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8/3/2019 Case Pres Hard Copy
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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Introduction
This case presentation is about C. Guillermo ( Patient X )a 3 y.o. boy from La Torre, Talavera,
Nueva Ecija which have been admitted last October 5, 2011 at San Jose District Hospital. The Patient
was diagnosed with Bronchopneumonia, moderate risk.
Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill
with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in
your blood, your body cells cant work properly. Because of this and spreading infection through
the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia
affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches
throughout both lungs.
Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is
the most common. Other pathogens include anaerobic bacteria, Staphylococcus aureus,
Haemophilus influenzae, Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella
(Branhamella) catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gram-
negative bacilli. Major pulmonary pathogens in infants and children are viruses: respiratory
syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher
bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium
tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis,Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and Pneumocystis
carinii; and rickettsiae, primarily Coxiella burnetii (Q fever).
The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and
aspirating secretions from the upper airways. Other means include hematogenous or lymphatic
dissemination and direct spread from contiguous infections. Predisposing factors include upper
respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic
obstructive airway disease, age extremes, debility, immunocompromise (as in diabetes mellitus and
chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissibleagents.
Typical symptoms include cough, fever, and sputum production, usually developing over
days and sometimes accompanied by pleurisy. Physical examination may detect tachypnea and
signs of consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly
caused by bacteria, such as S. pneumoniae and H. influenzae.
http://nursingcrib.com/microbiology/cryptococcus-neoformans/http://nursingcrib.com/microbiology/cryptococcus-neoformans/ -
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Bronchopneumonia or bronchial pneumonia or Bronchogenic pneumonia is the acute
inflammation of the walls of the bronchioles. It is a type of pneumonia characterized by multi faci of
isolated, acute consolidation, affecting one or more pulmonary lobules. And it is classified under
Bacterial pneumonia. The bronchopneumonia pattern has been associated with hospital- acquired
pneumonia, and with specific organisms such as Staphylococcus aureus, Klebsiella pneumonia, E.coli and
Pseudomonas. It can also be secondary (complication of some other disease): Viral infection (influenza,
measles); aspiration of food or vomiting;
obstruction of bronchus with foreign body,
neoplasm and others; inhalation of
poisonous gases; major surgery; sever
chronic diseases (tuberculosis), malnutrition;
and, hipostatics (long lying after suffering
stroke).
Hospital acquired pneumonia, also
known as nosocomial pneumonia, is defined
as the onset of pneumonia symptoms more than 48 hours after the admission in patients with no
evidence of infection at the time of admission. Pneumonia is the most common cause of death among
infectious diseases. They take the fifth place in the statistics of diseases causing death.
Bacterial and viral lower respiratory tract infections are categorized into four groups: Acute
Bronchitis, an acute inflammation of the tracheobronchial tree; Bronchiectasis is the permanent
dilatation and subsequent destruction of sub segmental bronchi; Lung abscess is the parenchymal
destruction caused by an indolent suppurative process; and, pneumonia is an infection of the distal
portion of the lungs, involving the respiratory bronchioles, alveolar ducts, sacs and alveoli. Primary care
providers frequently evaluate patients with cough, which is the single most common symptom of
respiratory illness.
The objective of this presentation is to gain more knowledge about the disease and to prevent
the development of further complications.
This study aims to:
Conduct and evaluate an assessment for the client
Render series of nursing interventions for the clients care
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Provide and disseminate important information as teachings to the client and the significant
others to boost the knowing and understanding of the nature of the said health condition.
Improve skills and knowledge as health care providers in the clinical area
Demographic data
Name : Patient X
Hospital Number : 5994
Sex : male
Age : 3 years old
Date of Birth : April 9, 2008
Birthplace : Cabanatuan City
Address : Purok 1, La Torre, Talavera, Nueva Ecija
Citizenship : Filipino
Religion : Roman Catholic
Status : Single
Weight : 14 kg.
Date of admission : October 5, 2011 at 1:53 p.m.
Name of Mother : W. Guillermo
Physician : Dr. De Guzman
Diagnosis
Bronchopneumonia, moderate risk
History of Present Illness
Last September 28, 2011, 1 week PTA, Patient X have productive cough associated with
colds (watery) without other symptoms noted. The next day, he was brought to a Pedia and
was given with home medications. After 6 days the parent doesnt noticed any improvement
with the childs condition the patient is still with productive cough and associated with on and
off fever.
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Few hours prior to admission, the patient still have cough and fever, consulted once and
then admitted. The patient shows decrease in appetite, tachypnea, and decrease in activity
level.
History of Past Illness
The patient were fully immunized, (-) allergies and (-) surgeries PTA.
Family Medical History
Unremarkable
Physical Assessment:
Pertinent physical assessment findings upon admission
Pulse rate : 115 bpm
Respiratory rate : 42 bpm
Temperature : 39.3*C
Weight : 14 kg.
HEENT : PG AS, (-) NAD , (-) TOC
Neuro Exam : Conscious and coherent
Chest and lungs : SCE, (-) retraction, tachypneic, crackles (+) right
Heart : AP
Abdomen : Soft, flat, NABI, (-) tenderness
Extremities : (-) edema
Clinical Impression : Bronchial pneumonia, moderate risk
Recent Physical Assessment
BODY PARTS METHOD USED NORMAL PATIENT FINDINGS
HAIR
*Color
* Amount and
distribution
Inspection &
Palpation
Varies
Vary
Fine
None
Black
thick
No signs of abnormality
None
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*Texture
*Presence of
parasites
SCALP
*Symmetry
*Texture
HEAD
*Size
*Shape
*Consistency
FACE
*Symmetry
*Facial Features
TRACHEA,
THYROID, LYMP
NODE
EYES
*Position &
Appearance
*Blinking
*Shape
Inspection &
Palpation
Inspection &
Palpation
Palpation
Symmetrical
Smooth, firm
Normal
Symmetrical &
Round
Hard & Smooth
Symmetrical
May vary,
centered head
position
Lids margins
moist and pink;
lashes short,
evenly spaced,
and curled
outward
Symmetrical,
involuntary, at
approximate 15
Symmetrical
No signs of abnormality
Normal
No signs of abnormality
Symmetrical
No lymph nodes noted
No signs of abnormality
Black
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*Color of Iris
EAR
*Size & Shape
LIPS
*Color
*Consistency
ABDOMINAL
*Color
*Umbilicus
SKIN
*Generalized
color
* Color variations
in the patches of
the body
*Texture
Right Arm
Left Arm
Right Leg
Left Leg
Nails
*color
*Shape
*Texture
Inspection
Inspection
Inspection
Inspection
blinks per min
Round
Uniform color
Ears of equal size
and similar
appearance
Pinkish
Light to Dark
Brown
Moist, smooth
with no lesion
Normally pallor
Sunken centrally
In Dark Skin;
Light to dark
brown
in dark skin;
Lighter colored
palms, soles, nail
beds and lips.
Smooth, soft
Normal
Normal
Normal
Tiny Red Spots(Skin rash
caused by insect bites
skin (normal)
No signs of abnormality
No signs of abnormality
No signs of abnormality
No signs of abnormality
No signs of abnormality
No signs of abnormality
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Pinkish
Round Nail
Nail is round,
mobile, hard
Pathophysiology
Normal flora invades the lower resp. tract:
Escherichia Coli
Pseudomonas aeruginosa
Lung Contamination
inflammation
Release of endotoxins
Antigen- antibody response
Consolidation of lung tissue
Chest X-ray:
White atch infiltrate
Damage to bronchial tubes
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Diagnostic Tests
1. Hematology
Ref. No.: 12/05/IP Time out: 2:20 p.m.
Date : October 5, 2011
Component Result Reference Values Interpretation
RBC count 4.36Male: 4.5- 6x 10
12/ L
Female: 4- 5.5 x 1012
/L
Decreased erythrocyte counts is
associated with disorders such as
malnutrition
Hct .36Male: 0.40-0.54
Female: 0.77- 0.47
A decreased hematocrit indicate
hemodilution
Hgb 123Male: 120-170 g/ L
Female: 110-150 g/ LNormal
Platelet count 390 150- 450 x 109/ L Normal
WBC count 9.1Adult: 5-10 x 10
9/ L
Children: 6.2- 11.2 x 109/ LNormal
Segmenters 0.51 0.50 0.70 Normal
Lymphocytes 0.43 0.20- 0.40
Decreased as pneumonia is
present
Monocytes 0.06 0- 0.07Not a characteristic of specific
disorders
2. Urinalysis
Ref. No.: 17/05/IP Time out: 6:01 p.m.
Date : October 5, 2011
Physical
Color : Yellow
Clarity : Slightly turbid
Specific gravity: 1.005
pH : 5.5
Chemical
Glucose : negative
Albumin : negative
Ketone : negative
Urobilinogen : normal (0.2-1 EV/dl)
Nitrite : negative
Bilirubin : negative
Microscopic
RBC : 0-1/ HPF
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Pus cells : 0-1/ HPF
Epithelial cells : Rare/ LPF
Mucous Threads: Few/ LPF
Bacteria : Rare/ HPF
Amorphous urates: few/ LP
Urinalysis shows normal findings and has no significant relevance with the disease.
Anatomy and Physiology (normal)
The respiratory system consists of all the organs
involved in breathing. These include the nose, pharynx, larynx,
trachea, bronchi and lungs. The respiratory system does two
very important things: it brings oxygen into our bodies, which
we need for our cells to live and function properly; and it helps
us get rid of carbon dioxide, which is a waste product of cellular
function. The nose, pharynx, larynx, trachea and bronchi all
work like a system of pipes through which the air is funneled
down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the
bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes
wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder
for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common
respiratory symptoms include breathlessness, cough, and chest pain.The Upper Airway and Trachea
When you breathe in, air enters your body through
your nose or mouth. From there, it travels down your
throat through the larynx (or voicebox) and into the
trachea (or windpipe) before entering your lungs. All these
structures act to funnel fresh air down from the outside
world into your body. The upper airway is important
because it must always stay open for you to be able tobreathe. It also helps to moisten and warm the air before it
reaches your lungs.
The Lungs
The lungs are paired, cone-shaped organs which take up most of the space in our chests,
along with the heart. Their role is to take oxygen into the body, which we need for our cells to live
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and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each
have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of
tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only
two, because the heart takes up some of the space in the left side of our chest. The lungs can also be
divided up into even smaller portions, called 'bronchopulmonary segments'.
These are pyramidal-shaped areas which are also separated from each other by
membranes. There are about 10 of them in each lung. Each segment receives its own blood supply
and air supply.
Air enters your lungs through a system of pipes called the bronchi. These pipes start from
the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs,
until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are
where the important work of gas exchange takes place between the air and your blood. Covering
each alveolus is a whole network of little blood vessel called capillaries, which are very small
branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the
capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse)
between them. So, when you breathe in, air comes down the trachea and through the bronchi into
the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls
of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which
crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this
way, you bring in to your body the oxygen that you need to live, and get rid of the waste product
carbon dioxide.
Blood Supply
The lungs are very vascular organs, meaning
they receive a very large blood supply. This is
because the pulmonary arteries, which supply the
lungs, come directly from the right side of your
heart. They carry blood which is low in oxygen and
high in carbon dioxide into your lungs so that the
carbon dioxide can be blown off, and more oxygen
can be absorbed into the bloodstream. The newly
oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your
heart. From there, it is pumped all around your body to supply oxygen to cells and organs.
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The Pleurae
The lungs are covered by smooth membranes that we call pleurae. The pleurae have two
layers, a 'visceral' layer which sticks closely to the outside surface of your lungs, and a 'parietal'
layer which lines the inside of your chest wall (ribcage). The pleurae are important because they
help you breathe in and out smoothly, without any friction. They also make sure that when your
ribcage expands on breathing in; your lungs expand as well to fill the extra space.
The Diaphragm and Intercostal Muscles
When you breathe in (inspiration), your muscles need to work to fill your lungs with air.
The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does
much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in,
the diaphragm contracts and flatten out, expanding the space in your chest and drawing air into
your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also
help by moving your ribcage in and out. Breathing out (expiration) does not normally require your
muscles to work. This is because your lungs are very elastic, and when your muscles relax at the
end of inspiration your lungs simply recoil back into their resting position, pushing the air out as
they go.
The Respiratory System and Ageing
The normal process of ageing is associated with a number of changes in both the structure and
function of the respiratory system. These include:
Enlargement of the alveoli. The air spaces get bigger and lose their elasticity, meaning that
there is less area for gases to be exchanged across. This change is sometimes referred to as
'senile emphysema'.
The compliance (or springiness) of the chest wall decreases, so that it takes more effort to
breathe in and out.
The strength of the respiratory muscles (the diaphragm and intercostal muscles) decreases.
This change is closely connected to the general health of the person.
All of these changes mean that an older person might have more difficulty coping with
increased stress on their respiratory system, such as with an infection like pneumonia, than a
younger person would.
Functions:
Works closely with circulatory system, exchanging gases between air and blood:
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Takes up oxygen from air and supplies it to blood (for cellular respiration).
Removal and disposal of carbon dioxide from blood (waste product from cellular
respiration).
Homeostatic Role:
Regulates blood pH.
Regulates blood oxygen and carbon dioxide levels.
Medical Management
GENERIC NAME
cefuroxime axetil
BRAND NAME
Ceftin
ACTION
Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic
instability; usually bactericidal.
INDICATION
1. Serious lower respiratory tract infection, UTI , or secondary or skin-structure infections,
before or joint infection, septicemia, meningitis and gonorrhea.
2. Perioperative prevention.
3. Bacterial exacerbation of chronic bronchitis or secondary bacterial infection of acute
bronchitis.
4. Acute bacterial maxillary sinusitis.
5. Pharyngitis and tonsillitis.
6. Otitis media.
7. Uncomplicated skin and skin structure infection.
8. Uncomplicated UTI.
9. Uncomplicated gonorrhea.
10. Early Lyne disease.
11. Impetigo.
SIDE EFFECTS
CEREBROVASCULAR- phlebitis, thrombophlebitis
GASTROINTESTINAL- diarrhea, pseudomembranous, colitis, nausea, anorexia, vomiting
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HEMATOLOGIC- hemolytic anemia, thrombocytopenia, transient neutropenia, eosinophilia
SKIN- maculopapular and erythematous rashes, urticarial, pain, induration, sterile abscess,
temperature elevation, tissue sloughing at IM injection site
OTHER- anaphylaxis, hypersensitivity reactions, serum sickness
NURSING RESPONSIBILITIES
1. Before giving drug, ask patient if he is allergic to penicillins or cephalosporins.
2. Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin
while awaiting results.
3. For IM use, inject deep into a large muscle, such as the gluteus maximus or the side of the
thigh.
4. Absorption of oral drug is enhanced by food.
5. Alert: tablets and suspension arent bioequivalent and cant be substituted milligram-for-
milligram.
6. Monitor patient for signs and symptoms of super infection.
GENERIC NAME
gentamicin sulfate
BRAND NAME
Cudomycin, Garamycin
ACTION
Inhibits protein synthesis by binding directly to the 30S ribosomal subunit; bactericidal.
INDICATION
Serious infections caused by sensitive strains of pseudomonas acruginosa, Escherichia coli,
Proteus, Klebsiella, or Staphyloccocus. To prevent endocarditis before GI or GU procedure or
surgery.
SIDE EFFECTS
CENTRAL NERVOUS SYSTEM- encephalopathy seizure, fever, headache, lethargy, confusion,
dizziness, numbness, peripheral neuropathy, vertigo, ataxia, tingling
CEREBROVASCULAR- hypotension
EENT- ototoxicity, blurred vision, tinnitus
GI- vomiting, nausea
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GU- nephrotoxicity, possible increase in urinary exertion of casts,
HEMATOLOGIC- agranulocytosis, leukopenia, thrombocytopenia, anemia, eosinophilia
MUSCULOSKELETAL- muscle twitching, myasthenia gravis,-like syndrome
RESPIRATORY- apnea
SKIN- rash, urticarial, pruritus, injection site pain
NURSING RESPONSIBILITIES
1. Obtain specimen for culture and sensitivity test before giving. Begin therapy awaiting
results.
2. Evaluate patients hearing before and during therapy. Notify prescriber if patient complains
of tinnitus, vertigo or hearing loss.
3. Weigh patient and review renal function studies before therapy begins.
4. Monitor renal function: urine output, specific gravity, UA, BUN and creatinine levels and
creatinine clearance. Report to prescriber evidence of declining renal function.
5. Watch for signs and symptoms of super infection such as continued fever, chills and
increased pulse rate.
6. Therapy usually continues for 7 to 10 days. If no response occurs in 3 to 5 days, stop
therapy and obtain new specimens for culture sensitivity testing.
GENERIC NAME:
ipratropium bromide
BRAND NAME:
Atrovent
ACTION
Inhibits vagally mediated reflexes by antagonizing acetylcholine at muscarinic receptors on
bronchial smooth muscle.
INDICATION
Bronchospasm in chronic bronchitis and emphysema. Rhinorrhea caused by allergic and
non-allergic perennial rhinitis. Rhinorrhea caused by the common cold. Rhinorrhea caused by
seasonal allergic rhinitis.
SIDE EFFECTS
CNS- dizziness, pain, headache, nervousness
CV- palpitations, hypertension, chest pain
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EENT- blurred vision, rhinitis, pharyngitis, sinusitis, epistaxis
GI- nausea, GI distress, dry mouth
MUSCULOSKELETAL- back pain
RESPIRATORY- URTI, bronchitis, bronchospasm, cough, dyspnea, increased sputum
SKIN- rash
OTHER- flulike symptoms, hypersensitivity reactions
NURSING RESPONSIBILITIES
1. If patient uses a face mask for a nebulizer, take care to prevent leakage around the mask
because eye pain or temporary blurring of vision may occur.
2. Safety and effectiveness of use beyond 4 days in patients with a common cold havent been
established.
3. Alert: patient with a severe peanut allergy could have an anaphylactic reaction after using
Atrovent inhalation aerosol metered-dose inhaler (MDI). Get a thorough allergy history from
patient before giving any drug.
4. Look alike-sound alike: Dont confuse Atroventwith Alupent.
GENERIC NAME:
acetaminophen
BRAND NAME:
Acetaminophen
ACTION
Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of
prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The
drug may relieve fever through central action in the hypothalamic heat-regulating center.
INDICATIONS
Mild pain or fever
SIDE EFFECTS
HEMATOLOGIC- hemolytic anemia, leukopenia, neutropenia, pancytopenia
HEPATIC- jaundice
METABOLIC- hypoglycemia
SKIN-rash urticarial
NURSING RESPONSIBILITIES
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1. Alert: Many OTC and prescription products contain acetaminophen; be aware of this when
calculating total daily dose.
2. Use liquid form for children and patients who have difficulty swallowing.
3. In children, dont exceed five doses in 24 hours.
Management
(Medical Management)
Antibiotics are prescribed based on Gram stain results and antibiotic guidelines
Supportive treatment includes hydration, antypiretics, antihistamines, or nasal
decongestants
Bed rest is recommended
Oxygen therapy is given for hypoxemia
( Nursing management)
Assess clients for s/sx
Note changes in temperature; pulse; amount, odor and color of secretions; and
breath sounds
Frequency and severity of cough
Encourage hydration: fluid intake (2-3 L/day) to loosen secretions
Provide appropriate method of oxygen therapy
Place client in semi-fowlers position
Educate the parents/guardian of the patient about the disease
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Nursing Care Plan
Assessment Subjective:
Napansin ko na hirap sa paghinga yung anak ko, nag-iba yung
parang hinahabol niya yung paghinga niya. Mas nahihirapan siya kaysa
nung unang araw ng ubo niya as verbalized by the mother.
Objective:
CR= 110
RR= 35
Temp. = 38.6
Wt. = 14 kg.
Adventitious breath sound (rales)
Productive cough
Dyspnea
Diagnosis Ineffective airway clearance related to secretions in the bronchi
Planning Short term:
After 8 hour of nursing intervention the patient will be able to:
Maintain airway patency
Expectorate secretion readily Demonstrate reduction of congestion with clear breath sounds
and the mother will be able to:
Verbalize understanding of cause(s) and therapeutic management
regimen of her son
Identify potential complications and how to initiate appropriate
preventive or corrective actions
Long term
(not applicable because of one day duty in the hospital)
Implementation Independent:
Assess clients respiration and breath sounds, noting rate and sounds
Evaluate clients cough/gag reflex and swallowing ability
Position client in semi fowlers position for maximum lung
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expansion
Change position every 2 hours to decrease gravity pressure on the
diaphragm and to enhance ventilation to lung segments
Monitor clients feeding intolerance, and abdominal distention
Keep environment allergen free
Assist and teach the mother in nebulizing client accompanied with
bronchial tapping if not contraindicated
Increase fluid intake to loosen secretions
Monitor clients vital signs
Observe for signs of respiratory distress
Assess client/SOs knowledge of contributing causes, treatment plan,
specific medications, and therapeutic procedure
Provide information about the clients condition to the mother/ SO
Demonstrate/assist SO in performing specific airway clearance
techniques
Dependent:
Give expectorants/bronchodilators as ordered
Administers analgesics as ordered
Interdependent:
Assist with appropriate testing to identify causative/precipitating
factors
Assist with procedures (bronchoscopy) to clear/maintain open
airway
Assist with use of respiratory devices and treatments
Assist in obtaining sputum specimen
Evaluation After 8 hour of nursing intervention the patient was able to:
Maintain airway patency (partially met)
Expectorate secretion readily (partially met)
Demonstrate reduction of congestion with clear breath
sounds(partially met)
and the mother was able to:
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Verbalize understanding of cause(s) and therapeutic management
regimen of her son (goal met)
Identify potential complications and how to initiate appropriate
preventive or corrective actions (goal met)
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Assessment Subjective:
Yung tatay niya ay naninigarilyo as verbalized by the mother
Objective:
Risk diagnosis is not evidenced by signs and symptoms
Diagnosis Risk for infection related to insufficient knowledge to avoid exposure to
pathogens secondary to bronchopneumonia
Planning After 4 hours of nursing intervention the mother/SO will be able to:
Verbalize understanding of individual causative/risk factor(s)
Identify interventions to prevent/reduce risk of infection
Understand on how to promote safety environment on her child
Implementation Independent:
Assess client for any sign of infection and document initial finding
Educate mother for the risk factors
Stress proper hygiene by all caregivers to avoid infection
Educated significant others close to the client about the effects of
smoking to the client
Monitor/assist with the use of adjuncts
Review individual nutritional needs with the mother
Instruct client/SO in techniques to prevent spread of infection
Discuss the role of smoking in respiratory infections
Dependent:
Administer medication as ordered
Interdependent:
Obtain appropriate fluid specimen for observation and culture and
sensitivity testing
Evaluation After 4 hours of nursing intervention the mother/SO was able to:
Verbalize understanding of individual causative/risk factor(s) (goal
met)
Identify interventions to prevent/reduce risk of infection (goal met)
Understand on how to promote safety environment on her child
(goal met)
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WESLEYANUNIVERSITYPHILIPPINES-COLLEGE OF NURSING
Discharge Planning
Meds
Instruct the mother about the medicine
Evaluation
Evaluate whether the mother understand the teaching.
Evaluate the clients response to the treatment given in the ward
Evaluate the mothers need for additional learning
Treatment
Refer patient for home care to facilitate adherence to therapeutic regimen
Instruct mother about the follow-up care
Health education
Review principles of adequate nutrition and rest to the mother
Advise mother to increase the activities of the client gradually after fever subsides
Repeat instructions and explanations as needed to the mother
Observe personal hygiene
Instruct the mother to avoid smoking near the client which lower the resistance to
pneumonia
Include information about ways to reduce potential for infection
Diet
As for our client, Diet as tolerated
Instruct the mother on what is nutritional foods that her child needs
Spiritual
Assist parents to learn effective coping, for them to understand that its not their fault
but they can do something to prevent and help their child to avoid it.