Baby Y, a 2 months old baby boy, first child of Mr. and Mrs. Veruela, is born at Central Luzon Doctors’ Hospital via Cesarean Section. Their family is recently residing at #90 Villa Socorro, Pob. Norte, Paniqui, Tarlac. He was born w/o any complications.  

Four days prior to admission, the patient has cough and colds, swelling of left eyelid, difficulty of breathing and nasal congestion. They sought medical care last July 9, 2009 due to with difficulty of breathing. And he was admitted at Central Luzon Doctors Hospital, St. Therese Unit pediatric ward last July 9, 2009 diagnosed with bronchopneumonia.  

Bronchopneumonia, a community acquired pneumonia, is an acute inflammation of the walls of smaller bronchial tubules with varying amounts of pulmonary consolidation due to spread of the inflammation into peribronchiolar alveoli and the alveolar ducts. Most cases are caused by organisms aspirated from the mouth (Wikipedia.com).

OBJECTIVES

After/within the exposure, we will be able to perform or assist the treatment process: 

• Establish good relationship with the patient and significant others.

• Gain knowledge regarding the patient’s health condition, the procedures done, and its treatment.

• Proper assessment with the patient’s history• Recognition of patient’s problem to be prioritized for the

establishment of nursing diagnosis• Proper planning of patient’s care• Establishment of intervention like:• -carrying out measures to prevent complications• -monitoring patient’s response to the procedure done• -monitoring health teachings• -identifying risk factors to avoid complications• Encourage patient and significant others to accept the

treatments and medications that are appropriate for her condition

• The student nurses will be responsible health care team member by interacting and establishing a harmonious and professional relationship with all the other members of the health care team.

ASSESSMENT

A. NURSING HEALTH HISTORY

  Patient name: Baby “Y”Date of Confinement: July 09, 2009Ward: St. Therese Room number: 244 bed AExaminer : Dr. “Y” and Dr. “X”

I. Chief complaint: difficulty of breathing II. History of patient illness:

4 days prior to admission with cough & colds without fever 3 days prior to admission above sign and symptoms with fever 2 days prior to admission with consult to Attending Physician. Prior to admission with swelling of eyelids, with difficult

breathing with nasal congestion, with consult, advice admission. Patient born via cesarean section at Central Luzon Doctors Hospital.

Patient name: baby YDate of confinement: July 09, 2009Ward: ST. THERESERoom no: 244Examiner: Dr. y and Dr. x

I. Chief complaint: difficulty of breathing

II. History of patient illness: 4 days PTA (+) cough & colds (-) fever 3 days PTA above s/s (+) fever 2 days PTA (+) consult to AP PTA (+) swelling of eyelids (+) difficult breathing (+) nasal

congestion (+) consult, advice admission. Patient born via CS at CLDH. Born without complication D/C after 3 days

(-) illness thereafter.

B. PHYSICAL ASSESSMENT

Theorists Age Period Stage Characteristics

Freud Infancy

(2 months old)

Oral

(Birth to 1 yr.)

Receives satisfaction from oral needs being

met; attachment to mother important

because she usually meets infant’s needs

Erikson Infancy

(2 months old)

Trust vs Mistrust (Birth to 1½ yr.) learns world is good and can be trusted as

basic needs are met

Sullivan Infancy

(2 months old)

Infant

(Birth to 1½ yr.)

learns to rely on others, especially mother:

“good me/bad me”emerges.

Piaget Infancy

(2 months old)

Sensorimotor

(Birth to 2 yrs.)

Reflexive

(birth to 1 month)

Primary circular reactions

(1 to 4 months)

Predictable, innates survival reflexes Responds purposefully to stimuli;

initiates, repeats satisfying behavior

Kohlberg Infancy

(2 months old)

Preconventional

(Birth to 7 yrs.)

Premoral stage

(birth to 2 years)

Cannot differentiate right from wrong

Developmental stage

GENERAL SURVEY

Height: 25’ Weight: ___ Body make up: _____Communication pattern: not applicable

Skin: Color: Brown Turgor: Normal Bruises: Absence Of BruisesState Of Hydration: Normal

Eyes: Sclera: White Pupils: Constricted

 respiratory breathing: In Distress due to difficulty of breathing Body position/alignment Supine: X Fowlers:not applicable Semi fowlers: not applicable others: not applicable Alignment: not applicable Appropriate: not applicable Inappropriate: not applicable

OTHER HEALTH RELATED PATTERN Fatigue: not applicable Restlessness: X Weakness: X Insomnia: not applicableDyspnea: not applicable Dizziness: not applicable Pain: X (face scale of 6/10)

0 1 2 3 4 5 6 7 8 9 10

No pain

Mild pain

Moderate pain

Severe pain

Very severe pain

Worst possible pain

Coughing: Others: ___ Environment:

Room temperatureAdequate: X Inadequate: ____

LightingAdequate: X Inadequate: ____

Safety:Violation of medical asepsis: XViolation of safety measure: NONE

V/S:HR:146 beats per minuteTEMP: 38.3◦CRR: 44 beats per minute

PHYSICAL EXAMINATION FINDINGS HEAD/SKULLINSPECTION Skull: normocephalic, rounded Hair: evenly distributed, black in color Face: pallor Eyes: symmetric, with periorbital swelling Nose: with mucus secretion, with nasal flaring Mouth: pale lips, tongue move freely Ears: color is same as facial skin

PALPATION Skull: anterior fontanel is soft and flat without depression, posterior fontanel is closeEyes: periorbital-warm to touchLips: rough SKININSPECTION Uniform brown color, smooth when palpatedPALPATION Smooth, good skin turgor THORAX AND LUNGSINSPECTION Symmetrical in size, the color is same as

the body, tachypneic: 46cpm

PALPATION with tactile premituse, tachypneic: 46 cpm AUSCULTATION with crackles sound HEART INSPECTION No pulsation visibleAUSCULTATION Tachycardic: 146bpm

ABDOMENINSPECTION

Rounded, symmetrical, withou striae, without scars, umbilicus is depressed and beneath the abdominal surface, has subcostal retraction

PERCUSSION with dullness MUSCULOSKELETAL: Equal on both sides of the body NEUROLOGICAL SYSTEM:

has the ability to react, especially making some movements when he feels something irritable

 GENITALIA: No abnormalities present ANUS: No bleeding or other abnormalities EXTREMITIES: Symmetrical in size and shape, no rashes notice SENSORY: Sensation to light touch is active  REFLEXES:

The primitive reflexes are still active such as rooting, sucking, palmar, tonic neck, plantar, babinski, moro

PAST MEDICAL HISTORY A. Pediatric and adult illnesses

Mumps: not applicable Pertussis: not applicableHPN: not applicable Measles: not applicable

Rheumatic: not applicable Heart Disease: not applicableChickenpox: not applicable Pneumonia: not

applicable Hepatitis: not applicable Rubella: not applicableTuberculosis: not applicable Others: not applicableB. Immunization/testBCG:X DPT:X OPV: not applicableHEP B: XMEASLES: not applicableFor FIV not applicable For PNEUMONIA: not applicableOTHERS: not applicable

C. Hospitalizationnone

 D. Injuries

None E. Transfusion:

None

F.Obstetrics None

 G. Medication

Romicef 175 mg IVP q8Salinase drops 1 drop T.I.D

Aeknil drops 0.3 ml B.I.DOxacilin 150 mg IVP q6Cetrioxime 500 mg IV drip O.D H. Allergies

None

  I. Family history

Living/dead List: parent Age Gender Health status

or cause of

death

Disease

present in

the family

Living John Alvin 29 Male None None

Living Digna 28 Female Appendectomy none

SOCIAL AND PERSONAL HISTORY(before admission)

Birthplace: #90 Villa Socorro, Pob. Norte, Paniqui, TarlacEthnic Background: IlocanoBirthday: April 25, 2009Client position in the family: Only childResidence:

Home environmentSubdivisionNearby town

Diet: 5 oz formula of breast milk at least 10 x a dayBrief: description of average day:

“matutulog lang siya maghapon, tapos gigising, biglang iiyak, kapag gutom o kaya tumae”

NURSING HEALTH HISTORY

1. General Description of the client• The patient is 2 months old from Paniqui, Tarlac seek

for medical care because of cough and colds, with swelling of the left eyelids, DOB and nasal congestion.

2. Nutritional- metabolic pattern• The patient has usual diet of breast milk at least 10x a

day and/or 5 oz of formula milk a day. The patients weigh 5.4 kilos and height of 25 inches

3. Sleep-rest pattern• Usually sleep the whole day and only woke up when

he voids, urinate or hungry (16 to 18 hours of sleep a day)

4. Elimination pattern• The patient usually consuming 5-6 diapers a day• Stool(4x a day)

Note: PRIOR TO ADMISSION

Routine Blood Count SI Result SI Ref Value Interpretation

WBC 16.1 4-10 increase

RBC 3.14 M (4.5-5.5) decrease

HGB 8.0 M (13.0-17.0)decrease

HCT 23.8 M (40-50) decrease

MCV 75.8 83-99 FL decrease

MCH 27 27.0-32.0 PG

MCHC 33.6 31.-34.5 g/dl

Platelet 373 150-400

MVP 8.9 6.5-11um3

Lymphocytes % 31.2 20-40

MXD % 12.9 2-10 increase

Neutrophiles % 55.9 40-80

Lymphocytes # 5.0 1-3 increase

MXD # 2.1 0.2-1 increase

Neutrophiles # 9.0 2-5 increase

CHEST X-RAY Radiologic Findings: The lung fields are clear.Heart is not enlarged.The diaphragm and custophrenic sulci are intact.The rest of the visualized chest structures are unremarkable.Impression:

Normal chest PA findings.Note:

For repeat Chest X-ray (Doctor’s Order) 

ROUTINE URINE ANALYSIS

 Transparency: TurbidColor: Dark yellowOccult Blood: negativeBilirubin: negativeUrobilinogen: 0.1 mg/dlKetone: negativeProtein: 1+Nitrite: negativeGlucose: negativeReaction: 5.5Specific gravity: 1.025Leukocytes: negativePus cells: 0-2/hpf Epithelial cells: occasionalA phosphates: A urates: plentyBacteria: moderate

ANATOMY AND PHYSIOLOGY

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. 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. 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. 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 intercostals 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. Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveoli in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over. Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane. 

 

Air usually moves into the body through the nose and into the nasal cavity. The nasal hairs catch and filter foreign substances that may be present in the inhaled air. The air is warmed and humidified as it passes by blood vessels close to the surface of the epithelial lining which contains goblet cells that produce mucus to trap dusts, microorganisms, pollen, and other foreign substances. The epithelial cells of this lining contain cilia—microscopic, hair-like projections of the cell membrane—which constantly moving and directing down toward the throat. Air then moves from the nasal cavity into the pharynx and larynx. The larynx contains the vocal cords and epiglottis, which close during swallowing to protect the lower respiratory tract from any foreign particles. From the larynx, air proceeds to the trachea, the main conducting airway into the lungs. The trachea divides into two main bronchi, which further divides into smaller and smaller branches. All of these tubes contain mucus-producing goblet cells and cilia to entrap any particles that may have escaped the upper protective mechanisms. The walls of the trachea and conducting bronchi are highly sensitive to irritation. When receptors in the walls are stimulated, a central nervous system reflex is initiated and a cough results. The cough causes air to be pushed through the bronchial tree under tremendous pressure, cleaning out any foreign irritant. This reflex, along with the similar sneeze reflex, forces foreign materials directly out of the system, opening it for more efficient flow of gas. Throughout the airways, many macrophage scavengers freely move about the epithelium and destroy invaders. Mast cells are present in abundance and release histamine, serotonin, adenosine triphosphate, and other chemicals to ensure a rapid and intense inflammatory reaction to any cell injury.

The end result of these various defense mechanisms is that the lower respiratory tract is virtually sterile—an important protection against respiratory infection that could interfere with essential gas exchange. Gas exchange occurs in the alveoli. In this process, carbon dioxide is lost from the blood and oxygen is transferred to the blood. The exchange of gases at the alveolar level is called ventilation. The alveolar sac holds the gas, allowing needed oxygen to diffuse across the respiratory membrane into the capillary while carbon dioxide, which is more abundant in the capillary blood, diffuse across the membrane and enters the alveolar sac to be expired. The respiratory membrane is made up of the capillary endothelium, the capillary basement membrane, the interstitial space, the alveolar basement membrane, the alveolar epithelium, and surfactant layer. The sac is able to stay open because the surface tension of the cells is decreased by the lipoprotein surfactant. Absence of surfactant leads to alveolar collapse

Precipitating factors:

Exposure to pathogenUpper respiratory tract infection

Pathogens invade lower respiratory

tract specifically bronchi, bronchioles,

terminal bronchioles and alveoli.

Cells of the mucosal linings, the airways are

injured

Secretions of large amount of mucous brought

about the injury of mucous secreting cells or goblet

cell that line the respiratory

Injured cells release the biochemical mediators

of the inflammatory response histamine,

Bradykinin and other.

Inflammatory immune response

Is initiated by biochemical mediators.

Vasodilation of Capillary

WBC such as Europhiles and monocytes

and other to enter the blood stream

Increase capillary permeability which

causes capillary to open up and allowing

plasma, blood cells and plasma protein out

of

Increase blood flow Phagocytes and removal of debris occur

Forms exudates and this exudates

Leak into the airway and alveoli (edema)

Bring more nutrients to the area.

As phagocytosis occurs, the phagocytes

Release endogenous pyrogens Fluid (mucous exudates) accumulates in the

Bronchi, bronchioles and alveoli

Pyrogens stimulates the hypothalamus

to increase body temperature.fever

Antipyuretic and TSB

crackles

Airways is cloged with exudates Alveoli looses air spaces and solidifies.

Less oxygen reaches the alveoli Decreased lung compliance and recoil

Decrease oxygen and carbon dioxide

exchange

Decrease oxygenation of body

Tissues and vital organs of

hypoxemia

Shortness of breath

Oxygen inhalation

Chest retraction

Predisposing factors:

AgeImmature immune system

Polluted environment (noxious gases)

Legends:

CLIENTS PROFILE 

The patient is the first child of MR. and MRS Veruela, he is born at CLDH via CS, he is born normal w/ a history of rash when he is one month old. Four days PTA, the patient has cough and colds, swelling of left eyelids, DOB, nasal congestion

We are looking forward for a better condition as much as possible the patient may go home. METHODS MedicationsRomicef 175 ml IVF q 8°Solinase drops 1gtt, T.I.DAlnix drops 0.3 mL, B.I.DAeknil 50 mg q 4°Ventolin nebule 3xOxacillin 150 mg IVP q 6°Ceftriaxone 500 mg IV drip O.DTreatment

Medication and supervisions are must be followed Health TeachingsInstruct the family of the patient to position the client with head slightly elevated to maintain open airway.

O.P.DFor flexible nasopharyngoscopy under sedation in an institution that offer such (Manila

Doctors Hospital) ASAP, to assess possible cause of upper airway obstruction ASAP.

SocialThe father of the baby is a smoker, therefore the patient becomes passive smoker.

Drug Name Classification

Dosage Action Indication Contraindication Side Effects Adverse Effects

Cefuroxime Sodium

(Romicef)

Cephalosporin, Second Generation

175 ml IVF q8º

Chemical Effect: inhibits cell wall synthesis, promoting osmotic instability, usually bactericidal.

Lower respiratory tract infections due to S. pneumonia, H. influenza (including ampicilin resistant).

Patientshypersensitive to drug, sulfonamides, or aspirins, or other NSAIDS and in patient with severe hepatic or renal impairment. Also contraindicated for treating perioperative pain after coronary artery bypass graft surgery. Use

continuously in patients with history of sensitivity in penicillin and in patients with renal impairments.

Dizziness Headache Abdomin

al cramps Diarrhea,

nausea, Dyspnea.

Hypersensitivity reactions (serum sickness anaphylaxis) pain, induration, phlebitis, haemolytic anemia.

Nursing Responsibilities

Before giving first dose ask patient about previous reactions to cephalosporins or penicilins. Be alert for adverse reactions and drug interactions.

Drug Name

Classification

Dosage Action Indication Contraindication Side Effects Adverse Effects

Sodium Chloride

(Salinase Drops)

Electrolyte 1 gt TID Sodium is the major cation of the body’s extracellular fluid. It plays a crucial role in maintaining the fluid and electrolyte balance. Excess retention of sodium results in overhydration (edema, hypervolemia) which is often treatedwith diuretics. Abnormally low levels of sodium result in dehydration.

Relief of inflamed, dry or crusted nasal membranes.

Congestive Heart Failure (CHF),

Severely in impaired renal function,

Hypernatremia, fluid retention.

Hypernatremia:

Excessive NaCl may lead to hypopotassemia and acidosis. Postoper

ative Intolerance of NaCl: Cellular dehydration, weakness, asthenia, disorientation anorexia, nausea.

Hypervolemia Increased BUN

levels Distension Deep

Respiration Abscess Tissue Necrosis Extensive

hemolysis

Nursing Responsibilities Document indications for therapy, monitor electrolytes, ECG, liver and renal function studies Observe for signs and symptoms of hypernatremia.

Drug Name

Classification

Dosage Action Indication Contraindication

Side Effects Adverse Effects

Paracetamol

(Aeknil Drops)

Non-opioid analgesic, antipyretic

0.3 ml BID

May produce analgesic effect by blocking pain impulses, by inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by acting I hypothalamic heat regulating center.Therapeutic Effect: Reliefs pain and reduces fever.

Mild pain or fever

Patients hypersensitive to drug use cautiously in patients with history of chronic alcohol abuse because hepatotoxicity may occur after therapeutic doses.

Drowsiness

Nausea Heartbur

n Vomiting

Rash Uticaria Liver Damage Jaundoice

Nursing Responsibilities

Assess patient’s temperature before administering meds. Give liquid form to children and other patients who have trouble swallowing. When giving oral form, calculate dosage based on level of drug because drops and elixir have different concentrations. Tell patient not to use drug for fever that’s above 103 º F (39.5º). Lasts longer than 3 days or recurs.

Drug Name

Classification

Dosage Action Indication Contraindication

Side Effects Adverse Effects

Salbutamol

(Ventolin)

Sympathominetic

1 ml, nebule TID

Stimulates beta 2 – receptors of the bronchi, leading to bronchodilation. Causes less tachycardia and as longer – acting than isoproterenol. Has minimal beta -1only.

Prophylaxis and treatment of brochospasm due to reversible obstructive airway disease. Inhalation solution for acute attacks of brohospasm.

Aerosol for prevention of exercised induced brochospasm and tablets area not recommended for children less than 12 years of age. Used during lactation.

Diarrhea Dry mouth Appetite

loss Epigastric

pain Dizziness Drowsiness Headache Cough Restless Wheezing Chest pain

or discomfort

Palpitations Tachycardia Urticaria Angioedema Pallor Musclespasm Oropharyngeal

edema

Nursing Responsibilities

When given by nebulization, either a face mask or mouth piece maybe used. Use compress air or oxygen with a gas flow of 6- 10 L per min. Document symptoms characteristics, onset, duration, frequency, and any precipitating factors. Monitor pulmonary status (breath sounds, VS, peak flow or ABGs for effects of the therapy) Observe for evidence of allergic responses.

Drug Name

Classification

Dosage Action Indication Contraindication

Side Effects Adverse Effects

Penicillin(Oxacillin

)

Antibiotic 50 mg IVP q 6º

The bacterial action of penicillins depends on their ability to bina penicillin- binding proteins (PBP-1 and PBP-3) in the cytoplasmic membranes of bacteria, thus inhibiting cell wall synthesis.

Serious streptococcal infections (empyema, endocarditis, meningitis, pericarditis, pneumonia)

Hypersensitivity to penicillins, B-Lactamase inhibitors and cephalosporins.PO use of penicillins during the acute stages of empyema, bacteremia, pneumonia, meningitis, pericarditis and purulent or septic arthritis. Use with caution in clients with a history of asthma, hay fever or urticaria. Clients with cystic fibrosis have a higher incidence of side effects with broad spectrum penicillins.

Skin rashes

Hives Wheezing Fever Hypotens

ion Abdomin

al cramps or pain

Nausea and vomiting

Dizziness Oliguria Fatigue Lethargy Electrolyt

e imbalance following IV use.

Anaphylaxis Seizures Haemolytic

anemia Vascular collapse Bronchospasm Stevens

Johnson’s Syndrome

Nursing Responsibilities

IM and IV administration of penicillin causes a great deal of local irritation, thus: inject slowly. Detain in an ambulatory care site for at least 20 minutes. After administering to assess for anaphylaxis.

Drug Name

Classification

Dosage Action Indication Contraindication

Side Effects

Adverse Effects

Ceftriaxone

Sodium

Antibiotic, Cephalosporin, Third generation

500 mg IV drip OD

Inhibits cell wall synthesis, promoting osmotic instability, usually bactericidal. Hinders or kills susceptible bacteria.

Serious infections of lower respiratory and urinary tracts.

Patients hypersensitive to drug or other cephalosporins. Use cautiously in patients with history of sensitivity to penicillin.

Dizziness

Fever Headac

he Nausea Vomiti

ng Rash

Diarrhea Leukopenia Pseudomemb

ranous colitis Hypersensiti

vity reactions (serum- sickness)

Nursing Responsibilities

If adverse GI reactions occur, monitor patient’s hydration. Assess patient’s infection before therapy and regularly there after. Before giving first dose, ask patient about previous reactions to cephalosporins or

penicillin.

Cues Nursing Diagnos

is

Scientific Explanation

Problem Statement

(Goal)

Nursing Intervention Rationale Evaluation

Subjective:

“ Nahihirapan huminga ang baby ko dahil sa plema” as verbalized by the mother ”

Objectives:

Dyspneic

flaring of nostrils

with sputum :clear

with crackles

RR: 46

With retraction

O2 regulated @ 1L

Tachycardic

CR: 146 bpm

Ineffective Airway Clearance r/t ability to maintain patent airway.

Secretion or obstruction on the respiratory

tract.

Airway inflammation

Inflammatory immune

response is initiated by biochemical

mediator

Increase capillary

permeability.

Edema

Alveoli loses air space

Airway is clogged

After 30 minutesOf nursing interventions, airway patency will maintain, secretions will be readily expectorated and there will be signs of a reduction in congestion.

Monitor vital signs and record accordingly

Slightly elevate head of the patient by placing a pillow underneath.

Performed nasopharyngeal suctioning as ordered

assisted with pulmonary hygiene measures such as postural drainage, percussion and vibration

Provide supplemental oxygen.

Provide supplemental humidification via use of nebulizer.

Administer anti microbial as prescribed.

Limit visitors as indicated.

This is the baseline for comparison.

Proper positioning helps in draining secretions and promotes expectoration, lung expansion and facilitates the movement of secretion.

Stimulates cough or mechanically clears airway in patient who is unable to cough effectively

This technique helps mobilize and clear secretion.

To offset increase oxygen demands and consumption.

Nebulization helps in liquefying secretions for better and faster expectoration of secretions

Prescribed medicines, such as bronchodilators helps in aiding airway clearance.

Reduces likelihood exposure to other infectious pathogens.

After 30 minutes of nursing interventions, the goal was met through the reduction in congestion

Cues Nursing Diagnosis

Scientific Explanation

Problem Statement

(Goal)

Nursing Intervention Rationale Evaluation

Subjective:

“ Nahihirapan huminga yung anak ko tsaka may halak” as verbalized by the mother. Objectives:

Tachypneic

Dyspneic

RR: 46

Cracles noted upon auscultation

Irritability

Rapid shallow breathing

With Subcostal retraction

With Nasal flaring

Ineffective breathing pattern r/t collection of secretions in airway.

Cell of the mucosal lining, the airways are

injured

Release biochemical mediators

Increase capillary

permeability

Forms exudates

Fluid accumulation in

bronchi, bronchioles and

alveoli

Airway is clogged with

exudates

Shortness of breath

After 1 hour of nursing intervention, patient will decrease secretions in airway as evidence by effective breathing pattern.

Auscultate chest.

Position patient properly.

Elevate patient by placing small pillow under his head.

Limit visitors and maintain a calm attitude/voice when dealing with the infant.

Administer oxygen as prescribed the physician.

Assist with nebulization.

Administer prescribed medications

To evaluate presence/character of breath sounds or secretions

To promote ease of maximum respiration.

To decrease anxiety.

Anxiety can cause baby to cry thus adding factors that contribute to difficulty in breathing.

To provide adequate oxygenation

To treat and manage any other underlying causes.

Facilitates liquefaction and removal of secretions and cause bronchodilation

After 1 hour of nursing interventions, the goal was met as evidence by decreased secretions.

Cues Nursing Diagnosis Scientific Explanation

Problem Statement

(Goal)

Nursing Intervention Rationale Evaluation

Subjective:

Ø

Objectives:

Dry lips

Mouth breathing

Irritability

Pale in appearance

Impaired oral mucous membrane r/t chemical exposure to tobacco.

Cell of the mucosal lining, the airways are

injured

Secretion of large amount of mucous brought about the injury of mucous secreting cells that line the respiratory

Fluid accumulates at the bronchi,

bronchioles and alveoli

Decrease oxygen and carbon

dioxide exchange

Decrease oxygenation of the body tissue and vital signs

Pallor

After 3 hours of nursing interventions, the patient will maintain moist oral mucous membranes that are free from ulcerations and debris.

Inspect the oral cavity at least once daily and note any discoloration, lesions, edema, bleeding or dryness. Refer to a physician or specialist as appropriate.

Assisted the family perform oral care.

Keep the patient’s lips moisten by using cotton swabs and normal saline solution.

Oral infection can reveal signs of oral disease, symptoms of systemic disease, drug side effect or trauma of the oral cavity.

To promote proper oral hygiene

Uses of cotton swabs, decreases the likelihood of oral bleeding and normal saline solution keeps the patient from acquiring other pathogens.

After 3 hours of nursing interventions, the patient maintained intact oral mucous membrane.

Cues Nursing Diagnosis

Scientific Explanation

Problem Statement

(Goal)

Nursing Intervention

Rationale Evaluation

Subjective:

“Nilalagnat ang anak ko” as verbalized as the mother. Objectives

:

Warm to touch

Pallor

Weak in

Appearance T : 38.3

RR: 46

CR: 146 bpm

WBC: 16.1

Hyperthermia r/t inflammatory response to illness.

Inflammatory immune

response is initiated by biochemical

mediator

White blood cells enter the blood stream

Phagocytosis occurs

Phagocytes release

endogenous pyrogens

Pyrogens stimulates the

hyphothalamus to increase body

temperature

Fever

After 1 hour of nursing interventions, body temperature will be decreased from 38.3°C to 37°C.

Monitor vital signs.

Apply tepid sponge bath.

Maintain bed rest

Instruct family to use loose clothing

Administer prescribed medications

provide a calm and restful environment

This is for baseline comparison.

Tepid sponge bath helps in lowering patient’s temperature.

To reduce metabolic demands and oxygen consumption

Loose clothing increases comfort and decreases the possibility of increasing body temperature.

To facilitate fast Recovery

To conserve energy of the patient, thus promoting fast recovery

After 1 hour of nursing interventions, the patient was able to maintain body temperature within the normal range which is 36.7° C-37°C.

Cues Nursing Diagnosis

Scientific Explanation

Problem Statement

(Goal)

Nursing Intervention

Rationale Evaluation

Subjective:

“Hindi diretso ang tulog ng baby ko” as verbalized by the mother. Objectives:

Irritability

Constant crying

Difficulty of breathing

With fever

With crackles

Shortness of breath

With subcostal retraction

Sleep deprivation r/t prolonged physical discomfort.

Cells of mucosal

linings, the airway is injured

Injured cells release

biochemical mediators

Manifested through fever,

crackles, shortness of

breath, retractions

Sleep disturbance

After 3 hours of nursing interventions, the patient will maintain continuous undisturbed sleep.

Observe for underlying physiological illnesses causing sleep loss like pneumonia.

Keep environment quiet for sleeping.

Encourage family to use soothing music to facilitate sleep.

Limits visitors

Symptomatology of disease state can cause insomnia.

Noise disrupts sleep.

Music results in better sleep quality, longer sleep duration and greater sleep efficiency.

To decrease likelihood of the disturbing the petient

After 3 hours of nursing interventions, the patient maintained continuous undisturbed sleep.

IMPLEMENTATION Medical management (Patient-Based) Course in the Ward July 09,2009

At 3:00 am, Baby Y admitted under the service of Dr. I. secured patient’s consent. Patients temperature, pulse, respiration of shift X record. Patient is instructed nothing per Orem. Intravenous fluid of D5 0.3 NaCl .500cc regulated at 19-20/min. For diagnostic test such as complete blood count, Urinalysis and chest x- ray. Medication as follows: Romicef 175 ml Intravenous fluid every eight hours, Salinase drops 1drop, three times a day, Alnix drops 0.3 mL, two times a day, Aeknil 50 mg every 4 hours, Ventolin nebule 3x, Oxacillin 150 mg Intravenous fluid every six hours, Ceftriaxone 500 mg intravenous drip once a day. Attending Physician ordered suctioning of mouth and nasal secretions, as needed. And provide O2 therapy at 11 pm as ordered by the physicians.

July 10, 2009 

Attending Physician ordered suctioning of mouth and nasal secretions, still PRN. Continue medications. Scheduled patient for chest x-ray. Intravenous fluid to follow, D5 0.3 NaCl @SR, The Patient is still nothing per Orem. July 11, 2009 

The Attending Physician ordered decrease nebulizations to q 12°, suctioning PRN. Continue Medications (Ceftriaxone and Ocillin). At 1:40 pm, examined stool and nasal drainage for culture.

Nursing Management Nursing Intervention Phase

• Monitor V/S• Remained NPO• Suctioned Nasal and secretion• TSB done• Administers medication as prescribed by the physician• Position the patient with head slightly elevated• Administered supplemental humidification• Maintained IVF’s as ordered by the physician

Health Teaching• Instructed the family of the patient to position the client

with head slightly elevated to maintain an opening on the airway.

• Encourage family of the patient to observe proper hygiene

• Report to the physician severity of the condition of the patient.

RECOMMENDATION

We recommend that monitoring of the patient should be more vigilant as a much as possible. We also recommend that proper ventilation and sanitation must be maintained. Also, suctioning of the oral and nasal secretions, must be continuous.

The patient has difficulty of due to accumulation of sputum in the airway passage. During this time, the family of the patient to keep the head slightly elevated to maintain an open airway.

Observe for any signs of aspirations that might occur due to excessive secretions.

EVALUATION

PATIENT CENTERED

At the end of the study, we are able to establish good and strong relationship with the family. The family is aware and can identify signs and symptoms of pneumonia, and risk factors. The family also has established awareness on the personal hygiene. They further showed importance by hand washing. Its importance in preventing transfer of microorganism and or worsening of the disease. Proper assessment result to correct and apt diagnosis, that will help the family especially in planning of care.

 EVALUATION 

At the end of this study, we are able to established good and strong relations with the family. The family aware and can identify signs and symptoms of pneumonia, and its risk factors. The family also has established awareness on personal hygiene. They further showed its importance by adhering to the teaching of the student nurse e.g. frequent hand washing. Its importance in preventing transfer of microorganisms and/or worsening of the disease. Proper assessment results to correct and apt diagnosis that will help the family especially the patient in planning of care. 

We didn’t just focus on the nurse-patient relationship on this study but we also able to established harmonious and professional relationship with all the other members of health care team. This study will not be successful without the collaborative effort of the patient’s family, nurses on duty, attending physician, the other members of the group, and our hardworking and very supportive clinical instructor, Mrs. Glennar Pascual.

END OF THE SLIDES

THANK YOU!!!!