NOTRE DAME OF MIDSAYAP COLLEGE

COLLEGE OF NURSING
A.Y. 2022-2023

TABLE OF CONTENTS

I. Introduction… ............................................................................................................. 3
II Objectives. .................................................................................................................. 5
III. Patient’s Profile........................................................................................................ 6
a. Biographic Data… ..........................................................................................6
b. Clinical Data… ............................................................................................... 6
c. Health History ................................................................................................ 22
d. Family History and Current Lifestyle… ........................................................ 23
IV. Health Assessment… ................................................................................................. 6
V. Review of Anatomy and Physiology .......................................................................... 24
VI. Pathophysiology… .................................................................................................... 28
a. Definition of Diagnosis… ................................................................................ 28
b. Etiology… ........................................................................................................ 28
c. Symptomatology ............................................................................................... 30
d. Schematic Diagram… ....................................................................................... 33
e. Narrative….……………………………………;…...........................................35
VII. Course in the Ward............................................................................................................36
i. Medical Management
a. Doctor’s Progress Notes… ................................................................... 36
b. Laboratory/Diagnostic Examination. .................................................... 42
c. Pharmacologic Management (Drug Study)… ....................................... 47
ii. Nursing Management… .................................................................................. 60
a. Nursing Care Plan… ............................................................................. 60
VIII. Prognosis… ............................................................................................................. 68
IX. Discharge Plan ........................................................................................................... 72
X. Conclusion… .............................................................................................................. 74
XI. Recommendation ....................................................................................................... 76

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A.Y. 2022-2023

XII. Learnings……………………………………………………………………….77

XIII. Acknowledgement……………………………………………………………..77
XIV. References… ......................................................................................................... 78

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A.Y. 2022-2023

I. INTRODUCTION

Community acquired pneumonia (CAP) affects children frequently. The majority

of CAP cases in the first two years of life are caused by viruses. Following this time,

Chlamydia pneumoniae, Mycoplasma pneumoniae, and Streptococcus pneumoniae

become increasingly prevalent. Younger infants experience non-specific CAP symptoms,

whereas older children typically experience cough and tachypnea. An x-ray of the chest

can help to confirm the diagnosis. The majority of youngsters can be treated empirically

as outpatients with oral antibiotics without particular laboratory tests. Those with serious

infections or symptoms that are chronic or getting worse require more thorough testing

and may need to be admitted to the hospital. Based on the patient's age, the severity of

their pneumonia, and their knowledge of the local antimicrobial resistance patterns, the

type and dosage of medicines should be chosen.

Neonatal pneumonia symptoms include poor feeding, hypotonia, floppiness,

lethargy, apnea, an elevated or depressed body temperature, and hypotension. When a

respiratory infection is present in older children, tachypnea and, on rare occasions,

hypoxia that progresses to apnea and the requirement for ventilator assistance may be

present. The World Health Organization has established diagnostic standards for

diagnosing pneumonia. The need is the presence of tachypnea and a cough. Children one

to five years old, children two to twelve months old, and children younger than two

months old are considered to have tachypnea if their respiratory rate exceeds 60 breaths

per minute, respectively.

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17% of all deaths in children under five globally are caused by pneumonia, which

results in the loss of about 1.6 million lives. Approximately 90%-95% of these deaths

occur in underdeveloped countries. Data from September 2013 indicated, according to

the United Nations International Children's Emergency Fund (UNICEF), that South Asia

and sub-Saharan Africa have seen the majority of deaths. According to data from the

Philippines for the same year, pneumonia had the highest rate of infant mortality

(1.8/100,000 people), while the mortality rate for children between the ages of 1 and 4

was 25.2/100,000 people. 1 For the past five years, this pattern has been consistently

seen.

The patient, a 1-year-old male with fever as his chief complaint and a final

diagnosis of Pediatric Community Acquired Pneumonia-Moderate Risk, has been

admitted to Dr. Amado B. Diaz Provincial Hospital as a patient for the aforementioned

condition since February 27, 2023 at 10:50 am. To establish an effective nursing care

plan that is crucial to the patient's well-being, it is crucial to understand the patient's

condition and how it develops by studying Pediatric Community Acquired Pneumonia-

Moderate Risk.

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A.Y. 2022-2023

II. OBJECTIVES

General Objectives:

The aim of this study is to understand the pathophysiology of Pediatric

Community Acquired Pneumonia-Moderate Risk (PCAP-MR), to provide pertinent

information that will help increase knowledge and comprehension of the aforementioned

disease, including its signs and symptoms, which will aid in identifying various nursing

interventions and help build crucial skills needed by future nurses.

Specific Objectives:

● Define Pediatric Community Acquired Pneumonia-Moderate Risk (PCAP-MR) and

its effects to the body

● Identify the signs and symptoms

● Understand the pathophysiology

● Map out drug study indicated on the doctors notes and its appropriate nursing

managements

● To put together appropriate individualized nursing care plans

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A.Y. 2022-2023

III. PATIENT’S PROFILE

A. Gordon’s Health Assessment

ADMISSION ASSESSMENT

a. Biographic Data

Date of Admission: February 27, 2023/10:50 am

Name: Kabilan, Sahamad Kulintang

Date of Birth: June 20, 2021

Age: 1

Sex: Male

Primary significant other: Mohamad Kabilan-Father

Name of primary information source: Grandmother

b. Clinical data

Chief Complaint: Fever

Admitting medical diagnosis: Pulmonary Edema

Final Diagnosis: Pediatric Community Acquired Pneumonia-Moderate Risk

Surgical procedure: None

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VITAL SIGNS Date of Assessment: February 27, 2023/10:50am

Temperature: 38.6 C

Pulse Rate: 118 bpm

Respiratory Rate: 32 cpm

Blood Pressure:

Weight: 10.5 kgs

Height: 75.7cm

BMI: Normal BMI

Do you have any allergies? - No

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

OBJECTIVE

1. Mental Status

a. Oriented: oriented to person

b. Sensorium: patient is alert.

c. Memory: N/A

2. Vision

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a. Visual acuity: Not assessed

b. Pupil size: pupil size in both eyes is normal.

c. Pupil reaction: pupil reaction in both eyes is normal.

3. Hearing

a. Assessed

b. Ears: right and left ear is normal and functions within normal limits.

c. Hearing aid: patient does not use hearing aid.

4. Taste

a. Tongue movement: normal and movable

b. Tongue appearance: normal and pinkish

5. Touch

a. Blunt: N/A

b. Sharp: N/A

c. Light touch sensation: N/A

d. Proprioception: N/Al

e. Heat: N /A

f. Cold: N/A

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g. Any numbness: N/A

h. Any tingling: N/A

6. Smell

a. Nostril: N/A

7. Cranial Nerves: N/A

8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.) - Normal

9. Reflexes: Normal

10. Any enlarged lymph nodes in the neck? - None

11. General Appearance:

● Hair: Black & straight hair

● Skin: Brown, smooth and soft to touch

● Nails: Pinkish, short nails

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NUTRITIONAL-METABOLIC PATTERN

OBJECTIVE

1. Skin Examination

a. Moist

b. Lesions: No

c. Rash: No

d. Turgor: Firm

e. Color: Pink

2. Mucous Membranes

a. Mouth

i. Moist

ii. Lesions: No

iii. Color: Pink

iv. Teeth: Normal.

v. Dentures: Has one denture in the upper part.

vi. Gums: Normal

vii. Tongue: Normal, moist and pink

b. Eyes

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i. Moist

ii. Color of Conjunctiva: Pink

iii. Lesions: No

3. Edema

a. General: No

Abdominal girth: Not Assessed

Ankle girth: Not Assessed

4. Thyroid: Normal

5. Gag reflex: Present

6. Can patient move easily (turning, walking): Yes

7. Upon admission, was the patient dressed appropriately for the weather? – Yes

8. Breast exam: N/A

ELIMINATION PATTERN

OBJECTIVE

1. Auscultate abdomen: Not assessed

a. Bowel sounds: Not assessed

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2. Palpate abdomen:

a. Tender: No

b. Soft: Yes

c. Masses: No

d. Distention (include distended bladder): No

e. Overflow urine when bladder palpated? No

3. Rectal Exam:

a. Sphincter tone: Describe: Not assessed

b. Hemorrhoids: Not assessed
c. Stool in rectum: Not assessed
d. Impaction: Not assessed
e. Occult blood: Not assessed

4. Ostomy present: No

ACTIVITY-EXERCISE PATTERN

OBJECTIVE

1. Cardiovascular

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a. Cyanosis: No

b. Pulses: Easily palpable

Carotid: Yes; Jugular: Yes; Temporal: Yes

Radial: Yes; Femoral: Yes Popliteal: Yes

Postibial: Yes; Dorsalis Pedis: Yes

c. Extremities:

i. Temperature: Warm

ii. Capillary refill: Normal

iii. Nails: Normal

iv. Hair distribution: Normal

d. Heart: PMI location: Fifth intercostal space midclavicular line

i. Abnormal rhythm: No

ii. Abnormal sounds: No

2. Respiratory

a. Rate: 14cpm

b. Have patient cough. Any sputum? No

c. Fremitus: Present

d. Any chest excursion? No

e. Auscultate Chest:

i. Any abnormal sounds (rales, rhonchi)? No

f. Have patient walk in place for 3 minutes (if permissible):N/A

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ii. Any shortness of breath after activity? N/A

iii. Any dyspnea? N/A

v. BP after activity: N/A

vi. Respiratory rate after activity: N/A

vii. Pulse rate after activity: N/A

3. Musculoskeletal

a. Range of motion: Normal

b. Gait: Normal

c. Balance: Normal

d. Muscle mass/strength: Normal

e. Hand grasp: Right: Normal

Left: Normal

f. Toe wiggle: Right: Normal

Left: Normal

g. Postural: Normal

h. Deformities: No

i. Missing limbs: No

j. Uses mobility aids (walker, crutches, etc)? N/A

k. Tremors: No

4. Spinal cord injury: No

5. Paralysis present: No

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SUBJECTIVE

1. Have the patient rate each area of self-care on a scale of 0-4. (Scale has been

adapted by NANDA from E. Jones, et. Al., Patient Classification for Long Term

Care; User’s Manual. HEW Publication No. HRA-74-3107, November 1974.)

0 – Completely independent

1 – Requires use of equipment or device

2 – Requires help from another person for assistance, supervision or teaching

3 – Requires help from another person and equipment device

4 – Dependent; does not participate in activity

Feeding – 3; bathing/hygiene – 4; dressing/grooming – 4; Toileting – 4; Ambulation – 3

SELF-PERCEPTION AND SELF-CONCEPT PATTERN

OBJECTIVE

1. During this assessment, patient appears irritable

2. Did any physiologic parameters change? Face reddened: No, Voice volume changed:

Yes, Voice quality changed: No

3. Body language observed: Irritable

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4. Is current admission going to result in a body structure or function change for the

patient? Unsure at this time

ROLE-RELATIONSHIP PATTERN

OBJECTIVE

1. Speech Pattern

a. Is English the patient’s native language? No

Native language is Tagalog, there is no interpreter needed.

b. During interview have you observed any dysfunctional family interactions? No

SEXUALITY-REPRODUCTIVE PATTERN

OBJECTIVE:
Not assessed.

SUBJECTIVE
Not assessed.

COPING-STRESS TOLERANCE PATTERN

OBJECTIVE

1. Observe behavior: Are there any overt signs of stress? None observed

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VALUE-BELIEF PATTERN

OBJECTIVE

1. Observe behaviour: Is the patient exhibiting any sign of alterations in mood (anger,

crying, withdrawal, etc.)? Crying

SUBJECTIVE

1. Religion: Islam

GENERAL SURVEY

The patient is conscious, alert, febrile, no abnormal breath sounds upon

auscultation, while in MHBR position on the bed.

PAST HEALTH HISTORY

Patient K has no significant past medical history and had no known allergies.

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A.Y. 2022-2023

PRESENT HEALTH HISTORY

Patient K, 1-year-old male, was admitted on February 27, 2023, at 10:50 am with

an elevated temperature of 38.6°C, pulse rate of 118 bpm, and respiratory rate of 32 cpm.

The patient reported no significant past medical history and had no known allergies. On

physical examination, the skin appeared moist with no lesions or rash, firm turgor, and a

pink color. Mucous membranes examination revealed moist and pink mouth with normal

teeth and pink conjunctiva with no lesions. No edema was detected in the general body,

abdominal girth, or ankle girth. The thyroid examination was normal, and the gag reflex

was present. These findings suggest that the patient may be suffering from an acute

illness or infection that has caused the elevated vital signs. Further diagnostic tests and

treatment may be necessary to determine the underlying cause and manage the

symptoms.

FAMILY HEALTH HISTORY

Patient K’s grandmother stated none of them has a health history of any syndrome.

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IV. ANATOMY AND PHYSIOLOGY

The respiratory system is a complex network of organs, tissues, and cells that exchange gases

between the body and its surroundings. Its primary function is to provide oxygen to the body's

cells while also removing carbon dioxide, a waste product of metabolism.

The nose, pharynx, larynx, trachea, bronchi, and lungs comprise the respiratory system. Air

enters the body via the nose or mouth and travels down the pharynx to either the esophagus or

the trachea. The trachea, also known as the windpipe, is a tube that connects the pharynx to the

bronchi, the main air passages leading to the lungs.

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The bronchi divide into smaller and smaller tubes called bronchioles inside the lungs, which

eventually terminate in tiny air sacs called alveoli. The exchange of gases between the air and

the bloodstream occurs within the alveoli. Oxygen from the air diffuses into the bloodstream

and is transported to the body's tissues, while carbon dioxide, produced as a waste product by

the cells, is transported back to the lungs and exhaled.

The respiratory system is also important in maintaining the body's acid-base balance. The

respiratory system contributes to the proper pH balance in the blood by regulating carbon

dioxide levels in the body.

Parts of the lungs  Nose: the external component of the

respiratory system that serves as the

primary entry point for air into the body. It

filters, warms, and moistens the air we

breathe while also detecting odors.

Furthermore, the nose can humidify the air

to keep the nasal passages moist.

 Nasal cavity: is the hollow space inside the

nose that filters, warms, and moistens the

air we breathe. It also detects odors and

helps with speech production.

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 Pharynx: a muscular tube that connects the

nasal cavity, mouth, and esophagus to the

esophagus and larynx. It acts as a conduit

for air and food, guiding them to their

respective destinations and making

swallowing easier. The pharynx is

important for both the respiratory and

digestive systems, as well as for infection

protection.

 The larynx: also known as the voice box,

is in charge of producing sound as well as

protecting the airway during swallowing. It

houses the vocal cords, which vibrate as

air passes through them to generate sound.

Furthermore, the larynx prevents food and

liquid from entering the lungs during

swallowing.

 The trachea: serves as a passageway for air

between the larynx and the lungs. It also

has cilia and mucus-producing cells, which

aid in protecting the respiratory system

from harmful particles and bacteria.

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 The alveoli: are tiny, air-filled sacs in the

lungs that facilitate gas exchange. They

allow oxygen to enter and carbon dioxide

to exit the bloodstream. The alveoli's large

surface area allows for efficient gas

exchange, making them an essential

component of the respiratory system.

 Bronchus: are airways that branch off the

trachea and lead to the lungs. Their

primary function is to deliver oxygen and

carbon dioxide to the lungs and to

facilitate gas exchange in the alveoli. They

also have protective mechanisms like

mucus production and cilia to help keep

foreign particles and bacteria out of the

lungs.

 Bronchioles: are small, branching air

passages in the lungs that aid in the

delivery of oxygen and carbon dioxide to

the alveoli. Their primary function is to

control the amount of air that enters the

alveoli by contracting or dilating in

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response to the body's oxygen

requirements. They also protect the

respiratory system by producing mucus

and containing cilia, which aid in the

removal of foreign particles and bacteria.

 Lungs are the main organs of the

respiratory system and are responsible for

exchanging oxygen and carbon dioxide

between the air we breathe and the

bloodstream. They contain bronchi,

bronchioles, and alveoli, which facilitate

gas exchange and help to filter out harmful

particles and bacteria. The lungs also play

a role in regulating the body's pH balance

and protecting against infections.

 Diaphragm: is a dome-shaped muscle at

the bottom of the rib cage that is essential

for breathing. It flattens and expands the

chest cavity when it contracts, allowing air

to enter the lungs. It returns to its dome

shape when relaxed, pushing air out of the

lungs. The diaphragm is required for

proper respiratory system function.

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V. PATHOPHYSIOLOGY

Definition of the disease

Community-acquired pneumonia (CAP) is defined as an acute infection of the

pulmonary parenchyma in a patient who has acquired the infection in the community, as
distinguished from hospital-acquired (nosocomial) pneumonia. CAP is a common and
potentially serious illness with considerable morbidity. Lower respiratory tract infection
includes pneumonia, bronchitis, bronchiolitis, or any combination of the three. In the
United States, pneumonia is the most common cause of hospitalization in children.

Etiology

Etiology Present Justification

Predisposing Factors:

Precipitating Factors: From 6 months of age

 Age onwards, the maternal IgG

antibodies transmitted to

the child have decreased a

lot, at this time, the child’s

immune system is not yet

complete, but it is not until

3-4 years of age that this

system can fully produce

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these antibodies.

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This puts a child at risk of

acquiring CAP.

 Birth defects, Cleft lip and cleft palate

such as cleft occur when a baby's lip or

palate the roof of the mouth does

not form properly in the

womb. Cleft conditions

increase children's risk of

developing health

problems. They struggle to

receive adequate nutrition

due to their condition,

which subsequently

weakens their immune

response.

 Being born Survivors of preterm

prematurely birth face a lifelong

morbidity, with

increased risks of

cerebral palsy,

intellectual disability

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(Doyle, 2001; Mwanki

et al., 2012), respiratory

disease (Jobe et al.,

2008) and vision

impairment (O’Connor

et al., 2007). Preterm

infants are at high risk of

acquiring infections, and

this is a significant

contributor to mortality

in this group.

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 Nervous system Some people with cerebral

problems, such as palsy have weakened
seizures or immune systems that make
cerebral palsy them more susceptible to

infections and viruses.

Respiratory problems. A

variety of respiratory issues

can develop and cause life-

threatening situations for

people with cerebral palsy.

 Heart or lung COPD weakens the

disease present at respiratory system,

birth increasing vulnerability to

pneumonia. Because people

with COPD have weakened

airways and immune

systems, they are more

likely than people without

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COPD to die of

pneumonia.

 Weak immune HIV finds the white blood

system (this can cells , called CD4 cells.

occur due to HIV gets inside the CD4

cancer treatment cell and makes copies of

or disease such as itself. Then, HIV kills the

(HIV/AIDS) CD4 cell and the new HIV

copies find other CD4 cells

to get inside and start the

cycle again. HIV kills

immune system cells that

help the body fight

infections and diseases.

 Recent surgery or Surgery-related factors

such as sympathetic
trauma
nervous system activation,
blood transfusion, and
anesthetic agents induce a
postoperative
immunosuppression.
Traumatic injuries induce

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a complex host response

that disrupts immune
system homeostasis and
predisposes patients to
opportunistic infections
and inflammatory
complications.

Symptomatology

Signs/Symptoms Present Justification

Cough 
Pneumonia is an infection that
Fever  inflames the air sacs in one or
both lungs. The air sacs may
Chills 
fill with fluid or pus (purulent
Dyspnea material), causing cough with
phlegm or pus, fever, chills,
Fatigue  and difficulty of breathing.

Rigors 

Plural information, or
pleurisy, causes roughening of
the smooth surfaces of the
parietal and visceral pleurae.
Pleuritic Chest pain As these surfaces rub against
each other with normal
inspiration and expiration, a
scratching sound or friction
rub may be heard. This may
also occur in 4% of patients
with pneumonia or pulmonary
embolism.

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Schematic diagram of
Pneumonia
Alteration in net bacterial lung resistance caused by either:
 Decreased bactericidal ability of the alveolar macrophages
 Extreme virulence of the bacteria
 Increased susceptibility of host to infection

Acute inflammation occurs that causes excess water and plasma proteins go to the
dependent areas of the lobes.

RBCs, fibrin, and polymorphonuclear leukocytes infiltrate the alveoli.

Containment of the bacteria within the segments of pulmonary lobes by cellular

recruitment.

Consolidation of leukocytes and fibrin within the affected area.

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Stage of congestion:
Engorgement of alveolar spaces with fluid and hemorrhagic exudates.

Proliferation and rapid spread of organism through the lobe.

Stage of red hepatization:

Coagulation of exudates occurs resulting to the red appearance of the affected lung.

Stage of gray hepatization:

The decrease in number of RBC in the exudates is replaced by neutrophils; which

infiltrate the alveoli making the lung tissue to be solid and grayish in color.

PNEUMONIA

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NARRATIVE

The patient was diagnosed with pulmonary edema upon admission but was later
given a final diagnosis of PCAP MR after some tests. Unlike edema, pneumonia is
caused by viral, fungal, or bacterial infection. As your lungs become infected, fluid builds
up in the air sacs (alveoli). While pulmonary edema and pneumonia cause buildup in the
lungs, the former is primarily caused by CHF. Pneumonia, on the other hand, is caused
by an infection.

Prior to admission, he experienced fever attributed to his illness, as well as cough,

chills, fatigue and rigor. The patient’s age is the main predisposing factor that increased
his risk of acquiring CAP. Since the patient is only one year old with under developed
immunesystem.

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VI. COURSE IN THE HOSPITAL

Medical Management

a. Doctor’s Progress Notes

eating well can
help improve
Date Ordered Progress Notes Doctor’s Order Rationale
mental
acuteness, boost
- Please admit dc For management
2/27/2023 your energy
Wt: 10.5kg levels, and
10:50am
Temp: 38.6 C increase your
PR: 118bpm - TPR Q4 For monitoring
resistance to v/s
RR: 32cpm illness.
- DFA eating well can help
For mental
improve
monitoring
acuteness, boost your
2/27/2023 energyv/slevels, and
T: 38.1 C
4:00pm increase your
PR: 140bpm
RR: 56cpm resistance
For to illness.
maintenanace
of fluid and
For replacement
electrolytes or
- IVF D5.3NaCl 500ml maintenance
especiallyof
to fluid
8:00pm KVO patients who
& electrolytes.
T: 38.4 C need calories
PR: 126bpm and hydration.
RR: 60cpm

12:00am T: 37.8 C
PR: 120bpm
RR: 40cpm

4:00am T: 37 C
PR: 128bpm
RR: 46cpm

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2/28/2023
8:00am T: 37.3
PR: 98bpm
RR: 56cpm

12:00pm T:37C -DFA

PR:95bpm
RR:55cpm

6:00pm
T: 37.7 C
PR: 98bpm
RR: 48cpm - TPR Q4

3/1/23
8:00 am
T: 37.5 C - D5IMB KVO
PR: 110bpm
RR: 40com

12:00pm
- Paracetamol @
10:30 help treat pain
T: 37.7 C and reduce a
PR: 90 bpm high
RR: 39cpm temperature
4:00pm (fever).

T: 37.5 C -BT d/c @ 11:20am A blood

transfusion is a
PR: 84bpm
routine medical
8:00pm RR: 34cpm procedure in
which donated
blood is
T: 37.5 C provided to you
PR: 89bpm through a
3/2/23 RR: 34cpm narrow tube
12:00am placed within a
vein in your
arm.
T: 37.1 C
PR: 90bpm
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 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2022-2023

4:00am RR: 35cpm

6:00am T: 37 C
PR: 85bpm
RR: 34cpm

8am T:37.3 C
PR: 88bpm
RR:34cpm

12:00pm
T:37.3
PR: 98bpm
RR: 30cpm

3/3/23
8:00am T:37.2 C
PR: 95bpm
RR: 35cpm

12:00pm
T: 36.8 C
PR: 106bpm
RR: 40cpm

T:37.4 C
PR: 108bpm
RR: 40cpm

37
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2022-2023

b. Laboratory/ Diagnostic Examination

PROCEDURE PURPOSE NORMAL RESULT INTERPRETATION

RANGE

02/27/23
A tests Hematological tests
Hematology
include tests can help diagnose
on the blood, anemia, infection,
blood hemophilia, blood-
proteins and clotting disorders, and
blood- leukemia.
producing
organs. A
test used to
determine the
amount of
hemoglobin
in the blood.
Hgb is the
pigment part
of the
erythrocyte,
and the
oxygen-
carrying part
of the blood.

For men, a normal

WBC They help (4.5 to 11.0 × 7.8
white blood cell count
the body 109/L)
is anywhere between
fight
5,000 and 10,000
infection
white blood cells per
and other
μl of blood. For
diseases.
women, it is a reading
of between 4,500 and
11,000 per μl, and for
children between
38
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2022-2023

5,000 and 10,000.

allows it to M:120-160g/L 73
Hemoglobin pick up F:110-150g/L If a hemoglobin test
oxygen reveals that your
from the air hemoglobin level is
we breathe lower than normal, it
and deliver means you have a low
it red blood cell count
everywhere (anemia).
in the body.

measures
Hematocrit the M:40.0 – 50% 0.22 A hematocrit level
proportion F:37.0-48.50% below the normal
of red blood range, meaning the
cells in your person has too few red
blood. blood cells, is called
anemia.

A platelet
count is a Too few platelets can
Platelet test that 150 – 450 x be a sign of cancer,
40
measures 10^9/L infections or other
the number health problems. Too
of platelets many platelets put
in your you at risk for blood
blood. clots or stroke. There
Platelets are are tens of thousands
cells that of platelets in a single
help your drop of blood.
blood clot

Segmented
Segmenters neutrophils Normally, most of the
are the 47 - 55 % 0.44 neutrophils circulating
mature in the bloodstream are
neutrophils in a mature form, with
that respond the nucleus of the cell
to being divided or
inflammatio segmented.
n&
infection.
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 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2022-2023

B
lymphocyte A type of immune cell
Lymphocytes
s make 20.0 – 40.0% 0.47 that is made in the bone
antibodies, marrow and is found in
and T the blood and in lymph
lymphocyte tissue. The two main
s help kill types of lymphocytes
tumor cells are B lymphocytes and
and help T lymphocytes.
control
immune
responses.

Macrophage
Monocytes s surround A type of immune cell
and kill 3.0 – 90.0% 0.09 that is made in the
microorgani bone marrow and
sms, ingest travels through the
foreign blood to tissues in the
material, body where it becomes
remove a macrophage or a
dead cells, dendritic cell.
and boost
immune
responses.

40
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2022-2023

02/27/23 10PM M:40.0 – 50% 0.21

F:37.0-48.50%
Hematocrit

Platelet 150 – 450 x 40

10^9/L

02/28/23
Hematocrit M:40.0 – 50% 0.20
F:37.0-48.50%

Platelet
150 – 450 x 42
10^9/L

02/28/23 2PM
Hematocrit M:40.0 – 50% 0.24
F:37.0 –
48.50%

Platelet 150 – 450 x

35
10^9/L

02/28/23 10PM
Hematocrit
M:40.0 – 50%
0.21
F:37.0 –
48.50%

41
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2022-2023

150 – 450 x
Platelet 43
10^9/L

03/01/23 5AM
Hematocrit M:40.0 – 50%
0.22
F:37.0-48.50%

Platelet
150 – 450 x
48
10^9/L

03/01/23 10PM
Hematocrit M:40.0 – 50%
0.29
F:37.0-48.50%

150 – 450 x
10^9/L
Platelet 62

03/02/23 M:40.0 – 50%

0.31
Hematocrit F:37.0-48.50%

(4.5 to 11.0 ×
WBC 7.7
109/L)

Hemoglobin M:120-160g/L
103
F:110-150g/L

150 – 450 x
Platelet 65
10^9/L
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 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2022-2023

X-RAY REPORT

Chest AP to There are hazy X-rays pass from the

evaluate infiltrates in anterior to the
the the inner and posterior of the patient
lungs, - hence Anterior-
mid lung
heart and Posterior (AP)
zones. projection.
chest
wall and
may be Heart is not Look for equal
used to enlarge radiolucency between
help the left and the right
diagnose Diaphragm lungs zones. The
shortness and horizontal fissure on
of breath, costophrenic the right divides the
persistent sinuses are upper and middle
cough, intact lobes; from the hilum
fever, to the 6th rib at the
chest axillary line. You
The bony should also check soft
pain or
injury. thorax is tissues outside the
unremarkable thorax for
subcutaneous air,
Impression: foreign body, bizarre
Pneumonia density, etc.

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 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

C. Pharmacologic Management (Drug Study

Generic Name Drug Brand Mode of Indication Contraindication Adverse/ Usual/ Nursing
Classification Name Action Side Actual Responsibilities
Effects Dose

Ceftriaxone Therapeutic Rocephin Inhibits Lower Contraindicated in CNS: Meningitis Monitor signs of
class: cell-wall respiratory patients Headache, Children: pseudomembran
synthesis, infections hypersensitive to dizziness, Initially, ous colitis,
Antibiotics promoting caused by lethargy. including
drug or other 100 mg/kg
osmotic Streptococcu GI: diarrhea,
instability; s pneumonia, cephalosporins. pseudome IM or IV; abdominal pain,
Pharmacologic usually Staphylococc mbranous then 100 fever, mucus in
class: bactericidal us aureus, Use cautiously in colitis, mg/kg/day stools, and other
Haemophilus patients diarrhea, as a single severe or
Third- influenza, hypersensitive to anorexia, dose or in prolonged GI
generation E.coli, penicillin because nausea, divided problems
cephalosporin Enterobacter vomiting. (nausea,
of possibility of doses every
aerogenes. vomiting, and
Intra- cross-sensitivity Hematolog 12 hours heartburn).
abdominal with other beta- ic: for 7 to 14 Monitor signs of
infections lactum antibiotics. bleeding, days. allergic
caused by eosinophili Maximum reactions and
E.coli, To reduce a, dose is 4 anaphylaxis,
Klebsiella development of hemolytic g/day. including
pneumoniae anemia, pulmonary
drug-resistant leukopenia, symptoms
bacteria and thrombocyt Acute (tightness in the
maintain osis. bacterial throat and chest,
47
NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

effectiveness of otitis wheezing, cough

antibacterial drugs, media dyspnea) or skin
use drug only to Skin: reactions (rash,
pain, Children: pruritus,
treat or prevent
induration, 50 mg/kg urticaria).
infections proven tenderness Monitor signs of
IM as a
or strongly at injection single dose. blood
suspected to be site, rash. Don’t dyscrasias,
caused by bacteria. exceed 1 g. including
Other: eosinophilia
Use cautiously in super (fatigue,
Acute
infections, weakness, and
patients with otitis
disulfiram- myalgia),
history of colitis, like media hemolytic
renal insufficiency, reaction Children: anemia (malaise,
or GI or with 50 dizziness,
gallbladder alcohol mg/kg/day jaundice, and
disease. IV or IM abdominal pain),
leukopenia
for 1 to 3
(fever, sore
consecutive throat, mucosal
days in lesions, signs of
patients infection),
unresponsi thrombocytosis
ve to initial (headache,
antibiotic dizziness, chest
pain, fainting,
therapy and visual
in patients disturbances,
with numbness or
penicillin tingling in the
hands and feet).
48
NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

allergy. Monitor
injection site for
pain, swelling,
and irritation.
Report
prolonged or
excessive
injection site
reactions to the
physician.

49
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

Generic Name Drug Brand Mode of Indication Contraindication Adverse/ Usual/ Nursing
Classification Name Action Side Actual Responsibilities
Effects Dose

Furosemide Therapeutic Lasik Inhibits the Furosemide Contraindicated in: CNS: Edema Observe 6rights
class: reabsorption is indicated  Hypersensi Headache, PO in giving
of sodium for the tivity; dizziness, (Children medication
and chloride treatment of  Cross- weakness, >1 mo): 2
Anti- from the edema restlessness mg/kg as a
hypertensive loop of associated sensitivity , fever. single Test if the
Henle and with with CV: dose; may patient is
distal renal congestive thiazides orthostatic be ↑ by 1–2 allergic to the
Pharmacologic tubule. heart failure, and hypotensio mg/kg drug.
class: Increases Edema due sulfonamid n, every 6–8
renal to cardiac, es may thrombophl hr Monitor weight,
Loop diuretics excretion of hepatic ebitis with (maximum
occur; blood pressure,
water, &renal IV dose = 6
sodium, disease,  Hepatic administrat mg/kg). and pulse rate
chloride, burns; mild coma or ion. routinely with
magnesium, to moderate anuria; GI: PO long term use
potassium, HTN,  Some abdominal (Neonates): and during rapid
and hypertensive liquid discomfort 1–4 dieresis. Use can
calcium. crisis, acute and pain, mg/kg/dose lead to profound
products
Effectivenes heart failure, diarrhea, 1–2
may water and
s persists in reduced anorexia, times/day.
impaired urinary contain nausea, IM IV electrolyte
renal output due to alcohol, vomiting. (Children): depletion.
function. gestoses, avoid in 1–2
Therapeutic chronic renal patients Hepatic: mg/kg/dose Lab tests:
Effect(s): failure, with hepatic every 6–12 Obtain frequent
Diuresis and nephrotic dysfunction hr;
alcohol blood count,
subsequent syndrome , increased Continuous
50
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

mobilization intolerance. liver infusion– serum and urine

of excess enzymes 0.05 electrolytes,
fluid Use Cautiously in: Skin: mg/kg/hr, CO2, BUN,
(edema,  Severe dermatitis, titrate to
blood sugar, and
pleural hepatic purpura, clinical
effusions). uric acid values
impairment photosensit effect.
Decreased ivity IM IV during first few
(may
BP. reactions, (Neonates): months of
precipitate transient 1–2 therapy and
hepatic pain at IM mg/kg/dose periodically
coma; injection every 12– thereafter.
concurrent site, toxic 24 hr.
use with epidermal
Monitor for
potassium- necrolysis.
S&S of
sparing
hypokalemia.
diuretics
may be
Monitor I&O
necessary);
ratio and
 Electrolyte
pattern. Report
depletion;
decrease or
 Diabetes unusual increase
mellitus; in output.
 Hypoprotei Excessive
nemia (↑ diuresis can
risk of result in
ototoxicity) dehydration and
; hypovolemia,
 Severe circulatory
renal
51
NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

impairment collapse, and

(↑ risk of hypotension.
ototoxicity) Weigh patient
; daily under
Potential fetal standard
risk; conditions.

Monitor urine
and blood
glucose &
HbA1C closely
in diabetics and
patients with
decompensated
hepatic
cirrhosis. Drug
may cause
hyperglycemia.

52
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

Generic Name Drug Brand Mode of Indication Contraindication Adverse/ Usual/ Nursing
Classification Name Action Side Actual Responsibilities
Effects Dose

Paracetamol/ Antipyretics, Abenol, Inhibits the PO, Rect: Previous CNS: tablet Before:
Acephen, agitation Check the body
Acetaminophen Nonopioid Acet, synthesis of Treatment of: hypersensitivity; (V), 325mg temperature. Do
Analgesics APAP, prostaglandi Mild pain, Products anxiety, 500mg not exceed
Artritol, ns that may Fever. IV containing alcohol, fatigue, 4gm/ffi4hr. in
Aspirin headache, adults and
Free serve as Treatment of: aspartame,sacchari insomnia, caplet 75mg/kg/day in
Anacin, mediators of Mild to n, sugar, or pyrexia. 325mg children.
Atasol, pain and moderate tartrazine (FDC CV: HTN, 500mg Do not take for
Cetafen, hypotensio >5days for pain
Feverall, fever, hain, yellow dye #5) n, 650mg in children, 10
Fortolin, primarily in Moderate to should be avoided peripheral days for pain in
Infantaire the CNS. severe pain in patients who edema, capsule adults, or more
, Little periorbital than 3 days for
Fevers, Has no with opioid have edema, 325mg fever in adults.
Mapap, significant analgesics, hypersensitivity or tachycardia 500mg Extended-
Nortemp anti- Fever intolerance to (IV) Release tablets
Children' Gl: nausea, are not to be
s, inflammator these compounds; vomiting, caplet, chewed.
Ofirmev, y properties Severe hepatic abdominal extended-
Pain-Eze, or G impairment/active pain, release Avoid using
Pediaphe diarrhea OTC drugs with
n, toxicity. liver disease. constipatio 650mg Acetaminophen.
Pediatrix, n (IV) This drug is not
Silapap, GU: tablet, oral- for regular use
Silapap oliguria with any form of
Infant's, Hematologi disintegrati liver disease.
Taminol, c: ng
Tempra,T hemolytic 80mg DURING:
ylenol, anemia, Take with food
Valorin leukopenia, 160mg or milk to
neutropenia minimize Gl
, upset.
53
NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

pancytopen tablet Avoid alcohol.

ia, anemia. Report NffV.
Hepatic: chewable cyanosis,
jaundice 80mg shortness of
Metabolic: breath and
hypoalbum abdominal pain
inemia solution or as these are
hypervole suspension, signs of toxicity.
mia, oral Report paleness,
hypomagne weakness, and
semia 160mg/5m heartbeat skips
L Report
Musculosk abdominal pain,
eletal: jaundice, dark
muscle liquid oral urine, itchiness
spasms, 160mg/5m or clay-colored
extremity L stools.
pain AFTER:
Respiratory 500mg/5m Monitor CBC,
: abnormal L liver and renal
breath syrup oral functions.
sound, Assess for fecal
dyspnea, 160mg/5m occult bood and
hypoxia, L nephritis. Report
atelectasis, pain that persists
pleural for more than 3-
effusion, 5 days
pulmonary
edema,
stridor,whe
ezing
Skin: rash,
urticaria;
infusion
site pain,
pruritus

54
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

Generic Name Drug Brand Mode of Indication Contraindication Adverse/ Usual/ Nursing
Classification Name Action Side Actual Responsibilities
Effects Dose

Salbutamol + Therapeutic Combiven Ipratropium Chronic Hypersensitivity to Significant: Maximum Before:

class: t respimal, is a Hypersensiti Dose: Solution for
Ipratropium Bronchodilator DuoNeb, nonselective obstructive salbutamol, vity Soft-mist nebulization
Pharmacologic Combiven competitive pulmonary ipratropium or reactions inhaler: 6(Duoneb): The
t antirhuscari disease. fenoterol, atropine (urticaria, inhalations/ choice of using a
Class: nic agent. It angioedema, day mouthpiece
Anticholinergic causes Treatment of or its derivatives. rash, Nebulizatio versus a face
Agent; Beta2- bronchodilat chronic Hypertrophic anaphylaxis, n solution: 6mask must be
ion by obstructive obstructive bronchospas vials [18made based on the
Adrenergic blocking the m, mL/day skills and
Agonist action of pulmonary cardiomyopathy, oropharynge understanding of
acetylcholin disease tachyarrhythmia. al oedema). Minimum each individual
e induced (COPD) in paradoxical Dose: patient.
stimulation bronchospas Soft- -f the patient is
of those patients m, ocular mistinhaler. using other
guanylcycla who are complicatio One nebulized
se, hence currently on a ns inhalation 4 medications,
reducing (mydriasis, times daily instruc them to
formation of regular blurred Nebulizatio use albuterol
cyclic bronchodilator vision, ipratropium first
guanosine who continue narrow- n solution. and walt 10
monophosp angle Initial: 1 minutes before
hate to have glaucoma, using other
(cGMP) at bronchospasm eye pain), vial (3 mL) nebulized
parasympath s and require a serious (ipratropium medications as
etic site. hypokalaem directed.
Salbutamol second ia, bromide 0.5
activates bronchodilator gastrointesti mg/albuterol Inhalation
adenyl nal motility spray(Combivent
cyclase, the disturbances 2.5 mg) Respimat):
enzyme that , rapidly every 6 Instruct patient on
stimulates worsening proper inhalation
the dyspnoea, hours technique
production ECG according to
of cyclic changes, allergy. product directions
47
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

adenosine- lactic -prior to first use,

3',5'- acidosis, insert the
monophosp urinary cartridge into the
hate retention. inhaler and prime
(CAMP). Rarely. the unit by
Increased myocardial actuating the
CAMP leads ischaemia. inhaler toward the
to activation ground until an
of protein Cardiac aerosol cloud is
kinase A, disorders: visible and then
which Palpitations, repeating the
inhibits tachycardia. process three
phosphoryla more times. The
tion of Gastrointesti unit is then
myosin and nal considered primed
lowers disorders: and ready for use.
intracellular Dry mouth, During:
ionic Ca nausea. Sotion for
concentratio nebulization
ns, resulting Nervous (Dugeb)
in smooth system -Deliver solution
muscle disorders: by jet
relaxation. Headache. nebulization
connected to an
Respiratory, air compressor,
thoracic and equipped with a
mediastinal mouthpiece of
disorders: suitable face mask
Coughing, over <= 15
dysphonia. minutes.
-Advise the
patient that using
the 'blow by
technique
(holding the face
mask or open tube
near the patient's
nose and mouth)
is not
recommended.
Inhalation spray
(Combivent
Respimat).
-Hold the inhaler
upright with the
48
NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

orange cap closed,

so as to not
accidentally
release a dose of
medicine. Turn
the clear base in
the direction of
the white arrows
on the label until
clicks (half a
turn). Then, flip
the orange cap
until it snaps fully
open.
-Have patient
breathe out slowly
and fully, and
then close their
lips around the
end of the
mouthpiece
without covering
the air vents.
- Instruct patient
to point the
inhaler to the back
of his/her throat.
- The patient
should hold the
breath for 10
seconds or for as
long as
comfortable.
After:
Inhalation spray
(Combivent
Respimat)
- Close the orange
cap until it is time
to use the inhaler
again.
-The mouthpiece
including the
metal part inside
49
NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

the mouthpiece,
should be cleaned
with a damp cloth
or tissue only, at
least 1 time a
week; any minor
discoloration in
the mouthpiece
does not affect the
inhaler. If the
outside of the
inhaler gets dirty,
wipe it with a
damp cloth.

50
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

Generic Name Drug Brand Mode of Indication Contraindication Adverse/ Usual/ Nursing
Classification Name Action Side Actual Responsibilities
Effects Dose

Phytonadione Functional: Vitamin Promotes Prevention, None known Pain, 0.5 ml Monitor PT,
K
antihemorrhagi hepatic treatment of Cautions: Renal soreness, Route: IM international
C formation of hemorrhagic impairment. swelling at normalized ratio
coagulation states in newborns (esp. IM (INR) routinely
Chemical: factors II, neonates. premature): Risk injection in those taking
Fat-soluble VII, IX, X. Antidote for of hemolysis, site, anticoagulants
vitamin. Essential for hemorrhage jaundice. pruritic
normal induced by hyperbilirubinemia erythema Assess skin for
clotting of oral (with ecchymoses,
blood. anticoagulant repeated petechiae Assess
Readily s. injections), gums for
absorbed hypoprothro facial gingival
from Gl mbi nemic flushing, bleeding.
tract states due to altered Erythema
(duodenum) vitamin K taste
after IM deficiency Assess urine for
subcutaneou Hypoprothro hematuria.
s mbi nemia Assess Hct,
administrati caused by platelet count.
on malabsorptio urine/stool
Metabolized n or inability culture for
in liver. to synthesize occult blood.
Excreted in vitamin K
urine; Assess for
eliminated decrease in B/P,
by biliary increase in pulse
51
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

system rate, complaint

Onset of
coagulation abdominal/back
of action pain, severe
(increased headache (may
factors. be evidence of
hemorrhage)

Assess for
increase in
amount of
discharge during
menses

Assess
peripheral
pulses Check for
excessive
bleeding from
minor cuts,
scratches.

52
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

Generic Name Drug Brand Mode of Indication Contraindication Adverse/ Usual/ Nursing
Classification Name Action Side Actual Responsibilities
Effects Dose
Short-term
Ranitidine Histamine Zantac Competitive treatment of Ranitidine is CNS 50 mg q8h Assessment for
Hydrochlonde antagonists ly inhibits active contraindicated for headache,
the action of duodenal patients known to malaise, 1.History allergy
histamine at ulcer have dizziness, to ranitidine,
the H2 hypersensitivity to somnolenc impaired renal
receptors of Short-term the drug or any of e, or hepatic
the penetal treatment of the ingredients. insomnia, function,
cells of the active, Acute porphyria, vertigo, lactation,
stomach, benign Treatment with Dermatolo pregnancy
inhibiting gastric ulcer ranitidine may gic: rash,
basal gastric mask the alopecia 2.Physical skin
acid Maintenance symptoms of other lesions,
secretion therapy for gastric disease, CV orientation,
and gastric duodenal Raised liver Tachycardi affect, liver
acid ulcer at enzymes may a, evaluation,
secretion reduced occur with high bradycardia abdominal
that is dosage doses. examination,
stimulated GI normal output,
by food, Short-term constipatio renal function
insulin, treatment for n, diarrhea, tests, CBC
histamine, GERD nausea and
cholinergic vomiting. Interventions:
agonists, Pathologic abdominal
gastrin and hypersecretor pain, 1. Administer
pentagastrin y conditions hepatitis oral drug with
. (Zollinger- meals and at
53
NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

Ellison GU bedtime
syndrome) impotence
or 2. Decrease
Treatment of decreased doses in renal
erosive libido and liver failure
esophagitis
Hematologi 3. Provide
Treatment of c concurrent
heartburn, leucopenie, antacid therapy
acid granulocyt to relieve pain
indigestion, openia
sour stomach thrombocyt 4.Administer IM
openia dose undiluted,
pancytopen deep into large
ia muscle group

5. Arrange for
regular follow-
up including
blood test, to
evaluate effects.

54
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

Generic Name Drug Brand Mode of Indication Contraindication Adverse/ Usual/ Nursing
Classification Name Action Side Actual Responsibilities
Effects Dose

Hydrocortisone Corticosteroids Hydrocor Enter target Shock due to Systemic fungal Severe Tablet Note degree of
tisone,
Cortef, cells and acute infections, headache, 5 mg involuntary
Alkindi binds to adrenocortica premature infants confusion, 10 mg movements
Sprinkle cytoplasmic l slurred 20 mg muscle spasm or
receptors insufficiency, speech, rigidity and
initiates anaphylaxis arm or leg Powder for drooling.
many asthma and weakness, injection
complex COPD. trouble Provide patient
reactions walking, 100 mg safety when
that is loss of 250 mg vertigo is
responsible coordinatio 500 mg present.
for anti- n, feeling 1g
inflammator unsteady, Monitor for
y actions. very stiff consistency like
muscles, the color and
high fever, amount of stool.
profuse
sweating, If patients
or tremors; develop urinary
Serious eye hesitancy, assess
symptoms for bladder
such as distention.
sudden
vision loss,
blurred
vision,
tunnel
55
NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

vision, eye
pain or
swelling, or
seeing
halos
around
lights;
Serious
heart
symptoms
include
fast,
irregular,
or
pounding
heartbeats;
fluttering
in the
chest;
shortness
of breath;
sudden
dizziness,
lighthearte
dness, or
passing
out.

56
 NOTRE DAME OF MIDSAYAP COLLEGE
COLLEGE OF NURSING
A.Y. 2020-2021

ii. Nursing Management

NURSING CARE PLAN (POTENTIAL)

ASSESTMENT NSG Dx PLANNING INTERVENTION RATIONALE

DATE: Risk for In the 8 hours Independent: - Factors can
02/29/2023 hyperthermia of shift, the - Identify include excessive
TIME: 8:00 AM secondary to patient will underlying heat production,
Pediatric maintain core cause. such us occurs
SUBJECTIVE: Community- temperature with convulsions,
“Iritable po siya, Acquired within infections or
ma’am,” as S.O Pneumonia normal sepsis and use of
verbalized Moderate range. - Note sympathomimetic
Risk (PCAP chronological drugs.
Objective: MR) related and - Infants, young
Vital sign to in developmental children, and
(Temperature) appropriate age of client. elderly persons
clothing are most
V/S: susceptible to
CR – 98 bpm - Monitor core damaging
RR – 56 cpm temperature by hyperthermia.
Temp – 38.7oC appropriate
route (e.g., - Rectal and
tympanic, tympanic
rectal). Note temperatures most
the presence of closely
temperature approximate core
elevation temperature.
(37oC) or fever
(38oC).
- Assess
neurological - High fever
responses, accompanied by
noting the level changes in
of mentation may
consciousness indicate septic
and orientation, state or
reaction to heatstroke.
stimuli,

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reaction of
pupils, and
presence of - Dysrhythmias and
posturing or electrocardiogram
seizures. (ECG) changes
- Monitor heart are common due
rate and to electrolyte and
rhythm. acid-base
imbalances,
dehydration,
specific action of
catecholamines,
and direct effects
of hyperthermia
on blood and
cardiac tissue.

Dependent:
- Administer
medications - To control
(e.g., shivering and
dantrolene, seizures.
chlorpromazine
, or diazepam),
as ordered. - To treat
- Administer underlying cause
medications, as such as infection,
indicated, such malignant
as antibiotics, hyperthermia, or
dantrolene, or thyroid storm.
beta-adrenergic
blockers.
- To promote rapid
Collaborative: cooling core.
- Assist with
internal cooling - To offset
methods to increased oxygen
treat malignant demands and
hyperthermia. consumption.
- Provide - To support
supplemental circulating
oxygen. volume and tissue
- Administer perfusion.
replacement
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fluid and
electrolytes.

NURSING CARE PLAN (ACTUAL)

ASSESTMEN NSG Dx PLANNIN INTERVENTION RATIONALE

T G
DATE: Ineffective In the 8 Independent:
02/29/2023 thermoregulatio hours of - Note client’s - Can directly impact
TIME: 8:00 n secondary to shift, the age and ability to maintain
AM Pediatric patient will developmenta or regulate body
Community- maintain l level. temperature.
SUBJECTIVE: Acquired body - Thermoregulation is
“Iritable po Pneumonia temperature - Obtain history a controlled process
siya, ma’am,” Moderate Risk within concerning that maintains the
as S.O (PCAP MR) normal present body’s core
verbalized related to limits. symptoms, temperature in the
environmental correlate with range at which most
Objective: temperature. previous biochemical
Skin warm to episodes or processes work best
touch family (36.5oC-37.5oC)
history, and
V/S: diagnostic - Tympanic,
CR – 98 bpm studies. temporal, and oral
RR – 56 cpm temperatures most
Temp – 38.7oC closely approximate
- Monitor core temperature.
temperature
by appropriate
route (e.g.,
tympanic,
temporal, - To prevent or
oral) using the compensate for
same site and client’s heat
device over production or heat
time and loss (e.g., may need
noting to add or remove
variation from clothing or blankets,
client’s usual avoid drafts, reduce
or normal or increase room
temperature. temperature and
- Maintain humidity).
ambient
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temperature in
comfortable - To control shivering
range. and seizures.

Dependent:
- Review
client’s
medications - To treat underlying
for possible cause such as
thermoregulat infection, malignant
ory side hyperthermia, or
effects (e.g., thyroid storm.
diuretics,
certain
sedatives and - To identify potential
antipsychotic internal causes of
agents, temperature
anticholinergi imbalances.
cs,
anticonvulsan
ts, some heart - That can cause or
and blood contribute to body
pressure temperature
medications, disturbances.
anesthesia).
- Administer
medications, - To restore or
as indicated, maintain body and
such as organ function.
antibiotics,
dantrolene, or
beta- - To restore or
adrenergic maintain body
blockers. temperature within
normal range.
Collaborative:
- Monitor
laboratory
studies (e.g.,
tests
indicative of
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infection,
organ
damage, drug
screens)
- Collaborate in
treatment of
underlying
conditions
(e.g., severe
malnourishme
nt,
dehydration).
- Administer
fluids,
electrolytes,
and
medications,
as
appropriate.
- Initiate
emergent
and/or
immediate
interventions
such as
occlusive
wrap in
delivery
room; cooling
or warming
measures
(e.g., fluids,
electrolytes,
nutrients, and
medications
[e.g.,
antipyretics,
antibiotics,
neoplastics])

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VIII. PROGNOSIS

A. Ideal

A patient undergoes an oophorectomy due to kinking of the cyst that causes her right

flank pain. If the pain did not manage earlier it causes complications to her that will lead

to death. The post-operative drugs need to be worked out to avoid complications such as

infection because there is a presence of the post-op wounds.

B. Actual

CRITERIA POOR FAIR GOOD JUSTIFICATION

1. Duration of * The patient was diagnosed in

illness the year 2019 with a
diagnosis of ovarian new
growth. She suffered right
flank pain due to the large
size of the cyst that caused a
twisting of the cyst (torsion).

2. Onset of illness * The onset of illness is poor

because the patient was
diagnosed 4 years ago with
ovarian new growth.

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3. Precipitating * It is poor because her aunt

was diagnosed with ovarian
cancer which is related to her
diagnosis. Some evidence
suggests that certain
individuals may be more
genetically predisposed to
specific types of functional
ovarian cysts (PubMed,
2020).

4. Willingness to * Good because the pt. took

take medication her post op. medications.
Post-surgical pain control
helps speed your recovery
and reduces chances of
complications (Centers for
Disease Control and
Prevention, 2020).

5. Age * Poor because at her age she is

prone for development of
ovarian cyst. Ovarian cysts
and tumors may occur at any
age but are most common
between puberty and
menopause.(Alder, 2021)

6. Environment * Good because the

environment of the patient is
located in an urban area that
will not affect the
development of the cyst.

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7. Family support * Good because the family of

the pt. is there for her to help
and assist for recovery. Her
husband is there at her side
while she is recovering.
Presence of family or friends
can improve patient
outcomes at any stage in
rehab (Johnson, 2022)

COMPUTATION:

GOOD - 3/7 = 0.42

FAIR – 0/7 = 0

POOR – 4/7 = 0.52

INTERPRETATION: Poor, because the patient was diagnosed with ovarian new

growth. She noticed a palpable mass at her abdomen. One of the causes of her

development of cyst is there a family history of ovarian cancer that causes her to develop

a cyst at ovary. Lack of financial support causes her to not undergo a surgery immediately

that leads to her a complication such as torsion.

And now she is admitted to the hospital for recovery from oophorectomy surgery. The

patient is taking her medications accurately. The patient appeared weak because of the

post-op surgery and pain at the incision site. With good family support the patient will be

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able to recover quickly because her family and her husband is always there to help him to

care for his wife to recover fully.

VII. PROGNOSIS

A. Ideal
A patient undergoes a blood transfusion due to the patients may need a higher hemoglobin (Hb)
trigger than that suggested by the AABB guidelines. If it is not managed earlier, t causes complications
that will lead to death. The drugs for PCAP needs to be worked out to avoid complications such as
infection because there is a presence of ineffective airway.

B. Actual

CRITERIA POOR FAIR GOOD JUSTIFICATION

1. Duration of The patient was

Illness * diagnosed with
PCAP. He
suffered in
difficulty of
breathing that
causes fatigue.

2. Onset of The onset of

* illness is fair
Illness
because the
patient got
relieved in his
condition.

3. Precipitating It is poor because

* some evidence
suggests that
contain
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individuals may
be more
genetically
predisposed to
specific types of
pneumonia.

Poor because the

4. Willingness to * patient refused
take medications the medications.
PCAP drugs helps
to speed the
recovery and
reduces chances
of complications.

5. Age * Poor because at

his age, he is
prone for the
development of
pneumonia.
Pneumonia may
occur at any age
but are most
common in
pediatric patients.

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IX. Discharge Plan

Medication:

 Give the patient instructions on taking medication at home.

 Discuss how to take the drug, its precise dosage, and how often to take it in order to ensure
effectiveness and prevent over- or under-dosing.

 Emphasize the significance of taking prescription medications as directed, especially

antibiotics.

 Provide a copy of the take-home prescription that reflects the dosage, frequency, and days to
take the medication.

 Emphasize on continuing to take the prescribed maintenance medication.

Exercise:

When directed by his or her healthcare professional, have your youngster resume his
or her regular activities. Find out what activities are safe for your youngster by asking
the healthcare provider.

Teachings:

Make sure the child receives adequate rest. He or she might feel worn out and not desire to
accomplish as many things as usual.

When instructed by their healthcare provider, have the youngster resume their regular activities.
Inquire with the medical professional about the appropriate activities for the child.

Don't let the child near a smoking area. Coughing and other symptoms in children can get worse
when exposed to smoke.

Place the child in a partially upright position for sleep. The child should sleep with a couple
pillows beneath their heads or in a recliner. Coughing is aggravated when lying down.

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Diet:

 Make sure the child consumes a nutritious diet. That consists of a lot of fresh fruits, vegetables,
whole grains, low-fat dairy products, and lean protein.

 Make sure the child drinks enough fluids to maintain a light yellow urine. This might aid in
thinning mucus.

Out-patient visit:

Do as child's doctor instructed and attend all follow-up appointments.

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X. Conclusion

Case studies demand attention and the gathering of adequate information. It is also an effective
teaching tool because it makes students think about the full range of a patient's care, from gathering
adequate data to diagnosing and treating a medical condition. It could take a lot of time and effort, but
it will benefit the student in learning about the disease and how to provide appropriate nursing
intervention and quality care for their patient.

A child with pneumonia can experience rarely cough; more commonly they present with poor
feeding and irritability, as tachypnea, retractions , grunting and hypoxemia. Cough is the most common
presenting symptom of pneumonia. Infants may have a history of antecedent upper respiratory
symptoms.

As student nurses, we studied various disease conditions in order to understand how they occur
and cause complications in the human body system. We must plan what we will do when providing a
nursing intervention to our patient. One of the most important is how we give health education to the
patient. It must be easy to understand for them to interact and show cooperation. The result will benefit
both the student nurse and the patient. The former was able to teach well and will show how skilled
and capable they are, while the latter will participate and be able to help themselves improve their
health and prevent situations that can worsen the condition.

The group was able to gather the needed data through an interview and physical assessment of the
patient and with the baseline data from the patient’s record. And with the patient’s diagnosis, we were
able to recognize the signs and symptoms that can result in the needed care. We thoroughly study the
anatomy and physiology of the lungs, as well as how it relates to the disease process. as well as
comprehending the pathophysiology of pneumonia so that we can better understand it. The group was
also identifying the drug studies, which helped recognize how the drug worked in the body and its
effect. As well as distinguishing a nursing problem that was based on a patient assessment and that
resulted in a nursing care plan to provide a specific nursing intervention, whether it was an actual or
potential need.

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XI. Recommendation

It is our duty as aspiring nurses and health educators to make sure that the
general public is informed about the information that pertains to them and to urge them
to use it.

For us student nurses, it is important for us to be well-equipped with the

necessary knowledge or information about the disease so that the patient and
family of someone who has Pediatric Community Acquired Pneumonia- Moderate
Risk can receive the appropriate care.

For the nurses, they must provide the patient or the patient’s significant other with
the necessary information regarding the disease in order for the patient's significant other
to be aware of the patient’s current health condition. At the same time, it is crucial to
provide health knowledge so that the patient's significant other will exercise caution the
next time they or their families might acquire the same disease.

For the community, ensuring that they are aware of the condition with the goal
that its incidence can be decreased by good understanding, particularly awareness of the
signs and symptoms, the initial interventions to be given, and prevention of the
aforementioned disease's recurrence.

Last but not least, for future researchers to do research on this case in the same
manner, we need a deeper understanding of the disease, how it develops, and of course,
how it might be prevented. Also, being informed of the disease's most recent trends
would help us consider our daily activities in consideration of the disease's increasing
popularity.

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XII. Learnings

Being exposed to the various ward areas, particularly the pediatric ward, helps us
foresee our future workloads and provides us the chance to design our own way of doing
things as future nurses while honing our skills and using the knowledge we learned in the
four corners of our classrooms.

Via nurse-patient interaction and giving nursing interventions to our patients,

enhanced our perception of nursing and how absolutely amazing a profession it is.
Interacting with patients and doing discussions with them to gather information are more
challenging than we had thought, but it is so fulfilling to be in the actual area.

Giving care to a child with Pediatric Community Acquired Pneumonia-Moderate

Risk (PCAP-MR) gives us student nurses a unique perspective that helps us dig a little
deeper and analyze the problem in hand, which requires for nursing interventions. We
also comprehend the causes, symptoms, and effects of the disease on the human body.

We put in a lot of effort and keep our attention on learning even when we're
exhausted. In order to overcome the obstacles, pressures, and difficulties we will face in
our chosen profession, we are motivated by the goals and ambitions that fuel us
physically and mentally and provide us with various forms of support.

As nursing students, we are fortunate of the opportunity to witness and assist

patients who require medical care. We became aware that because our health is so
important to our wellbeing, our profession holds the key to the development of humanity.
And we anticipate having many more experiences like this in the future.

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XIII. Acknowledgement

Without the participation and collaboration of so many people, some of whose identities may
not be listed, this case study could not have been completed. We truly appreciate and gladly
acknowledge their contributions. We would like to particularly express our appreciation to the
following:

To the Dr. Amado B. Diaz Provincial Hospital, we would like to convey our sincere gratitude
for giving us the chance to perform our case study at their facility. Also, we want to thank their
personnel at NS1 and NS2 for the knowledge and abilities they shared with us throughout the entirety
of our duty.

We also want to express our sincere gratitude to the College of Nursing at Notre Dame of
Midsayap College for all the knowledge and skills they have given us over the course of our
educational journey.

We are immensely grateful to Ma'am Jennie J. Pauya, RN, our clinical instructor, for every
aspect of her presence. We want to convey our deep appreciation for all of your assistance and
encouragement. Also, thank you for sharing all of your expertise, insight, and abilities with us; they
have helped us survive our first hospital exposure.

Last but not least, we would like to thank our parents for their constant support and
encouragement in helping us pursue our academic and professional goals.

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XIV. References

Pub Med (2002) Health Canada, National Advisory Committee on Immunization Statement on

recommended use of pneumococcal conjugate vaccine. CCDR. 2002;28:1–32.

Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired

pneumonia in adults. Clin Infect Dis. 2000;31:347–82. [PMC free article] [PubMed] [Google Scholar]

Elsevier – Patient Education (2020) Community Acquired Pneumonia (Child)

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