Andres Bonifacio College

School of Nursing
College park, Dipolog City

Pediatric Ward Case Book

Submitted by: Mr. Roeder Cuerda BSNIII

Submitted to: Mrs. Julyn Marie Gallardo RN,MN
 Patients Profile
Name: X
Date of Birth: May 8 2016
Age: 6 months and 29 days
Gender: female
Church: Roman Catholic (unbaptized)
Address:San Vicente Manukan Zamboanga Del Norte
Weight: 6kg
Height: 29 inches
BMI= 11.0 (Underweight)
Civil Status: Single/Child
Attending Physician: Dr. Abdulla
Admitting Diagnosis: Cellulitis L lateral
ward: Pediatric Charity Ward
Room no. PCW EXT 06
Chief Complaint: Swollen left neck
History of Past Hospitalization: Unremarkable
History of past Illness: Mother of client reported that patient X have had fever 2 weeks ago
accompanied by cough and colds. But the fever have subsided with slow recovery from cough
and colds. But my client had fallen of the bed and hitted her posterior part of the head 3 inches
above the nape.
History of present illness: During Assessment Clients mother reported that three days prior to
admission she woke up at 3 am in the morning because her daughter cried. Then soon after her mother noticed
red spot on her neck and is gradually swelling after, with changes in her voice (pagaw) on the second day and
they then decided to bring the child to the hospital for consultation
Family History: + Hypertension , - diabetes, - cancer
 Physical Assessment
Assessor: Roeder Cuerda
Patient: X
Vital Signs

8 AM 12 PM
Blood Pressure n/A n/A
Temperature 36.2oC 36.2oC
Pulse Rate 132 127
Respiratory 35 32
Rate

General Appearance:
Not well groomed
Patient is very irritable
Always carried by her mother and cries when her mother put her to bed.
Never seen the client smile
Integumentary System:
Brown skin complexion

Has a warm to slightly hot skin temperature when touched.

Swollen neck erythematous 10x5cm in size
Moist skin
Dirty Nails
Good capillary refill.
Dirt on folds of the skin specially on the neck.

Hair and Head and neck:

Head circumference 16.5 inches
Neck circumference with the enlargement 12 inchest
Chest circumference 19 inches
Eyelids and eyebrows are symmetrical
Pupils respond to light normally
 Unable to turn neck on the left laterally
Has a presence of dandruff.
No nasal secretion
No teeth yet
Swollen neck erythematous 10x5cm in size
No abnormal drainage from eyes and ears.
Messy short hair.
Lump on his posterior part of the head 3 inches above the nape
Palpable lymph nodes

Ears:
Auricles has the same color as the facial skin.
Symmetrical in size and shape.
Aligned at the outer canthus of the eye.

Thorax:
 Crackles on both lungs upon auscultation.
No Murmurs, bruits.
Symmetrical during chest excursion test.

Abdomen:
Bowel sound: 19 ticks per minute
No tenderness and rebound tenderness on the Liver, appendix and stomach
No abdominal distention.

Extremities: extremities dont have any problem both arm and legs have optimal range of motion
no injuries, discoloration but both hands and feet are cold and clammy
 Gordons Functional Health Pattern
Usual Initial Ongoing
HEALTH PERCEPTION/ HEALTH December 7 2017
Vital Signs 8:00 am vital signs
MANAGEMENT
Blood Pressure n/A 8am 12pm
Blood n/A n/A
Temperature 36.5oC
Pressure
Does take meds such as paracetamol Pulse Rate 132 BPM temperature 36.8 36.4
when febrile. Respiratory Rate 35CPM Pulse rate 132 135
No drug allergies vital signs 12 pm. Respiratory 23 28
No food restrictions rate
Tiki-tiki food supplement Blood pressure Medications:
Does consult physician or any temperature 36.2oC D5LR infusing well at 26 gtts/ml 1l
health professionals only when Pulse rate 137BPM at Left cephalic vein.
sick. Respiratory 22CPM clindamycin 65mg q 8hours IVTT
Went to mang hihilot one week rate, gentamycin 32 mg q 24 hours
ago due to fever, cough and IVTT
colds. paracetamol 65mg q 4 hours or
Medications: prn when febrile IVTT
D5LR infusing well at 26 gtts/ml 1l
at Left cephalic vein.
clindamycin 65mg q 8hours IVTT
gentamycin 32 mg q 24 hours IVTT
 paracetamol 65mg q 4 hours or prn
when febrile IVTT
No drug allergies.
No drug allergies.
No food restrictions
No food restrictions Irritable and always cries.
Irritable and always cries. swollen neck
swollen neck Has cough no colds
Has cough no colds No fever
No fever Confined

WBC count very high =54.9

cells per microliter. Normal
values 5.0-10.0 cells per micro
liter.

Confined.

Nutritional Metabolic client has good appetite was able to

breast fed for 6 months and going. breast feed 5 times daily . client still has good appetite
according to mother no refusal to
eat and drink.
BMI= 11.0 (UNDERWIGHT)

consumed 3 table spoons of water at 11 BMI= 11.0 (UNDERWIGHT)

am after eating lunch (rice with tinula)
 Starting consuming soft food
at the age of 6 months such as
porridge, cerelac half serving. breast fed four times during the
Consumes half cup of water whole shift.
118ml.
No difficulty in swallowing. drank 2 tablespoons of water.
Has good appetite.
No history of stomach
anomalies.
Mother gave her child bear
brand 3 days after birth due to
insufficient breast milk.

Elimination Pattern
Defecates in a diaper or
lampin.
No history of diarrhea.
Defecated twice a day
reguraly
No history of UTI and urinary
problems.
client have defecated twice and
urinated in a diaper.
client have defecated twice and urinated
in a diaper.
Diarrhea absent
Diarrhea absent
Stool characteristics: yellow non-watery
no blood or sputum
Stool characteristics: yellow non-watery
no blood or sputum.
Activity Exercise Pattern
highly dependent to mother.
Usually plays and smiles when
cuddled.
unable to crawl yet but is able to
reach out things.
bathes daily.
Sleep rest Pattern
No difficulty sleeping.
usually sleeps at 7pm and wakes
up at 4 am in the morning
Takes short morning naps sleeps at at 4 pm in the afternoon and sleeps at 7
9 am in the morning and wakes up pm at night and wakes up 3am in the
at 12.
ADL SCALING
CRITERIA:
Client still did not tae a bath
Bathing with sponge, bath, or shower=
0
Dressing= 0 always carried by mother.
Toilet Use= 0
Transferring (in and out of bed or
chair)= 0 sometimes respond with a smile
Urine and Bowel Continence=0 when cuddled.
Eating=0
Have not showered and bathed for one
week now.
always carried by her mother at all times
mother reported that client has no
usual length of sleep at night is 8
hours.
difficulty sleeping at night and also takes
short naps in the morning.
Sleeping hours depends from day to day.
mostly she sleeps at 1 pm and wakes uo
morning.
Cognitive Perceptual
Mother stated that my client does
respond to stimuli like cries when
theres a strong noise, facial
changes when given sampalok
always jolly and in a good mood.
Self Perception/self concept
mother reported that client
responds well against disturbing
stimuli when mother is on her side.
Unable to speak nor report signs of pain.
client always cry.
Client still always crying and
irritable.
no cognitive changes lately.
client still wake up when disturbed. High level of consciousness.
has high level of consciousness.
mother have reported that there is a
slight change in her daughters
attitude and behavior she is now
more irritable and cries most of the
times compared when she was at
home with not bitted by a bug on
her neck.
Role Relationship

Only daughter and only child of her

20 year old mother.

Sexually reproductive

child 7 months old

Coping/stress tolerance

Usually cries when in pain, doesnt

eat when sick and mother as her
most trusted companion.
DX: Acute Pain (neck) r/t inflammatory changes in tissue from infection.
Assessment Planning Intervention Rationale Evaluation
Objective Cues: At the end of my 8 INDEPENDENT
hour duty my client Pain Assessment is the
assess characteristics fifth Vital sign and the
Client very irritable will manifest
of pain. Duration, first step for planning
decreased pain
always cries. (neck) evidenced by:
precipitating and management strategies.
relieving factors.
client cries every time lesser crying
she is moved and the episodes non pharmacologic
Provide icepack to measures such as ice
neck is affected. clients neck if not
normal heart rate and packs or hot bag can
contraindicated. help reduce pain when
Cries for more than respiratory rate
done with pain relievers.
appropriate for age
10-15 minutes. HR-100-150
RR-30-55
Stops crying when Evaluate pain To evaluate the
response to main effectiveness of the main
carried by her mother. uniform skin and medication and other
management
body temperature strategies that relieves
strategies. pain.
heart rate: 157BPM
Respiratory rate: irritability will be eliminate additional patience experience
39CPM minimize (cries stressors or exaggeration in pain
everytime she is when externam stimuli
Excessive sweating. sources of such as noise, and other
cold and clammy skin. touched or discomfort when body disturbances
possible (noise, affecting them.
she wont turn her disturbed) heat, annoying
neck on the left side pillows, clothes
where the with rough edges)
inflammation is
present. Provide rest fatigue exaggerates
periods to facilitate clients perception of
WBC count = 59.4 comfort sleep and pain.
cells per micro liter. relaxation.

Client cries everytime Dependent:

the neck is disturbed. administer Pain
Medication such as Regular administration
Subjective Cues: paracetamol
of analgesia is most
effective rather than an
client verbalized: mg IVTT Q hours as needed basis.
nay nausob niya
or PRN when
kanang koan mag cge
febrile.
na siyag hilak dile
pareha atong wala pa
na paakan iyang liog.
DX. Impaired skin integrity r/t trauma from insect bite as evidenced by: swelling and change in
skin tissue color (red) on the Left neck.
Assessment Planning Intervention Rationale Evaluation.
At the end of my 8 INDEPENDENT t
hour duty there will determine further Information about the
Objective Cues cause of injury guides
be no signs of cause of tissue specific interventions in the
complications or damage(irritation from plan of care.
swollen neck and severity to develop rough bed sheets and
with regards to clothes, insect bites)
10x5cm in size structure and
erythematous. function and the skin assess for elevated Fever is a systemic
condition of the body temperature. manifestation of infection
and inflammation.
neck.
change in skin tissue
color (red) on the Left Patient who scratches
maintained ability to the skin attempts to
neck. move neck fro up identify signs of itching relieve itch, itching
and down and right and scratching. may open skin lesions
with sight movement increasing the risk for
neck diameter 12 to the left. infection.
inches.(head 16.5
inches) swelling of the neck cleanse are with cleansing removes
will not exceed normal saline or a non- majority of pathogens.
10X5Cm in size. toxic cleanser as
WBC count 59.4 cells appropriate
per micro liter. absence of to enhance faster
dysphagia and total Provide tissue care as healing.
loss of voice . needed.
 discourage rubbing scratching and rubbing
may delay wound
and scratching provide
healing and may
Vital signs: reduced visibility ofgloves or chip the nails increase risk of infection.
redness on the as necessary.
8 12 center of the swollen
As a primary source of
part of the neck. Do not discontinue
AM PM breast feeding.
food for her age, breast
milk contains a lot of
Blood n/A n/A antibodies.
Pressure
Temperature 36.2oC 36.2oC
Teach S.O the
accurate information
methods in increases the patients
Pulse Rate 132 127 maintaining tissue SOs ability to manage
Respiratory 35 32 integrity. therapy independently and
Rate reduce the risk for
infection.

DEPENDENT
Administer Antibiotics
as ordered such as Wound infection may be
treated more easily with
Clindamycin 65 mg topical agents although
IVTT q 8 hours. intravenous antibiotics may
be ordered,
Gentamycin 32mg
IVTT q 24 hours.
SOURCES:
Nursing Diagnoses, Definitions and Classification 2012-14 - Nanda International
Nursing Diagnoses 2015-17 - NANDA International
http://nanda-nursinginterventions.blogspot.com
http://www.healthline.com/health/gastritis-acute#2
Kozier and erbs Fundamentals of Nursing 10th edition
 DX: Imbalanced Nutrition: Less than body requirements r/t increased metabolic needs caused by
disease process.
Assessment Planning
Objective Cues: At the end of my 8 hour duty
there will be enhancement on
my clients nutritional intake
height 73.66 cm
as evidenced by:
weight 6kg longer periods of breast
feeding more than 10 minutes
age 6 months per breast feed with frequency
of atleast 3-5 daily.
BMI
11.1(underweight) maintained or enhanced
appetite for feeding.
pale skin, cold and
no further drop on clients BMI
clammy.
Wight gain for atleast .10 - .25
moist/ dry skin.
kg daily.
Lab results- uniformed body temperature.
RBC- Enhanced blood circulation on
extremities (no longer pale)
110 (120-140 g/dl)
Pale skin.
Intervention Rationale Evaluation
Measure weight and Baseline data of the
nutritional intake of
height do not estimate.
the client whether the
client is consuming
assess signs of poo what is prescribed
nutritional intake( with full tolerance.
insufficient food, faulty
nutritional diet) A well maintained
environment help
enhances appetite for
give health teaching to eating.
mother to increase food
consumption on allow client to choose
nutritious foods such as what healthy foods he
wants to eat, for the
green leafy vegetables,
client to eat more and
enhance fluid intake. achieve balanced
nutrition fast.
collaborate or refer to a
dietitian for better Proper choice of food
helps stabilize
assessment and
nutritional status.
recommendation
 regarding nutritional
MUAC 13 cm status.
(moderately Weight monitoring is a
underweight) must to know the
ensure environment us progress of your whole
15-17 cm normal pleasant , facilitate nutritional plan.
value proper positioning and
proper latching.
Breast feeding 5
times daily but in
short intervals.
Breast feeds for only
3-5 minutes. monitor laboratory
anemia occur in
result that indicate malnutrition leading to
Subjective Cues: mo nutritional wellbeing weakness and are
totoy raman pud siya deterioration RBC. usually decreased in
pero dali ang jud malnutrition (RBC)
kaau mahuman.
suggest or refer to such supplements can
physician the use of be used to increase
supplements between calories and protein
without interfering with
meals.(tiki-tiki)
voluntary food intake.
Dx: Ineffective Peripheral tissue perfusion.

Assessment Planning Intervention Rationale Evaluation

Objective Cues: At the end of my 8hour Assist client during With hypotension the risk
duty there will be ambulation and put of falling is high due to
Hgb Count absence complications decreased blood supply
HGB= 11.8 below normal side rails up.
brought by ineffective in the brain.
(13.8-17.2) peripheral tissue
perfusion as evidenced Assist client in Changing position every
Blood pressure= by: changing position in 2 hours helps those
bed every 2 hours. dependent body parts to
90/60 mmhg. be circulated with blood
Absence of edema on
thus it helps in optimum
extremities.
Poor capillary refill body circulation.
>3 seconds Absence of dependent Teach client to do Deep breathing exercises
skin discoloration
deep breathing help your lungs get more
(Cyanotic)
Pale nail beds on exercises. oxygen for circulation.
hands and feet. Absence of altered
Green leafy vegetables
sensations on Encourage client to
and red meats are high in
extremities. eat high iron foods iron which is vital for
such as red meats blood and body
Subjective cues: Absence of injury
and green leafy nourishment.
client verbalized brought by accidental fall
when standing. vegetables.
Malipung pako Increasing fluid intake
increases blood volume
inig mo tinug Maintained mental status. Encourage client to
through blood plasma
increase fluid intake thus helps in supplying
6-10 glasses a day. extremities with adequate
blood supply.
 Bleeding is one common
cause for decreased
Assess for epistaxis tissue perfusion.
and other signs of
bleeding.
Sufficient fluid intake
maintains adequate filling
Monitor Clients Iv
pressures and optimizes
Fluid cardiac output needed for
tissue perfusion.
Pathophysiology: