin siya” clearance related response to infection nursing
as verbalized by the
mother . to ineffective coughcauses tissue edema and interventions, the
Objective cues: and retained exudates formation in the client will be able
> Use of accessory secretions. lungs, the inflammatory to demonstrate
muscles when breathing response can narrow and behaviors to
>crackles heard in left potentially obstruct achieve airway
lower lobe of the lungs
upon auscultation bronchial passages and clearance.
>non – productive cough alveoli. (Medical-
>cyanotic lips Surgical Nursing
>dyspneic Critical Thinking for
>tachypneic- 58 breaths collaborative care,
per minute
vol.1,5th edition,
>nasal flaring
Ignatius, et.al, page
2390)
 INTERVENTION RATIONALE

>Assessed respiratory >Use of accessory muscles to breathe indicates an abnormal

movements and use of increase in work of breathing. (Nursing Care Plan, 6th edition,
accessory muscles. Gulanick/Myers pg. 480)

>Monitored vital signs >To obtain baseline data. (Pediatric Nursing Care Plans, 3rd
especially the RR. edition,Karla L. Luxner,RNC,ND,pg. 67)

>Auscutated the lung sounds, >Bronchial lung sounds are commonly heard over areas of lung
noting areas of decreased density or consolidation. Crackles are heard when fluid is present.
ventilation and presence of (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 480)
adventitious sounds.

>Evaluated Baby X’s cough

and swallowing ability. >To determine ability to protect own airway. (Pediatric Nursing
Care Plans, 3rd edition,Karla L. Luxner,RNC,ND,pg. 67)
 INTERVENTION RATIONALE

>Monitored chest x – ray >These determine progression of disease process. (Nursing Care
reports. Plan, 6th edition, Gulanick/Myers pg. 480)

>Advised the mother to >Hydration helps decrease the viscosity of secretions, facilitating
breastfeed Baby X every 2 – expectorations. (Pediatric Nursing Care Plans, 3rd edition,Karla
3 hours. L. Luxner,RNC,ND,pg. 67)

>Advised the mother that > Positioning facilitates chest expansion and respiratory efficiency by
after each feeding, elevate reducing pressure of abdominal organs on diaphragm. (Pediatric
the head of bed at least 30 Nursing Care Plans, 3rd edition,Karla L. Luxner,RNC,ND,pg. 68)
degrees.
>Chest physiotherapy helps to aid immobilization of secretions.
>Back tapping performed (Nursing Care Plan,7th edition, Doenges, et.a pg 108l)
after each nebulization.
 INTERVENTION RATIONALE

>Instructed the client to have>Discharges from the nebulizer are often foul tasting and smelling.
oral care after each (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 480)
nebulization.

>Administered antibiotic at >Facilitates liquefaction and removal of secretions. This antibiotic

correct time intervals.
inhibits cell wall synthesis during bacterial multiplication.(Nursing
Ciprofloxacin 100 mg OD
Care Plan,7th edition, Doenges, et.al pg 108)

>Fluids are regulated to replace losses and aid immobilization

>Provided
secretions.(Nursing Care Plan,7th edition, Doenges, et.a pg 108l)
supplemental fluids
-IV- D5 0.3 NaCl 500cc
regulated at 30 mcgtts per
minute a per doctor’s order.
 INTERVENTION RATIONALE EVALUATION

>Administered > Relaxes bronchioles by

medication as The client
indicated. acting on beta – adrenergic demonstrated
patent airway as
- Salbutamol receptors.(MIMS 7th
evidenced with
sulfate – edition 2006 pg 78) breath sounds
brochodilator as clearing, absence
per doctor’s order of dyspnea and
cyanosis,
decreased RR
with 48 breaths
per minute and
decreased
adventitious
breath sounds.
 ASSESSMENT NURSING SCIENTIFIC PLANNING
DIAGNOSIS EXPLANATION

Subjective cues: Elevated body Invasion of infectious After 30

temperature agent (Virus) triggers minutes of
“Nilalagnat na naman siya.” above normal nursing
the immune system to
related to sent neutrophil and kill interventions,
respiratory tract offending organism the client will
Objective Cues: infection. be able to
through inflammatory
>Hyperthermic-38.3ºC response that leads to decrease body
>Tachycardic- 190 beats per minute elevation of body temperature.
>Tachypneic- 58 breaths per minute temperature.
>hot to touch (Medical-Surgical
Nursing
>Flushed cheeks Pathophysiological
>result of CXR, basal pneumonia, left Concept, pge 496)
>nasal flaring
>irritability
>with ongoing IV fluid D5IMB regulated
at 34 – 35 gtts per minute
 INTERVENTION RATIONALE

Determined precipitating factors. Identification and management of underlying cause are essential
to recovery. (Nursing Care Plan, 6th edition, Gulanick/Myers
pg. 105)

Obtained age and weight.

Extremes of age and weight increase the risk for inability to
control body temperature. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 105)

Monitored axillary temperature. Provide information about the effectiveness of care. (Pediatric
Nursing Care Plans, 3rd edition,Karla L. Luxner,RNC,ND,pg.
453)

Monitored environment temperature; Room temp or every number of blankets should be altered to
limit / add bed linens as indicated. maintain near normal body temperature. (Pediatric Nursing Care
Plans, 3rd edition,Karla L. Luxner,RNC,ND,pg. 453)

Provided Tepid Sponge Baths, avoid use May reduce fever. (Pediatric Nursing Care Plans, 3rd
of alcohol. edition,Karla L. Luxner,RNC,ND,pg. 453)

Removed extra clothing and covered the Helps reduce skin temperature. (Pediatric Nursing Care Plans,
child may have on after the antipyeretic 3rd edition,Karla L. Luxner,RNC,ND,pg. 453)
has taken effect.
 INTERVENTION
Taught the mother about possible side effects Information helps prevent adverse effects from
of anti-pyretic medicine
Provided the mother with instructions about
management of childhood fever.
Discussed to the mother the precipitating
factors and preventive measures, including
maintenance of adequate fluid intake, change in
environment, taking medications as prescribed.
Provided supplemental fluids -IV - D5IMB IV
fluid regulated at 34 – 35 gtts per minute,as per associated with dehydration. (Pediatric Nursing
doctor’s order.
Administered antipyeretic medicine as ordered
-Paracetamol 100 mL TID.
RATIONALE
medicine. (Pediatric Nursing Care Plans, 3rd
edition,Karla L. Luxner,RNC,ND,pg. 454)
Empowers parents to care for their child. (Pediatric
Nursing Care Plans, 3rd edition,Karla L.
Luxner,RNC,ND,pg. 454)
Families need to learn how to prevent future
episodes of hyperthermia. (Nursing Care Plan, 6th
edition, Gulanick/Myers pg. 106)
Additional fluids help prevent elevated temperature
Care Plans, 3rd edition,Karla L.
Luxner,RNC,ND,pg.454)
Decreases fever by inhibiting effects/ heat
regulating centers and by hypothalamic action
leading to sweating & vasodilation. ( Pediatric
Nursing Care Plans, 3rd edition,Karla L.
Luxner,RNC,ND,pg. 454)
 EVALUATION

The client’s
temperature
decreased as
evidenced by :
temperature =36.4
ºC
warm to touch
 ASSESSMENT NURSING SCIENTIFIC
DIAGNOSIS EXPLANATION

Objective cues: Impaired gas In pneumonia,

exchange oxygen is the gas
> Use of accessory muscles related to
when breathing exchange affected
alveolar most; therefore,
>crackles on lower lobe of the capillary hypoxemia is the
lungs membrane primary problem.
>non – productive cough changes. Carbon dioxide
>tachypneic- 58 breath per retention is common
minute in pneumonia.
>mouth breather (Medical-Surgical
Nursing
>cyanosis in lips and nail bed Pathophysiological
>nasal flaring Concept, pge 496)
>dyspnea
>result of CXR, Pneumonia in
inner lung zone
>restlessness
 PLANNING

After 2 hours of
nursing interventions,
the client will
demonstrate improve
ventilation & oxygen
tissues & absence of
symptoms of
respiratory distress.
 •INTERVENTION
 Assessed respiratory rate, depth &
ease.
 Monitored heart rate.
 Monitored body temperature as
indicated. Assisted the comfort
measures to reduce fever & chills;
addition or removal of bedcovers,
comfortable room temp.
 Observed color of the skin & nail bed, vasoconstriction or the body’s response to fever
noting presence of peripheral cyanosis with chills; however, cyanosis of skin membranes
with central cyanosis.
 Maintained bed rest.
•RATIONALE
Manifestations of respiratory distress are
dependent on inactive of the degree of the lung
involvements in underlying general health status.
(Pediatric Nursing Care Plan, Axton, et. Al, pg.
296)
Tachycardia is usually present as a result of fever
dehydration but may represent a response to
hypoxemia. (Pediatric Nursing Care Plan, Axton,
et. Al, pg. 296)
A fever as early increase metabolic demands &
oxygen consumption & alters cellular oxygenation.
(Pediatric Nursing Care Plan, Axton, et. Al, pg.
297)
Cyanosis of nail beds may represent
around the mouth is indicative of systemic
hypoxemia. (Pediatric Nursing Care Plan, Axton,
et. Al, pg. 297)
Prevents over exhausting & reduces oxygen
consumption demands to facilitate resolution of
infection. (Pediatric Nursing Care Plan, Axton, et.
Al, pg. 297)
 INTERVENTION
 Elevated heads and
encouraged frequent position
changes.
RATIONALE
These measures promote maximal
inspiration; enhance expectorant of
secretions to improve ventilation.
(Pediatric Nursing Care Plan, Axton,
et. Al, pg. 297)

Chest physiotherapy helps to aid

 Back tapping performed after
immobilization of secretions. (Nursing
each nebulization. Care Plan,7th edition, Doenges, et.a
pg 108l)

 Instructed the mother to have Discharges from the nebulizer are often
oral care to her baby after each foul tasting and smelling. (Nursing Care
nebulization. Plan, 6th edition, Gulanick/Myers pg.
480)

 Administered medication as Relaxes bronchioles by acting on beta –

indicated. -Salbutamol sulfate adrenergic receptors.(MIMS 7th edition
-brochodilator 2006 pg 78)
 EVALUATION

The client
demonstrated improved
ventilation and oxygen
tissues and absence of
symptoms of
respiratory distress as
manifested by the
decrease in apical
pulse- 132 beats per
minute and respiratory
rate of 48 breaths per
minute.
DRUG STUDY
 NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION

Generic Name Nonopiod Mild pain HEMATOLOGIC

Paracetamol / Analgesics and : hemolytic
Antipyretics
Acetaminophen or fever anemia,
> Thought to leucopenia
produce analgesia
Brand Name: by blocking pain
HEPATIC:
>Acephen impulses by jaundice
inhibiting synthesis METABOLIC:
of prostaglandin in hypoglycemia
Dosage: the CNS or of other
>100ml substances that SKIN: rash,
sensitize pain urticaria
Route:
receptors to
>Per orem stimulation. The
drug may relieve
Frequency:: fever through
central action in
>TID the hypothalamic
Form:
>Liquid
 CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS

Contraindicated in Use liquid form for May decrease

patients hypersensitive children and glucose and
to drug patients who have hemoglobin levels and
difficulty hematocrit
swallowing.
Use cautiously in
patients with long-term May decrease
alcohol use because In children, don’t neutrophil, WBC, RBC,
therapeutic doses exceed five doses in and platelet counts .
cause hepatotoxicity in 24 hours.
these patients.
K=3.5 – 5 mmol/L
Hgb=12 – 16 g/dL
Hct=0.37 – 0.51
g/dl
WBC=4,500 –
11,000 cubic mm
 NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION

Generic Name: Bronchodilator >To prevent CNS: dizziness,

Salbutamol exercise – weakness
Sulfate >Relaxes induced
bronchial muscles brochospasm. CV: Tachycardia,
Brand Name: by acting on beta
Ventolin – adrenergic >To prevent or GI: nausea,
receptors. treat vomiting.
Dose: bronchospasm in
0.5 cc + patients with RESPIRATIORY:
1.5cc NSS reversible bronchospasm
obstructive airway
Route: disease.
Inhalation

Frequency:
Q8

Form:
Liquid
 CONTRAINDICATION NURSING RESPONSIBILITIES MONITORING
PARAMETERS

>Contraindicated in >Obtain baseline assessment of >May decrease in

patients hypersensitive patient’s respiratory status, and potassium level.
to drug or its assess patient often during therapy. K=3.5 – 5 mol/L
components. >Evaluate the client’s respiratory
status and V/S.
>Use cautiously in >Be alert for adverse reactions and
patient with CV drug interactions.
disorders. >Teach the mother the correct use
of inhalation devices.
>Advise the mother not to use more
doses that ordered.
>Oral care after nebulization.
NAME OF DRUG CLASSIFICATION INDICATION ADVERSE REACTION

Generic Anti- infectives Serious UTI CNS: seizures,

Name: > Third- headache, dizziness,
and lower
>Ceftazidime generation parethesia
respiratory
Brand Name: cephalosporin CV: Phelibitis,
that inhibit cell- tract infection; thrombophebitis
> Ceptaz wall synthesis.
skin; GI: nausea, vomiting,
Dosage: Promoting diarrhea, abdominal
>300 ml osmotic instability gynecologic, cramps
; usually
Route: bactericidal CNS infection. GU: vaginitis
>Through IV Hematologic:
Frequency:: agranulocytosis,
leukopemia, eosinophilia
>q 8 0
SKIN: maculopapular
Form: and erythenayous rahes
>Solution OTHER: anaphylaxis
 CONTRAINDICATION NURSING MONITORING PARAMETERS
RESPONSIBILITIES

Contraindicated in Obtain specimen May increase alkaline

patients hypersensitive to for culture and phosphatase, ALT, AST, bilirubin
drugs or other sensitivity tests and LDH levels. May decrease
cephalosporins. before giving first hemoglobin level.
Use cautiously in dose. Therapy may May increase eosinophil count.
patients hypersensitive to begin while awaiting May decrease granulocyte and
penicillin because of results. WBC counts.
possibility of cross- For I.M. use, inject 
ALT =5 – 28 u/L
sensitivity with other deep into a large
beta- lactam antibiotics muscle, such as the BUN =8.2 – 20 mg/dL
gluteus maximus or Creatinine =0.4 – 0.7 mg/dL
the side of the thigh.
AST =15 – 30 u/L
Bilirubin =0 – 3.4 umol/L
Hgb=12 – 16 g/Dl
WBC=4,500 – 11,000 cubic mm
Eosinophil =0 – 4%
Platelet =150,000 – 4500,000
cubic mm
LDH =60 – 160 mg/dL
 NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Generic Name: Anticonvulsants Anticonvulsant, CNS: drowsiness,
>Phenobarbital febrile seizures lethargy,
Status hangover
Brand Name: As a
barbiuturate,may epilepticus CV: bradycardia,
> Solfoton hypotension,
depress CNS and Sedation
Dosage: increase seizure syncope
Short- term
>30 mg threshold. As a treatment of GI: nausea,
Route: sedative, may insomia. vomiting
interfere with HEMATOLOGIC:
>Per orem transmission of exacerbation of
Frequency:: impulses from porphyria
> HS thalamus to cortex
of brain. RESPIRATORY:
Form: Respiratory
>Tablet depression, apnea
SKIN: rash
OTHER: injection
site pain
 CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS

Contraindicated in ALERT: watch for signs May decrease

patients of barbiturate toxicity: bilirubin level
hypersensiyive to coma, May cause false-
barbiturates and in cyanosis,asthmatic positive
those with history of breathing. phentolamine
manifest or latent Don’t stop drug abruptly test result
porphyria because this may worsen Bilirubin =0 –
Contraindicated in seizures 3.4 umol/L
patients with hepatic
or renal dysfunction,
respiratory disease
with dypnea or
obstruction, or
nephitis.
 NAME OF CLASSIFICATION INDICATION ADVERSE
DRUG REACTION
Generic Anti-infectives Colmlpicated CNS: seizures,
Name: intra-abdominal confusion, derpression,
dizziness, fatigue,
> Ciprofloxacin > Inhibits infection headache

Brand Name: bacterial DNA Severe or CV: chest pain,

synthesis, complicated UTIedema,
> Cipro thrombophebitis
mainly by Nosocomial
GI:diarrhea, nausea,
Dosage: blocking DNA Pneumonia vomiting, abdominal
>100 mg gyrase; pain or discomfort.
Route: bactricidal GU: crystalluria,
interstinal nephritis
>Per orem
HEMATOLOGIC:
Frequency:: leucopenia,
neutropenia
> OD
SKIN: rash
Form:
>Tablet
CONTRAINDICA NURSING MONITORING PARAMETERS
TION RESPONSIBILITIES

Contraindicate Obtain specimen May increase alkaline

d in patients for culture and phospatase, ALT, AST, Bilirubin,
sensitive to sensitivity tests BUN, creatinine, LDH and GGT
levels.
fluroquinolones before giving first
May increase eosinophil count.
Use cautiously dose. Begin
with CNS therapy, awaiting
disorders, such results ALT =5 – 28 u/L
as seizure Monitor patient’s BUN =8.2 – 20 mg/dL
disorders intake and output Creatinine =0.4 – 0.7 mg/dL
and observe patient
AST =15 – 30 u/L
for signs of
crystalluria Bilirubin =0 – 3.4 umol/L
Creatinie =18 – 35
Eosinophil =0 – 4%
Platelet =150,000 –
4500,000 cubic mm
 NAME OF CLASSIFICATI INDICATION ADVERSE
DRUG ON REACTION

Generic Electrolytes Hypocal – cemic CNS: tingling

Name and replace emergency sensations, sense
ment of oppression or
> Calcium Hypocal – cemic heat waves with
Gluconate solutions tetany I.V.
Brand Name: Dietary CV: bradycardia,
> Calcium > Replaces supplement arrhythmias
Gluconate calcium and GI:constipation
maintain irritation, chalky
Dosage: calcium taste, hemorrhage
>80 mEq level GU:polyuria, renal
Route: calculi
> through IV METABOLIC:
hypercalcemia
Frequency::
SKIN: local
>q 8 reactions
Form:
>Solution
 CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS

Contraindicated in Use all calcium May increase

cancer patients with product with extreme calcium level
bone metastases and in caution in digitalized Calcium =5.0 –
those with ventricular patients and patients 6.0 mEq/L
fibrillation, with sarcoidosis
hypercalcemia, Double check that you
hypophosphatemia, or are giving the correct
renal calculi. form of calcium
 Prognosis
Baby X was admitted last February 8, 2009 12:40 pm at Batangas
Regional Hospital with a chief complaint of seizures, fever, cough and cold.

Different management was also rendered to Baby X like giving

antibiotics as indicated may help to eradicate pathogenic microorganisms that
cause lower respiratory infection. Antipyretics may also be given if there is an
elevated temperature. Importance of rest should be taught to the client’s mother
and also to avoid pollutants and irritants to the respiratory system.

After 11 days of therapeutic management, the prognosis for recovery

is good since Baby X is not experiencing facial pallor and peripheral cyanosis
was diminished which shows normal distribution of oxygen was attained. There
was also a decrease evidence of respiratory distress hence discharge planning
was possible. He responded to it positively that medicates the improvement
with Baby X’s status.

He was discharged last February 19, 2009 at around 9 o’clock in the

morning.
 DISCHARGE PLANNING
Subjective:
“Pwede na raw kaming umuwi sabi ng Doktor”.
Objective:
Stable vital signs:
Temperature - 36.8oC
Respiratory rate - 42 breaths per minute
Pulse rate - 132 beats per minute
Assessment:
May go home as per Doctor’s order.

Planning:
After 30 minutes of nursing interventions, the mother will be able to
enumerate ways on how to provide adequate care to Baby X.

Implementation:
Conducted health teaching to the mother as follows:

MEDICATONS:
> Instructed the mother to give home medications prescribed by physician upon
discharge.
• Ciprofloxacin 100 mg/pptab 1 pptab once a day 8:00 in the morning for 14
days
• Phenobarbital 30 mg/tab 1 tab once a day 8:00 in the morning
ENVIRONMENT AND EXERCISE:

> Advised mother and relatives to provide a clean and allergen –

free environment conducive for patient’s recovery.
> Advised the mother and relatives to provide a quiet and calm
environment.
> Emphasized the importance of stress and injury free
environment to prevent trauma and any other complication.
>Instructed the mother to have adequate rest and sleep for Baby
X.

TREATMENT:

> Advised the mother to turn the client from time to time to
prevent further complication of pneumonia.
> Demonstrated the mother on how to do chest tapping after each
nebulization.
> Instructed the mother to place towel at the back of the child
when perspiration is extreme.
> Advised the mother to change clothing as necessary.
HYGIENE:

> Advised the mother to provide good personal hygiene of the

client especially oral care after each nebulization.

OPD:
> Informed the mother and relatives that further monitoring will be
conducted and so the need for regular check – up is highly
recommended. To come back at the hospital for check – up on February
26, 2009.

DIET:
> Instructed the mother to continue breastfeeding Baby X every 3
– 4 hours.

SPIRITUALITY:
> Advised the mother to seek God’s help for the recovery and
give improvement of the patient’s health and never forget to ask guidance
and support from our Lord.

Evaluation:
The mother was able to enumerate ways on how to provide
 SPIRITUALITY:

> Advised the client to seek God’s help for the

recovery and give improvement of the patient’s
health and never forget to ask guidance and
support from our Lord.

Evaluation:

The client was able to enumerate ways on how to

provide adequate care.
 ACKNOWLEDGEME
NTall the trials and challenges, there came
Despite the final
conquest. Words alone cannot describe those who had contributed in
one way or another towards the completion of this case study.

We lift up our glorious praises and endless thanks to the

Almighty God for continually blessing us while the preparation of this
case study and for giving us the strength to overcome trials and for
every little thing he’d done for us. Likewise, we extend our sincere
gratitude and deepest appreciation to the following people who
unselfishly shared their expertise, invaluable assistance and
inspiration for the realization of this case study.
 To our dear parents, for assisting us in our needs, financially and
emotionally; for being there whenever we need them, for staying on our
side through ups and downs and most of all for making us a responsible
individual.

To our Clinical Instructor, Mrs. Consuelo A. Cena, for sharing her

knowledge to the best of her ability; for guiding us the right way, we will
treasure all the learnings that she had taught us.

To the patient, Mrs. X, for allowing us to make the study of her

son’svcondition. Baby X, who is suffering from deprivation of health and are
ailing, they are the reasons why this study was conducted, though no bad
intents of continued agony is felt.
 To the staff of the IMC, especially Ma’am Rose, for letting
us lend books and assisting us in all our needs without hesitations.

To the different theorists and authors that influenced the

large arena of patient care, differentiating nursing among other
profession in dealing with its clientele. Their works served as basis
of this study.

To our friends and to all the important person in our lives.

For suggestions they gave for the enrichment of this work.
 bibliography
Applying Nursing Process, Alfaro- Le Fevre Rosalinda, pg. 207
Current Diagnosis and treatment,Marcus A.Krupp and Milton J. Chatton
Delmar’s Manual of Laboratory and Diagnostic Test, Rick Daniels
Delmar’s Pediatric Nursing Care Plans, 3rd edition,Luxner
Health Assesment & Physical Examination, Estes
Health Assesment in Nursing 3rd edition, Janet Weber & Jane Kelley
Human Anatomy and Physiology, Hole,Jr,et.al, 6th edition
Laboratory and diagnostic tests with nursing implications Seventh Edition,Joyce
Lefever Kee
Laboratory Tests and Diagnostic Procedures 5th Edition, Chernecky
Medical-Surgical Nursing, Brunner and Suddharts, Smeltzer,vol.1 & 2
Medical-Surgical Nursing Pathophysiological Concept, pge 496
Medical-Surgical, 6th edition, Burner et al, pg 468-469
Medical-surgical nursing, Smeltzer,et al.
Medical- Surgical Nursing Critical Thinking for collaborative care, vol.15th edition,
Ignatius, et.al. pg. 633-639
Medical Surgical for Nursing 7th edition Lewis et.al.
MIMS 107th edition 2006
Nurses’ Pocket Guide 11th edition, by Donges et. Al.
Nursing Care Plan,7th edition, Doenges, et.al
Nursing Care Plans; 6th edition, Donenges et. Al, pg. 130.
Nursing Care Plan, Meg Gulanck,et. Al, pg. 3
Nursing Care Plan 6th edition Gulanick/Myers
Pediatric Nursing Care Plan, Axton, et. Al, pg. 296-300
Portable Diagnostic Tests, Lippincott
www.emedicine.com
www.medscape.com