NURSING HEALTH HISTORY

A. Biographical Data

Name: Jaissen Malong

Address: Sitio Daang Bakal Sta Cruz Guiguinto, Bulacan
Age: 1 year and 2 months old.
Sex: Female
Race: Filipino
Marital Status: Single
Occupation: None
Religious Orientation: Roman Catholic
Health Care Financing and Usual Source of Medical Care: None

B. Chief Complaint or Reason for Visit

The patient was brought to the hospital due to cough, colds, fever and diarrhea.

C. History of Present Illness

As narrated by the client’s mother, one week prior to admission the patient developed on and off fever with cough and colds. The patient also passes out soft stools but no
consult done. The patient was given paracetamol and carboceistein. They brought her to the hospital for further medication and management last morning of September 21,
2009. She was then diagnosed with Broncho Pneumonia; the physician prescribed her with Paracetamol drops every 9 hours, Vitamin K TIV (thru intravenous) and Combivent
Nebulizer q8 (every 8 hours).

D. Past history

Upon interview, her mother told the student nurses that Jaissen does have a complete immunization. She has also no other diseases from past except from some fevers. She
has no known allergies. Prior to admission she was taking multivitamins as her dietary supplement.
E. Family History of Illness

The patient’s grandmother has history of high blood pressure, one of her aunt from the mother’s side and grandfather from her father’s side have a history of Tuberculosis.
One of her aunt in her mother’s side is clubfooted.

F. Functional Health Pattern

Psychological

1. Self Perception-Self Concept Pattern

As stated by the client’s mother as part of their health maintenance she is always giving her child with supplements such as multivitamins and giving her
appropriate foods for her growth. She also brings her child to the hospital when home remedy is not effective. The only family member in their house who’s using
tobacco is the client’s father.

2. Role Relationship Pattern

She has a very close bond with her family especially with her mother since she takes care of her 24/7. She is the first and only child in her family. Her mother
said that she is a very sweet child.

3. Sexuality and Reproductive Pattern

N/A

4. Cognitive Perceptual Pattern

As stated by the patient’s mother, the patient is normal in terms of her cognitive abilities. She has good memory and she obeys simple commands. She has no
problem with her senses.
5. Coping Stress Tolerance Pattern

Her mother said that she usually cry and have tantrums when something is wrong or when she is not feeling well.

Value Belief Pattern

She is a Roman Catholic and her parents bring her to mass every Sunday. They teach her to believe and fear God. They usually believe in quack doctors.

Elimination

The client’s bowel movement PTA was 2-3 times a day. A week before hospitalization the client’s bowel movement was 6 times a day, with soft and watery
stools. After admission, the patient’s bowel movement goes back to normal to 2-3 times a day. She urinates frequently with a 6 diaper pad change a day. The client
has no excess perspiration and no odor problems.

Rest and Activity

The client sleeps approximately about 9-10 hours during night time. She has no problem in sleeping. She doesn’t take naps during morning and afternoon.

Activity-Exercise Pattern
According to the mother, PTA the client is very fond of watching educational television shows like Barney and Friend. She’s also fond of playing with her doll and the
patient is “napaka likot” as verbalized by the mother. In the hospital the client is unable to move freely due to her health condition and her IV infusion. Because of her
young age and her condition she requires assistance and supervision from her parents in all her daily activities.

Nutritional and Metabolic Pattern

Prior to hospitalization Jaissen’s usual food intake are milk, porridge, rice with soups and she’s also fond of eating biscuits, drinking zesto and other juice products. At
the hospital she was advised to eat porridge, apple, banana and crackers. She is currently having +5cc distilled H2O very slow IV push every 8 hours. The only skin
problem was dry and cracked lips due to the disease process.
Patient’s Name: Jaissen Malong  The usual diaper brand name: Pampers.
Age: 1 yr. and 3 months  No food or medication allergies
Civil Status: Single  They have pets at home. (Dog and Cat)
Gender: Female  Patient has a stuffed animal toy.
Religion: Roman Catholic Skin
Nationality: Filipino
Address: Sitio Daang Bakal Sta Cruz, Guiguinto, Bulacan • white skin color all over the body
• well-hydrated, perspiration was noted
PHYSICAL ASSESSMENT • warm to touch
• smooth, soft and even
GENERAL SURVEY:
A. State of Awareness: • easily lifted and turned back immediately to its normal state in less
Patient is alert and responsive to environment and to external stimuli. than 2 seconds
B. There are no signs of respiratory distress, pain, but is a little anxious
when touched and assessed by a stranger. Hair and Scalp
C. Gait was not assessed because child was either lying or sitting during
the whole time of assessment. • Hair is evenly distributed
D. Good Posture. • No presence of lice, dandruffs or nits.
E. There are no signs of immobility or other unnecessary or not • Hair was cut cleanly.
purposeful movements. • Scalp is smooth and inelastic without the presence of lesions and
F. Hair is clean cut, used fresh clothes with no noticeable body odor but nodules
nails are clean.
G. Speech is not clear but speaks 1 to 2 syllabic words that are simple. Nails
H. Mood is unpredictable, sometimes cooperative and sometimes not. But
the child smiles or cries in accordance to his mood. • Nail bed is pink but the translucent, white tips were free of dirt
• Uniformly thick and at a constant rate
INTEGUMENTARY SYSTEM
• the shape is well-rounded and convex with a 160 degree-angle
Health History:
 mother verbalized, “minsan nagkakaroon ng rashes dahil sa
diaper.”

RESPIRATORY SYSTEM
Health History:
 Heredofamilial disease: none
 Had a non-productive cough PTA
 Father is smoking but not anywhere near the house
Posterior Chest
• No presence of lesions and color is the same all throughout the body
• Thorax is symmetrical
• No bulging or active movement during breathing
• Anteroposterior diameter is 1/3-1/2 of the transverse diameter
• No lumps, masses or pulsations noted upon palpation
• Resonant sounds were felt over the lung fields and Dullness over the
peripheral lung fields
• Bronchovesicular sounds were heard over the lung fields and vesicular
sounds over the lung periphery without any adventitious sounds.
• Bronchial sound was heard at the suprasternal notch, brochovesicular
sounds were heard over the lung fields, and vesicular sounds over the
lung periphery
CARDIOVASCULAR SYSTEM
Health History:
 Heredofamilial disease: Hypertension (Paternal Grandmother)
 No presence of discoloration (blueness) when child is crying
 No growth delay
• No visible signs of pulsations
• No presence of nodules and lumps
• Flat sounds were felt upon percussion over the bony areas and dull
sounds were felt over the heart.
• S1 was best heard at the Mitral artery (5th ICS midclavicular line), and
S2 was best heard over the pulmonic artery.
• No heart mumurs were heard
• Pulse rate = 100bpm, bounding and palpable

Anterior Chest
MATURATION OF SYSTEMS:
• RR = 30 cpm, regular , normal breathing without the use of accessory  Respiration is slightly slow compared during infancy period
muscles  Prone to develop upper respiratory tract infections due to
• Abdominal breather short and straight internal structures of the ear and throat
• Protuberant tummy  Heart rate slows from 110-90, approximately
 Brain develops about 90% of its adult size
• Symmetrical expansion upon inspiration and expiration
 Stomach has increased capacity, secretions become more
• No bulging acidic and GI infections becomes less common
• No lumps, masses, or pulsations upon palpation
  Complete myelination makes the control of the urinary and
anal sphincters
 Passive immunity obtained during intrauterine life is no longer DEVELOPMENTAL MILESTONE:
operative because IgG and IgM antibodies becomes slowly  Gross Motor Development
mature o Walks alone with wide stance for extra balance
o Seats self on a chair
COGNITION / LANGUAGE: o Can run
 Cognitive Development  Fine Motor Development
o Stage 5 – 3P Circular Reaction o Able to grasp a very small object
 Tries to discover ways to handle objects to find new
results IMMUNIZATION:
 Involving trial and error experimentation  3 shots of Hepatitis B
 Patient was curious about her IV Infusion. She keeps  BCG
looking at the bottle of IV.  OPV
 Language Development  DPT
o Uses one word sentences or holophrase or two-word  Measles
 “ma-ma” “pa-pa”  Chicken Pox
 Rotavirus Vaccine
 NURSING CARE PLAN
Problem: Cough and Colds
Nursing Diagnosis: Ineffective airway clearance related to increased mucus production secondary to broncho pneumonia
Taxonomy: Activity-Exercise Pattern

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Short Term Objectives Independent

After 8 hours of duty and - Assessed/monitored vital signs - Changes in vital signs may indicate Patient was able to
appropriate nursing care acute pain or discomfort verbalize, “ ok na yung
interventions, the patient - Provided additional comfort measures - Improves circulation, reduces muscle paghinga niya.maluwag
Subjective Cues will be able to demonstrate like backrub, heat/cold application tension and anxiety associated with na. Di na din siya
behavior to achieve airway pain. Enhances well-being inuubo ”
“sobra yung ubo niya,” as clearance and will have an - Assisted patient with deep breathing - Deep breathing facilitates maximum
verbalized by patient’s improved condition exercises expansion of the lungs/smaller
mother airways
Long Term Objectives - Observed characteristic of cough e.g. - Cough can be persistent but
persistent, moist, etc. Assisted with ineffective especially if the patient is
Objective Cues After 3 days of duty and measures to improve effectiveness of elderly
- Patient has occasional appropriate nursing cough effort
non-productive cough interventions the patient will - Encouraged intake of fluid of 3000 ml -
Fluids aid in mobilization and
- RR 30 cpm be able to appear relaxed, per day expectoration of secretions
- decreased sound on left noticeable improvement in - Encouraged/assisted with abdominal or - Provides patient with some means to
chest airway clearance. pursed lip breathing exercises cope with/control dyspnea and
- pt appears weak reduce air trapping
- patient looks to be - Encouraged to avoid allergenic - Prevents development of further
lacking sleep substances (e.g. dust, chemicals, attacks
- harsh breath sounds smoke, etc)

Dependent

- Administer medications as prescribed - Bronchodilator; relaxes bronchial,

(Combivent Nebulizer) uterine, an vascular smooth muscles
by stimulating beta 2 receptors
 HEALTH TEACHINGS

M The patient’s significant others were informed about the

importance of taking proper medications on the right dose,
route, and time as prescribed by the physicians.
E Encouraged her significant others to provide quiet environment
to promote non pharmacological pain management.
T Instructed her significant others how to manage the patient
when in pain related to bronchial asthma.
H Demonstrated proper hand washing and encouraged good
grooming to promote self-esteem.
O Emphasized the importance of attending follow up check up to
monitor the status of the client.
D Encouraged her significant others to provide diet as ordered by
physicians and explained its importance on the present situation
of the patient.
S Instructed her significant others when at home to watch out
when the patient is in pain to prevent accident that may
contribute in worsening of the present situation.
 DRUG STUDY

•Chloramphenicol
•Metronidazole
•Paracetamol drops
•Vitamin K
•Combivent Nebulizer
NAME MECHANISM OF INDICATION DOSAGE, ROUTE CONTRAINDICATION ADVERSE NURSING
ACTION AND FREQUENCY REACTION RESPONSIBILITY
 A broad-spectrum Salmonella Adult: 250-500mg 6 History of Serious and fatal • Ask first if the
Generic name: antibiotic effective infections, hourly. May be given hypersensitivity or blood dyscrasias. GI patient is
Chloramphenicol against gram- shigellosis, rickettsial PO every 6 hour. toxic reactions, intolerance; hypersensitive
positive and gram- infections, Infant: 25mg/kg/day. lactation, pregnancy. neurological to the drug.
negative bacteria meningitis, brain May be given TIV reactions; • Advise the
against anaerobes. It abscess, and with distilled water hypersensitivity, patient to take
is primarily pulmonary every 8 hour. Gray syndrome; the medication
bacteriostatic. It infections. optic neuritis. before meal.
binds to the 50S • Be alert for
subunit of the the adverse
ribosome, thereby reactions of
inhibiting bacterial the drug.
protein synthesis.
• Report if the
patient has
shown
symptoms of
Gray
syndrome
(body limpness
cyanosis,
cardiovascular
collapse hypothermia
vomiting, refusal to
suck and loose green
stools.)

NAME MECHANISM OF INDICATION DOSAGE, ROUTE CONTRAINDICATION ADVERSE REACTION NURSING

ACTION AND FREQUENCY RESPONSIBILITY
 . A common use of Infants and Hypersensitivity to Flushing,, coordination 1. Ask first if the
Generic Name: Metronidazole is an this medication Children: metronidazole, impaired, dizziness, patient is
Metronidazole antibiotic especially would be the nitroimidazole fever, headache, hypersensitive to the
effective against treatment of colitis, Amoebiasis: Oral: derivatives, or any insomnia, irritability, drug.
Brand Name: anaerobic infections. which may or may 35-50 mg/kg/day in component of the seizure, vertigo, 2. Advise the patient
(Flagyl; Flagyl I.V. Unlike many not be caused by divided doses every formulation; Erythematous rash, to take the
RTU; MetroCream; antibiotics, It inflammatory bowel 8 hours for 10 days pregnancy (1st urticaria, medication after
MetroGel; penetrates the disease. trimester - found to be dysmenorrheal, meal.
MetroLotion; blood-brain barrier Amoebiasis, Anaerobic carcinogenic in rats). Nausea, anorexia, 3. Be alert for the
Noritate; Rozex) and treat central Aspiration infections: Oral: 15- abdominal cramping, adverse reactions of
nervous system Pneumonia, 35 mg/kg/day in constipation, diarrhea, the drug.
infections. It also Bacteremia, divided doses every furry tongue, glossitis, 4. Do not give to
penetrates bone, Bacterial Infection 8 hours proctitis, stomatitis, pregnant woman.
making it especially Meningitis unusual/metallic taste,
useful in oral/dental Pelvic Inflammatory I.V.: 30 mg/kg/day in vomiting, xerostomia,
infections. In Disease divided doses every Cystitis, darkened urine
addition, it has anti- Peritonitis 6 hours (rare), dysuria,
inflammatory Pneumonia. incontinence, polyuria,
properties in the vaginitis,Neuromuscula
large intestine and is r & skeletal: Peripheral
a very effective anti- neuropathy, weakness,
diarrhea Nasal congestion,
medication. It is an rhinitis, sinusitis,
effective antibiotic pharyngitis Flu-like
against certain syndrome, moniliasis.
protozoal infections,
especially giardia.

NAME MECHANISM OF INDICATION DOSAGE, ROUTE CONTRAINDICATION ADVERSE REACTION NURSING

ACTION AND FREQUENCY RESPONSIBILITY
 . In children: aged Paracetamol should In rare cases 1. Ask first if the
Generic Name: Paracetamol The preparation is from 3 months to1 not be used in hypersensitivity patient is
Paracetamol Drops possesses indicated in year - 60-120 mg hypersensitivity to the reactions, hypersensitive to the
prominent diseases (2.5-5 ml syrup), 3-4 preparation and in predominantly skin drug.
Brand Name: antipyretic and manifesting with times daily; 1-6 severe liver diseases. allergy (itching and 2. The preparation
(Tempra, analgesic effects. Its pain and fever: years - 120-240 mg rash), may appear. should be used with
Biogesic,Neo- anti-inflammatory headache, (5-10 ml syrup), 3-4 Long-term treatment care in patients with
kiddielets) activity is weak and toothache, mild and times daily; children with high doses may liver and renal
has no clinical moderate older than 6 years - cause a toxic hepatitis diseases.
significance. The postoperative and 250-500 mg, 3-4 with following initial 3. The treatment with
mechanism of action injury pain, high times daily. In symptoms: nausea, the preparation is not
is related to temperature, children younger vomiting, sweating, and advisable during the
depression of the infectious diseases than 3 months the discomfort. first trimester of the
prostaglandin and chills (acute preparation should Occasionally a pregnancy. In nursing
synthesis by catarrhal be used only on gastrointestinal women the preparation
inhibition of the inflammations of the doctor’s discomfort may be should be used with
specific cell upper respiratory prescription. seen. strictly observation of
cyclooxygenase, tract, flu, small-pox, Duration of the the therapeutic dose
and depression of parotitis, etc.). treatment in children and duration of the
the should not exceed 5 treatment.
thermoregulatory days, whereas in 4. Report if initial
center in the adults it may be symptoms of toxic
medulla oblongata. continued up to 10 hepatitis are
days. observe.
 NAME MECHANISM OF INDICATION DOSAGE, ROUTE CONTRAINDICATION ADVERSE REACTION NURSING
ACTION AND RESPONSIBILITY
FREQUENCY
. • hypersensitive to Serious Reactions 1. Ask first if the
Vitamin K It is a fat-soluble Dosage forms: 5 drug//component patient is
vitamin that plays Hypoprothrombinemia mg; SC; IM; IV • hereditary • anticoagulant hypersensitive to
an important role , [vitamin K hypoprothrombine- resistance the drug.
in blood clotting deficiency] mia • hypersensitivity, 2. Report for serious
Hemorrhagic dz, Dose: 2.5-5 mg PO • overanticoagulation severe incl. fatal adverse reactions
newborn qd prn; Alt: 1-2 mg due to heparins (SC, IM, IV) are observed.
SC/IM/IV x1; Info: • caution in neonates • anaphylaxis (SC, 3. Tell the mother
renal dosing, hepatic subsequent doses • caution in elderly IM, IV) that Vitamin K
dosing based on INR pts • hyperbilirubinemi deficiency is very
[anticoagulant a (neonates) rare.
induced] • hemolytic anemia
Dose: 0.5-5 mg (neonates)
PO/SC/IM/IV x1;
Info: may repeat oral Common Reactions
dose in 12-48h or
parenteral dose in 6- • taste changes
8h based on INR (SC, IM, IV)
hemorrhagic dz, • flushing (SC, IM,
newborn IV)
Dose: 1-2 mg • injection site
SC/IM/IV x1; Info: hematoma
higher doses may be
necessary if mother • injection site pain
on anticoagulant tx
 NAME MECHANISM OF INDICATION DOSAGE, ROUTE CONTRAINDICATION ADVERSE REACTION NURSING
ACTION AND RESPONSIBILITY
FREQUENCY
. • Hypertrophic • Fine tremor of 1. Ask first if the
Combivent It is bronchodilator. In adults, obstructive skeletal muscle; patient is allergic to
Nebulizer It is taken by Asthma, COPD. maximum of 2 cardiomyopathy or palpitations; albuterol,
inhalation to help Management of puffs tid-qid. tachyarrhythmia. headache, ipratropium,
control the reversible Maximum of 12 • History of dizziness, atropine,
symptoms of lung bronchospasm puffs per day. hypersensitivity to nervousness; belladonna,
diseases, such as associated with soya lecithin or dryness of mouth; hyoscyamine, or
asthma, chronic obstructive airway More than 12 year, related food throat irritation; scopolamine, or to
bronchitis, and diseases in patients 1 vial every 6-8 products. urinary retention. other inhalation
emphysema. It who require more than hours. aerosol medicines.
helps decrease a single Also ask if allergic to
coughing, bronchodilator. Children 2-12 soya lecithin or
wheezing, year: related food
shortness of 3 drops/kg/dose substances such as
breath, and (max: 2500 mcg of soybeans and
troubled breathing salbutamol) every peanuts.
by increasing the 6-8 hours. 2. Report to the
flow of air into the doctor if the
lungs. patient’s difficulty in
breathing continues
after using a dose of
this medicine or if r
condition gets
worse.
 Bulacan State University
College of Nursing
S.Y. 2009-2010

A CASE STUDY
(PNEUMONIA)

Submitted by: Submitted to:

Jill S. Tolentino Ma’am Joicylyn Martin, RN
BSN 2H Group 5