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We are the second year students of Saint Joseph Institute of

Technology exposed at the Butuan Medical Center, Pink Section <Pedia
Ward>. To make our exposure to be more exciting, we are assigned to
do case study and divided our group into two.

It was February 13 2010 that we started to gather information

about our case study and find the most interesting case that will surely
captured our minds about it. At room 207, we’ve notice a very young
mother carrying her baby boy, a two months old with a complaint of
having a fever, cough and cold for almost seven days. We see the baby
boy pale, with mucus secretion on the nose and prolonged coughing.
Baby boy is diagnosed with bilateral pneumonia by Dr. Burdeos as his
physician. We chose bilateral pneumonia as our case to be study out of
curiosity. This is also our first time to encounter this kind of case and
because of that, we are willing to do this to challenge our minds in
analyzing the problem and enhances our hidden knowledge, and also to
gain new experiences which would bring new learnings for the rest of
the group. At the end of the case study, our group will be able to
understand what is pneumonia all about, and prevention/ treatment of
the occurrence of the disease.

What is bilateral pneumonia or pneumonia? It is an inflammatory

illness of the lungs. Frequently, it is described as lung
parenchyma/alveolar inflammation and abnormal filling of fluids<
consolidation and exudation>.

Alveoli are microscopic air- filled sacs in the lungs responsible for
absorbing oxygen. Pneumonia can be result from a variety of causes
including infection of bacteria, viruses, fungi or parasites and chemical
or physical injury to the lungs. Its can be also officially described as
idiopathic that is, unknown when infectious causes has been excluded.

Typical symptoms associated with pneumonia include cough,

chest pain, fever and difficulty in breathing. Diagnostic tools include X-
rays and examination of the sputum. Treatment depends on the cause of
pneumonia; bacterial Pneumonia is treated with antibiotics.

According to the International Union Against Tuberculosis and

Lung Disease, Pneumonia kills more than any other condition affecting
the lungs; it is a prime cause of death in young children. There are also
10 to 12 million deaths occur annually in children under 5 years of age
over 90% are in the developing world. It is small children who are less
than one year of age living in the poorest communities who most often
suffer and die from this condition. Pneumonia is often a result of other
infections such as measles and pertussis. The frequency of pneumonia in
children could be reduced by 10- 20% through immunization with these
vaccines. Many Developing countries have very low immunization rates
due to funding and delivery problems.

According also to Butuan Medical Center there are fifteen cases

of babies ages 2mos old and above that are reported to have pneumonia
by year November 2009 to January 2010.

Nursing Health History is the first part of the client’s health

status, it is systematic collection of subjective data provided by the
patient’s significant other’s verbalizations and supplemental by
objective data gathered during Physical assessment. It is needed for
solving and determining a patient’s problem and for the nurse to know
what interventions to be applied and what may be the cause of the

For the patient’s trust, privacy, dignity and respect we gave him
and we decided to hide his name and called him Patient X.

Since our patient cannot really express much of himself due to he

is still a baby, we chose to gather information from his mother whom is
very close to him.

Patient X is an 2 months old baby. A Roman Catholic, with fair

complexion and weighs about 4 lbs. He was born on December 9, 2009
through normal spontaneous delivery at Butuan Medical Center
(BMC). He was the eldest and the only son. Patient X with her mother is
living at Purok 2, Kinamlutan, Butuan City with his family, and has
been used to the catholic traditions since his mother and grandparents
are Catholics.

Upon interview, his mother told us that Patient X had its first
immunization (BCG). He has also no other diseases from past. As the
mother told us that Patient X has an allergies on talc powders such as
Johnson and Johnson powder and some non- hypoallergenic powders.

Before the hospitalization in Butuan Medical Center, Patient X

already suffers from fever, cough and colds. It was January 7, 2010
when the mother brought Patient X to the hospital for further
medication. But then it was not accepted by the hospital because there is
no vacancy on that time.
It was February 12 2010 when the mother of Patient X decided to admit
Patient X at the BMC around 10:25 am immediately at the emergency
room. Upon the admission, he was immediately assessed, taking its
initial Vital signs of T = 38.3°C♣ ; P = 120 bpm♣ ; R = 18bpm♣ . O2
inhalation administered at 1-2 lpm; CBC is requested at 10:55am♣ ;
started IVF of D5 .3 NaCl 500 with solvent refilled with 100 cc at 16
cc/hr; for chest x- ray (APL) requested;

Date Ordered: February 12, 2010

Date Performed: February 12 2010

Result Normal Significance

Values Interpretatin

RBC 4.23 4.5 – 6.0 x Normal


WBC 16.70 10.1 5 – 10 x Increase Indicates

10/L presence of
HgB 95 130 – 140 Decrease Indicates
g/dl occurrence of
Hct 0.30 0.30 normal

Platelets 317 150 – 400 x

09/L Normal
Salbutamol nebulation T nebule
Generic Name: Salbutamol
Brand Name: Pharmacia and Upjohn (marsman)
Classification: Anti-Asthma
Indications :Bronchospasm in bronchial
Asthma of all types, chronic
Bronchitis and Emphysema
Contraindications: Hypersensitivity
Precautions: Hyperthyroidism, diabetes mellitus,closed-angle glaucoma,
cardiovascular disease, pregnancy and lactation.

Patient Teaching:
-Instruct patients on dosage and not

-Shake the inhaler

-Clear nasal passages and throat

- Breath out,expelling as such air from lungs as possible

-Place mouthpiece well into mouth

Nursing Consideration:
-Syrup maybe taken by children as young as age 2, contains no alcohol or
-Glue extended release tablets consciously to patients with gastro Intestinal
-Aerosol form maybe used 15 minutes before exercise to prevent exercise
; for npo; brought to ward as ordered by Dr. Burdeos.

During February 13 2010, Dr. Burdeos ordered to continue O2

inhalation; checked vital signs;

Cefuroxime 750 mg IVTT

Generic Name:Cefuroxime Axetil
Brand Name:Ceftin
Classification: Antibiotic
Indication :For skin structure infection caused by streptococcus pneumoniae
Contraindications: Contraindicated for patients hypersensitive to drug
Adverse Reaction:
Cardiovascular: Phlebitis ,thrombophlebitis
Gastrointestinal Tract: Pseudo membranous colitis, nausea, vomiting,
diarrhea .
Hematologic: Transient neutropenin , eosinophiln, hemolytic anemia,
Skin: Maculopopular and erythematous rashes, urticaria pain ,in
duration , sterile obscesses , increase temperature , tissue sloughing at
intra muscular injection site.

Nursing Consideration:
-Use contiously in patients hypersensitive to penicillin because of
possibility of cross-sensitivity with other beta-lactam antibiotics. Also use contiously
in breastfeeding women and in patients with history of colitis.
-For intramuscular administration, inject deeply into a large muscle
mass such as the gluteus maximus or the lateral aspect of the thigh.
-Absorption of cefuroxime axetil is enhanced by food.
-Cefuroxime axetil tablets may be crushed fpr patients who can’t
swallow tablets .Tablets may be dissolves in small amount of juice. However the
drug has a bitter taste that is difficult to mask even with food.

Patient’s Teaching:
-Tell patient or patient’s significant other to take all of the drug as
prescribed even after he feels better.
-Advised patient’s significant others whwn patient receiving drugs
intra venous through tubing to report discomfort at intra venous insertion site.

Cefaclor 50 mg/ml as medication

Generic Name: Cefaclor
Brand Name: Ceclor
Classification: Antibiotic
Indication: For respiratory , skin and soft tissue infections
Contraindication: Contraindicated in patients hypersensitivity to drug.
Adverse Reaction :
Central Nervous System: Fever, seizures, dizziness, headaches.
Gastro Intestinal Tract: Nausea, vomiting, diarrhea,
dyspepsia, abdominal cramps, pseudo membranous colitis, oral condidiasis.
Skin: Maculopapular rash, dermatitis, pruritis, urticaria
Respiratory: Dyspnea

Nursing Consideration:
-Use contious in patients with hypersensitive to penicillin
because of the possibility of cross-sensitivity with other beta-lactam antibiotic. Also
use contiously in breastfeeding women and in patients with history of colitis.
-If large doses are given, therapy is prolonged or patient is
high-risk, monitor patient for super infection.

Patient Teaching:
-Instruct patient or patient’s significant others to take drug
with food or milk to lessen gastro intestinal discomfort.
-Tell the patient or patient’s significant others to take the
entire amount of drug exactly as prescribed even after the patient feels better.

-Advised patient or patient’s significant others to notify

prescriber if rash or if signs and symptoms of super infection such as re occurring
fever, chills, malaise.
Developmental Milestone
The optimal development of children is considered vital to society
and so it is important to understand the social, cognitive, emotional, and
educational development of children. Increased research and interest in
this field has resulted in new theories and strategies, with specific
regard to practice that promotes development within the school system.
In addition there are also some theories that seek to describe a sequence
of states that comprise child development. According to Freud’s theory,
an infant is categorized in oral phase where a child is seeking pleasure
through his mouth. The most powerful urge is to seek immediate
satisfaction of impulses such as hunger or discomforts. In relation to the
child, When the mother breast-feeds the child, the child experiences oral
pleasure and subsequently sucks his or her finger in order to recover
this pleasure. The nature of the breast-feeding determines the kind as
well as intensity of oral sexuality.

According to Erickson’s psychosocial trust vs. mistrust which is

the foundation of all psychosocial tasks. Because an infant is utterly
dependent, the development of trust is based on the dependability and
quality of the child’s caregivers. If a child successfully develops trust, he
or she will feel safe and secure in the world. Caregivers who are
inconsistent, emotionally unavailable, or rejecting contribute to feelings
of mistrust in the children they care for. Failure to develop trust will
result in fear and a belief that the world is inconsistent and
unpredictable. In relation to patient X, the child develops trust on the
day that he was delivered and cuddled by his mother. Until the day that
he was took cared.

According to piaget’s cognitive tasks, he categorized infants in

sensory motor where they developed to have object permanence(infants
learns that objects has identity of their own). Infants also begins to
recognizes familiar faces, objects and sounds. In relation to Patient X,
he had familiarize faces of his mother and other members of the family.
With its motor development, at 1 month old he already lifts head
temporarily, but generally, head must be supported, head sags. At 2
months old, he can carry hand or object to mouth at will reaches for
objects but misjudges distances, step o dances reflexes fading, grasp,
tonic reflexes, Moro reflexes fading.


1. Self Perception-Self Concept Pattern
As stated by the client’s mother as part of their health maintenance, he
is always giving his child with supplements such as vitamins and giving
him appropriate nutrients for his growth. He also brings his child to the
hospital when home remedy is not effective. The only family member in
their house who’s using tobacco is the client’s father.

2. Role Relationship Pattern

He has a very close bond with his family especially with his mother since
she takes care of him 24/7. He is the first and only child in his family.

3. Sexuality and Reproductive Pattern

Patient x is male, and yet a 2 mos old baby.

4. Cognitive Perceptual Pattern

Baby X can do its reflexes such as blink reflexes that are appropriate of
his age. By touching his hand Baby X can hold strong.

5. Coping Stress Tolerance Pattern

His mother said that he usually cry when something is wrong or when
he is not feeling well.

6. Value Belief Pattern

He is a Roman Catholic and her parents bring her to mass every
Sunday. As much as possible patient X mother wanted her baby to be
involved in believing in God. They also usually believe in quack doctors.

7. Elimination
Normally consumed more than four diapers. The consumption of
diapers before and during hospitalization is decreased. Patient X
consumed only two diapers.

8.Rest and Activity

The client sleeps approximately about 9-10 hours during night time. He
has no problem in sleeping. He always take naps during morning and

9. Activity-Exercise Pattern
According to the mother, PTA the client is “napaka likot” as verbalized
by the mother. In the hospital the client is unable to move freely due to
his health condition and his IV infusion. Because of his young age and
his condition he requires assistance and supervision from his parents in
all his daily activities.

10.Nutritional and Metabolic Pattern

Prior to hospitalization Patient X usual food intake are milk, cerelac.
Prior to admission Patient X is ordered Npo. He is currently having
+28cc solvent very slow IV push.
Physiology of Gas Exchange
Each branch of the bronchial tree eventually sub-divides to form very
narrow terminal bronchioles, which terminate in the alveoli. There are
many millions of alveloi in each lung, and these are the areas
responsible for gaseous exchange, presenting a massive surface area for
exchange to occur over. Each alveolus is very closely associated with a
network of capillaries containing deoxygenated blood from the
pulmonary artery. The capillary and alveolar walls are very thin,
allowing rapid exchange of gases by passive diffusion along
concentration gradients.
CO2 moves into the alveolus as the concentration is much lower in the
alveolus than in the blood, and O2 moves out of the alveolus as the
continuous flow of blood through the capillaries prevents saturation of
the blood with O2 and allows maximal transfer across the membrane.
How do the lungs normally work?
The chest contains two lungs, one lung on the right side of the chest, the
other on the left side of the chest. Each lung is made up of sections
called lobes. The lung is soft and protected by the ribcage. The purposes
of the lungs are to bring oxygen (abbreviated O2), into the body and to
remove carbon dioxide (abbreviated CO2). Oxygen is a gas that
provides us energy while carbon dioxide is a waste product or
"exhaust" of the body.

Nostrils/Nasal Cavity
During inhalation, air enters the nostrils and passes into the nasal
cavities which the foreign are removed, the air is heated and
moisturized before it is brought further into the body. It is the part of
the body that houses the sense of smell.

It is a small cavities that lined the mucous membrane within the
bones of the skull.

It is a throat carries foods and liquids into the digestive tract and
carries air into the respiratory tract.

It is also called voice box located between the pharynx and
trachea. It is the location of the adam’s apple, which in reality a thyroid
gland and houses the vocal cords.

Trachea-The trachea begins immediately below the larynx (voicebox)

and runs down the center of the front part of the neck ends behind the
upper part of the sternum. Here it divides to form two branches which
enter the lung cavities. The trachea (windpipe) forms the trunk of an
upside-down tree and is flexible, like a vacuum tube, so that the head
and neck may twist and bend during the process of breathing. The
trachea, or windpipe, is made up of fibrous and elastic tissues and
smooth muscle with about twenty rings of cartilage, which help keep the
trachea open during extreme movement of the neck. The lining includes
cells that secrete mucus along with other cells that bear very small
hairlike fringes. This mucus traps tiny particles of debris, and the
beating of the fringes moves the mucus up and out of the respiratory
tract, keeping the lungs and air passages free. In Russian folk medicine,
there is the thought that rubbing the chest with pork fat will cure a cold.
Mustard plasters and boiled snails in barley water were thought to be
effective by others, and nobody knows what the ingredients were for
early "cure-all tonics" and "snake oil" kits. It is now believed that the
best medicine is to rest, keep warm, drink plenty of fluids, and eat good,
digestible meals. Sounds good to me...and certainly better smelling.
Lungs- Air, which is inhaled through the mouth and nasal passages,
travels through the windpipe or "trachea" into two main air passages.
These divide into smaller branches which separate into even smaller
"twigs" like an upside-down tree. The respiratory system is mainly
contained in two lungs. The little air sacs at the end of the twigs
comprise the fruit of the tree, and through its thin walls gasses pass into
and out of the blood. The right lung is made up of three compartments,
each of which contain a branch and each of which stems off into smaller
"twigs," which hold the air sacs (or "fruit" of the tree) that process the
oxygen in the air to be released into the blood and expel carbon dioxide,
which is exhaled through the nose and mouth. The left lung cavity
contains only two sections (each with its own branches, twigs and fruit)
and encloses the heart, which processes the oxygenated blood and
returns deoxygenated blood into the lungs for exhalation. Breathing is
an automatic process which comes from the brain stem and is so strong
a force that the involuntary reflexes will not allow us to stop breathing
for any length of time. The passageways in the respiratory system are
lined with various types of epithelia to prepare the air properly for
utilization and with hair-like fibers called cilia that move in a wave-like
motion to sweep debris out of the lungs for expulsion. The women in
ancient Greece and Rome wore corsets of linen to restrain their figures.
The female waistline has been moved up and down over the passage of
time, but this became a real health hazard when whalebone corsets
came into use during the last part of the 19th and early part of the 20th
centuries, because they constricted the vital organs in the body -
especially those of the respiratory and digestive systems. Women with
"wasp-like" waists fainted so often that those who were well-off
purchased "fainting" couches; and when a woman "swooned," the cry,
"Cut her laces!" often allowed her enough air to recover.
Bronchi- The bronchus is the air passage into the lungs. Each lung has
one main bronchus, which begins at the end of the trachea or windpipe.
The bronchus divides into smaller branches known as segmental
bronchi, which then divide into bronchioles. (See "Bronchial Bulbs")
Bronchioles- the small airways of the lung extending from the bronchi
to the alveoli. The bronchioles become inflamed and constricted in
asthma, causing breathing difficulties.
Alveoli- The alveoli are the final branchings of the respiratory tree and
act as the primary gas exchange units of the lung. The gas-blood barrier
between the alveolar space and the pulmonary capillaries is extremely
thin, allowing for rapid gas exchange. To reach the blood, oxygen must
diffuse through the alveolar epithelium, a thin interstitial space, and the
capillary endothelium; CO2 follows the reverse course to reach the

There are two types of alveolar epithelial cells. Type I cells have long
cytoplasmic extensions which spread out thinly along the alveolar walls
and comprise the thin alveolar epithelium. Type II cells are more
compact and are responsible for producing surfactant, a phospholipid
which lines the alveoli and serves to differentially reduce surface tension
at different volumes, contributing to alveolar stability.
Pathophysiology of Pneumonia

Predisposing Factor: Precipitating Factor:

Age- less than one year of age Bacteria: S. pneumoniae

Decrease resistance: general/ immune Environment:
Virulent organism Psittacosis <pet bird>
Defective clearance mechanism: Legionella <water>
Cough/ gag reflex: coma, paralysis, addiction Aspergillosis <air, water>
Mucosal injury: smoking, aspiration, toxin Histoplasmosis < bird
Pulmonary edema: cardiac, ARDS dropping and
Obstruction: tumor, foreign bodies bat caves>
Bronchialdilatation: as bronchiectasis

Virulent Microorganism Streptococcus


Microorganism enters the lung


Organism enters to the lungs

Microorganism enters the lung

Organism enters to the lungs

Microorganism enters the lung


Infectious organism
lodges Infiltration of
bronchus Airway damage

necrosis Lung invasion

Stimulation of
in bronchial

Alveolar collapse Necrosis of pulmonary

pyrogen in the

Bad prognosis

Good prognosis:
-Tepid sponge
-Paracetamol, Overwhelming
Mucolytics/bo sepsis

Increase Death
pyrogen in the
body Fever

Sign and symptoms: Difficulty of breathing, Cough, colds, Shivering, Nausea and vomiting, Itchiness of the throat
Physical Assessment

Physical examination follows a methodical head to toe format in the

Cephalocaudal assessment. This is done systematically using the
techniques of inspection, palpation, percussion and auscultation with
the use of materials and investments such as the penlight, thermometer,
sphygmomanometer, tape measure and stethoscope and also the senses.
During the procedure, I made every effort to recognize and respect the
patient’s feelings as well as to provide comfort measures and follow
appropriate safety precautions.


-on our visit, Patient X is lying on bed wearing a baby’s clothes

colored white. Patient X is 2 months old, who weighs 4lbs. The baby is
conscious when we took and recorded the vital signs as follows:
Temperature:38.3 C
Pulse Rate:120 bpm
Respiratory Rate:18 bpm

Mental Status
Patient X is still a baby and can’t be questioned.
O>Motor Function
not yet applicable
O>Assessment of the Head
Head is round in shape. Hair is still short, straight and evenly
distributed. Scalp is smooth and white in color, minimal lesions were
O>Assessment of the Eyes
His eyes are symmetrical, white in color, almond shape. Pupils constricts
when diverted to light and dilates when he gazes afar, conjunctivas are
pink. Eyelashes are equally distributed and skin around the eyes is intact.
The eyes involuntarily blink.
O>Assessment of the Mouth
She has yet complete set of teeth. Oral mucosa and gingival are pink in
color, moist and there were no lesions nor inflammation noted. Tongue is
pinkish and is free of swelling and lesions. Presence of uvula was noted
and there is absence of swelling.
O>Assessment of the Neck
Lymph nodes noted. Neck has strength that allows movement back and
forth, left and right. Patient is able to freely move her neck.
O>Assessment of the Lungs and Thoracic Region
Chest is symmetric in volume, no tenderness and masses. Rib cage is also
symmetrical and full- lung expansion. He has difficulty in breathing.

O>Assessment of the Heart

Heart was not assessed.

O>Assessment of the Abdomen

His abdomen is in uniform in color, not distended, rounded symmetric
contour and movements upon respiration. The quadrant when auscultated
for bowel sounds is normal and no rebounds tenderness for flatulence or
gastric bubbles. There are no masses or tenderness noted.

O>Assessment of the Upper Extremities

Skin: White in color; presence of rashes in the arms, neck. Skin is smooth,
moist and soft to touch.
Hands: Medium in size with 5 fingernails in each side. Nails are short,
small dusty particles are present. A capillary refill of 1-2 seconds was
Arms: Able to move through active ROM. Able to extend arms in front or
push them out to the side.
O>Assessment to the Lower Extremities
Size of the feet is undefined with lines on the sole, no presence of scars
and lesions. Ten fingers are present. Nails are clean and short. No
apparent pain
upon movement therefore indicates negative Homan’s sign. Patient can’t
do ambulation.
O>Assessment of the Genitourinary
Patient urinates 1-2times a day and has not defecated yet prior to
O>Assessment of the Perineum
Absence of lesions and swelling.
Date identified: February 13,2010
S:”Init pa kaayo ning bata” as verbalized by the mother.
O: -Increase body temperature (38.3oC)
-Flushed skin
-Warm to touch
-Seizures noted
Nursing Diagnosis: Hyperthermia related to ongoing disease
Scientific Basis: Elevated temperature that results of depresses
the hypothalamus. As a result of soaring body temperature
increases the metabolic rate, which in turn, increases heat
Nursing Goal: Within 2o of rendering nursing interventions, the
patients temperature will decrease from 38.3oC to normal which is

Independent Rationale
1.) Assess the general condition of -To gather baseline data of the
the patient. patient.
2.) Monitor patient’s temperature.
-To determine if there’s any
3.) Determine the recent alteration of the temperature.
environmental exposure of the -May help identify causative
patient. environmental factors.
4.) Demonstrate Tepid Sponge -May help to lower down
Bath to the patient. temperature.
5.) Instruct the patient’s significant
others to let the baby wear loose -To prevent from feeling cold and
clothing and bed linens. shivering.
6.) Encourage the patient’s
significant others to avoid the baby -To have adequate rest and sleep.
in noisy environment.
7.) Advise the patient’s significant
others to increase fluid intake or -To meet the increased metabolic
breastfeeding as possible. demands and prevent dehydration.
8.) Advise the mother to provide
cooling blanket.
-Used to reduce fever.

Collaborative Rationale
1.) Administer antipyretics -To reduce fever by it’s central
medication. action on the hypothalamus.

Evaluation: After 2o rendering nursing intervention the, the patient’s

body temperature was able to decrease from 38.3oC down to 37.5oC.

S:”Dile kayo siya kaginhawa”as verbalized by the mother.

O: -Decreased respiratory rate 18 cbpm.
- Nonproductive Coughing noted
-Pale looking
Nursing Diagnosis: Ineffective airway clearance related to mucous
Scientific Basis: Inability to clear secretions from the respiratory tract
to maintain a clear airway.
Nursing Goal: Within 2o of rendering nursing interventions, the
patient’s airway will be free from mucous obstruction/secretions.

Interventions Rationale
1.) Assess the condition of the -To identify the health needs of the
patient patient.
2.) Monitor for the respirations -To determine the alteration of
and breath sounds of the patient. respiratory rate.
3.) Monitor the infant for feeding -May compromise airway.
intolerance, abdominal distention
and emotional stresses. -To help identify the cause of
4.) Observe for signs of respiratory airway obstruction.
distress. -To take advantage of the
5.) Demonstrate the proper relaxation on the diaphragm and
position of the patient elevate the enhancing ventilation.
head of bed. -To prevent fatigue of the patient.
6.) Encourage patient’s significant
others to let the patient have -Can help liquefy viscous
adequate rest and sleep secretions.
7.) Instruct the mother to let the
baby increase breastfeeding as

Collaborative Rationale
1.) Administer analgesic -To improve cough when pain is
medication. inhibiting effort.
-To clear airway when viscous
2.) Suction naso/tracheal/oral. secretions are blocking airway.

Evaluation: After 2o of rendering nursing interventions the patient’s

airway was able to free from mucous obstructions or secretions.


S:”Maglisod siya og ginhawa” as verbalized by the mother.

O: -Difficulty of breathing
-Pale looking
-Crying noted
Nursing Diagnosis: Impaired gas exchange related to ongoing disease
Scientific Basis:Excess or deficit in oxygenation or carbon dioxide
elimination at the alveoli-capillary membrane.
Nursing Goal: Within 2o of rendering nursing intervention the patients
tissues will have adequate oxygenation.

Interventions Rationale
1.) Assess the vital signs especially - To monitor any alteration
respiratory rate
2.) Auscultate breath sounds of the -To note areas of decreased
patient. adventitious breath sounds.
3.) Elevate head of bed . -To maintain airway.
4.) Maintain adequate intake -For mobilization of secretions.
output of the patient.
5.) Emphasized the importance of -To improve stamina and reducing
nutrition to the patient’s the work of breathing.
significant others.
6.) Encourage the patient’s -To promote optimal chest
significant others to maintain expansion and drainage of
frequent position changes of the secretions.
7.) Instruct the patient’s significant
others to identify specific supplier -To facilitate independency.
for supplemental oxygen necessary
the respiratory devices.

Collaborative Rationale
1.) Administer medications as -To treat underlying conditions.
prescribed by the doctor such as
antibiotic and bronchodilators.

Evaluation: After 2o of rendering nursing interventions, the patient’s

tissues had adequate oxygenation.


S:”Daghan lagi rashes sa iyang lawas”as verbalized by the mother.

O: -Rashes noted on the scalp, neck and axilla.
-Redness noted between the inguinal region.
Nursing Diagnosis: Impaired skin integrity related to skin irritation.
Scientific Basis: Inflammatory condition of the skin, possible evidenced
by disruption of skin surface and possibly altered circulation and
altered nutritional state.

Nursing Goal: Within 8o of rendering nursing interventions, the patient

will maintain optimal nutrition.
Independent Rationale
1.) Assess the blood supply of the -To evaluate actual for impairment
affected area. of circulation.
2.) Inspect the patient’s skin -To describe lesions characteristics
frequently. and observe changes.
-To stimulate circulation and assist
3.) Keep the area clean and dry. bodies natural process.
-To minimize redness and skin
4.) Advised patient’s significant irritation.
others to use petroleum jelly or
cream on the affected area.
5.) Encourage the mother to stay -To prevent of acquiring of other
the baby in safe and polluted-free infection.
6.) Instructed to use clean water -To avoid skin irritation on the
and mild soap. affected area.
7.) Emphasized the mother to have -Help to lessen acquiring any
properly adequate breastfeeding infections.
per demand.
8.) Encourage the mother to eat
nutritious foods. -Nutrients from the mother may
take through breastfeeding.

Collaborative Rationale
1.) Administer medications as -To prevent difficulty of treatment.
prescribed by the doctor if severe
reactions occur including


S:”Ambot ani nga bata dile ko kasabot sige man hilak-hilak” as

verbalized by the mother.
O: -Irritability
-Changes movements/uncoordinated movements.
-Pale looking

Nursing Diagnosis: Disorganized infant behavior related to lack of

feeding tolerance.
Scientific Basis: Disorganized physiological and neurobehavioral
responses of the infant to the environment.
Nursing Goal: Within 2o of rendering nursing intervention the patient
will be able to satisfy her needs by identifying appropriate responses
through breastfeeding.

Independent Rationale

1.) Assess the general condition of -To determine his/her behavior

the patient. properly.
2.) Discuss infant growth and
development as appropriate. -Augments parent’s knowledge of
3.) Provide patient’s significant co-regulation.
others the positive feedback for -To progress continuum as parents
progressive parental involvement and increases to take on more
in care giving process. complex care activities.
4.) Encourage parents to hold
infant including skin to skin -May have a positive effect on
contact or kangaroo care as infant development.
5.) Support and encourage parents -Support may have enhance coping
to be with infant and participate and strengthen attachment to the
actively in all of care. baby.
6.)Let the mother eat more
nutritious foods that are riched in -May help the nutrients through
vitamins and minerals. breastfeeding.

Collaborative Rationale
1.) Administer medication as prescribed -
by the doctor appropriately.
• Take the entire course of any prescribed medications. After a
patient’s temperature returns to normal, medication must be
continued according to the doctor’s instructions, otherwise the
pneumonia may recur. Relapses can be far more serious than the
first attack.
• Get plenty of rest. Adequate rest is important to maintain
progress toward full recovery and to avoid relapse.
• Drink lots of fluids, especially water. Liquids will keep patient
from becoming dehydrated and help loosen mucus in the lungs.
• Keep all of follow-up appointments. Even though the patient feels
better, his lungs may still be infected. It’s important to have the
doctor monitor his progress.
• Encourage the guardians to wash patient’s hands. The hands
come in daily contact with germs that can cause pneumonia.
These germs enter one’s body when he touch his eyes or rub his
nose. Washing hands thoroughly and often can help reduce the
• Tell guardians to avoid exposing the patient to an environment
with too much pollution (e.g. smoke). Smoking damages one’s
lungs’ natural defenses against respiratory infections.
• Give supportive treatment. Proper diet and oxygen to increase
oxygen in the blood when needed.
• Protect others from infection. Try to stay away from anyone with
a compromised immune system. When that isn’t possible, a
person can help protect others by wearing a face mask and always
coughing into a tissue.
Learning Insights