A Case Study
Presented to the Faculty of
The Ateneo de Davao University
College of Nursing
A Case Study on
Anemia 2o to Sepsis 2o
Bronchopneumonia
Submitted by:
Kristi Ann CabonitaMarie Allexis CampanerFrancis Thomie CaranayRico Janrev CastañedaRashed Eduard Ceniza
Joanna Paula Concepcion
Submitted to:
Loreen S. Marcelo, RN
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September 25, 2010
TABLE OF CONTENTS
i. Acknowledgement.……………………………………………………………………………. 2
I. Introduction……………………………………………………………………………………. 3
II. Objectives (General & Specific)………………………………………………………………. 5
III. Patient’s Data………………………………………………………………………………….. 8
IV. Genogram……………………………………………………………………………………… 13
V. Health History…………………………………………………………………………………. 14
VI. Developmental Data…………………………………………………………………………… 17
VII. Physical Assessment…………………………………………………………………………... 20
VIII. Complete Diagnosis…………………………………………………………………………… 27
IX. Anatomy and Physiology……………………………………………………………………… 30
X. Etiology……………………………………………………………………………………….. 39
XI. Symptomatology……………………………………………………………………………… 54
XII. Pathophysiology……………………………………………………………………………… 62
XIII. Doctor’s Order……………………………………………………………………………….. 66
XIV. Diagnostic Examination………………………………………………………………………. 93
XV. Drug Study……………………………………………………………………………………. 109
XVI. Nursing Theories……………………………………………………………………………… 184
XVII. Nursing Care Plans……………………………………………………………………………. 192
XVIII. Prognosis ……………………..………………………………………………………………. 217
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XIX. Discharge Planning ……………………..……………………………………………………. 222
XX. Recommendation …………………………………………………………………………….. 224
XXI. Bibliography …..……………………………………………………………………………… 225
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ACKNOWLEDGMENT
In accomplishing great things, we must not only think, but believe in the power of our
cognition; not only aim but make our visions tangible; and at the end of the day, not only smile
at the thought of accomplishment, but look back to where the strength to achieve such success
came from.
The proponents would like to extend their warmest gratitude to all the people who
helped make the success of this undertaking a reality.
First and foremost, to our parents, for giving us support and encouragement every day,
for making us feel loved and cared for.
To our Clinical Instructor, Mrs.Loreen Marcelo RN, for her invaluable time and effort
rendered to us; for her guidance all throughout the our ward exposure. For being a friend and
companion in the area.
And lastly, to the Almighty Father, for His unceasing love and blessings; for giving us
enough power and fortitude to face all the hardships in the making of this work. To Him be all
glory and praise!
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INTRODUCTION
Anemia is a common problem among acutely ill patients, especially those who develop
sepsis. There are many factors contributing to the development of anemia in these patients, in-
cluding blood sampling and other losses, decreased RBC synthesis and possibly increased RBC
destruction. Increased RBC uptake may be due to changes in RBC morphology during inflam-
matory processes. Anemia is common in sepsis in part because mediators of sepsis (TNF-α and
interleukin-1β) decrease the expression of the erythropoietin gene and protein. Although treat-
ment with recombinant human erythropoietin decreases transfusion requirements, its use in ran-
domized, controlled trials failed to increase survival. Erythropoietin takes days to weeks to in-
duce red-cell production and thus may not be effective. Sepsis is a severe illness caused by
overwhelming infection of the bloodstream by toxin-producing bacteria. Microorganisms invad-
ing the body cause infections. Sepsis is also called Systemic inflammatory response syndrome
(SIRS). Sepsis can also be triggered by events such as pneumonia,
With more than 750,000 new cases a year in the United States and a mortality rate of up to
50 percent, sepsis is a serious problem. The condition kills more than 1,400 Americans a day,
making it the leading cause of mortality in the ICU. There are approximately 1, 000,000 cases
of sepsis a year in the Asia,7 and the frequency is increasing, given an aging population with
increasing numbers of patients infected with treatment-resistant organisms, patients with
compromised immune systems, and patients who undergo prolonged, high-risk surgery
(University of British Columbia, Critical Care Medicine, St. Paul's Hospital, Vancouver, BC,
Canada.)
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The significance of studying this case is to enhance or broaden our knowledge as well as the
patient’s who are suffering this disease and also to those people who are in high risk of having
this disease for us to share our knowledge for the primary prevention and simple interventions
of the disease. Thus they are in a pursuit for knowledge to be able to impart it to others. It can
be alarming since many people are confused and unaware of the symptoms presented. With this
study, the student nurses hope to apply their learning in taking care not only of their patients but
also of themselves.
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OBJECTIVES
After 3 days of data gathering, research and analysis, the student nurse shall have
devised objectives that will guide them for the proper understanding and fair interpretation of
the case of their chosen patient.
GENERAL OBJECTIVES
Cognitive
The student nurse’s first main goal is to gain knowledge through the completion of the
case study and to impart this learning to the patient, and to those directly and indirectly involved
with the completion of this case.
Specific Objectives under Cognitive aspect
Within the 3 days span of duty, the student nurses will be able to:
- Gather significant data from the patient’s chart which includes the doctor’s order, labo-
ratory exams and etc. to have complete information about the patient’s current condition.
- Research on the anatomy and physiology of the client’s affected system.
- Research on the possible causes and also the symptoms the patient experienced that may
suggest the current condition of the patient.
- Research and understand the disease process of the patient’s illness.
- Determine and interpret the medical management employed including laboratory and di-
agnostic procedures.
- Identify and study the drugs prescribed to the patient which affects the patient’s current
situation.
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Psychomotor
- In this aspect, the student nurse’s goal is to apply all what they have learned during the
process of completing this case study to improve nursing care that will meet the patient’s
need for the improvement of her general welfare.
Specific Objectives under Psychomotor aspect
Within the 3 days span of duty, the student nurses will be able to:
- Conduct a thorough physical assessment and to interpret the assessment in order to give
the care the patient need
- Formulate nursing care plans and apply them to satisfy the patient’s needs and give ap-
propriate nursing interventions.
- Make a discharge plan for the patient using M.E.T.H.O.D and validate the patient’s
prognosis according to categories.
Affective
- With the knowledge gained and through the application of this knowledge, another goal
is that the student nurses will be able to empathize with the current situation of the pa-
tient and to gain some values like the value of patience and calmness which is important
for a them to have in order to become better nurses in the future.
Specific Objectives under Affective aspect
Within the 3 days span of duty, the student nurses will be able to:
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- Establish rapport and therapeutic communication in order to gain information about the
patient which includes the medical and family health history, expectations of her condi-
tion, gather significant data from the patient’s chart and to her family and etc.; and for
the betterment of nursing care.
- Assume the role of being the patient’s advocate.
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PATIENT’S DATA
Name: Trudis
Age: 4 months old
Address: Purok 2 Salvacion, Panabo City
Civil status: child
Nationality: Filipino
Religion: Roman Catholic
Birth Place: Panabo City
Birthdate: 5/15/10
Name of Father: Michael Visperas
Name of Mother: Shiela Mae
Admitting Diagnosis: Anemia secondary to sepsis secondary to pneumonia
Admitting physician: Dr. Evangeline Arnaiz
Date of Admission:
Hospital: Southern Philippines Medical Center
Informant: Mother
History record:
Immunization: I BCG, I DPT
(-) HPN (-) CA
(-) DM (-) Leukemia
(-) PTB
Chief Complaint: Fever
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History of Past illness:
Patient has no other past illness as verbalized by the mother. Trudis was born healthy
with a normal delivery. She has already been immunized with I BCG and I DPT.
History of present illness:
Six days prior to admission patient has intermittent high grade fever, (+) cough- non-
productive. She was first admitted at Carmen District hospital and at the same day she was
immediately referred to SPMC. The mother medicated ,the child with paracetamol and with a
herbal medicine called calabong. Three days PTA patient defecated soft stool for four times
approximately 2 tbsp per episode. Day of admission (+) for vomiting.
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FAMILY BACKGROUND AND HEALTH HISTORY
Family Background
The patient's parents; Shiela and Michael has been married for eight years. The couple
lives at Panabo city with their 4 children. Michael works as a truck driver for a businessman for
almost 5 years, where he earns 6,000 a month. On the other hand Shiela only stays at home to
take care of their children.Shiela's youger sister, also lives with them and helps them to look
after the children. The couple also owns a small sari-sari store at their house where they gain
2000-3000 a month. Tessa is the youngest among the four siblings. The oldest child in the
family is aged 8 years old, who studies at a public school near their place. The second child is
aged 5 years old who is still at playschool at a day care center. Their third child is aged 2 years
old who still doesn't go to school. The family belongs to the lower class. Shiela is a gravida 4
para 4. She stated that she has completed the prenatal check-ups needed with all the pregnancy
she had. She also claimed to be fully immunized with tetanus toxoid. Shiela gave birth to all her
children at the local government hospital in Carmen.
Lifestyle and Diet:
Shiela wakes up at around 5 a.m to prepare food for the children and her husband. Their
usual meals include fish, meat and vegetables. In the morning their eldest child is sent to school.
While Shiela stays at home and takes care of the other 3 children and at the same time watches
over their, with the help of her sister.
Effects/ Expectation of illness:
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Shiela verbalized that it was the first time that a child of hers was admitted to a hospital.
Because of this she stated to take better care of her children. She has learned to immediately
seek help to prevent further complications of her child's condition. She and her husband expects
their youngest child to recover after the treatment and management done to Trudis.
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GENOGRAM
Legend:
Male =
Female=
† = DeceasedЖ = Has Anemia 2o to Sepsis 2o
Bronchopneumonia = Hypertension∆ = Diabetic
GrandmamaGrandpapa†∆
Grandmommy∆
Grandaddy
FrancisMarie
CandiceMikko
Camille TudisЖ
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DEVELOPMENTAL DATA
Erikson's Stages of Psychosocial Development
Erikson's eight stages reflect both positive and negative aspects of the critical life periods.
Erikson envisions life as a sequence of levels of achievement. Each stage signals a task that must
be achieved. The resolution of the task can be complete, partial, or unsuccessful. Erikson
believes that the greater the task achievement, the healthier the personality of the person; failure
to achieve a task influences the person's ability to achieve the next task. These developmental
tasks can be viewed as a series of crises, and successful resolution of these crises is supportive to
the person's ego. Failure to resolve the crises is damaging to the ego.
Stage Description Result Justification
Infants
(0 to 18 months)
Trust vs.
Mistrust
The first stage of Erik Erikson's
theory centers around the infant's
basic needs being met by the par-
ents. The infant depends on the
parents, especially the mother, for
food, sustenance, and comfort. The
child's relative understanding of
world and society come from the
parents and their interaction with
ACHIEVED The parents of the baby always see to it
that the baby is comfortable. They
provide everything that the baby needs.
Trudis is breastfed on demand and
safety of the baby is the top priority of
the parents. The baby has everything
that she needs like blankets and
clothings which is provided by the
parents. The parents are warm towards
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the child. If the parents expose the
child to warmth, regularity, and de-
pendable affection, the infant's
view of the world will be one of
trust. Should the parents fail to pro-
vide a secure environment and to
meet the child's basic need a sense
of mistrust will result. According
to Erik Erikson, the major develop-
mental task in infancy is to learn
whether or not other people, espe-
cially primary caregivers, regularly
satisfy basic needs. If caregivers
are consistent sources of food,
comfort, and affection, an infant
learns trust- that others are depend-
able and reliable. If they are ne-
glectful, or perhaps even abusive,
the infant instead learns mistrust-
that the world is in an undepend-
able, unpredictable, and possibly
their baby as shown by them carrying
the baby. They always think of the
needs of the baby especially if it comes
to health. They see to it that the baby
gets the proper health care needed.
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dangerous place.
Piaget's Phases of Cognitive Development
Piaget concluded that there were four different stages in the cognitive development of
children. The first was the Sensory Motor Stage, which occurs in children from birth to
approximately two years. The Pre-operational Stage is next, and this occurs in children aged
around two to seven years old. Children aged around seven to eleven or twelve go through the
Concrete Operational stage, and adolescents go through the Formal Operations Stage, from the
age of around eleven to sixteen or more.
Stage Description Result Justification
Sensory Motor
Stage (Birth -
2yrs)
Piaget's ideas surrounding the
Sensory Motor Stage are
centred on the basis of a
'schema'. Schemas are mental
representations or ideas about
what things are and how we
deal with them. Piaget deduced
that the first schemas of an
infant are to do with movement.
Piaget believed that much of a
ACHIEVED The client had achieved this
stage since the client, as what we
have observed is able to recognize
thing around her. The client was
also able to follow dangling toy,
which her parents have, from side to
side and tries to get them. She also
turns her head to the sound around
her especially to the voice of her
parents. Her motor development is
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baby's behaviour is triggered by
certain stimuli, in that they are
reflexive. A few weeks after
birth, the baby begins to
understand some of the
information it is receiving from
it's senses, and learns to use
some muscles and limbs for
movement. These
developments are known as
'action schemas'.
Babies are unable to consider
anyone else's needs, wants or
interests, and are therefore
considered to be 'ego centric'.
During the Sensory Motor
Stage, knowledge about objects
and the ways that they can be
manipulated is acquired.
Through the acquisition of
information about self and the
also good as she could held her head
up in a prone position for a long
time.
Trudis is positive for reflexes like
sucking, yawning and many more.
She begin to learn things as
evidenced by her laughing when
ever her mother or father makes
faces in front of her. She knows and
recognize her mother and father.
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world, and the people in it, the
baby begins to understand how
one thing can cause or affect
another, and begins to develop
simple ideas about time and
space.
Babies have the ability to build
up mental pictures of objects
around them, from the
knowledge that they have
developed on what can be done
with the object. Large amounts
of an infant's experience is
surrounding objects. What the
objects are is irrelevant, more
importance is placed on the
baby being able to explore the
object to see what can be done
with it. At around the age of
eight or nine months, infants
are more interested in an object
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for the object's own sake.
A discovery by Piaget
surrounding this stage of
development, was that when an
object is taken from their sight,
babies act as though the object
has ceased to exist. By around
eight to twelve months, infants
begin to look for objects
hidden, this is what is defined
as 'Object Permanence'. This
view has been challenged
however, by Tom Bower, who
showed that babies from one to
four months have an idea of
Object Permanence.
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Freud's Model of psychosexual development
According to Freud’s theory of psychosexual development, the personality develops in
five overlapping stages from birth to adulthood. The libido changes its location of emphasis
within the body from one stage to another. Therefore, a particular area has special significance to
a client at a particular stage. If the individual does not achieve a satisfactory progression at each
stage, the personality becomes fixated at that stage.
Stage Description Result Justification
Oral (Birth to 1
½ year)
The oral stage begins at
birth, when the oral
cavity is the primary
focus of libidal energy.
The child, of course,
preoccupies himself
with nursing, with the
pleasure of sucking and
ACHIEVEDTrudis is a 4 months old baby
who shows pleasure in sucking
and putting things into her mouth.
She is breastfed on demand by
her mother. Her mother said that
if Trudis cries, she either checks
the diaper or breastfed the baby.
The mother has no problems in
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accepting things into the
mouth. The oral
character who is
frustrated at this stage,
whose mother refused to
nurse him on demand or
who truncated nursing
sessions early, is
characterized by
pessimism, envy,
suspicion and sarcasm.
The overindulged oral
character, whose nursing
urges were always and
often excessively
satisfied, is optimistic,
gullible, and is full of
admiration for others
around him. The stage
culminates in the
primary conflict of
weaning, which both
breastfeeding the baby and she is
equipped with adequate
knowledge on the proper
breastfeeding technique. She is
very attached to her baby and
cares for her a lot. But, she just
not let the baby put anything on
her mouth. She doesn’t disregard
the child’s safety which is far
more important.
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deprives the child of the
sensory pleasures of
nursing and of the
psychological pleasure
of being cared for,
mothered, and held. The
stage lasts
approximately one and
one-half years.
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Physical Assessment
General Survey
Physical assessment was taken on September 12, 2010 at 11:45am, approximately 120
hours after time of admission. Received lying on bed in supine position, awake, conscious
though visibly tired.
Upon entering the room of a four month old female who lying next to parents with a
height of 61 centimeters and a weight of 6.2 kilograms, head circumference of 39 centimeters,
chest circumference of 41 centimeters and abdominal circumference of 44 centimeters and is
wearing a white colored tank top and a diaper underneath one layer of blue colored underwear.
Appears clean. No noted foul body odor. Appeared relaxed though tired. With occasional
smiling. No noted crying throughout assessment. Noted lesion on right posterior area of the
wrist. Skin on noted parted is significantly darker than that of the rest of the body. Initial vital
signs during time of assessment are:
Cardiac Rate: 139
Temperature: 37.5
Respiratory Rate: 39
Neurologic Status
Is able to smile though with no noted crying throughout the duration of the assessment.
Able to suck and swallow especially evident during breastfeeding. Eye movement in unison.
Blinks when eyes are exposed to light. Turns head when sound is generated. Sucking reflex is
present; Palmar reflex is present; Planter reflex is present.
No noted signs of neurologic disabilities.
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Skin
Skin is generally light brown in color and uniform throughout most of the body; areas of
lighter pigmentation include the palms, lips and nail beds. Noted bruising, dark in color, on right
posterior wrist approximately 3 by 4 centimeters in size. Noted redness on left gluteus maximus.
No noted foul body odor. Upon palpation, noted skin is dry. Skin felt generally warm on areas
under the cover of clothing but cooler on the arms and extremities. No noted significant
birthmarks, bleeding or lesions aside from the aforementioned. With a Temperature of 36.0°C.
Skin has fair skin turgor.
Head
Inspection, the skull is normocephalic and symmetric has smooth skull contour. With a
head circumference of 39 centimeters. Hair is black in color, unevenly distributed, soft and thin.
Has dry hair. No noted change in pigmentation. No noted bruises, lesions, nodules or swelling.
Posterior fontanelle is hard indicating it has closed. Anterior fontanelle is soft and flat. No noted
bulging or depression. Facial movements are symmetrical and is particularly evident when
showing emotions such as smiling.. No presence of infection or infestation was noted.
Eyes
During inspection, eyebrows are evenly distributed, have thin hair that are black in color.
Eyebrows were symmetrically aligned with equal movement. The skin of the eyelids were intact,
no discharges and no discoloration. Lids close symmetrically however with noted infrequent
blinking with a rate of 4 blinks per minute; bilateral blinking. Upon inspection, sclera is
generally white. No noted visible sclera above cornea. When lids are closed, sclera is not visible.
No noted tearing from lacrimal duct and lacrimal sac. No noted discharge. Has brown colored
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iris; pupils are black in color, equal in size of about 2mm. Both pupils constrict when illuminated
and are briskly reactive to light. Both eyes coordinated and move in unison. No noted strabismus,
bleeding or purulent discharge.
Ear
Auricles are aligned with the outer canthus of the eye. Upon palpation, found to be firm and not
tender; no noted pain. No noted tenderness upon palpation of the mastoid process. Pinnea recoils
after it is folded. Upon inspection with a penlight, no noted excessive discharge of cerumen or
blood. Blinking reflex noted when producing loud noise. No noted difficulty in hearing.
Nose
Upon inspection, nose is wide, symmetric straight and uniform in color. Upon palpation,
no noted tenderness or lesions. With noted minimal amount of mucous discharge from the nose.
Upon inspection with a penlight, mucosa is pink; no noted swelling, redness, growth or lesions.
Nasal septum is intact and in the midline between the nasal chambers. No noted nasal flaring.
Mouth
Upon inspection outer lips are dark pink in color; appeared soft, moist and smooth; with
symmetrical contour. No noted dryness and roughness. Inner, lips are pinkish red and uniform in
color; is moist, soft and smooth. Has no teeth. Gums are pink, moist and appear firm. No noted
swelling on gums. Tongue is in central position of the mouth, light pink in color; moist; slightly
rough with noted thin whitish coating in some areas. Able to move side to side. Smooth tongue
base with prominent veins. No noted lesions or dryness. Palate is intact. Soft palate is pink and
smooth. Hard palate is light pink and irregular in texture. Uvula is positioned in midline of
palate.
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Neck
Neck is generally uniform in color. Neck is short with not noted head lag when turning
head. Lymph nodes are not swollen and tender. Thyroid gland is not visible. Trachea is in the
center of the neck.
Chest and Lungs
Has symmetrical anterior chest expansion with a respiratory rate of 39 breaths per
minute. Spine is vertically aligned. Noted productive coughing with green colored sputum. Upon
auscultation, faint crackles can be heared. Noted occasional irregular breathing pattern. Right
and left shoulders are of the same height. Anterior chest wall is intact, no noted tenderness or
masses. Posterior chest has full and symmetric respiratory excursion. Upon percussion of the
posterior chest, sounds resonate; no noted dullness or flatness over lung tissue. Upon
auscultation of the upper chest using a stethoscope, noted faint wheezing. No noted chest
indrawing.
Back and Extremities
Upon inspection upper extremities are grossly proportional to body shape for age, equal
in size on both sides of the body. Noted bruise on right posterior wrist. No noted deformities or
edema on upper extremities. No noted tremors or palpable nodules. Clavicles are intact, no
lumps noted; No noted variation in size of hands; Has five phalanges on each hand; No noted
deformities or unusual length of fingers; Two prominent palmar creases are visible and do not
completely transverse the palm; No noted single transverse or Simian crease. Nails of upper
extremities are trimmed and cleaned. Noted capillary refill of approximately 3 seconds. Lower
extremities are grossly proportional to body shape for age, equal in size and length on both sides
27
of the body. Toenails are trimmed and cleaned. No noted deformities or edema. Unable to
ambulate. Manipulation of the ankles reveals full flexibility in the form of plantar flexion of the
foot. Foot returns to neutral position after manipulation. Joints in upper and lower extremities
have good range of motion; No noted signs of hip dislocation; No noted signs of abnormal
curvature of the spine; No protrusions or deformities noted. Joints move smoothly with no noted
deformities, swelling, pain, tenderness. Spinal column vertically aligned. Spinal column is
straight with no noted protrusions or deformities.
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COMPLETE DIAGNOSIS
Anemia secondary to Sepsis Secondary to Bronchopneumonia
ANEMIA
Anemia is a condition that occurs when the number of red blood cells (RBCs) and/or the amount
of hemoglobin found in the red blood cells drops below normal. Red blood cells and the
hemoglobin contained within them are necessary for the transport and delivery of oxygen from
the lungs to the rest of the body. Without a sufficient supply of oxygen, many tissues and organs
throughout the body can be adversely affected. Anemia can be mild, moderate or severe
depending on the extent to which the RBC count and/or hemoglobin levels are decreased. It is a
fairly common condition, affecting both men and women of all ages, races, and ethnic groups.
P. 769 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7th edition J.B Lippincott
Company
Anemia is a medical condition in which the red blood cell count or hemoglobin is less than
normal. The normal level of hemoglobin is generally different in males and females. For men,
anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women as
hemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on the
source and the laboratory reference used.
P. 336 Rick Randle Contemporary Medical Surgical Nursing 2007
29
Anemia is a condition in which your blood has a lower than normal number of red blood cells.
Anemia also can occur if your red blood cells don't contain enough hemoglobin Hemoglobin is
an iron-rich protein that gives blood its red color. This protein helps red blood cells carry oxygen
from the lungs to the rest of the body.
Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition
SEPSIS
Sepsis is any adverse medical conditions due to the presence of any microorgansim in the blood.
Usually, the layperson using the term blood poisoning is referring to the medical condition that
arise when bacteria or their products reach the blood.
Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition
Sepsis is a serious infection usually caused by bacteria which can originate in many body parts,
such as the lungs, intestines, urinary tract, or skin that make toxins that cause the immune
system to attack the body's own organs and tissues
Infection that progress to the blood stream causing systemic infection is called sepsis. It results
from the presence of microorganism in the blood stream.
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P,1482 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7 th edition J.B Lippincott
Company
Bronchopneumonia
Bronchopneumonia occurs as a diffuse pattern of infection in both lungs more often in the lower
lobes. One or Several species if microorganisms cause the infection beginning in the bronchial
mucosa and spreading into the local alveoli the inflammatory exudates form in the alveoli
interfering with oxygen diffusion. Onset tends to insidious with mild fever, cough and rales.
Congestion causes productive cough and purulent sputum.
P.382 Gould B, Patho physiology for Health Professions 3rd edition, Saunders
Bronchopneumonia or bronchial pneumonia or "Bronchogenic pneumonia is the acute inflam-
mation of the walls of the bronchrioles. It is a type of pneumonia characterised by multiple foci
of isolated, acute consolidation, affecting one or more pulmonary lobes.
Smeltzer, Suzzane C. and Brenda G. Bare. Medical Surgical Nursing. Volme 2. 10 th
Edition. Lippincott Williams & Wilkins: Philadelphia. Copyright © 2004.
31
Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung
generally associated with, and following a bout with bronchitis. This is really a specific type of
pneumonia that is localized in the bronchioles and surrounding alveoli.
P. 464 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7 th
edition J.B Lippincott Company
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ANATOMY AND PHYSIOLOGY
Respiratory System
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 impor-
tant 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,
chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygen we need and
to get rid of the waste product carbon dioxide.
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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) be-
fore 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 to breathe. It also helps to moisten and warm the air before it reaches your lungs.
The Lungs
Structure
Air travels to the lungs through a series of air tubes and passages. It enters the body
through the nostrils or the mouth, passing down the throat to the larynx, or voice box, and then to
34
the trachea, or windpipe. In the chest cavity the trachea divides into two branches, called the
right and left bronchi or bronchial tubes, that enter the lungs.
In the adult human, each lung is 25 to 30 cm (10 to 12 in) long and roughly conical. The
left lung is divided into two sections, or lobes: the superior and the inferior. The right lung is
somewhat larger than the left lung and is divided into three lobes: the superior, middle, and infe-
rior. The two lungs are separated by a structure called the mediastinum, which contains the heart,
trachea, esophagus, and blood vessels. Both right and left lungs are covered by an external mem-
brane called the pleura. The outer layer of the pleura forms the lining of the chest cavity.
The branches of the bronchi eventually narrow down to tubes of less than 1.02 mm (less
than 0.04 in) in diameter. These tubes, called bronchioles, divide into even narrower tubes, called
alveolar ducts. Each alveolar duct ends in a grapelike cluster of thin-walled sacs, called alveoli (a
single sac is called an alveolus). From 300 million to 400 million alveoli are contained in each
lung. The air sacs of both lungs have a total surface area of about 93 sq m (about 1000 sq ft),
nearly 50 times the total surface area of the skin.
In addition to the network of air tubes, the lungs also contain a vast network of blood ves-
sels. Each alveolus is surrounded by many tiny capillaries, which receive blood from arteries and
empty into veins. The arteries join to form the pulmonary arteries, and the veins join to form the
pulmonary veins. These large blood vessels connect the lungs with the heart.
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 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 sec-
35
tions 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 mem-
branes. There are about 10 of them in each lung. Each segment receives its own blood supply
and air supply.
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 blood-
stream. 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.
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.
36
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 flattens out, expanding the space in your chest and draw-
ing 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 nor-
mally 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 Cardiovascular System
The Blood
37
Blood is denser and more viscous than water, which is part of the reason it flows more
slowly than water. The temperature of blood is about 38°C, which is slightly higher than normal
body temperature, and it has a slightly alkaline pH ranging from 7.35 – 7.45. Blood constitutes
about 8% of the total body weight. The blood volume is 5 - 6 liters in an average-sized adult
male and 4 – 5 liters in an average-sized adult female. Several hormonal negative feedback
systems ensure that blood volume and osmotic pressure remain relatively constant. Especially
important systems are those involving aldosterone, antidiuretic hormone, and atrial natriuretic
peptide, which regulate how much water is excreted in the urine.
Components of Blood
Whole blood is composed of two components: blood plasma, a watery liquid that
contains dissolved substances, and formed elements, which are cells and cell fragment.
Blood Plasma
38
When formed elements are removed from blood, a straw-colored liquid called
blood plasma is left. Plasma is about 91.5% water and 8.5% solutes, most of which are proteins.
Some of the proteins in plasma are also found elsewhere in the body, but those confined to blood
are called plasma proteins. Among other functions, these proteins play a role in maintaining
proper blood osmotic pressure, which is an important factor in the exchange of fluids across
capillary walls.
Plasma proteins:
- Albumins (54% of plasma proteins)
- Globulins (38%)
- Fibrinogen (7%)
Formed Elements:
RBC or Red Blood Cell
Red blood cells or erythrocytes contain the oxygen-carrying protein hemoglobin, which is
a pigment that gives whole blood its red color. A healthy adult male has about 5.4 million red
blood cells per microliter of blood, and a healthy adult female has about 4.8 million. To maintain
39
normal quantities of RBCs, new mature cells must enter the circulation at the astonishing rate of
at least 2 million per second, a pace that balances the equally high rate of RBC destruction.
Red blood cells are biconcave discs with a diameter of 7-8 micrometers and are highly
specialized for their oxygen transport function. Each one contains about 280 millions
hemoglobin molecules. A hemoglobin molecule consists of a protein called globin.
Red blood cells live only about 120 days because of the wear and tear their plasma
membranes undergo as they squeeze through blood capillaries.
WBC or White Blood Cell
Unlike red blood cells, white blood cells or leukocytes have a nucleus and do not contain
hemoglobin. WBCs are classified as either granular or agranular, depending on whether they
contain conspicuous chemical-filled cytoplasmic vescicles that are made visible by staining.
40
Granular leukocytes include neutrophils, eosinophils, and basophils; agranular leukocytes
include lymphocytes and monocytes.
In a healthy body, some WBCs, especially lymphocytes, can live for several months or
years, but most live only a few days. During a period of infection, phagocytic WBCs may live
only a few hours. WBCs are far less numerous than red blood cells, about 5,000-10,000 cells per
microliter of blood. RBCs therefore outnumber white blood cells by about 700:1. Leukocytosis,
an increase in the number of WBCs, is a normal, protective response to stresses and surgery.
Platelet
Besides the immature cell types that
develop into erythrocytes and leukocytes,
hemopoietic stem cells also differentiate
into cells that produce platelets. Under the
influence of the hormone thrombopoietin,
myeloid stem cells develop into
megakaryocyte-colony-forming cells that,
in turn, develop into precursor cells called
megakaryoblasts. Megakaryoblasts transform into megakaryocytes, huge cells that splinter into
2000-3000 fragments. Each fragment, enclosed by a piece of the cell membrane, is a platelet or
thrombocyte. Platelets break off from the megakaryocytes in red bone marrow and then enter the
blood circulation. Between 150,000 – 400,000 platelets are present in each microliter of blood.
They are disc-shaped, 2-4 micrometers in diameter, and exhibit many granules but no nucleus.
41
Platelets help stop blood loss from damaged blood vessels by forming a platelet plug. Their
granules also contain chemicals that, once released, promote blood clotting. Platelets have a short
life span, normally just 5 – 9 days.
The Blood Vessels
There are 3 types of
blood vessels: the arteries, the
veins and the capillaries. An
artery is a vessel that carries
blood away from the heart. It
carries oxygenated blood.
Small arteries are called
arterioles. Veins, on the other
hand are vessels that carries
blood toward the heart. It
contains the deoxygenated blood. Small veins are called venules. Often, very large venous spaces
are called sinuses. Lastly, capillaries are microscopic vessels that carry blood from small arteries
to small veins (arterioles to venules) and back to the heart.
42
The walls of the blood vessels, the arteries and veins have three main layers: tunica
adventitia, tunica media and tunica intima. Tunica adventitia which is a fibrous type of vessel is a
connective tissue that helps hold vessels open and prevents tearing of the vessel wall during body
movement. Tunica media is a smooth muscle, sandwiched together with a layer of elastic
connective tissue. It permits changes of the blood vessel diameter. It allows the constriction and
dilation of the vessels. Last but not the least is the tunica intima. Tunica intima, which in Latin
means inner coat, is made up of endothelium that is continuous with the endothelium that lines
the heart. In arteries, it provides a smooth lining. However in veins it maintains the one-way flow
of the blood. The endothelium, which makes up the thin coat of the capillary, is important
because the thinness of the capillary wall
allows the exchange of materials between
the blood plasma and the interstitial fluid of
the surrounding tissues.
Circulation of the blood in blood vessels
There are two circulatory routes
of blood as it flows through the blood
vessels: the systemic and the
pulmonary circulation. In systemic
circulation, blood flows from the left
ventricle of the heart through blood vessels
to all parts of the body (except gas
exchange tissues of lungs) and back to the
43
atrium. In pulmonary circulation on the other hand, venous blood moves from the right atrium to
right ventricle to pulmonary artery to lung arterioles and capillaries where gases exchanged;
oxygenated blood returns to the left atrium via pulmonary veins; from left atrium, blood enters
the left ventricle.
Inflammation
Cells damaged by microbes, physical agents, or chemical agents initiate a defensive
response called inflammation. The four characteristic signs and symptoms of inflammation are
redness, pain, heat, and swelling. Inflammation can also cause the loss of function in the injured
area, depending on the site and extent of injury. Inflammation traps microbes, toxins, and foreign
material at the site of injury and prepares the site for tissue repair. Thus, it helps restore tissue
homeostasis.
Because inflammation is one of the body’s nonspecific defenses, the response of a tissue
to, say, a cut is similar to the response to damage caused by burns, radiation, or bacterial or viral
44
invasion. In each case, inflammation has three basic stages: vasodilation and increased
permeability of blood vessels, phagocyte emigration, and ultimately, tissue repair.
Among the substances that contribute to vasodilation, increased permeability, and other
aspects of the inflammatory response are the following:
Histamine. In response to injury, mast cells in connective tissue and basophils and
platelets in blood release histamine. Neutrophils and macrophages attracted to the site of
injury also stimulate the release of histamine, which causes vasodilation and increased
permeability of blood vessels.
Kinins. These polypeptides, formed in blood from inactive precursors called kininogens,
induce vasodilation and increased permeability and serve as chemotactic agents for
phagocytes.
Prostaglandins. These lipids are released by damaged cells and intensify the effects of
histamine and kinins. It may also stimulate the emigration of phagocytes through capil-
lary walls.
45
ETIOLOGY AND SYMPTOMATOLOGY
A. ETIOLOGY
Predisposing
Factors
Present/
AbsentRationale Justification
Age Present Extremes of age predisposes an individual to pneumonia.
Those who are aged 65 and above and those who are very
young are more susceptible to acquiring pneumonia due
to weakened immune system and under developed
immune system respectively.
http://emedicine.medscape.com
The patient is aged 4
months, by this age, the
immune system is not
yet well developed as
compared to adults and
older children, thus
predisposing the child
to pneumonia.
Congenital
Anomalies
Absent Congenital Anomalies such as hereditary dyskinesis of
the cilia and squamous metaplasia hinder the body’s
ability to eliminate invading pathogens, thus predisposing
one to acquiring infections in the respiratory tract.
Congenital Abnormalities of the Lung by Karan Madan.
http://www.indiachest.org
There are no diagnostic
findings that would
indicate any congenital
abnormalities in the
child that would
predispose her to the
condition.
Precipitating Present/ Rationale Justification
46
Factors Absent
Immobility Absent Prolonged immobility causes limited expansion of the
lungs immobility changes the distribution of ventilation
and blood flow through the lungs and patients are unable
to take a deep breath, also, respiratory muscle weakness
occurs due to limited physical activity and metabolic
changes. It results in an increase in the work of breathing
which causes a decrease in the ability of the patient to
cough. With decreased lung expansion and weakened
respiratory muscles, secretions stagnate and pool which
increases the risk for hypostatic pneumonia.
http://www.healthcentral.com/encyclopedia/408/205.html
The patient did not
have immobility.
Whooping cough,
measles, or
bronchitis,
Absent Weakening of the body's defenses occurs in many
illnesses, particularly in the very young and very old. It is
for this reason that bronchopneumonia is a frequent
complication of childhood diseases such as measles and
whooping cough. In adults it is often a complication of
influenza, and it is likely to attack old people who are
confined to bed with any illness or injury which prevents
them from moving about properly. Bronchopneumonia
may follow an attack of bronchitis at any age.
http://www.rnceus.com/
The patient did not
have any history of
such diseases.
47
Immunesuppression Absent The cause of bronchopneumonia is seldom the virulent
microbe Streptococcus pneumoniae, but usually one or
other of several different microbes which are commonly
found in the respiratory passages of healthy people.
Under normal circumstances these microbes are held in
check by the body's natural defenses – the immune
system – but when these defenses are weakened the
microbes multiply rapidly and may then cause disease.
The patient is not
immnunocompromised.
Alcoholism Absent Alcohol abuse is associated with an increased incidence
and severity of pneumonia. In both the general
population and individuals consuming excess alcohol,
Streptococcus pneumoniae is the most frequent lung
infection pathogen. Alcohol intoxication impairs the
pneumococcal-induced increase in granulocyte
recruitment into the alveolar space, decreased bacterial
clearance from the lung, and increased mortality.
Acute Alcohol Intoxication Impairs the Hematopoietic
Precursor Cell Response to Pneumococcal Pneumonia.
The patient did not
have any intake of
alcohol; nor did the
mother in the course of
pregnancy.
48
Raasch CE, Zhang P, Siggins RW 2nd, Lamotte LR,
Nelson S, Bagby GJ.
http://www.ncbi.nlm.nih.gov/pubmed/20659065
Malnutrition Absent Malnutrition is a condition caused by a deficiency or ex-
cess of one or more essential nutrients in the diet. Malnu-
trition is characterized by a wide array of health prob-
lems, including extreme weight loss, stunted growth,
weakened resistance to infection, and impairment of in-
tellect. Severe cases of malnutrition can lead to death.
Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft
Corporation. All rights reserved.
The patient is well
nourished.
Smoking Absent Smoking depresses the activity of scavenger cells and
affects the respiratory tract’s ciliary cleansing
mechanism, which keeps breathing passages free of
inhaled irritants, bacteria, and other foreign matter. When
smoking damages this cleansing mechanism, airflow is
This was not present in
the patient.
49
obstructed and air becomes trapped behind the
obstruction. The alveoli greatly distend, diminished lung
capacity. Smoking also irritates the goblet cells and
mucus glands, causing an increased accumulation of
mucus, which in turn produces more irritation, infection,
and damage to the lung. In addition, carbon monoxide (a
by product of smoking) combines with hemoglobin to
form carboxyhemoglobin. Hemoglobin that is bound by
carboxyhemoglobin cannot carry oxygen efficiently.
Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft
Corporation. All rights reserved.
Environment Absent Environmental conditions such as those with high
incidences of inhalational exposure to noxious substances
contribute much in the formation of pneumonia.
Inhalation of certain chemicals or smoke may cause
pulmonary inflammation.
http://www.healthcentral.com
The patient lives in
Exposure to
Microorganisms
Entry of microorganisms causative of the pneumonia
cause infection. Streptococcus pneumonia,
Staphylococcus pneumonia and Haemophilus influenza
50
are among the most common causes of pneumonia.
51
B. SYMPTOMATOLOGY
Symptoms Present/Absent Rationale Justification
Fever Present Is a frequent medical
symptom that
describes an increase
in internal body
temperature to levels
that are above
normal. It is
stimulated by
cytokines (IL-1 &
IL-6). These
cytokines send
signals in the
hypothalamus that
serves as our
thermoregulatory
center, thus
prostaglandin is
released. Once
prostaglandin is
Vital Signs upon admission
reveal a temperature of 38.6.
52
released, it causes an
increase in the set
point. In response to
this, the
hypothalamus
neurally initiates
shivering and
vasoconstriction that
increases the core
body temperature to
the new set point,
and fever is
established.
Pain in the chest
over the affected
lung
Absent Difficulty of
breathing may lead
to chest pain due to a
deprivation of
oxygen circulating in
the lungs and heart.
Chemical mediators
like bradykinin and
prostaglandin also
This is not manifested by the
patient.
53
play a role in the
pain felt.
Dyspnea Present The alveoli are the
main site for oxygen
and carbon dioxide
exchange in the
lungs. Once the
exudates are poured
into the alveoli, it
impairs the oxygen-
carbon dioxide
exchange because
the space intended
for air is already
filled with fluid
causing dyspnea or
difficulty in
breathing.
There are occasions within the
shift that that the patient’s
respiratory rate rises above
the normal range with
apparent labored breathing,
indicating dyspnea.
Productive cough Present It is a sudden audible
expulsion of air from
the lungs with
The patient had productive
cough.
54
sputum. It is an
essential protective
response that serves
to clear the lungs,
bronchi, and trachea
or irritants and
secretions or to
prevent aspiration of
foreign material into
the lungs.
Alterations in
body temperature
Present Hyperthermia or
hypothermia are
characteristic signs
of sepsis, occurring
due to
The patient was febril upon
admission.
Decreased red
blood cells
Present A decrease in the
number of red blood
cells is called ane-
mia. Anemia is a
common problem in
acutely ill patients,
especially in those
Laboratory results show a
decrease in RBCs, and a
blood transfusion was
ordered.
55
who develop sepsis.
There are many fac-
tors contributing to
the development
of anemia in these
patients, including
blood sampling and
other
losses, decreased red
blood cell (RBC)
synthesis, and possi-
bly increased
destruction. In-
creased RBC uptake
may be due to
changes in RBC
morphology
and the RBC
membrane during
inflammatory
processes.
Anemia in sepsis:
56
the importance of
red blood cell
membrane changes
Micheal Piagnerelli,,
MD, Et al.
Tachycardia Absent Tachycardia is
characterized by
rapid beating of the
heart. Heart rate
considered as
tachycardia is above
120 in newborns,
above 180bpm in 6
month old infants,
more than 160bpm
in 1 year old clients
and above 130 in
two-year olds.
RN Notes. 2nd
Edition, by Ehren
Myers, RN.
This was not manifested by
the patient.
57
Since there is an
impaired exchange
of gases in the lungs,
and oxygen transport
to tissues is
inefficient, the heart
compensates by
pumping fast.
Crackles Present Crackles (or rales)
are caused by fluid
in the small airways
or atelectasis.
Crackles are referred
to as discontinuous
sounds; they are
intermittent,
nonmusical and
brief. Crackles may
be heard on
inspiration or
expiration. The
Upon auscultation, crackles
were heard on both lung
fields.
58
popping sounds
produced are created
when air is forced
through respiratory
passages that are
narrowed by fluid,
mucus, or pus.
Crackles are often
associated with
inflammation or
infection of the small
bronchi, bronchioles,
and alveoli. Crackles
that don't clear after
a cough may indicate
pulmonary edema or
fluid in the alveoli.
This is common in
pneumonia.
Tachypnea Present Also known as fast
breathing. For
There are occasions within the
shift that that the patient’s
59
pediatric clients,
breathing is
considered fast when
it reaches the rate of
above 30cpm in ages
1 to 4 years, above
35cpm in those aged
6-11 months and
above 60cpm in
newborns to
5months.
RN Notes. 2nd
Edition, by Ehren
Myers, RN.
. A decrease in
oxygen would cause
the body to
compensate to
increase the oxygen
supply in the body.
This results to the
increase in the
respiratory rate rises above
the normal range with
apparent labored breathing.
60
respiratory rate.
WBC changes Present White blood cells are
responsible for the
defense system in
the body. White
blood cells fight
infections and
protect our body
from foreign
particles, which
includes harmful
germs and
bacteria.Thus,
elevated WBC
counts indicate
infection.
Laboratory results show
elevated levels of white blood
cells.
Decreased blood
pressure
Absent Due to the cascade
of interactions
between WBCs and
microorganisms that
invades the body,
This is not manifested by the
patient.
61
components of blood
WBC also increase
in number. One
component of WBC,
neutrophils, release
nitric oxide in the
process, a potent
vasodilator. Thus
causing a decrease in
blood pressure.
Easy Fatigability Absent A decrease in
circulating red blood
cells impairs the
transport of oxygen
in the different areas
in the body.
Decreased oxygen
delivery to the
musculoskeletal
tissues cause easy
fatiguability.
This is not manifested by the
patient.
Respiratory Absent Respiratory acidosis No ABG results would
62
Acidosis is acidosis
(abnormally
increased acidity of
the blood) due to
decreased ventilation
of the pulmonary
alveoli, leading to
elevated arterial
carbon dioxide
concentration. In
cases of pneumonia,
respiratory acidosis
occur as a result of
the impaired gas
exchange in the
lungs.
indicate respiratory acidosis.
Pallor Present Pallor is due to a
reduced amount of
oxyhemoglobin in
skin or mucous
membrane, a pale
color which is
The baby was reported to be
pale.
63
caused by anemia. It
is more evident on
the face and palms.
64
Pathophysiology(Community Acquired Pneumonia)
Precipitating Factors:
Predisposing Factors:Age
Causative agent gains access to the reparatory
tract
Through aspiration or inhalation
Penetrates the LRT
Irritation of the site occurs
Alveolar macrophages (primary defense) in the site fights off the
microorganisms
Bacteria adheres to the alveolar
macrophages
Phagocytosis (cell eating mechanism) occurs
Engulfed microorganisms will be removed
65
Weakened immune system due to predisposing factors
Microorganism become virulent and is
present in large number
Overwhelms the alveolar macrophages
Activation of the inflammatory response
Release of multiple inflammatory mediators
Bradykinin Histamine Prostaglandin
Increase capillary permeability
Causes vasodilation
Cause pain Cause pain and fever
Extravasation of fluid into tissues and cavity
Plasma enters into the inflammatory site
(bronchioles and alveoli)
66
Terminal bronchioles are filled with debris
and exudates
Cytokines send signal in the
hypothalamus
Prostaglandin is released
Increase set point in the
hypothalamus
Hypothalamus neurally initiates
shivering and vasoconstriction
Increase in the core body
temeprature
Exudates in the alveoli
cause irritation
Body attempts to expel out
foreign substances
and fluid out of the lungs
Stimulation of the cough
reflex
Increase mucus production by goblet cells
Exudates in the alveoli
Impairs oxygen-carbon dioxide
exchange in the alveoli
Body compensates
dyspnea
Increase in respiratory rate
tachypnea
Productive coughChills and fevers
67
Continuous inflammation of the alveoli and bronchioles
occur
Bacterial dissemination
Conditions exacerbate and bacterial spread
becomes systemic
Sepsis
Exudation of fluids into the cavity
Fluids accumulate and consolidate
Fluids consume a lot of space in the lungs
Decreased lung expansion
Dyspnea
68
Continuous inflammation of the alveoli and bronchioles
occur
Bacterial dissemination
Conditions exacerbate and bacterial spread
becomes systemic
Sepsis
Exudation of fluids into the cavity
Fluids accumulate and consolidate
Fluids consume a lot of space in the lungs
Decreased lung expansion
Dyspnea
14
Outer membrane component of microorganisms trigger the release of
chemical mediators
Cytokines, tumor-necrosis factor, platelet-activating factors, interleukin, prostaglandins and leukotrines are released
Increased RBC destruction
Mediators damage endothelial liningProduction of adhesion
molecules and neutrophils
Neutrophilic endothelial reaction leads to further endothelial injury
Neutrophil components release nitric oxide
Septic shock
anemia
Decrease in the oxygen carrying capacity of the blood
Tissue hypoxia
musculoskeletal skin CNS Circulatory
Easy fatigability, weakness
pallorConfusion, dizziness High pulse rate,
increased
15
If treated:AntibioticsIron SupplementsDietary Modifications
Good Prognosis
If not treated: ComplicationsHeart ProblemsNerve DamageImpaired Mental Function
Bad Prognosis
DOCTOR’S ORDER
DATE ORDER RATIONALE REMARKS
09/07/10 Admitting orders
Please admit to IMCU
under Pedia 3 service
level 3
For close monitoring of the patient
and proper management of his
condition
Admitted
BF with SAP Mothers are encouraged to give their
newborns breastmilk because of the
benefits of Breastfeeding such as
nutritional, immunological,
emotional and psychological. A
strict aspiration precaution if ordered
when patient is at risk for aspiration,
because of this, feeding would be
strictly watched.
Mother
informed
Start venoclysis with D5
0.3 NaCl 500 cc @ 25
cc/hr
Intravenous lines provide easy
access for drug administration
intravenously (IVTT). Intravenous
solutions containing dextrose and
sodium chloride are indicated for
parenteral replenishment of fluid,
Started
minimal carbohydrate calories, and
sodium chloride as required by the
clinical condition of the patient.
Labs:
WT = 6.2
kL
CBC with PC CBC with PC determines the
quantity of each quantity of blood
cell in a given specimen of blood,
often including the amount of
hemoglobin, hematocrit, and the
proportion of various white blood
cells. This is done to know any
condition of the client that may
affect his medical management.
Done
BT Blood typing is a method to tell what
specific type of blood you have.
What type you have depends on
whether or not there are certain
proteins, called antigens, on your red
blood cells.
Done
Urinalysis Urinalysis is performed to screen for
urinary tract disorders, kidney
disorders, urinary neoplasm and
Done
other medical conditions that
produce changes in the urine. This
test also is used to monitor the
effects of treatment of known renal
or urinary condition. This test is also
used to monitor the effects of certain
procedures done to patient and to
check if genito-urinary is in normal
state or not.
Chest X-ray – APL A chest radiograph, commonly
called a chest x-ray (CXR), is
a projection radiograph of
the chest used to diagnose conditions
affecting the chest, its contents, and
nearby structures. Chest radiographs
are among the most common films
taken, being diagnostic of many
conditions. By convention on the PA
View, the x-rays enter the patient
posteriorly and exit anteriorly (with
the patient’s chest on the film
cassette), therefore minimizing the
Not done
cardiac magnification. On the lateral
view, the patients left side is against
the film, therefore the right side
would be magnified.
Blood GS/CS A blood culture is done when a
person has symptoms of a blood
infection. Blood is drawn from the
person one or more times and is
tested in a laboratory to find and
identify any microorganism present
and growing in the blood. If a
microorganism is found, more
testing is done to determine the
antibiotics that will be effective in
treating the infection.
Not done
PBS Examination of the peripheral blood
smear should be considered, along
with review of the results of
peripheral blood counts and red
blood cell indices, an essential
component of the initial evaluation
of all patients with hematologic
Not done
disorders. The examination of blood
films stained with Wright's stain
frequently provides important clues
in the diagnosis of anemias and
various disorders of leukocytes and
platelets.
Coomb’s test – direct
and indirectCoomb’s test (antiglobulin test or
AGT) refers to two clinical blood
tests used in immunohematology and
immunology. The Coombs' test
looks for antibodies that may bind to
your red blood cells and cause pre-
mature red blood cell destruction
(hemolysis). The two Coomb’s tests
are the direct Coomb’s test (also
known as direct antiglobulin test or
DAT), and the indirect Coomb’s test
(also known as indirect antiglobulin
test or IAT). The indirect Coomb’s
test looks for unbound circulating
antibodies against a series of stan-
Done
dardized red blood cells.
Serum Na, K This is done to measure the
concentration of electrolytes which
are needed for both the diagnosis
and management of renal, endocrine,
acid-base, water balance, and many
other conditions. Their importance
lies in part with the serious
consequences that follow from the
relatively small changes that diseases
or abnormal conditions may cause.
This is done for diagnosing dietary
deficiencies, excess loss of nutrients
due to urination, vomiting, and
diarrhea, or abnormal shifts in the
location of an electrolyte within the
body.
Done
Meds:
Ampicillin 30 mg
IVTT q6 hours
Ampicillin is a beta-lactam antibiotic
that has been used extensively to
treat bacterial infections.
Given
Gentamycin 30 mg Gentamicin is an aminoglycoside Given
IVTT OD antibiotic, used to treat many types
of bacterial infections, particularly
those caused by Gram-negative
bacteria. Gentamycin is given
together with ampicillin bcause one
of the concern of giving antibacterial
is the number of bacteria that
become resistant to the drug
necessitating combination therapy or
use of other antibiotics.
TSB for fever Tepid sponge bath would help lower
the temperature of the body thus
providing comfort to the body
relieves it from distress
Done
I&O q shift and record Intake and output helps gauge fluid
balance in the body of the patient.
This would also check if patient’s
elimination pattern is normal or
impaired.
Done
VS q4 hours and record Vital signs are important for baseline
assessment and to monitor patients
condition which evaluates the whole
Taken and
recorded
treatment course, especially the
medications he received that could
be a contributing factor in the
variation results of the vital signs.
Inform Dr. Sojor/
Quinones/ Pedrero
regarding admission
This may create a collaborative
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
Done
O2 inhalation via face
mask in cone @ 6 LPM
as needed for DOB
This is to relieve hypoxia, headache,
nausea, as well as to restore the
ability of the cells of the body to
carry on normal metabolic function.
Given
Refer accordingly This may create a collaborative
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
Referred
Paracetamol 100 mg
IVTT, 0.6 mL q 4 hours
for T>38oC
Paracetamol is used for fever
reduction.
Noted
09/08/10 Dx:
S/F PBS please give
referral form
Examination of the peripheral blood
smear should be considered, along
with review of the results of
peripheral blood counts and red
blood cell indices, an essential
component of the initial evaluation
of all patients with hematologic
disorders. The examination of blood
films stained with Wright's stain
frequently provides important clues
in the diagnosis of anemias and
various disorders of leukocytes and
platelets.
Referral
form
Follow up all labs re-
sult now
This is done since the laboratory
results are needed in the medical
management of the patient’s
condition.
Followed up
Rx:
IVF @ same rate This may continuously administer
parenteral replenishment of fluid,
minimal carbohydrate calories, and
sodium chloride as required by the
Hooked
clinical condition of the patient.
Meds: Day 1 please give Rx
Ampicillin Ampicillin is a beta-lactam antibiotic
that has been used extensively to
treat bacterial infections. Strict
compliance for treatment regimen is
very important for proper treatment
and prevent the growth of drug-
resistant bacteria
Given
Still w/ Gentamycin Gentamicin is an aminoglycoside
antibiotic, used to treat many types
of bacterial infections, particularly
those caused by Gram-negative
bacteria. Gentamycin is given
together with ampicillin bcause one
of the concern of giving antibacterial
is the number of bacteria that
become resistant to the drug
necessitating combination therapy or
use of other antibiotics.
Given
febrile
episodes
VS q 4 hours Vital signs are important for baseline
assessment and to monitor patients
Taken and
recorded
(+) LBM
condition which evaluates the whole
treatment course, especially the
medications he received that could
be a contributing factor in the
variation results of the vital signs.
Refer accordingly This may create a collaborative
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
referred
Follow up BT result This is done since the laboratory
result is needed in the medical
management of the patient’s
condition which is blood transfusion.
Followed up
To secure PRBC 100cc
aliqout and transfuse 70
cc to run un 4 hours after
proper cross matching
Packed red blood cells (PRBCs),
also called "packed cells," are a
preparation of red blood cells that
are transfused to correct low blood
levels in anemic patients. This
increases the amount of hemoglobin
in the blood that can carry oxygen
perfused from alveoli of the lungs to
Not done
tissues.
For PBS prior to Blood
transfusion
This is done to have a baseline data
to determine whether the medical
management given was right.
Not done
09/09/10
8:20 am
Dx: S/F PBS give
request
Examination of the peripheral blood
smear should be considered, along
with review of the results of
peripheral blood counts and red
blood cell indices, an essential
component of the initial evaluation
of all patients with hematologic
disorders. The examination of blood
films stained with Wright's stain
frequently provides important clues
in the diagnosis of anemias and
various disorders of leukocytes and
platelets.
DONE
Continue IVF with D5
0.3 NaCl 500 cc @ 25
cc/hr
Intravenous lines provide easy
access for drug administration
intravenously (IVTT). Intravenous
solutions containing dextrose and
sodium chloride are continuously
Continued
given for parenteral replenishment of
fluid, minimal carbohydrate calories,
and sodium chloride as required by
the clinical condition of the patient.
Continue medications: Day 2
(-) fever
(+) pale
looking
(+) cough
(+) rash
Ampicillin
Gentamycin
Ampicillin is a beta-lactam antibiotic
that has been used extensively to
treat bacterial infections. Strict
compliance for treatment regimen is
very important for proper treatment
and prevent the growth of drug-
resistant bacteria
Given
Gentamicin is an aminoglycoside
antibiotic, used to treat many types
of bacterial infections, particularly
those caused by Gram-negative
bacteria. Gentamycin is given
together with ampicillin bcause one
of the concern of giving antibacterial
is the number of bacteria that
become resistant to the drug
necessitating combination therapy or
Given
use of other antibiotics.
Continue VS monitoring
q4 hours
Vital signs are important for baseline
assessment and to monitor patients
condition which evaluates the whole
treatment course, especially the
medications he received that could
be a contributing factor in the
variation results of the vital signs.
Taken and
recorded
Continue I&O
monitoring q4 hours
Intake and output helps gauge fluid
balance in the body of the patient.
This would also check if patient’s
elimination pattern is normal or
impaired.
Monitored
Refer accordingly if with
unusualities
This may create a collaborative
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
Referred
Still securing PRBC for
BT
Packed red blood cells (PRBCs),
also called "packed cells," are a
preparation of red blood cells that
are transfused to correct low blood
Secured
levels in anemic patients. This
increases the amount of hemoglobin
in the blood that can carry oxygen
perfused from alveoli of the lungs to
tissues.
09/10/10
7:20 am
Dx: PBS result after 10
working days
This is done to allow enough time
for further testing in case of
inclusive or doubtful results
Continue IVF with D5
0.3 NaCl 500 cc @ 25
cc/hr
Intravenous lines provide easy
access for drug administration
intravenously (IVTT). Intravenous
solutions containing dextrose and
sodium chloride are continuously
given for parenteral replenishment of
fluid, minimal carbohydrate calories,
and sodium chloride as required by
the clinical condition of the patient.
Continued
(-) fever
comfortable
Asleep
(+) rash
Continue medications: Day 3
Ampicillin Ampicillin is a beta-lactam antibiotic
that has been used extensively to
treat bacterial infections. Strict
compliance for treatment regimen is
Given
very important for proper treatment
and prevent the growth of drug-
resistant bacteria
Gentamycin Gentamicin is an aminoglycoside
antibiotic, used to treat many types
of bacterial infections, particularly
those caused by Gram-negative
bacteria. Gentamycin is given
together with ampicillin bcause one
of the concern of giving antibacterial
is the number of bacteria that
become resistant to the drug
necessitating combination therapy or
use of other antibiotics.
Continue VS monitoring
q4 hours
Vital signs are important for baseline
assessment and to monitor patients
condition which evaluates the whole
treatment course, especially the
medications he received that could
be a contributing factor in the
variation results of the vital signs.
Taken and
recorded
Continue I&O
monitoring q shift, then
record
Intake and output helps gauge fluid
balance in the body of the patient.
This would also check if patient’s
elimination pattern is normal or
impaired.
Monitored
and recorded
Refer accordingly This may create a collaborative
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
Referred
9 am Still for PRBC
transfusion
Packed red blood cells (PRBCs),
also called "packed cells," are a
preparation of red blood cells that
are transfused to correct low blood
levels in anemic patients. This
increases the amount of hemoglobin
in the blood that can carry oxygen
perfused from alveoli of the lungs to
tissues.
Noted
Please extract blood for
cross matching without
fail – c/o clerk on duty
Blood Cross Matching refers to the
complex testing that is performed
prior to a blood transfusion, to
Done
determine if the donor's blood is
compatible with the blood of an
intended recipient, or to identify
matches for organ transplants.
09 /11/10
7 am
Dx: F/U PBS result after
10 working days
This is done to allow enough time
for further testing in case of
inclusive or doubtful results
Noted
Rx:
awake
comfortable
afebrile
IVF @ SR This may continuously administer
parenteral replenishment of fluid,
minimal carbohydrate calories, and
sodium chloride as required by the
clinical condition of the patient.
Done
Ampicillin day
Gentamycin 4
Ampicillin is a beta-lactam antibiotic
that has been used extensively to
treat bacterial infections. Gentamicin
is an aminoglycoside antibiotic, used
to treat many types of bacterial
infections, particularly those caused
by Gram-negative bacteria.
Gentamycin is given together with
ampicillin bcause one of the concern
of giving antibacterial is the number
of bacteria that become resistant to
the drug necessitating combination
therapy or use of other antibiotics.
Given
VS q4 hours and record Vital signs are important for baseline
assessment and to monitor patients
condition which evaluates the whole
treatment course, especially the
medications he received that could
be a contributing factor in the
variation results of the vital signs.
Taken and
recorded
I&O q shift and record Intake and output helps gauge fluid
balance in the body of the patient.
Monitored
and recorded
This would also check if patient’s
elimination pattern is normal or
impaired.
Refer accordingly This may create a collaborative
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
Referred
09/12/10 F/U with
Rx: IVF @ SR
This may continuously administer
parenteral replenishment of fluid,
minimal carbohydrate calories, and
sodium chloride as required by the
clinical condition of the patient.
Followed up
awake
comfortable
(-) fever
Continue meds: day 5
Ampicillin
Gentamycin
Ampicillin is a beta-lactam antibiotic
that has been used extensively to
treat bacterial infections. Gentamicin
is an aminoglycoside antibiotic, used
to treat many types of bacterial
infections, particularly those caused
by Gram-negative bacteria.
Gentamycin is given together with
ampicillin bcause one of the concern
Given
of giving antibacterial is the number
of bacteria that become resistant to
the drug necessitating combination
therapy or use of other antibiotics.
Please monitor:
VS q4 hours Vital signs are important for baseline
assessment and to monitor patients
condition which evaluates the whole
treatment course, especially the
medications he received that could
be a contributing factor in the
variation results of the vital signs.
Taken and
recorded
I&O q shift Intake and output helps gauge fluid
balance in the body of the patient.
This would also check if patient’s
elimination pattern is normal or
impaired.
Monitored
and recorded
Refer accordingly This may create a collaborative
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
referred
09/13/10 Follow up CBC, platelet This is done since the laboratory
results are needed in the medical
management of the patient’s
condition.
Not done
comfortable IVF @ same rate This may continuously administer
parenteral replenishment of fluid,
minimal carbohydrate calories, and
sodium chloride as required by the
clinical condition of the patient.
Done
(-) fever Continue
NRD Ampicillin – D6 Ampicillin is a beta-lactam antibiotic
that has been used extensively to
treat bacterial infections.
Given
Gentamycin – D6 Gentamicin is an aminoglycoside
antibiotic, used to treat many types
of bacterial infections, particularly
those caused by Gram-negative
bacteria. Gentamycin is given
together with ampicillin bcause one
of the concern of giving antibacterial
is the number of bacteria that
become resistant to the drug
Given
necessitating combination therapy or
use of other antibiotics.
VS q4 hours Vital signs are important for baseline
assessment and to monitor patients
condition which evaluates the whole
treatment course, especially the
medications he received that could
be a contributing factor in the
variation results of the vital signs.
Taken and
recorded
I&O q shift Intake and output helps gauge fluid
balance in the body of the patient.
This would also check if patient’s
elimination pattern is normal or
impaired.
Monitored
and recorded
Refer accordingly This may create a collaborative
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
Referred
09/14/10 Dx: ff. up CBC, platelet
count
This is done since the laboratory
results are needed in the medical
management of the patient’s
Followed up
condition.
(-) fever
comfortable
Continue IVF @ SR Intravenous lines provide easy
access for drug administration
intravenously (IVTT). Intravenous
solutions containing dextrose and
sodium chloride are continuously
given for parenteral replenishment of
fluid, minimal carbohydrate calories,
and sodium chloride as required by
the clinical condition of the patient.
Continued
Meds:
Ampicillin – D7 Ampicillin is a beta-lactam antibiotic
that has been used extensively to
treat bacterial infections.
Given
Gentamycin – D7 Gentamicin is an aminoglycoside
antibiotic, used to treat many types
of bacterial infections, particularly
those caused by Gram-negative
bacteria. Gentamycin is given
together with ampicillin bcause one
of the concern of giving antibacterial
is the number of bacteria that
Given
become resistant to the drug
necessitating combination therapy or
use of other antibiotics.
VS q4 hours Vital signs are important for baseline
assessment and to monitor patients
condition which evaluates the whole
treatment course, especially the
medications he received that could
be a contributing factor in the
variation results of the vital signs.
Taken and
monitored
I&O q shift Intake and output helps gauge fluid
balance in the body of the patient.
This would also check if patient’s
elimination pattern is normal or
impaired.
Monitored
and recorded
Refer accordingly This may create a collaborative
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
Referred
42
DIAGOSTIC EXAMS
A. Actual Laboratory Tests and Diagnostic Examinations
Urinalysis
Urinalysis is performed to screen for urinary tract disorders, kidney disorders, urinary neoplasm and other medical conditions that
produce changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition.
Date Laboratory
Test
Normal Value /
Results
Result Clinical
Significance
Nursing Interventions
S
E
P
T
E
M
B
Color Straw yellow to
amber
Light
yellow
NORMAL Pretest:
Inform patient that he should avoid intense athletic
training or heavy physical work before the test, as these
activities may cause small amounts of blood to appear
in the urine.
Provide patient with urine container with lid.
Instruct the patient to collect a sample of urine,
Appearance Clear to faintly
hazy
Clear NORMAL
Reaction 4.0-8.0 7.0 NORMAL
43
E
R
8,
2
0
1
0
preferably on arising in the morning; must not be
contaminated by toilet paper, toilet water, feces or
secretions.
Tell females patients that they should use a clean
cotton ball moistened with lukewarm water (or antisep-
tic wipes provided with collection kits) to cleanse the
external genital area before collecting a urine sample.
To prevent contamination with menstrual blood, vagi-
nal discharge, or germs from the external genitalia, they
should release some urine before beginning to collect
the sample.
To minimize sample contamination, women who
require a urinalysis during menstruation should insert a
fresh tampon before providing a urine sample.
Inform males patients that they should use a piece
of clean cotton moistened with lukewarm water or anti-
septic wipes to cleanse the head of the penis and the
Specific
gravity
1.003- 1.030 1.005 NORMAL
Albumin Negative Negative NORMAL
Sugar Negative ++++ Glycosuria (glucose
in the urine) may be
the first indicator
that diabetes or
another
hyperglycemic
condition is present.
The glucose test
may be used to
screen newborns
for galactosuria and
other disorders of
44
carbohydrate
metabolism that
cause urinary
excretion of a sugar
other than glucose.
urethral meatus (opening). Inform uncircumcised males
that they should draw back the foreskin. After the area
has been thoroughly cleansed, they should use the mid-
stream void method to collect the sample.
If urine for culture is to be collected from an in-
dwelling catheter, it should be aspirated (removed by
suction) from the line using a syringe and not removed
from the bag in order to avoid contamination.
Posttest:
The lid must be sealed completely and the container must
be labeled properly.
Specimen must be delivered to the laboratory.
Pus cells ≤ 4 cells/hpf 1.2 NORMAL
Red Blood
Cells
≤ 2 rbc hpf 0.5 NORMAL
COMPLETE BLOOD COUNT AND PLATELET COUNT
45
The complete blood count (CBC) is a screening test, used to diagnose and manage numerous diseases. It can reflect problems with
fluid volume (such as dehydration) or loss of blood. It can show abnormalities in the production, life span, and destruction of blood
cells. It can reflect acute or chronic infection, allergies, and problems with clotting.
Date Exam Normal
Value
Rationale Result Remarks Clinical Significance Nursing Responsibilities
S
E
P
T
E
M
B
E
R
8,
Hemoglobin 115 – 155
g/dL
Measures the
amount of
oxygen-carrying
protein in the
blood.
78 Low Low hemoglobin may suggest
anemia, which can have many
causes. Possible causes of high
red blood cell count or
hemoglobin (erythrocytosis) may
include bone marrow disease or
low blood oxygen levels
(hypoxia).
1. Discuss and explain the
procedure and purpose of
the test.
2. Inform the patient that
no fasting is needed.
3. Inform the patient that a
needle and a syringe is used
to get a sample blood for the
test.
4. Assess the patient for
any factor that will probably
Hematocrit 0.36 – 0.46 Measures the
percentage of red
blood cells in a
0.25 Low Decreased hematocrit indicates
anemia, such as that caused by
iron deficiency or other
46
2
0
1
0
given volume of
whole blood.
deficiencies. Other conditions
that can result in a low
hematocrit include vitamin or
mineral deficiencies, recent
bleeding, cirrhosis of the liver,
and malignancies.
affect the results of the test.
5. Make sure patient is
well hydrated. Dehydration
elevates the test results.
6. If patient is connected
to IVF, make sure that the
blood is not taken from the
arm connected to the IVF.
Hemodilution causes false
decrease of the test results.
7. After the puncture,
assess the site for bleeding
or bruising.
8. If patient is under
treatment from an infection,
inform the patient that the
RBC count 4.20 – 6.10 Count of the
actual number of
red blood cells
per volume of
blood.
3.11 Low Low RBC count may indicate
iron deficiency anemia, Vitamin
B6, B12, and/or Folic Acid
deficiency, hereditary anemia,
and chronic diseases.
WBC count 5.0 – 10.0 Count of the
actual number of
white blood cells
per volume of
blood. Both
increases and
32.40 High A high WBC count
(leukocytosis) may signify an
infection somewhere in the body
or, less commonly, it may signify
an underlying malignancy.
47
decreases can be
significant.
test will be repeated to
monitor progress.
9. Any unnusualities noted
will be reported to the
physician.
Neutrophil 55 – 75 Count of the
actual number of
neutrophil per
volume of blood.
56 Normal NORMAL
Lymphocyte 20 – 35 Count of the
actual number of
lymphocyte per
volume of blood.
31 Normal NORMAL
Monocyte 2 – 10 Count of the
actual number of
monocyte per
volume of blood.
13 High Levels of monocytes can increase
in response to infection of all
kinds as well as to inflammatory
disorders. Monocyte counts are
also increased in certain
malignant disorders, including
48
leukemia.
Eosinophils 1 – 6 Count of the
actual number of
eosinophils per
volume of blood.
0 Low Decreased levels of eosinophils
can occur as a result of infection.
Thrombocyte 150 – 400 Number of
platelets in a
given volume of
blood. Both
increases and
decreases can
point to abnormal
conditions of
excess bleeding
or clotting.
527 High High blood platelet count is due
to high production of
thrombocytes in the bone
marrow. The other cause is that
the spleen removes less number
of thrombocytes from the body.
In majority of the cases, high
platelet count is caused, due to
increase in thrombocytes
production in the body.
MCH 25.60 –
32.20 pg
(mean
corpuscular
25.1 Low MCHC is decreased
("hypochromic") in microcytic
49
hemoglobin) the
average amount
of hemoglobin
per red blood cell,
in picograms.
anemias.
MCHC 32.20 –
35.50 g/dL
(mean
corpuscular
hemoglobin
concentration) the
average
concentration of
hemoglobin in the
RBC.
31.7 Low Decreased values point to
hypochromasia, decreased
oxygen- carrying capacity
because of decreased hemoglobin
inside the cell. Hypochromasia is
seen in iron deficiency anemia
and in thalassemia.
MCV 79.40 –
94.80 fl
(mean
corpuscular
volume) the
average volume
79.1 Low A low MCV, indicates your
RBCs are smaller than normal
(microcytic), such as is seen in
50
of the red cells,
measured in
femtolitres.
iron deficiency anemia.
Chemistry
Sodium 136 – 155
mmol/L
The test measures
the sodium levels
in the blood.
134.50 Low A low level of blood sodium
means you have hyponatremia,
which is usually due to too much
sodium loss, too much water
intake or retention, or to fluid
accumulation in the body
(edema). Hyponatremia is rarely
due to decreased sodium intake
(deficient dietary intake or
deficient sodium in IV fluids).
Most commonly, it is due to
sodium loss (Addison's disease,
diarrhea, excessive sweating,
51
diuretic administration, or kidney
disease).
Potassium 3.5 – 5.6
mmol/L
The test measures
potassium levels
of the blood.
4.95 Normal NORMAL
Blood typing
Blood type - Blood typing is a
method to tell
what specific
type of blood you
have. What type
you have depends
on whether or not
there are certain
proteins, called
antigens, on your
A - People with blood type A contains
the A antigen and contains B
antibodies.
52
red blood cells.
Bood type
Rh
- This is also an
antigen on the red
blood cell’s
surface and those
who have it are
called Rh+. Those
who haven't are
called Rh-.
Positive - Rh factor strictly refers only to
the most immunogenic D antigen
of the Rh blood group system.
Rh negative blood does not have
the D antigen. Immunization
against Rh can generally only
occur through blood transfusion
or placental exposure during
pregnancy.
Date Exam Normal
Value
Rationale Result Remarks Clinical Significance Nursing Responsibilities
S
E
P
Hemoglobin 115 – 155
g/dL
Measures the
amount of
oxygen-carrying
121.0 Low Low hemoglobin may suggest
anemia, which can have many
causes. Possible causes of high
10. Discuss and explain the
procedure and purpose of
the test.
53
T
E
M
B
E
R
14,
2
0
1
0
protein in the
blood.
red blood cell count or
hemoglobin (erythrocytosis) may
include bone marrow disease or
low blood oxygen levels
(hypoxia).
11. Inform the patient that
no fasting is needed.
12. Inform the patient that a
needle and a syringe is used
to get a sample blood for the
test.
13. Assess the patient for
any factor that will probably
affect the results of the test.
14. Make sure patient is
well hydrated. Dehydration
elevates the test results.
15. If patient is connected
to IVF, make sure that the
blood is not taken from the
arm connected to the IVF.
Hematocrit 0.36 – 0.46 Measures the
percentage of red
blood cells in a
given volume of
whole blood.
0.35 Low Decreased hematocrit indicates
anemia, such as that caused by
iron deficiency or other
deficiencies. Other conditions
that can result in a low
hematocrit include vitamin or
mineral deficiencies, recent
bleeding, cirrhosis of the liver,
and malignancies.
RBC count 4.20 – 6.10 Count of the
actual number of
red blood cells
4.54 Normal NORMAL
54
per volume of
blood.
Hemodilution causes false
decrease of the test results.
16. After the puncture,
assess the site for bleeding
or bruising.
17. If patient is under
treatment from an infection,
inform the patient that the
test will be repeated to
monitor progress.
18. Any unnusualities noted
will be reported to the
physician.
WBC count 5.0 – 10.0 Count of the
actual number of
white blood cells
per volume of
blood. Both
increases and
decreases can be
significant.
10.67 High A high WBC count
(leukocytosis) may signify an
infection somewhere in the body
or, less commonly, it may signify
an underlying malignancy.
Neutrophil 55 – 75 Count of the
actual number of
neutrophil per
volume of blood.
27 Low The low neutrophil count causes
are commonly related to the
function of the bone marrow,
which can be hampered due to
congenital disorders, cancer and
viral infections. In some cases, a
person may be affected by such
55
an infection which is too
overwhelming to be handled by
the white blood cells. As a result,
neutrophils are utilized at a rater
faster than they are produced.
Lymphocyte 20 – 35 Count of the
actual number of
lymphocyte per
volume of blood.
55 High Lymphocytes help provide a specific
response to attack the invading
organisms. Increase in levels would
indicate foreign invasion of bacteria
Monocyte 2 – 10 Count of the
actual number of
monocyte per
volume of blood.
11 High Levels of monocytes can increase
in response to infection of all
kinds as well as to inflammatory
disorders. Monocyte counts are
also increased in certain
malignant disorders, including
leukemia.
Eosinophils 1 – 6 Count of the 6 Normal NORMAL
56
actual number of
eosinophils per
volume of blood.
Thrombocyte 150 – 400 Number of
platelets in a
given volume of
blood. Both
increases and
decreases can
point to abnormal
conditions of
excess bleeding
or clotting.
624 High High blood platelet count is due
to high production of
thrombocytes in the bone
marrow. The other cause is that
the spleen removes less number
of thrombocytes from the body.
In majority of the cases, high
platelet count is caused, due to
increase in thrombocytes
production in the body.
MCH 25.60 –
32.20 pg
(mean
corpuscular
hemoglobin) the
average amount
26.7 Normal NORMAL
57
of hemoglobin
per red blood cell,
in picograms.
MCHC 32.20 –
35.50 g/dL
(mean
corpuscular
hemoglobin
concentration) the
average
concentration of
hemoglobin in the
RBC.
34.8 Normal NORMAL
MCV 79.40 –
94.80 fl
(mean
corpuscular
volume) the
average volume
of the red cells,
measured in
76.7 Low A low MCV, indicates your
RBCs are smaller than normal
(microcytic), such as is seen in
iron deficiency anemia.
58
femtolitres.
Coomb’s Test
Coomb’s test (antiglobulin test or AGT) refers to two clinical blood tests used in immunohematology and immunology. The
Coombs' test looks for antibodies that may bind to your red blood cells and cause premature red blood cell destruction (hemolysis).
The two Coomb’s tests are the direct Coomb’s test (also known as direct antiglobulin test or DAT), and the indirect Coomb’s test (also
known as indirect antiglobulin test or IAT). The indirect Coomb’s test looks for unbound circulating antibodies against a series of
standardized red blood cells.
Date Laboratory Test Normal
values
Rationale Result Clinical
significanc
e
Nursing Interventions
09/09/1
0
Direct Coomb’s
Test
Negative The direct Coomb’s test
is used to detect
antibodies that are
already bound to the
Negative NORMAL 1. Prior to performing the venipunc-
ture, the nurse should document any
medications the patient is currently
taking, since many medications have
59
surface of red blood
cells. These antibodies
sometimes destroy red
blood cells and cause
anemia. This test is
sometimes performed to
diagnose the cause of
anemia or jaundice.
been implicated in autoimmune
hemolytic anemia.
2. A blood sample collected by
venipuncture is used for antiglobulin
tests. The nurse collecting the speci-
men should observe universal pre-
cautions for the prevention of trans-
mission of bloodborne pathogens.
3. Do not refrigerate since refrigeration
of blood specimens that have cold
agglutinins may cause a false posi-
tive test.
4. Store the blood at room temperature
until separation of red cells and
serum or plasma.
5. Inform the patient that he/she may
feel discomfort when blood is drawn
Indirect Coomb’s
Test
Negative The indirect Coombs'
test is only rarely used
to diagnose a medical
condition. More often, it
is used to determine
whether a person might
have a reaction to a
blood transfusion.
Negative NORMAL
60
from a vein.
6. Inform also that bruising may occur
at the puncture site or the person
may feel dizzy or faint.
7. Apply pressure to the puncture site
until the bleeding stops to reduce
bruising.
8. Warm packs can also be placed over
the puncture site to relieve discom-
fort.
Blood Cross Matching
Blood Cross Matching refers to the complex testing that is performed prior to a blood transfusion, to determine if the donor's
blood is compatible with the blood of an intended recipient, or to identify matches for organ transplants. Cross-matching is usually
61
performed only after other, less complex tests have not excluded compatibility. Blood compatibility has many aspects, and is
determined not only by the blood types (O, A, B, AB), but also by blood factors.
Serial no. NVBSP 201000 54765
Date Cell
typing
Serum typing Rh
typing
Result of
compatibility
Nursing interventions
A cell B cell
09/10/10 Patient A NEG + + Three phases
Compatible
1. Adhere strictly to the policies regarding
typing cross-matching, and administering
the blood.
2. Make sure that the recipient’s blood sample
is correctly labelled when it is sent to the
laboratory.
3. Check each unit before administration to
make sure that it is not outdated, that the
unit has been designated for the correct re-
cipient, that the patient’s medical records’
donor A NEG + +
62
number matches the number on the blood
component, and that the blood type is ap-
propriate for the patient.
4. Maintain universal precautions when han-
dling all blood products to protect yourself.
5. Dispose used containers appropriately in
the hazardous waste disposal.
63
DRUG STUDY
Generic Name
Paracetamol
Brand Name Biogesic , Tempra
Classification Non-narcotic analgesic, Antipyretic
Ordered Dose Paracetamol 100 mg IVTT, 0.6 mL q 4 hours for T>38oC
Mode of ActionProduces analgesia by unknown mechanism, but it is cen-
trally acting in the CNS by increasing the pain threshold by
inhibiting cyclooxygenase. Reduces fever by direct action
on hypothalamus heat-regulating center with consequent
peripheral vasodilation, sweating, and dissipation of heat.
Unlike aspirin, has little effect on platelet aggregation, does
not affect bleeding time, and produces no gastric bleeding.
IndicationsFever reduction. Temporary relief of mild to moderate
pain. Generally as substitute for aspirin when the latter is
not tolerated or is contraindicated
Contraindications Hypersensitivity to acetaminophen or phenacetin;
64
use with alcohol. Renal insufficiency
Anemia
Clients with cardiac or pulmonary disease are more
susceptible to toxicity.
Hypersensitivity to paracetamol
severe liver diseases
Drug Interactions
Cholestyramine may decrease acetaminophen absorption.
With chronic coadministration, barbiturates,
carbamazepine, phenytoin, and rifampin may increase
potential for chronic hepatotoxicity. Chronic, excessive
ingestion of alcohol will increase risk of hepatotoxicity
Side Effects and Adverse
Reactions
In rare cases hypersensitivity reactions, predominantly skin
allergy (itching and rash), may appear. Long-term
treatment with high doses may cause a toxic hepatitis with
following initial symptoms: nausea, vomiting, sweating,
and discomfort. Occasionally a gastrointestinal discomfort
may be seen. Body as a Whole: Negligible with
recommended dosage; rash. Acute poisoning: Anorexia,
nausea, vomiting, dizziness, lethargy, diaphoresis, chills,
epigastric or abdominal pain, diarrhea; onset of
65
hepatotoxicity—elevation of serum transaminases (ALT,
AST) and bilirubin; hypoglycemia, hepatic coma, acute
renal failure (rare). Chronic ingestion: Neutropenia,
pancytopenia, leukopenia, thrombocytopenic purpura,
hepatotoxicity in alcoholics, renal damage.
Nursing Responsibilities 1. Monitor for S&S of: hepatotoxicity, even with
moderate acetaminophen doses, especially in indi-
viduals with poor nutrition or who have
2. ingested alcohol over prolonged periods; poisoning,
usually from accidental ingestion or suicide at-
tempts; potential abuse from psychological depen-
dence (withdrawal has been associated with restless
and excited responses).
3. Administer tablets or caplets whole or crushed and
give with fluid of patient's choice.
4. Chewable tablets should be thoroughly chewed and
wetted before they are swallowed.
5. Do not coadminister with a high carbohydrate meal;
absorption rate may be significantly retarded.
6. Store in light-resistant containers at room tempera-
66
ture, preferably between 15°–30° C (59°–86° F).
7. Do not take other medications (e.g., cold prepara-
tions) containing acetaminophen without medical
advice; overdosing and chronic use can cause liver
damage and other toxic effects.
8. Do not self-medicate adults for pain more than 10 d
(5 d in children) without consulting a physician.
9. Do not use this medication without medical direc-
tion for: fever persisting longer than 3 d, fever over
39.5° C (103° F), or recurrent fever.
10. Do not give children more than 5 doses in 24 h un-
less prescribed by physician.
67
Generic Name
Ampicillin
Brand Name Ampicillin, Principen
Classification Antibiotic,penicillin
Ordered Dose Ampicillin 30 mg IVTT q6 hours
Mode of Action Ampicillin exerts bactericidal action on both gram-positive
and gram-negative organisms. Its spectrum includes gram-
positive organisms e.g. S pneumoniae and other
Streptococci, L monocytogenes and gram-negative bacteria
e.g. M catarrhalis, N gonorrhoea, N meningitidis, E coli, P
mirabilis, Salmonella, Shigella, and H influenzae.
Ampicillin exerts its action by inhibiting the synthesis of
bacterial cell wall.
Indications Mild to moderate infections (i.e.; skin, intra-abdominal and
gynecological infections)
Prevention of Bacterial endocarditis
68
Respiratory and soft tissue infection
GI and GU infections
Gonococcal infections
Bacterial meningitis
Septicemia
Contraindications Allergy to penicillins, infectious mononucleosis
Use cautiously with reanal disorders
Indications Increased ampicillin effect with Probenecid
Increased rsik of rash with allupurinol
Increased bleeding effect with heparin and anticoagulatnts
Decreased effectiveness of tetracycline, chloramphenicol
DRUG –food
Oral ampicillin amy be less effective with food take on
with empty stomach
Side Effects and Adverse
Reactions
Side Effects: Mild diarrhea; pain, swelling, or redness at
69
injection site.
Adverse Effects:
CNS: Lethargy , Hallucinations, seizures
CV : heart failure
GI: stomatitis,gastritis, sore mouth, abdominal pain ,
bloody diarrhea
GU: Nephritis
Hematologic: Anemia , thrombocytpopenia, leucopenia,
prolonged bleeding time
Local: phlebitis,
Other: superinfections
Nursing Responsibilities Nursing Responsibilities:
1. Culture infected area before treatment
2. Give drug after negative Skin Test
3. Check IV site carefully for signs of thrombosis or
drug interaction
4. Take this drug around the clock
5. Take the full course of Therapy, do not stop taking
drug if feeling better
6. This antibiotic is specific to your problem and
should not be used to treat other infections
7. Instruct patient to report pain and discomfort on IV
70
Sites
71
Generic Name
Gentamicin Sulfate
Brand Name Pediatric Gentamicin Sulfate
Classification aminoglycosides
Ordered Dose Gentamycin 30 mg IVTT OD
Mode of ActionBactericidal: inhibits protein synthesis in susceptible
strains of gram negative bacteria; appears to disrupt func-
tional integrity of bacteria cell membrane , causing cell
death.
Indications Serious infections caused by strains of pseudomonas aerug-
inosa, proleus species, Escherichia coli, Klebsiella Enter-
obacter Serratia Species, citrobacter , Staphylococcus
species
Serious infection when causative organisms are not known
(often in conjuction with a penicillin)
ContraindicationsContraindicated to patients with allergy to any aminoglyco-
sides
Drug Interactions Drug-Drug: Increased ototoxic, nephrotoxic, neurotoxic
72
effects with other aminoglycosides, potent Diuretics ,
cephalosporins, ,vancomycin
Increased neuromuscular blockade and muscular paralysis
with aneasthetic,
Increased bactericidal effect with penicillins and
cephalosporins to treat gram negative organisms
Side Effects and Adverse
Reactions CNS: ototoxicity- tinnitus,dizziness, vertigo ,deafness
Vestibular paralysis,disorientation, depression, lethargy ,
visual disturbances , numbness, tremors
Muscle twitching, seizures, muscular weakness,
neuromuscular blockade
CV: palpitations, Hypotension , Hypertension
GI : hepatotoxicity, nausea, vomiting, anorexia , weight
loss, stomatitis , increased salivation,
GU: Nephrotoxicity
Hematologic: Thrombocytopenia, eosinophelia, anemia,
hemolytic anemia, luekopenia
Hypersensitivity : Purpura , Rash , urticaria, exfoliative
dermatitis, itching
73
LOCAL: Pain , irritation , arachnoiditis at IM injections
Sites
Other: Fever ,apnea,joint Pain and superinfections.
Nursing Responsibilities 1. Culture infected area before theraphy
2. Give drug after negative Skin Test
3. Avoid long term therapies because of in-
creased toxicities. Reduction in dose may
be clinically indicated
4. Monitor hearing with long term therapy
Ototoxicity may occur.
5. Ensure adequate hydration of patient before
and during the therapy
6. Monitor renal function test , CBC , Serum
drug levels during long term therapy
7. Report pain at injection stie,severe
headache.difficuly in hearing difficulty
breathing and rash.
74
NURSING THEORIES
Florence Nightingale’s Environmental Theory
Often referred to as the first nursing theorist, Florence Nightingale defined nursing as
“the act of utilizing the environment of the patient to assist him in his recovery”. This is because
during her time in hospitals during the 1800’s she discovered that the sanitary condition had a
direct effect on the health of the patients within the facilities. Poor sanitation in the hospital
often lead to sickness, infection or even death to the patients. Florence Nightingale theorized that
the environment in which the patient is in has a profound effect on the maintenance and
restoration of health of the said patient. She proceeded to like health with six environmental
factors
These include:
1. Pure/Fresh Air
2. Pure Water
3. Sufficient Food Supply
4. Efficient Drainage
5. Cleanliness
6. Light
These factors must be maintained in order to optimize the maintenance in health and/or facilitate
the recovery of the patients.
75
Nightingales Theory is a timeless and very important guide to all health professionals and
is also very important to our case. Our client is only four months of age and already has several
illnesses afflicting her. Due to these illnesses her body is a delicate state and may be even more
susceptible to environmental influences, most notably further infection. In order to prevent infec-
tion, the sanitary condition must be kept good. Also, her body must have the necessary nutrients
in order to recover meaning nutrition must be kept at optimal level. Pure air and water are para-
mount to the recovery of the patient to provide nourishment and proper ventilation. Efficient
drainage is necessary to prevent infection from waste products. Light is also important to provide
warmth and an ambience conducive to health. The environment must never be neglected since
good sanitary condition is key to a good, quick recovery. We have utilized this theory by at-
tempting to provide all of the necessary elements nightingale has specified for our patient during
the course of our clinical exposure.
Faye Glenn Abdellah’s 21 Nursing Problems
Faye Glenn Abdellah emphasized that nursing should always be patient-focused. What
she meant by patient-focused is that nurses should be able to identify the detectable conditions
ailing the patient and provide a nursing intervention in order to better the condition of the patient.
She professed that a nurse must first identify a problem of the patient and through the use of
critical thinking, subsequently solve the problem.
Abdellah’s Metaparadigm
76
Although she did not clearly provide a definition for each major concept, abdellah did
refer to individuals and/or families as “recipients of care.” Her description of health is the “total
health needs” of a person and “a healthy state of mind and body.” She includes society in the
planning for optimum health on local, state and international levels but emphasizes that nursing
service is primarily for the individual. Nursing for Abdellah is a comprehenseive service that is
based on an art and science and aims to help people, sick or well, cope with their health needs.
In order to aid nurses in identification and solving, Abdellah formulated a typology called
the 21 nursing problems. These problems were based on the physical, social and emotional needs
of the patient, the types of interpersonal relationships between the nurse and the patient and the
common elements of patient care.
Abdellah’s Typology of the 21 Nursing Problems are as follows:
1.To promote good hygiene and physical comfort
2. To promote optimal activity, exercise, rest, and sleep
3. To promote safety through prevention of accidents, injury, or other trauma and through the
prevention of the spread of infection
4. To maintain good body mechanics and prevent and correct deformities
5. To facilitate the maintenance of a supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition of all body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
77
9. To recognize the physiologic responses of the body to disease conditions
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory function
12. To identify and accept positive and negative expressions, feelings, and reactions
13. To identify and accept the interrelatedness of emotions and organic illness
14. To facilitate the maintenance of effective verbal and nonverbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional, and
developmental needs
19. To accept the optimum possible goals in light of physical and emotional limitations
20. To use community resources as an aid in resolving problems arising from illness
21. To understand the role of social problems as influencing factors in the cause of illness
Abdellah and her colleagues also found use of the typology as a means to evaluate
student nurses and the competency of nurses.
The 21 nursing problems are important in our case because our client has several of these
nursing problems. Through the 21 nursing problems we are able to identify the problem and
perform necessary interventions. This systematic approach enables more specific approaches to
the patient’s needs, especially one that is still recovering her illnesses. There are several of
problems that are present in our patient. Since our patient is still an infant, she cannot care for
78
herself in terms of maintenance of hygiene. We therefore identified it as our duty as student
nurses to provide good hygiene by means of performing diaper changes and perineal care for her.
Tepid sponge bathing was also performed not only for temperature control but also for hygienic
purposes. The bed of the patient did not feature bed rails, and since the patient is an infant she
maybe prone to accidents. We intervened with this problem by placing pillows near the edge of
the bed, removing any possible sharp and small objects from the perimeter of her rest area and
positioned her in the center of the bed. There were also problems that we tended to and
performed interventions such as the maintenance of good oxygen and nutrition supply, as well as
maintaining a therapeutic environment. Abdellah’s theory is an indispensable part of the nursing
practice since it provides a road map as to how we can provide precise, patient focused care.
Lydia Eloise Hall’s Care, Core, Cure Model
Lydia E. Hall formulated the Care, Core, Cure theory in the late 1960’s. The theorized
that care should only be provided by health professionals and that the patient or individual is
separated into three domains namely the care, cure and the core. These three represent the body,
the illness and the person respectively. The theory likens these to three independent but
interconnecting circles. The core is the person or patient to whom is in need nursing care is given
that service. The care circle represents the nurses whose focus is nurturing the patient and
maintenance of health through intervention and teaching to help the patient meet their needs. The
cure circle represents the role of the physicians, who are to intervene with the objective of
returning the patient to optimal health and alleviate him/her from their illness.
79
Lydia Hall’s theory is particularly applicable to the case of our patient because the theory
provides a clear outline to the roles of each of the health professionals and the patient when
dealing with health care. Our is a four month old infant and represents the core. Although the
patient is unable to set goals for herself due to her age, it is the will of the parents and the
obligation of the health professionals to return her to optimal health as evidenced by her
admission to the hospital. We as student nurses represent the care circle. As student nurses we
accomplished this goal by tending to her identified needs such as nutrition, hygiene and
performed close monitoring for any alterations in her condition. Comparatively speaking the
nurses also spend the most time with the patient more than any other health professional and
hence the circle for care is significantly larger than that of the other circles. Through the
systematic use of this theory we were able to assist in returning the patient to optimal health.
80
NURSING CARE PLAN
Name: Trudis Medical Diagnosis: Anemia 2o to Sepsis 2o to Bronchopneumonia
Age: 4 months old Sex: Female
DATE CUES NEED NSG
DIAGNOSIS
OBJ. OF CARE INTERVENTION EVALUATION
S
E
P
T
E
M
B
Subjective:
“Dili makahinga
ug tarong akong
anak paspas,
unya naa pud
siyay sipon.
A
I
R
W
A
Y
Ineffective
airway clearance
related to
presence
ofbronchial
secretions
secondary to
Within our eight
hours span of
care our patient
will be able to
maintain
patent airway as
1.) Assess respiratory
function, and respiratory
rate
e.g.,
breath
sounds
R:Provides a basis for
GOAL PARTIALLY MET
September 14,2010
@
7AM
After our eight hours span
of care our patient was
81
E
R
13,
2
0
1
0
11PM
Objective:
(+) Tachypnea
RR: 65 cpm
(+)clear Nasal
Secretions
Dyspnea
C
L
E
A
R
A
N
C
E
pneumonia
R: Maintaining a
patent airway is
vital to life.
Coughing is the
main mechanism
for clearing the
airway. However,
the cough may be
ineffective in
both normal and
disease states
secondary to
factors such as
pain from
surgical
evidenced by:
a.)
Independence
from oxygen
b.) Normal
respiration as
evidenced by
absence of
dyspnea and
crackles.
c.)Normal RR of
60 cpm
evaluating
adequacy of ventilation
2.) Auscultate breath
sounds.
R: Crackles indicate
presence of secretions
and inability to clear
airway.
3.) Checked for
obstruction
R; to maintain adequate
airway patency
4.) Document amount
and characteristic of
respiratory secretion
able to maintain
patent airway as evidenced
by:
a.) Independence from
oxygen
b.) Normal respiration as
evidenced by absence of
dyspnea.
c.)Normal RR of 60 cpm
*crackles still present
82
incisions/ trauma,
respiratory
muscle fatigue, or
neuromuscular
weakness,
neonates are also
at high risk.
Other
mechanisms that
exist in the lower
bronchioles and
alveoli to
maintain the
airway include
the mucociliary
system,
macrophages,
R: serves as baseline data
5.) Encouraged active
participation of mother in
care and treatment
decisions.
R: Maintains
independence and control
of decisions.
6.) Maintained a relaxed,
calm and quiet
environment.
R:To assist client to gain
optimal rest and sleep.
7.) Performed back
tapping.
83
and the
lymphatics.
Factors such as
anesthesia and
dehydration can
affect function of
the mucociliary
system. Likewise,
conditions that
cause increased
production of
secretions (e.g.,
pneumonia,
bronchitis, and
chemical
irritants) can
overtax these
R: To loosen secretions.
8.) Encouraged
breastfeeding of mother
per child's demand.
R: To provide optimum
nutrition and prevent
child from crying.
84
mechanisms.
Ineffective
airway clearance
can be an acute
(e.g.,
postoperative
recovery) or
chronic (e.g.,
from
cerebrovascular
accident [CVA]
or spinal cord
injury) problem.
Date Cues Needs Nursing Diagnosis Plan of Care Nursing Interventions Evaluation
85
September
14, 2010
@
2:00 AM
11-7
OBJECTIVE:
Temperature
of 38°C.
Pulse rate of
135bpm.
Flushed skin
noted.
Patient’s
skin is warm
to touch.
Diaphoresis
noted.
Restlessness
noted
N
U
T
R
I
T
I
O
N
A
L
&
M
E
T
Hyperthermia related to
increased metabolic
rate
® A state in which an
individual’s
temperature is elevated
above normal level.
Most incidents of
hyperthermia are due to
activity and salt and
water deprivation in a
hot environment.
Gulanick, et. al.
Nursing Care Plans.
At the end of
1 hour of nursing
care, the patient
will:
have a tem-
perature at
normal range,
be able to rest
1. Monitor body temper-
ature every 30 minutes
or more often if indi-
cated.
® Evaluates the ef-
fectiveness of inter-
ventions.
2. Employ measures to
reduce excessive
fever, such as remov-
ing blankets, applying
ice bags to axilla and
groins.
® Promotes patient’s
comfort and lowers
GOAL MET
September
15,2010
@
3:00 AM
Tempera-
ture
rechecked:
37.4°C.
Pulse rate:
130 bpm
Patient was
able to rest
86
A
B
O
L
I
C
P
A
T
T
E
R
N
body temperature.
3. Perform tepid sponge
bath.
® Provide patient
with comfort and
lowers body tempera-
ture.
4. Monitor and record vi-
tal signs.
®Increased heart rate,
cool skin and de-
creased blood pres-
sure may indicate hy-
povolemia, which
leads to decrease tis-
sue perfusion. In-
crease respiratory rate
87
compensates for tis-
sue hypoxia.
5. Remind the watcher of
the client on the im-
portance of having ad-
equate rest periods.
® Adequate rest peri-
ods promote client
comfort and avoid
exertional activities
that might worsen
fever.
6. Provide patient with
proper ventilation.
® Proper ventilation
would provide com-
fort to the patient thus
88
patient could be able
to rest
7. Encourage the watcher
to increase oral fluid
intake in feeding the
baby.
®Encouraging patient
may promote ade-
quate hydration.
8. Discuss precipitating
factors with the parent,
if known.
® Develops recom-
mendation for keep-
ing cool and avoiding
heat-related illnesses.
9. Encourage the watcher
89
about the adherence to
other aspects of health
care management, in-
cluding dietary habits.
® Encouraging ad-
herence to proper
care management
would help in provid-
ing wellness to the
patient.
10. Administer antipyretic
medication as ordered
and record effective-
ness.
® Antipyretic medi-
cations aids in the re-
90
duction of fever.
91
Date Cues Needs Nursing Diagnosis Plan of Care Nursing Interventions Evaluation
September
12, 2010
@
12:00 AM
11-7
OBJECTIVE:
Weak periph-
eral pulse
Capillary re-
fill time = 3
seconds
Pallor noted
Weakness
noted
Irritable
Awakening
earlier than
desired
A
C
T
I
V
I
T
Y
-
E
X
E
R
C
Disturbed Sleep
Pattern related to
discomfort due to the
coughing secondary to
bronchopneumonia
® Sleep is required to
provide energy for
physical and mental
activities. Disruption in
the individual’s usual
diurnal pattern of sleep
and wakefulness may
be temporary or
At the end of 7
hours of nursing
care, the patient
will be able to
have an adequate
amount of sleep
as evidenced by
the patient able to
have undisturbed
and enough time
to sleep.
1. Check patient’s
vital signs and monitor.
® Close monitoring
would help in knowing
any changes in the
patient’s body.
2. Document nursing
or caregiver observations
of sleeping and wakeful be-
haviors. Record number of
sleep hours. Note physical
(e.g., noise, pain or discom-
fort, urinary frequency)
and/or psychological (e.g.,
fear, anxiety) circum-
GOAL UNMET
September 13,
2010
@
7:00 AM
11-7
At the end of 7
hours of nursing
care the patient
was able to
sleep without
92
I
S
E
P
A
T
T
E
R
N
chronic. Such
disruptions may result
in both subjective
distress and apparent
impairment in
functional abilities.
Sleep patterns can be
affected by
environment, especially
in hospital critical care
units.
NANDA 11th edition
(Doenges)
stances that interrupt sleep..
® Often, the patient’s
perception of the
problem may differ from
objective evaluation.
3. Provide a quiet
and restful atmosphere.
® This would help
patient rest and prevent
fatigue.
4. Position patient
properly.
® This promotes optimal
lung ventilation and
perfusion and will
provide comfort to the
any disturbance.
93
patient.
5. Evaluate timing or
effects of medications that
can disrupt sleep.
® In both the hospital
and home care settings,
parents may be following
medication schedules
that require awakening of
the baby in the early
morning hours.
6. Limit the stimuli
around the area.
® This reduces stress felt
by the baby and
promotes sleep.
7. Instruct watcher
94
to promote position
changes for patient and
discourage staying at the
same position for a long
period of time.
® This would help in
reducing discomfort felt
by the baby.
8. Remind watcher
to provide patient with
proper hygiene for the
baby.
® Proper hygiene would
provide comfort which
may help the patient
sleep.
9. If patient is
95
asleep avoid doing any
interventions
® This would help the pa-
tient have a continuous
sleep
10. Record , evaluate
and refer the result of the
interventions done
® This would help in
providing the patient
with quality health care.
96
Date Cues Needs Nursing Diagnosis Plan of Care Nursing Interventions Evaluation
September
12, 2010
@
12:00 AM
11-7
OBJECTIVE:
Productive
cough with
yellowish
secretions
Respiratory
rate of 39
cpm
Diaphoretic
Faint wheez-
ing can be
heared.
A
C
T
I
V
I
T
Y
-
E
X
E
R
C
I
Risk for impaired gas
exchange related to
alveolar-capillary
membrane changes
® Pneumonia is
characterized by the
consolidation of the
alveoli causing
impairement of the gas
exchange and the
organisms causes
inflammation which
stimulates
tracheobronchial
At the end of 7
hours of nursing
care, the patient
will be able to
prevent the
impairment of gas
exchange as
evidenced by:
Maintain res-
piration at
normal rate
within normal
range
1. Check the client’s
vital signs.
® This would help
check for any abnor-
malities of the body.
2. Monitor patient for
signs of cyanosis
® Close monitoring
would prevent hy-
poxia.
3. Maintain oxygen ad-
ministration device
as ordered, attempt-
ing to maintain oxy-
GOAL MET
September
13,2010
@
7:00am
11-7
At the end of 7
hours of nursing
care, the
impairment of
gas exchange
97
S
E
P
A
T
T
E
R
N
secretions causing
decreased in airway
patency.
NANDA 11th edition
(Doenges)
gen saturation at
90% or greater.
®This would ensure
that the patient
would be provided
with adequate oxy-
genation.
4. Position client in a
moderate high back
rest
® This promotes op-
timal lung ventila-
tion and perfusion.
The patient will ex-
perience optimal
lung expansion in
was prevented
as evidenced by
the baby
maintaining the
respiratory rate
at 35cpm which
is at normal
range.
98
upright position.
5. Monitor the effects
of position changes.
® Putting the most
congested lung areas
in the dependent po-
sition (where perfu-
sion is greatest) po-
tentiates ventilation
and perfusion imbal-
ances.
6. Provide proper ven-
tilation.
® Adequate ventila-
tion would help the
patient to be com-
fortable and be able
99
to rest.
7. Use pulse oximetry
to monitor for oxy-
genation and pulse
rate.
®Pulse oxymetry is
a useful device in
monitoring for the
patient’s oxygena-
tion.
8. Anticipate need for
intubation and me-
chanical ventilation
if patient is unable to
maintain adequate
gas exchange.
®Early intubation
100
and mechanical ven-
tilation are recom-
mended to prevent
full decompensation
of the patient.
9. Administer oxygen
as ordered by the
physician
®This would aid in
the gas exchange.
10. Refer physician for
any problems
®Proper referral
helps in giving
proper management
for the problem of
101
the patient.
102
Date Cues Needs Nursing Diagnosis Plan of Care Nursing Interventions Evaluation
September
12, 2010
@
12:00 AM
11-7
OBJECTIVE:
Noted bruis-
ing, dark in
color, on
right poste-
rior wrist
approxi-
mately 3 by
4 centime-
ters in size
Noted red-
ness on left
gluteus
maximus
N
U
T
R
I
T
I
O
N
A
L
-
M
Risk for impaired skin
integrity related to
mechanical factors
such as pressures and
friction.
® Skin is the primary
defense of the body; it
protects the body
against infections
and diseases brought
about by the invasion
of microbes in the
At the end of the
8 hours shift the
client will
maintain tissue
integrity as
evidenced by:
a. absence of
redness and
irritation
b. no skin break-
down.
1. Assess general
condition of skin
® Assessment
would help check
for any abnormal-
ities of the body
2. Assess for environ-
mental moisture.
® Moisture may
contribute to skin
maceration.
3. Encourage the
watcher for the im-
plementation and
GOAL UNMET
September
13,2010
@
7:00am
11-7
At the end of the
8 hours shift the
client was not
able maintain
tissue integrity
103
Diaphoretic
Dry skin
noted
Fair skin
turgor
E
T
A
B
O
L
I
C
P
A
T
T
E
R
N
body. A normal skin is
moist and intact;
dryness of the skin is
more prone to friction
that may result to
impairment of the skin
integrity as compared
with a moist skin.
NANDA 11th edition
(Doenges)
posting of a turning
schedule, restricting
time in one position
to 2 hours or less
and customizing the
schedule to patient’s
routine and care-
giver’s needs
®Building up of
pressures on the
body could be pre-
vented through turn-
ing.
4. Encourage caregiver
to maintain func-
tional body align-
as evidenced by:
a. presence of
redness
and irrita-
tion but
there was
no skin
breakdown
noted.
104
ment.
®This would main-
tain the alignment of
the body.
5. Increase tissue per-
fusion by massaging
around affected area.
®Massaging red-
dened area may
damage skin further.
6. Clean, dry, and
moisturize skin, es-
pecially over bony
prominences, twice
daily or as indicated
by incontinence or
105
sweating.
® This would thus
help in preventing
the impairment of
the skin
7. Encourage the par-
ent to provide ade-
quate nutrition and
hydration
® Hydrated skin is
less prone to break-
down.
8. Remind watcher to
change the clothing
and diapers if
soaked
®This would help
106
prevent the irritation
of the skin.
9. Instruct the watcher
to maintain the hy-
giene of the patient.
®Hygiene is impor-
tant for the body to
prevent any impair-
ment of the skin.
10. Refer physician for
any problems
®Proper referral
would give the pa-
tient proper manage-
ment for the prob-
lem.
107
PROGNOSIS
GOOD FAIR POOR JUSTIFICATION
Onset of the
illness
√ The onset of anemia that results from sepsis 2o to
bronhochopneumonia, unlike diseases that has
sudden onset like heart attack, is not sudden
therefore it can still be treated while it is still at
early stage.
Duration of illness √ Anemia 2o to sepsis 2o to bronchopneumonia is a
disease that needs immediate intervention. The
duration of this disease depends upon the
intervention given. If these problems are not
treated, it may be fatal to the patient.
Precipitating
factors
√ The precipitating factor present in the patient is
exposure to microorganisms. Exposure to
microorganisms easily modified by cleaning the
cause of the exposure thus decreasing exposure to
microorganisms.
Willingness to
take medications
and treatment
√ The patient complies with the medications strictly.
Moreover, the mother is very willing to let her
child take the medications prescribed to her by the
doctor. The patient was also brought to the
108
hospital be her mother for treatment.
Age √ The age of the patient is 4 months. She is still an
infant therefore she is susceptible to disease. The
immune systems of infants are not yet properly
developed.
Environmental
factors
√ The client’s home as reported is conducive for rest
and sleep. The patient lives in a therapeutic
environment. There are smaller chances of
pollution and noise. It can be said that the
environment as well was generally peaceful and
calm is very favorable for rest and promotes better
health.
Family Support √ The family has been very supportive throughout.
Her mother was supportive. Her father may not be
with her in the hospital but he is working so hard
to gain money for her hospitalization.
Total 3 3 1 Computation:
Poor: (2*1)/7 = 2/7
Fair: (0*2)/7 = 0/7
Good: (5*3)/7 = 15/7
Total: 2.43
General Prognosis:
109
1-1.6 = POOR
1.7-2.3 = FAIR
2.4-3.0 = GOOD
Rationale for a Good Prognosis
As shown by the calculated prognosis in relation to the different factors involved,
the patient has a good chance of survival. The factors presented in relation to prognosis shows
that patient can cope up after being discharged. Anemia 2o to sepsis 2o to bronchopneumonia is a
disease that needs immediate intervention. The duration of this disease depends upon the
intervention given. If these problems are not treated, it may be fatal to the patient. The age of the
patient is 4 months. She is still an infant therefore she is susceptible to disease. The immune
system of infants are not yet properly developed. Therefore in this area, she has poor chance of
survival.
However, the onset of anemia that results from sepsis 2o to bronhochopneumonia, unlike
diseases that has sudden onset like heart attack, is not sudden therefore it can still be treated
while it is still at early stage. The precipitating factor present in the patient is exposure to
microorganisms. Exposure to microorganisms easily modified by cleaning the cause of the
exposure thus decreasing exposure to microorganisms. The patient complies with the
medications strictly. Moreover, the mother is very willing to let her child take the medications
prescribed to her by the doctor. The patient was also brought to the hospital be her mother for
treatment. The client’s home as reported is conducive for rest and sleep. The patient lives in a
110
therapeutic environment. There are smaller chances of pollution and noise. It can be said that the
environment as well was generally peaceful and calm is very favorable for rest and promotes
better health. The family has been very supportive throughout. Her mother was supportive. Her
father may not be with her in the hospital but he is working so hard to gain money for her
hospitalization. Because of these justifications, she has good chance of survival.
111
Discharge Plan
Medication:
Instruct the mother to strictly comply with all of the doctor’s orders
Instruct to take the entire course of any prescribed medications. Otherwise
the disease may recur. Relapses can be far more serious than the first
strike.
Encourage the watcher to take the exact dosage of medication.
Inform the watcher and significant others about the possible adverse ef -
fects of the drugs,
Provide information about the effects of skipping medication,
Promote proper storage of the medication to avoid losing its potency,
Instruct to check date of expiry before taking the medication,
Immediately notify health care provider if adverse reactions occur while
taking the medicine,
Exercise:
Encourage the patient to have adequate sleep.
Bed rest should be encouraged.
Encourage alternating activity with rest.
Treatment:
Inform watcher and significant others about the effects of the treatment.
112
Clarify some misconceptions about the treatment and its purposes
Inform watcher and significant others about the compliance of medication
and other treatment recommended outside the hospital
Encourage significant others to provide care and support to enhance pa -
tient’s recovery
Health teachings:
Instruct watcher to bathe the child regularly.
Encourage the mother to wash the hands of her baby properly, before and
after meals. The hands come in daily contact with microorganisms that can
cause diseases. Washing of hands thoroughly and often can help reduce
the risk.
Explain the risk of spreading the disease. Protect others from the infec -
tion.
Instruct significant others to avoid exposing the patient to an environment
with too much pollution. Such as, aerosols used in the bathroom or even
colognes and perfumes that can irritate the patient.
.
Outpatient order:
Instruct significant others and watcher to come back to the OPD for the
scheduled check-up.
Inform the significant others to report any abnormalities and unusualities
manifested by the patient.
113
Instruct watcher and significant others not to take medicines without the
doctor’s advice.
Diet:
Advise planning the diet of the watcher as prescribed by the physician
Encourage mother to breast the baby on demand
Advise increasing fluid intake.
114
RECOMMENDATION
Ther case study about Anemia secondary to Sepsis secondary to Bronchopneumonia had
given the group more information that could help us in the future during the course of our
nursing practice. It is necessary to promote and maintain optimum health of the patient necessary
for one’s wellness; in line with ther the group would like to recommend the following:
To the Parents:
Since this is a pediatric patient with several disorders and is unable to care for herself yet,
we advise that the parents should be more cautious and aware of her condition that may worsen,
reoccur or give rise to further complications. We recommend that the parent’s should follow the
discharge plan given to them for the care of the patient diligently, to follow her recommended
medication regimen religiously and comply with the diet and lifestyle modification given in
order to maintain and/or improve her health condition. Upon the occurrence of any unusualities,
they must immediately be take the initiative to seek medical attention and not allow a time gap
between the onset of symptoms and the beginning of treatment to take place.
The family plays an important role during the recovery of the patient. Our patient’s
present condition and ailments are something that should not be taken lightly for it brings stress
to the family not only on a physical level but also in the psychological, emotional and financial
aspect. Therefore, the family should always show their support and concern for the patient all
throughout her recovery. The family should also work hand in hand with the patient, carefully
giving just the right amount of care to facilitate return of normal daily functions without
115
overreliance. Other accountabilities of the family are to monitor continuously assisting the
patient in taking medications, check-ups, and providing appropriate food and rest. Also, they
should understand and learn more about her conditions and ailments for the purpose of avoiding
complications. Lastly, the family should also be an example to the patient by doing the right
exercises and taking the proper diet.
To the Student Nurses
Student nurses handle the lives of the patient while the patient is in their care. Therefore,
the student nurses should be very strict and careful in carrying out the different nursing
interventions that were formulated specifically for that patient. One should have a continuous
dedication and conscience to provide proper and essential needs to patients they cared for. The
totality of all skills and knowledge taught to the student nurse should be reflected on their actions
and effectiveness in caring for others.
To the Clinical Instructors
The clinical instructors should continue to provide not just knowledge but wisdom to
their students and bear in mind that students are, compared to the CI’s, new to the world of
nursing. Thus the clinical instructors must have patience and be able to guide their pupils through
demonstration of their admirable qualities and positive reinforcement rather the more detrimental
method of harsh verbal criticism. The clinical instructors should also remember to teach skills
that are essential to a nurse and do so with same clarity and consistency as they so ask from their
students.
116
To the Hospital
To the all the medical professionals in South Philippines Medical Center Pediatrics Ward,
we recommend that they continue their work and maintain and/or improve their quality of care.
May they keep in the life and quality of life of all those under their care lies in their hands.
To the College of Nursing
We recommend that the College of Nursing continue in its endeavor to train competent
student nurses and to assign us to areas that is most suited to our capabilities. We trust that
College of Nursing will assign us to areas of gradually increasing difficulty according to what
they see fit. We further advise that the we student nurses be assigned to areas more relevant to
the present concepts being discussed in our lecture classes as well to prove a more thorough and
enlightening related learning experience.
117
REFERENCES
Kozier and Erb’s Fundmentals of Nursing 8th Edition
Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale
Doenges et. al.
Textbook of Medical Surgical Nursing 11th Edition
Lippincot and Willers
David Mullins (2007) 501 Human Diseases
Thomsom Asian Edition (p.306), Singapore
Delamar Learning
Robert Berkow, MD (1997).The Merck Manual of Medical Information
Home Edition (p. 1284). New Jersey; Merck and Co. Inc.
WEBSITES
http://emedicine.medscape.com/
http://www.medterms.com/script/main/art.asp?articlekey=9809
http://www.medcompare.com/jump/650/Anemia.html
http://emedicine.medscape.com/article/1222849-overview
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