University of Perpetual Help System Laguna Dr. Jose G. Tamayo Medical University Sto.

Nio, Bian, Laguna

COLLEGE OF NURSING

Pediatric Community-Acquired Pneumonia (PCAP C)

In Partial Fulfillment of the Requirements in NCM 107 B
A Case Presented By Group 1 - 3/ N4X

Abellar, Justine A. Acabado, Melanisol C. Delfin, Gian Carlo D. Fermindoza, Jenny Gay S. Garcia, Leslie M. Gutierrez, Joana G. Olay, Nicole Neil N. Regis, Melanie B. Santos, Jeffrey M.

August 15, 2013

CONTENTS
I. Introduction Patients Profile

II.

III.

Physical Assessment

IV.

Anatomy and Physiology

V.

Pathophysiology

VI.

Medical Management

VII.

Laboratory and Diagnostic Tests

VIII.

Drug Study

IX.

Nursing Care Plan

INTRODUCTION

I. Introduction Pediatric community-acquired pneumonia (PCAP) Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites. Pneumonia is the infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles. Pneumonia can be community-acquired or hospitalacquired. Community acquired pneumonia occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization. Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi. The most common are: Streptococcus pneumoniae the most common cause of bacterial pneumonia in children; Haemophilusinfluenzae type b (Hib) the second most common cause of bacterial pneumonia; respiratory syncytial virus is the most common viral cause of pneumonia. Environmental Risk Factors include: indoor air pollution caused by cooking and heating with biomass fuels (such as wood or dung), living in crowded homes, parental smoking. Signs and Symptoms vary depending on the age of the child and the cause of the pneumonia, but common ones include: fever, chills, cough, nasal congestion, unusually rapid breathing (in some cases, this is the only symptom), breathing with grunting or wheezing sounds, labored breathing that makes the rib muscles retract (when muscles under the ribcage or between ribs draw inward with each breath) and causes nasal flaring, vomiting, chest pain, abdominal pain, loss of appetite (in older kids) or poor feeding (in infants), which may lead to dehydration, in extreme cases, bluish or gray color of the lips and fingernails. Incidence: Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.2 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide. Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa.

PATIENTS PROFILE

Name Age Gender Status Nationality Religion B-date B-place Address

: : : : : : : : :

C.R. 2 years old 9 months Female Child Filipino Roman Catholic November 5, 2010 Binan,Laguna Cabuyao, Laguna August 4, 2013/ 9:42am Dra. G.M.

Admission date and time : Attending Physician :

Initial Diagnosis PCAP-C

Final Diagnosis NONE

Chief Complaint Cough

History of present illness: Two weeks prior to admission, patient experienced cough, productive, no fever noted, no difficulty of breathing. Patient was given Cefexime 2.5 ml and cetirizine 2.5 ml which give temporary relief. One day prior to admission suddenly experienced fever, temperature maximum of 39 degree Celsius, patient was given Paracetamol suppository which gave temporary relief, associated with appearance of petechial rashes on the periorbital area. Persistence of the symptom, prompted to have the admission.

Maternal and obstetric history: Patient was born to a 27 years old G2P2 (2002) mother who had regular prenatal checkup and regular intake of vitamins. No history and exposure to radiation and teratogenic drugs. Patient had history of UTI during the course of pregnancy and asthma at 7 months.

Birth History: Patient was delivered live, via Caesarian Section attended by obstetrician and pediatrician with no noted complications. Routine newborn screening was done.

Neonatal History: Patient has no history of jaundice and cyanosis. Meconium was passed out within 24 hour of life.

Immunization History: (+) BCG

(+) DPT 3 doses (+) OPV 3 doses (+) Hep B 3 doses (+) Varicella Vaccine (+) Pneumonia Vaccine

Past Medical History: (+) Hospitalization = 2012 Aug ; cough, UPHS (+) Seizure at 5 months (+) Asthma, 2012, Montelukast and prednisone

Family History:

(+) HPN = Paternal (+) DM = Paternal (+) Seizure = Paternal (+) Asthma = Both (-) CVD (-) PTB

Aug. 8, 2013 vital signs:

Temperature Cardiac Rate Respiratory Rate Blood pressure Weight

: : : : :

36.1C 107 bpm 35cpm 90/60 14.1kg

Physical assessment

Psychological and social examination she is conscious and coherent

Erik Erikson Stages of psychosocial development Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt Toilet Training-Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.

Freuds Stages of Psychosexual Development

 Anal Stage: Age Range 1 to 3 years old The child begins to toilet train, which brings about the child's fascination in the erogenous zone of the anus. The erogenous zone is focused on the bowel and bladder control. Therefore, Freud believed that the libido was mainly focused on controlling the bladder and bowel movements. The anal stage coincides with the start of the childs ability to control their anal sphincter, and therefore their ability to give or withhold gifts at will. If the children during this stage can overcome the conflict it will result in a sense of accomplishment and independence.

PHYSICAL ASSESSMENT (Cephalo-caudal) August 8, 2013 Body Parts Skin (General) Technique Inspection Palpation Normal Findings -light to dark brown -no swelling Hair and scalp Inspection -good skin turgor Actual Findings - light to dark brown -no swelling - with good skin turgor. -no lesion Analysis

-no lesion

Head

Inspection

- hair distribution, -color black equal. - Equal and healthy hair and distribution. -face is -face is symmetrical symmetrical -no lesion -no swelling -symmetrically align -blinking symmetrically -Evenly distributed -no lesion -no swelling -symmetrically align -blinking symmetrically - Turned outward eyelashes; hair equally distributed -eyelashes are short - Moist

Neck

Inspection

Eyes Eye brows Eye lashes

Inspection Inspection Inspection

Eye lids

Inspection

-eye lid margins are moist -white in color -equally round and reactive to light and accommodation -equal in size -symmetrically align -no lesion -no swelling - no discharge

Sclera Pupil

Inspection Inspection

-white in color - Pupils equally reactive to light and accommodation. -equal and symmetrical -no lesion -no swelling - no discharge

Ears

Palpation Inspection

Nose

Inspection

-Symmetric and straight; no discharge or flaring; Uniform color -Pink in color, soft, moist, smooth texture, asymmetry of contour, ability to purse lips - Pink in color, soft, moist, smooth, glistening, and elastic texture. -no lesion -no swelling - moisten

-Symmetric and straight; no discharge or flaring; Uniform color -pink, moist and smooth in texture. -no lesion, no sores. - Pink color and moist. - no lesions and sores noted -no lesion -no swelling -moist - no sores noted -pink and moist, - healthy gums. -Good set of milk teeth.

Lips

Inspection

Buccal mucosa

Inspection

Tongue

Inspection

Gums

Inspection

-pink and moist

Teeth

Inspection

-symmetrically aligned, no tooth decay -Pink in color <2 secs

Nails Capillary refill

Inspection

-Pink in color <2 secs

Upper Extremities

Inspection Palpation

-symmetrically align -no lesion -no swelling -light to dark brown in color

-symmetrically align -no lesion -no swelling -light to dark brown in color - can do active range of motion.

ANTERIOR THORAX Breathing patterns

Inspection

-Quiet, rhythmic, and effortless respirations.

-Normal breathing pattern - no chest indwelling

Anterior Thorax

Auscultation Broncho vesicular and vesicular breath sounds. Auscultation Vesicular and broncho vesicular breath sounds

-Normal breath sounds heard on auscultation

POSTERIOR THORAX

Crackles on both lower lung fields

Crackles are often associated with inflammation or infection of the small bronchi, bronchioles, and alveoli.

Abdomen

Inspection Palpation

-smooth to touch -no lesion -no swelling -warm to touch -round and symmetrical -abdomen rises with inspiration in synchromy with chest -bilaterally symmetrical and equal -right foot has complete fingers -skin color is as same as the other parts of the body Normal skin color.

-smooth to touch -no lesion -no swelling -warm to touch -round and symmetrical -abdomen rises with inspiration in synchromy with chest. -bilaterally symmetrical and equal -right foot has complete fingers -skin color is as same as the other parts of the body -Normal skin color

Lower Extremities

Inspection

Posterior Lower

Inspection and

Extremities

palpation.

F. Functional Health Pattern Assessment

1.

Health Perception-Health Management Pattern

The childs health is fair as describe by the mother but now its already poor. She said that in maintaining the childs health she provided the child with nutritious food as much as possible and giving all the needs of the child like nice dress and proper hygiene. She gave the child time to play with other kids. The childs immunization was complete. The child was admitted to the hospital because of cough fever for 2 weeks. The mother know the real cause of the illness because the yaya has cough and cold. It began on July 22, 2010 in the child was warm to touch. Patient was given Cefexime 2.5 ml and cetirizine 2.5 ml which give temporary relief. One day prior to admission suddenly experienced fever, temperature maximum of 39 degree Celsius, patient was

given Paracetamol suppository which gave temporary relief, associated with appearance of petechial rashes on the periorbital area. Persistence of the symptom, prompted to have the admission. The child was hospitalized last August 2012 because of cough as stated by her grandmother. They expect that the child will get well soon as soon as possible so that the child will not suffer from staying in the hospital. During her pregnancy, the mother had her complete pre-natal check-up during her pregnancy stage. She did not take any medications & no complications during pregnancy.

2.

Nutritional and Metabolic Pattern

The childs appetite is usually good but upon hospitalization the childs appetite is poor. She doesnt like to eat fruits and vegetables. They were not fond of going to fast food or restaurants.

3.

Elimination Pattern

The child defecates once a day, usually every morning with soft, brown, formed & moderate in amount stool. She was toilet trained. The child doesnt have any problems in his urination. He doesnt have any trouble in his skin.

4.

Sleep-Rest Pattern

The child usually sleeps 9pm & wakes at 8am. She sleeps 11 hours a day with naps. The childs usual sleep routine was singing with his parents and listening bedtime stories. She had no usual sleep pattern problem. 5. Activity-Exercise Pattern

Walks with steady gait, runs with few falls, walks on toes, stands on one foot, jumps, kicks ball, throws ball overhand. The child could eat using spoon and fork with assistance. She doesnt want to be helped. The child needs help in toileting since she doesnt know where to defecate and urinate. She defecates and urinates on their comfort room. The child needs help to dress by herself, bath and brush his teeth.

The child watches TV for more than an hour she loves to watch cartoons. She watches with his parents. She was prohibited watching action movies to avoid being violent when he grows up.

6.

Cognitive-Perceptual Pattern

The child did not have any sensory perception deficits. She was 2 years old. She is a smart child

7.

Self-Perception Self-concept Pattern

The mother feels bad about her childs illness and she was concerned about the wellness of the child. The child verbalizes that he feels restless.

8.

Role Relationship Pattern

The child uses appropriate words for his age. Spoken language in their home is Tagalog and English. The child has one sibling. She was the youngest. Both the childs parents do the decision making and in disciplining the child. There was no marital problem and violence in the family.

9.

Sexuality-Reproductive Pattern The child did not verbalize any sexual curiosity according to her mother.

10.

Coping Stress Tolerance Pattern

The child needs to learn to decide for himself and if greater decisions are to be made she should ask approval from his parents. There were no losses for the past year. When the child is stress he turns to her mother. When the child was frustrated he plays with her toys. She was not afraid of her mother and always try things that she is not familiar of. 11. Value-Belief Pattern

The whole family was Roman Catholic as claimed by the mother. The mother just likes to be prayed for her childs wellness.

ANATOMY AND PHYSIOLOGY

Respiratory System

Nose or Nasal Cavity As air passes through the nasal cavities it is warmed and humidified, so that air that reaches the lungs is warmed and moist. The Nasal airways are lined with cilia and kept moist by mucous secretions. The combination of cilia and mucous helps to filter out solid particles from the air a Warm and moisten the air, which prevents damage to the delicate tissues that form the Respiratory System. The moisture in the nose helps to heat and humidify the air, increasing the amount of water vapour the air entering the lungs contains. This helps to keep the air entering the nose from drying out the lungs and other parts of our respiratory system. When air enters the respiratory system through the mouth, much less filtering is done. It is generally better to take in air through the nose. To review: The nose does the following: 1. 2. 3. Filters the air by the hairs and mucous in the nose Moistens the air Warms the air

Pharynx The pharynx is also called the throat. As we saw in the digestive system, the epiglottis closes off the trachea when we swallow. Below the epiglottis is the larynx or voice box. This contains 2 vocal cords, which vibrate when air passes by them. With our tongue and lips we convert these vibrations intospeech. The area at the top of the trachea, which contains the larynx, is called the glottis. Trachea The trachea or windpipe is made of muscle and elastic fibres with rings of cartilage. The cartilage prevents the tubes of the trachea from collapsing. The trachea is divided or branched into bronchi and then into smaller bronchioles. The bronchioles branch off into alveoli. Bronchi Similar to trachea with ciliated mucous membrane and hyaline cartilage. Lower end of trachea divides into right and left this. Bronchioles Thinner walls of smooth muscle, lined with ciliated epithelium. Subdivision of bronchi.At the end, alveolar duct and cluster of alveoli. Lungs The lungs are spongy structure where the exchange of gases takes place. Each lung is surrounded by a pair of pleural membranes. Between the membranes is pleural fluid, which reduces friction while breathing. The bronchi are divided into about a million bronchioles. The ends of the bronchioles are hollow air sacs called alveoli. There are over 700 million alveoli in the lungs. This greatly increases the surface area through which gas exchange occurs. Surrounding the alveoli are capillaries. The lungs give up their oxygen to the capillaries through the alveoli. Likewise, carbon dioxide is taken from the capillaries and into the alveoli.

pathophysiology

MEDICAL MANAGEMENT

Time

Doctors Order

Rationale

Nursing Consideration

August 4, 2013 - Please admit to - Patient has a right to ROC under the service choose his/her medical of Dr. Malayan practitioner or treatment - Please secure consent for this admission and management

- An informed consent is a sign of patient participation in medical treatment in written form.

- Make sure there is a witness when patient signs an informed consent.

- TPR q shift and record pls

-TPR is used to create baseline parameters.

- Observe proper documentation.

- DAT

-DAT means that the patient can eat any meals as long as he/she can tolerate.

- Temporary treatment for shock if any plasma - Carefully check

- IVF D5 0.3 NaCl 500cc x 6hrs at 20 -21 gtts/min

expander is unavailable and for patient having addisons crisis. For replacement or maintenance of fluid and electrolytes.

for regulation to avoid fluid overload or underload.

-It is a diagnostic test that gives information about the cells in the patient's blood. Diagnostics: a. CBC c platelet count - It is a radiograph projection of the chest used to diagnose conditions affecting the chest

b. Chest X-ray AP-L

- Paracetamol is an anti-pyretic and analgesic drug used to treat fever and pain.

Therapeutics - Paracetamol 150mg IV every 4 hrs for temp 38 and above. - Paracetamol 250mg/5ml, give 4ml every 4 hrs for temp - I &O is a parameter that checks how much fluids has been consumed or excreted in the patients body. - Paracetamol is given as a PRN order if the patient really needs it.

37.8 and above

- Vital signs are monitored to know how the body functions - Always check for fluid intake proprerly. including IVF consumed -History taking and physical examination are important tools to know what are the etiologic factors prior to a disease.

- Monitor I&O every shift

- Monitor VS every 2hrs

mesuring the fluid and electrolytes losses by how manny times the patient vomit througt the use of cup method

- Always double check VS readings if there is doubt.

- when doing PE it should be from head-toe.

-Do complete Hx and PE c/o PCIC/PHC

-Replace volume per volume losses with PLR

- It relieves inflammation (swelling, heat, redness, and pain) and is used to treat certain forms of

-Dr. Malayan informed with this condition

arthritis; skin, blood, kidney, eye, thyroid, and intestinal disorders (e.g., colitis); severe allergies; and asthma.

-Refer

- It is used in inhibition of eosinophil chemotaxis

- Rotate sites of IM repository injections to avoid local atrophy.

Meds: - Start hydrocortisone 60mg/IV every 6 hrs

- For maintenance of losses in fluids and electrolytes.

- Montelukast is a leuokotreine receptor antagonist (LTRA) - This should be used for the given after the maintenance treatment patient has eaten. of asthma and to relieve symptoms of seasonal allergies.

- Start cetrizine + phenylephrine (Alnix plus) 2.5ml BID in full stomach

-D5IMB is an IV solution that consists of 5% dextrose and water level. It is usually given to patients in hospitals that could potentially

- Assess for drug hypersensitivity.

- Replace losses

volume per volume as ordered

become ill through high sodium levels or low blood sugar levels.

- Replace patient meds: 4 mg chewable tablet or 4 mg granules orally once a day. - Carefully check for regulation to avoid fluid overload or underload.

1:30pm

- IVF to follow D5IMB 500cc x 11hrs at 45cc/hr

- It is a diagnostic test that checks the components of your urine.

- NS1 (Nonstructural Protein 1) is a test for dengue which allows rapid detection on the first day of fever, before antibodies appear some 5 or more days later. - Hold D5IMB instead IVF to follow D5NSS 500cc at 4cc/hr

3:45pm

- For repeat cbc with

platelet tomorrow at 6am

- for urinalysis

- for dengue NS1 to include to next blood extraction

8:46pm

- cut present management

August 5, 2013 5pm - IVF for follow D5NSS 500cc at 42cc/hr - For maintenance of losses in fluids and electrolytes. - Carefully check for regulation to avoid fluid overload or

7:45am

- follow up CBC with platelet result

underload.

9am

- Dr. Malayan updated - for repeat cbc with platelet tomorrow at 6am(8/6/13) - Nebulize with combivent 1 neb every 6hrs via facemask

- rounds with Dr, Malayan 9:45am - continue present management - start cefuroxime 250mg n every 8 ANST()

- Combivent is a drug used for treating COPD through inhalation from a nebulizer.

- Cefuroxime is a parenteral second generation cephalosphorin antibiotic used to treat infection. - IVF to follow D5NSS 500cc at 42cc/hr 3:30pm

- Assess for drug hypersensitivity.

- For maintenance of losses in fluids and electrolytes.

- Carefully check for regulation to avoid fluid overload or underload.

August 6, 2013

8:30am

- Continue with present management

2:30pm

- for repeat cbc with platelet tomorrow at 6am - am present management

12nn - IVF to FF: D5NSS at 42cc/hr

- For maintenance of losses in fluids and electrolytes.

- Carefully check for regulation to avoid fluid overload or underload.

August 7, 2013 7:50am - continue present management

11:30am

- rounds with Dr. Malayan

- Heraclene 1mg/cap OD c/o patient meds, continue present management

-Heraclene (Dibencozide) Capsule aids optimal consumption of nutritional protein ingestion and helps in the development and restoration of body tissues and kindles in the body the desire for food.

- Advise patient to avoid products that contain caffeine.

- Dr. Malayan updated - for report cbc with platelet tom at 6am (8/8/13) August 8, 2013 8:25am - Continue present management - For maintenance of losses in fluids and electrolytes. - Carefully check for regulation to avoid fluid overload or underload.

- IVF to follow D5NSS 1 liter at 42cc/hr

1:20pm

- continue present management

LABORATORY AND

DIAGNOSTIC TESTS

COMPLETE BLOOD COUNT (CBC)

The complete blood count or CBC test is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. DATE REQUESTED: August 4, 2013

RESULT

NORMAL VALUE 110-140 0.37-0.47 4.00-5.50 5.0-10.0 1.63-6.96 1.09-2.99 0.240-0.790 0.00-0.5% 0.00-0.80 80-98 26-32 320-360 10.2-14.5% 150-450

INTERPRETATION SIGNIFICANCE

Hemoglobin Hematocrit RBC count WBC count Neutrophils Lymphocytes Monocytes Eosinophiles Basophiles MCV MCH MCHC RDW Platelet count

132 .406 4.70 6.50 3.44 2.25 .739 .005 .064 86.3 28.1 325 10.2 124

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL DECREASED Indicate risk of bleeding

DATE REQUESTED: August 6, 2013

RESULT

NORMAL VALUE 110-140

INTERPRETATION SIGNIFICANCE

Hemoglobin

125

NORMAL

Hematocrit RBC count WBC count Neutrophils Lymphocytes Monocytes Eosinophiles Basophiles MCV MCH MCHC RDW Platelet count

.387 4.51 4.81 2.45 2.02 .309 0.00 .025 85.9 27.8 323 10.3 122

0.37-0.47 4.00-5.50 5.0-10.0 1.63-6.96 1.09-2.99 0.240-0.790 0.00-0.5% 0.00-0.80 80-98 26-32 320-360 10.2-14.5% 150-450

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL DECREASED Indicate risk of bleeding

DATE REQUESTED: August 7, 2013

RESULT

NORMAL VALUE 110-140

INTERPRETATION SIGNIFICANCE

Hemoglobin

119

NORMAL

Hematocrit RBC count WBC count

.376 4.41 3.76

0.37-0.47 4.00-5.50 5.0-10.0

NORMAL NORMAL DECREASED Decreased due to inadequate inflammatory defenses to suppress infection.

Neutrophils Lymphocytes Monocytes

2.03 1.41 .296

1.63-6.96 1.09-2.99 0.2400.790 0.00-0.5% 0.00-.0.80 80-98 26-32 320-360 10.214.5% 150-400

NORMAL NORMAL NORMAL

Eosinophiles Basophiles MCV MCH MCHC RDW

0.00 .024 85.2 26.9 316 10.0

NORMAL NORMAL NORMAL NORMAL DECREASED DECREASED Indicate presence of anemia. Indicate presence of anemia. Indicate risk of bleeding

Platelet count

122

DECREASED

DATE REQUESTED: August 8, 2013

RESULT

NORMAL VALUE 110-140 0.37-0.47 4.00-5.50 5.0-10.0

INTERPRETATION SIGNIFICANCE

Hemoglobin Hematocrit RBC count WBC count

118 .376 4.41 4.21

NORMAL NORMAL NORMAL DECREASED Decreased due to inadequate inflammatory defenses to suppress infection. Decreased. May indicate increase risk of infection

Neutrophils

1.42

1.63-6.96

DECREASED

Lymphocytes Monocytes Eosinophiles Basophiles MCV MCH MCHC RDW Platelet count

2.42 .326 .001 .018 26.8 26.8 315 10.1 176

1.09-2.99 0.240-0.790 0.00-0.5% 0.00-.080 80-98 26-32 320-360 10.2-14.5% 150-400

NORMAL NORMAL NORMAL NORMAL DECREASED NORMAL DECREASED DECREASED NORMAL Indicate presence of anemia Indicate presence of anemia Indicate presence of anemia

CHEST X-RAY (CHEST RADIOGRAPHY) The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and chest.

DATE REQUESTED: August 4, 2013 EXAMINATION DONE: Chest X ray Posterior Anterior Interpretation: The interstitial lung markings are accentuated with fine reticulation in the parihilar areas. The heart is not enlarged Diaphragm and sulci are normal Visualized bones are intact

Impression: INTERSTITIAL PNEUMONITIS CONSIDERED

URINALYSIS

The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders. It is ordered widely and routinely to detect any abnormalities that require follow up.

DATE REQUESTED: August 4, 2013

RESULT Color: Transparency: Reaction (pH): Glucose: Protein Ketones: Specific gravity: Pus cells: Light Yellow Slightly Hazy 6.5 Negative Negative 2.020

NORMAL VALUE Straw to Dark Yellow Clear-Hazy 5-8.5 Negative Negative Negative 1.003-1.029

INTERPRETATION SINIFICANT NORMAL NORMAL NORMAL NORMAL NORMAL INCREASED Indicate presence of dehydration Indicate presence of infection

10-12/hpf

2-3/hpf

INCREASED

RBC

1-2/hpf

Epithelial Cells

Few

Male: 0-3/hpf Female: 05/hpf Raremoderate

NORMAL

NORMAL

DENGUE NS1 Ag Assay Test This test is use for early diagnosis of dengue virus infection

DATE REQUESTED: August 5, 2013

TEST NAME

RESULT Negative

Dengue NS1Ag : IgG Negative : IgM Negative

Drug study

Drug Name Generic Name: Cefuroxime axetil Brand Name: Ceftin Classification: Cephalosporin 2nd generation Dosage:250mg/5 ml Frequency:Q8

Mode of Action -Secondgeneration cephalosporin that inhibits cellwall synyhesis,promot ing osmotic instability;usually bactericidal.

Indication -Lower respiratory infection

Interaction -Amino glycosides -Loop diuretics -Probenecid

Side Effect GI: nausea and vomiting

Nursing Consideration -Determine history of hypersensitivity reactions to drugs. -Check the IV site before giving the medicartion. -Instruct the parent or guardian of the patient to Notify the prescriber about rash or evidence of superinfection. -Administer medication with meals to decrease GI upset and enhance absorption. -Advise the parent or guardian of the patient to re portloose stools or diarrhea.

SKIN: rash,pruritus, urticaria

Contraindication: -Contraindicated in patients hypersensitivity to cephalosporin

Route: IV

Drug Name Generic Name: citirizine +penylphrine Brand Name: Alnix Plus Classification: Antihistamine Dosage: 2.5ml Frequency: BID

Mode of Action -A long-acting nonsedating antihistamine that selective inhibits pheripera H1 receptor.

Indication -Seasonal allergic rhinitis -Perennial allergic rhinitis,chronic urticaria

Interaction - CNS depressant -Theophylline -Barbiyuates -Hypnotics -Opiod analgesics

Side Effect -somnelence,head ache, dizziness,fatigue. -pharyngitis -dry mouth,nausea, vomiting,abdominal distress. -couhing,bronchospasm

Nursing Consideration -Assess for allergy symptoms: rhinitis, pruritus, urticaria, watering eyes, before and periodically during treatment. -Assess respiratory status and increase in bronchial secretions, wheezing, chest tightness: provide fluids to decrease viscosity or thickness of secretion. -Instruct the patients family to take 1hr before or 2 hrs after a meal to facilitate absorption. -Advise pts family to use sugarless gum, candy, frequent zip of water of minimize dry mouth. -Instruct pts family to inform physician if dizziness occurs or if symptoms persist.

Contraindication: -Contraindicated in patients hypersensitivity to drug. -Use cautiously in patients with renal and hepatic impairement.

Route: P.O

Drug Name Generic Name: clarithromycin Brand Name: Klaz Classification: Macrolide Antibiotic Dosage:250mg/5 ml Frequency: BID (on full stomach)

Mode of Action -Inhibits protein synthesis in susceptible bacteria, causing cell death.

Indication -Bacterial infection (pneumonia)

Interaction -Alprozalam Carbamazepine -Cyclosporine -Digoxin -Ritonavir -Thophylline -Fluconazole -Warfarin

Side Effect CNS:dizziness, headache, vertigo, fatigue GI: diarrhea, abdominal pain or discomfort,nausea,vo miting, pseudomembranous colitis. SKIN: rash(pediatric) HEMATOLOGIC: leukopenia,coagulati on abnormalities.

Nursing Consideration -Assess bowel pattern,discontinue drug if severe diarrhea occurs. -Assess patients infection before therapy and regularly thereafter. -Take drug with food if GI effects occur.Do not drink grapefruit juice while taking this drugs. -Shake suspension before use: do not refrigerate. -Instruct the pts family to take all medication prescribed for the length of time ordered and to continue drug therapy as prescribed even he feels better. -Instruct the pts family to report persistent adverse reactions. -Advise the pts family to report diarrhea, rash or itching, mouth sores.

Contraindication: -Contraindicated in patients hypersensitivity to clarithromycin, erythromycin, or any macrolide antibiotic.

Route: PO

Drug Name Generic Name: dibencozide BrandName: Heraclene Classification: Appetite Stimulants Dosage:1mg Frequency:OD

Mode of Action -Dibencozide increases the protein efficiency coefficient ie, the percentage of bound nitrogen for protein buildup in the body compared to ingested nitrogen with food intake.

Indication -Premature babies, low birth weight, retarded growth, poor appetite in infants, children and adults.

Interaction

Side Effect GI: Constipation, Diarrhea, N/V. CV: Tachycardia CNS: Overstimulation, Headache, Dizziness, Insomnia

Nursing Consideration -Advise the parent of the patient to avoid products that contain caffeine. -Report any evidence of excessive stimulation

Contraindication: - Hypersensitivity to drugs or its ingredients

Route:

Drug Name

Mode of Action

Indication

Interactio n -NSAIDs Cyclospori ne -Oral anticoagul ants Pottasiumdepleting drugs -Skin-test antigen

Side Effect

Nursing Consideration -Assess the pts condition before starting therapy and reassess regularly. -Tell the parents or guardian of the patient not to stop drug abruptly or without prescribers consent. -Warn the parents or guardian of the patient on long-term therapy about cushing effects (moon face,buffalo hump) and need to notify prescriber about sudden weight gain or swelling,ang easy bruising. -Monitor the patients weight and electrolyte level. -Instruct the parents or guardian of the patient to take Vit.D and calcium supplement. -Encourage the parents or guardian of the patient to deep breathing exercise. -Teach the parents or guardian

Generic Name: hydrocortisone sodium succinate

-Decreases inflammation,mainl y by stabilizing leukocyte lysosomalmembra nes;suppresses Brand Name: immune Solu-Cortef response;stimulate s bone Classification: marrow;and Corticosteroids/ influences Antiprotein,fat,and inflammatory carbohydrate metabolism. Dosage:60mg Frequency: Q 6hrs Route: IV

-Severe inflammation, -Adrenal insufficiency -Shock

Contraindication: -contraindicated in patients hypersensitivity to drug or its ingredients,in those receiving immunosuppressiv e doses together with live virus vaccine,and in premature infants.

-headache nausea/vomi ting -easy bruising carbohydrate intolerance -GI irritation -growth suspension in children,mus cle weakness

of the patient sign and symptoms of early adrenal insufficiency: fatigue,muscleweakness,jointpai n,fever,anorexia,nausea, Shortness of breath,dizziness,and fainting.

Drug Name Generic Name: paracetamol Brand Name: Tempra Classification: Analgesic/Antipyre tic Dosage: 250mg/5ml T - >37.8 Frequency:Q4

Mode of Action - Unknown. Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or other substances that sensitize pain receptors to stimulation.The drug may relieve fever through central action in the hypothalamic heat regulating center.

Indication -Mild pain or fever

Interaction - Barbiturates - Carbamazepine - Hydantoins - Fifampin - Sulfinpyrazone

Side Effect - hemolytic anemia - neutropenia - leukopenia - pancytopenia - jaundice - rash - urticaria

Nursing Consideration -Assess pts fever: temperature, diaphoresis. -Give with food or milk to decrease gastric symptoms;give 30mins before or 2hrs after meals;absorption may be slowed. - Advise the parents to do tepid sponge bath (TSB) to lower the body temperature (if the pt. is febrile 38 and above). - Tell parents to consult prescriber before giving drug to children younger than age 2. -Advise the parent of the patient that the drug is only for shortterm used and to consult prescriber if giving to children for longer than 5 days. -Tell parents to increase fluid intake to prevent dehydration.

Contraindication: -Contraindicated in patients hypersensitivity to drugs.

Route: PO

Drug Name Generic Name: paracetamol Brand Name:

Mode of Action - Unknown. Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or other substances that sensitize pain receptors to stimulation.The drug may relieve fever through central action in the hypothalamic heat regulating center.

Indication -Mild pain or fever

Interaction - Barbiturates - Carbamazepine - Hydantoins - Fifampin - Sulfinpyrazone

Side Effect - hemolytic anemia - neutropenia - leukopenia - pancytopenia - jaundice - rash - urticaria

Nursing Consideration -Assess pts fever: temperature, diaphoresis. -Give with food or milk to decrease gastric symptoms;give 30mins before or 2hrs after meals;absorption may be slowed. -Assess the IV site before giving medication. - Advise the parents to do tepid sponge bath (TSB) to lower the body temperature (if the pt. is febrile 38 and above). - Tell parents to consult prescriber before giving drug to children younger than age 2. -Advise the parent of the patient that the drug is only for short-term used and to consult prescriber if giving to children for longer than 5

Classification: Analgesic/Antipyre tic Dosage: 150mg T - >38 Frequency:Q4/pr n

Contraindication: -Contraindicated in patients hypersensitivity to drugs.

Route: IV

days. -Tell parents to increase fluid intake to prevent dehydration.

Drug Name

Mode of Action

Indication

Interaction

Side Effect

Nursing Consideration

Generic Name: montelukast sodium Brand Name: Singulair Classification: Bronchodilator Dosage:4mg granules Frequency: ODHS Route: PO

Selective,competitive leukotriene receptor antagonist that reduces early and late-phase bronchoconstriction from antigen challenge.

-asthma -seasonal allergic rhinitis

Phenobarbital -Rifampin

CNS:fever,headache, dizziness,fatigue.

-Assess patients underlying EENT:nasal condition before congestion,dental pain therapy and regularly GI:dyspepsia,infectious thereafter to gastroenteritis,abdominal monitor drug pain effectiveness. RESPIRATORY:cough -Assess respiration ausculted bilateral lung fields:rate and rhythm. -Assess for allergic reactions: rash, urticaria, and pruritus. -Take with or without food.May give directly in

Contraindication: -Contraindicated in patients hypersensitivity to drug. -Use cautiously and with appropriate monitoring in patients whose dosages of systemic corticosteroids are reduced. .

SKIN:rash

mouth or mixed w/a spoon of soft food (carrots, apple sauce, juice, milk rice).

-Assess patiens and familys knowledge of drug therapy.

Nursing Care plan

CUES

PROBLEM

SCIENTIFIC REASON Ineffective airway clearance occurs when an artificial airway is used because normal mucociliary transport mechanisms are bypassed and impaired.

DESIRED OUTCOME Short term goal: After 6 hours of Nursing Intervention, the Patient breathes without using nasal flaring. Long term goal: After 3 days of nursing intervention the patient breathes normally.

INTERVENTION/ RATIONALE Independent: Auscultate breath sounds. Note adventitious breath sounds like wheezes, crackles and rhonchi. Rationale: Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds. Keep environmental pollution to a minimum like dust, smoke and feather pillows, according to individual situation. Rationale: Precipitators of allergic type of respiratory reactions

EVALUATION STANDARD CRITERIA Outcomes partially met, the patient was able to demonstrate behavior to improved airway clearance

Objective: Nasal Flaring Abnormal breath sounds. (crackles) Productive cough (transparent) V/S taken as follows: RR-35

Ineffective airway clearance related to increase production of mucus secretion

The patient will be able to breathes without nasal flaring with RR of 35bpm to 28bpm

that can trigger or exacerbate onset of acute episode. Encourage or assist with abdominal or pursed lip breathing exercises. Rationale: Provides patient with some means to cope with or control dyspnea and reduce air tapping. Assist with measures to improve effectiveness of cough effort. Rationale: Coughing is most effective in an upright position after chest percussion. Position appropriately and discourage use of oil-based products

around nose. Rationale: To prevent vomiting with aspiration into lungs. Obtain sputum specimen, preferable before antimicrobial therapy is initiated. Rationale: To verify appropriateness of therapy.

COLLABORATIVE: Administered analgesics. Rationale: To improve cough when pain is inhibiting effort.

CUES

PROBLEM

SCIENTIFIC REASON The patients immune system is not fully activated until sometime after birth. Limitation in the patients inflammatory response result in failure to recognize, localize, and destroy invasive bacteria thus, increasing risk for infection

DESIRED OUTCOME

INTERVENTION/ RATIONALE

EVALUATION STANDARD CRITERIA

Subjective:

Risk for further infection r/t spread of pathogens Objective: Patient secondary to is diagnosed identified PCAP with PCAP

Vital Sign RR: 35 cpm HR:142 bpm TEMP: 36.6 WT: 14.1 kg Decrea sed WBC level 4.21

Short term goal: INDEPENDENT After 8 hrs of nursing 1. assess TPR, intervention auscultate the patient will free breath sounds from further infection - Assessments provide Long term goal: information about After several days of the spread of nursing intervention infection, infection will be increased RR and prevented. HR, decreased BP are signs of sepsis. Spread of infection may cause resp. distress 2. Ensure that all people coming in contact with patient. wash their hands well before & after touching the patient. - Hand washing prevents the spread of pathogens coming from the patient to

The patient After 8 hrs of will exhibit nursing no signs of intervention infection the patient are Free from further infection

the caregiver and vice versa 3. Ensure that all equipment used for patient is sterile, scrupulously clean &disposable. Do not share equipment with other patient. this would prevent the spread of pathogens to the patient from equipment 4. Place patient in isolette/ isolation room per hospital policy placing the patient in an isolette allows close observation of the ill neonate & protects other patient from infection 5. maintain neutral thermal

environment A neutral thermal environment decreases the metabolic needs of the patient. The patient has difficulty maintaining a stable temp 6. Provide respiratory support (oxygen) resp. support may be needed during the acute phase of the infection to prevent additional physiological stress 7. Monitor lab results as obtained. Notify care giver/ physician of abnormal findings lab results provide information about the pathogen and patients response to illness and

treatment 8. administer IV fluids as ordered (D10IMB) IV fluids help maintain fluid balance 9. Administer antibiotics as ordered. Antibiotics act to inhibit the growth of bacteria and destruction of bacteria.

CUES

PROBLEM

SCIENTIFIC REASON Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital outpatient center, or home

DESIRED OUTCOME Short term goal:After 8 hrs of nursing interventionthe patient will demonstrate fluid balance evidenced by individually appropriate parameters, e.g., moist mucous membranes, good skin turgor, prompt capillary refill, stable vital signs. Long term goal:After several days of nursing intervention the patient will experience fluid

INTERVENTION/ RATIONALE 1. Assess vital sign changes, e.g., increased temperature/p rolonged fever, tachycardia, orthostatic hypotension. Elevated temperature/ prolonged fever increases metabolic rate and fluid loss through evaporation. Orthostatic BP changes and increasing tachycardia

EVALUATION STANDARD The client will remain show no signs and symptoms of dehydration Subjective: Anim na bases na siyang nagsusuka. As verbalized by the patients caregiver

Subjective:

Risk for Deficient Fluid Anim na bases Volume may na siyang includeexcessi nagsusuka. As ve fluid loss verbalized by (fever, profuse the patients diaphoresis, caregiver mouth breathing/hyp erventilation, Objective: vomiting) Restlessness Vomiting (6x) Fatigue V/S taken as follows: RR: 35 cpm HR:142 bpm TEMP: 36.6 WT: 14.1 kg

Objective: Restlessness Vomiting (6x) Fatigue V/S taken as follows: RR: 35 cpm HR:142 bpm

setting.

balance.

may indicate

TEMP: 36.6 WT: 14.1 kg

CUES

PROBLEM

SCIENTIFI C REASON Pneumonia is inflammatio n of the terminal airways and alveoli caused by acute infection by various agents. Pneumonia can be divided into three groups: community acquired, hospital or nursing home acquired(no socomial), and pneumonia

DESIRED OUTCOME Short term goal: After 4hrs of nursing interventionthe patient will relief of pain and demonstrate relaxed manner, resting/sleeping and engaging in activity appropriately.

INTERVENTION/ RATIONALE INDEPENDENT

EVALUATION STANDARD CRITERIA The patient was relief on pain and demonstrated relaxed manner, resting/sleepi ng and engaging in activity appropriately.

Subjective:

Acute pain r/t localized inflammation and persistent cough.

Objective: Use of accessory muscle. Productive cough (transparent) Restlessness Fatigue V/S taken as follows: RR: 35 cpm HR:142 bpm TEMP: 36.6

The patient will relief of pain 1. Elevate head of and the bed, change demonstrate position relaxed frequently. manner, resting/sleepin Lowers g and diaphragm, promoting chest engaging in activity expansion and expectoration of appropriately secretions. 2.Assist patient with deep breathing exercises Deep breathing facilitates maximum expansion of the lungs and smaller airways. The patient will free from pian

Long term goal: After several days of nursing intervention the patient will display patent airway with breath sounds

in an immune compromis ed person. Causes include bacteria (Streptococ cus, Staphyloco ccus Haemophilu sinfluenzae, Klebsiella,L egionella). Community Acquired Pneumonia (CAD) is a disease in which individuals who have not recently been hospitalized develop an infection of

clearing

3. Demonstrate or help patient learn to perform activity like splinting chest and effective coughing while in upright position. Coughing is a natural selfcleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.

4. Force fluids to at least 3000 ml per day and offer warm, rather than cold fluids. Fluids especially warm

the lungs. It is an acute inflammator y condition thats result from aspiration of oropharyng eal secretions or stomach contents in the lungs.

liquid said in mobilization and expectoration of secretions COLLABORATIVE 5. Administer medications as prescribe: mucolytics or expectorants. Aids in reduction of bronchospasm and mobilization of secretions.

6. Provide supplemental fluids. Fluids are required to replace losses and aid in

mobilization of secretions.