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College of Nursing
Capitol Site, Batangas City
Presented By:
Alcaraz, Christine Gale
Acosta, Mary Anne
Atienza, Julius
Balmes, Jeneth
Bonado, Milagros
BSN 3-5
Presented To:
Mrs. Consuelo A. Cena RN
(clinical Instructor)
GENERAL APPEARANCE
ANTHROPOMETRIC MEASUREMENTS
Head Circumference – 44.5 cm
Chest Circumference – 44.5 cm
Abdominal Circumference – 42.5 cm
Length – 66 cm
Weight – 3.2 kg
BODY PART METHOD FINDINGS ANALYSIS
Skin
General Inspection No lesions Normal
Appearance
Color Inspection Pale Abnormal. Due to
decreased hemoglobin
level - 103.2 g/dL.
Upon admission Baby X’s Vital Signs was not stable, he had fever that
indicates infection, and he was tachypneic and tachycardic. Tachypneic is
frequently present in hypermetabolic and hypoxic states. By increase respiratory
rate the body is trying to supply additional oxygen to meet the body’s demand.
Tachycardic is due to difficulty of breathing, heart is needed to pump blood rapidly
to compensate the oxygen requirements of tissue and organs.
Lastly, upon observing of the nail bed, it was pale and this is due to
inability of the lungs to maintain adequate oxygenation of blood.
DIAGNOSTIC
AND
LABORATORY RESULTS
SUMMARY OF DIAGNOSTIC
AND LABORATORY RESULTS
(Results in Our Lady of Caysasay Medical Center)
February 5, 2009 at exactly 9:47 in the morning, laboratory exam for the
hematology was released. We found some abnormalities in the result. The white blood cells
and neutrophil levels were increased which indicates viral infections; lymphocyte level was
increased which indicates viral infections; monocyte was also decreased which may indicate
that Baby X is suffering from aplastic anemia; eosinophil level was decreased too which may
indicate that Baby X is in stress; RBC was decreased which indicates anemia; hematocrit and
hemoglobin levels were decreased which may indicate that Baby X is suffering from anemia;
MCV was decreased which may indicate iron – deficiency anemia and thalassemia; MCH
level which may indicate possible hypo chromic anemia; and platelet count which may
indicate anemia.
February 5, 2009 11:58 pm, laboratory exam for the hematology was again
released. We found some abnormalities again in the result. The white blood cells level was
increased which indicates viral infections; lymphocyte level was increased which indicates
viral infections; eosinophil level was decreased too which may indicate that Baby X is in
stress; RBC was decreased which indicates anemia; hematocrit and hemoglobin levels were
decreased which may indicate that Baby X is suffering from anemia; MCV was decreased
which may indicate iron – deficiency anemia and thalassemia; MCH level which may indicate
possible hypo chromic anemia; and platelet count which may indicate anemia.
February 5, 2009 8:26 am, laboratory exam for the
hematology was again released. We found some
abnormalities again in the result. The white blood cells level
was increased which indicates viral infections; RBC was
decreased which indicates anemia; hematocrit and
hemoglobin levels were decreased which may indicate that
Baby X is suffering from anemia; MCV was decreased which
may indicate iron – deficiency anemia and thalassemia; MCH
level which may indicate possible hypo chromic anemia; and
platelet count which may indicate anemia.
Blood chemistry was also done to Baby X on the same day, February 8,
2009. It revealed that glucose level was elevated which indicates renal failure and
the sodium level was decreased which indicates low sodium intake.
Why do you need to breathe? All of the cells in the body require oxygen.
Without it, they couldn't move, build, reproduce, and turn food into energy. Your
body gets oxygen from breathing in air which circulates to all parts of the body.
Nasal cavity (nose): the preferred entrance for outside air into the respiratory
system
Oral cavity (mouth): air also enters the body here
Adenoids: lymph tissue at the top of the throat that helps resist body infection
Tonsils: lymph nodes in the wall of the pharynx that are often removed when
infected
Pharynx (throat): catches incoming air from the nose and passes it downward to
the windpipe
Epiglottis: a flap of tissue that guards the entrance to the trachea
Larynx (voice box): contains the vocal cords
Esophagus: the passage leading form the mouth and throat to the stomach
Trachea (windpipe): the passage leading from the pharynx to the lungs
Ribs: bones supporting and protecting the chest cavity
Bronchi (tubes): trachea divides into these two main tubes, one
for each lung
Cilia: the bronchial tubes are lined with these very small hairs that
have a wave- like motion
Mucus: the movement of the cilia carries mucus upward into the
throat where it is coughed up or swallowed
Diaphragm: wall of muscle that separates the chest cavity from the
abdominal cavity
GENDER: MALE
INCOMPLETE IMMUNIZATION
ENVIRONMENT
LOWER CLASS
EASY ACCESS OF
MICROORGANISMS THAT MAY INFECTION OCCURS IN BOTH LUNGS
CAUSE INFECTION SUCH AS:
>STAPHYLOSCOCCUS AUREUS AND
KLEBSIELLA LUNG MUCOSA BECOMES SWOLLEN WITH
INCREASE MUCUS SECRETION
PNEUMONIA
SUMMARY OF PATHOPHYSIOLOGY
>Monitored vital signs >To obtain baseline data. (Pediatric Nursing Care Plans, 3rd
especially the RR. edition,Karla L. Luxner,RNC,ND,pg. 67)
>Auscutated the lung sounds, >Bronchial lung sounds are commonly heard over areas of lung
noting areas of decreased density or consolidation. Crackles are heard when fluid is present.
ventilation and presence of (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 480)
adventitious sounds.
>Monitored chest x – ray >These determine progression of disease process. (Nursing Care
reports. Plan, 6th edition, Gulanick/Myers pg. 480)
>Advised the mother to >Hydration helps decrease the viscosity of secretions, facilitating
breastfeed Baby X every 2 – expectorations. (Pediatric Nursing Care Plans, 3rd edition,Karla
3 hours. L. Luxner,RNC,ND,pg. 67)
>Advised the mother that > Positioning facilitates chest expansion and respiratory efficiency by
after each feeding, elevate reducing pressure of abdominal organs on diaphragm. (Pediatric
the head of bed at least 30 Nursing Care Plans, 3rd edition,Karla L. Luxner,RNC,ND,pg. 68)
degrees.
>Chest physiotherapy helps to aid immobilization of secretions.
>Back tapping performed (Nursing Care Plan,7th edition, Doenges, et.a pg 108l)
after each nebulization.
INTERVENTION RATIONALE
>Instructed the client to have>Discharges from the nebulizer are often foul tasting and smelling.
oral care after each (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 480)
nebulization.
Determined precipitating factors. Identification and management of underlying cause are essential
to recovery. (Nursing Care Plan, 6th edition, Gulanick/Myers
pg. 105)
Monitored axillary temperature. Provide information about the effectiveness of care. (Pediatric
Nursing Care Plans, 3rd edition,Karla L. Luxner,RNC,ND,pg.
453)
Monitored environment temperature; Room temp or every number of blankets should be altered to
limit / add bed linens as indicated. maintain near normal body temperature. (Pediatric Nursing Care
Plans, 3rd edition,Karla L. Luxner,RNC,ND,pg. 453)
Provided Tepid Sponge Baths, avoid use May reduce fever. (Pediatric Nursing Care Plans, 3rd
of alcohol. edition,Karla L. Luxner,RNC,ND,pg. 453)
Removed extra clothing and covered the Helps reduce skin temperature. (Pediatric Nursing Care Plans,
child may have on after the antipyeretic 3rd edition,Karla L. Luxner,RNC,ND,pg. 453)
has taken effect.
INTERVENTION RATIONALE
Taught the mother about possible side effects Information helps prevent adverse effects from
of anti-pyretic medicine medicine. (Pediatric Nursing Care Plans, 3rd
edition,Karla L. Luxner,RNC,ND,pg. 454)
Empowers parents to care for their child. (Pediatric
Nursing Care Plans, 3rd edition,Karla L.
Provided the mother with instructions about Luxner,RNC,ND,pg. 454)
management of childhood fever.
Families need to learn how to prevent future
Discussed to the mother the precipitating episodes of hyperthermia. (Nursing Care Plan, 6th
factors and preventive measures, including edition, Gulanick/Myers pg. 106)
maintenance of adequate fluid intake, change in
environment, taking medications as prescribed.
Provided supplemental fluids -IV - D5IMB IV Additional fluids help prevent elevated temperature
fluid regulated at 34 – 35 gtts per minute,as per associated with dehydration. (Pediatric Nursing
doctor’s order. Care Plans, 3rd edition,Karla L.
Luxner,RNC,ND,pg.454)
The client’s
temperature
decreased as
evidenced by :
temperature =36.4
ºC
warm to touch
ASSESSMENT NURSING SCIENTIFIC
DIAGNOSIS EXPLANATION
After 2 hours of
nursing interventions,
the client will
demonstrate improve
ventilation & oxygen
tissues & absence of
symptoms of
respiratory distress.
•INTERVENTION •RATIONALE
Assessed respiratory rate, depth & Manifestations of respiratory distress are
ease. dependent on inactive of the degree of the lung
involvements in underlying general health status.
(Pediatric Nursing Care Plan, Axton, et. Al, pg.
296)
Monitored heart rate. Tachycardia is usually present as a result of fever
dehydration but may represent a response to
hypoxemia. (Pediatric Nursing Care Plan, Axton,
et. Al, pg. 296)
Monitored body temperature as A fever as early increase metabolic demands &
indicated. Assisted the comfort oxygen consumption & alters cellular oxygenation.
measures to reduce fever & chills; (Pediatric Nursing Care Plan, Axton, et. Al, pg.
addition or removal of bedcovers, 297)
comfortable room temp.
Instructed the mother to have Discharges from the nebulizer are often
oral care to her baby after each foul tasting and smelling. (Nursing Care
nebulization. Plan, 6th edition, Gulanick/Myers pg.
480)
The client
demonstrated improved
ventilation and oxygen
tissues and absence of
symptoms of
respiratory distress as
manifested by the
decrease in apical
pulse- 132 beats per
minute and respiratory
rate of 48 breaths per
minute.
DRUG STUDY
NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Frequency:
Q8
Form:
Liquid
CONTRAINDICATION NURSING RESPONSIBILITIES MONITORING
PARAMETERS
Planning:
After 30 minutes of nursing interventions, the mother will be able to
enumerate ways on how to provide adequate care to Baby X.
Implementation:
Conducted health teaching to the mother as follows:
MEDICATONS:
> Instructed the mother to give home medications prescribed by physician upon
discharge.
• Ciprofloxacin 100 mg/pptab 1 pptab once a day 8:00 in the morning for 14
days
• Phenobarbital 30 mg/tab 1 tab once a day 8:00 in the morning
ENVIRONMENT AND EXERCISE:
TREATMENT:
> Advised the mother to turn the client from time to time to
prevent further complication of pneumonia.
> Demonstrated the mother on how to do chest tapping after each
nebulization.
> Instructed the mother to place towel at the back of the child
when perspiration is extreme.
> Advised the mother to change clothing as necessary.
HYGIENE:
OPD:
> Informed the mother and relatives that further monitoring will be
conducted and so the need for regular check – up is highly
recommended. To come back at the hospital for check – up on February
26, 2009.
DIET:
> Instructed the mother to continue breastfeeding Baby X every 3
– 4 hours.
SPIRITUALITY:
> Advised the mother to seek God’s help for the recovery and
give improvement of the patient’s health and never forget to ask guidance
and support from our Lord.
Evaluation:
The mother was able to enumerate ways on how to provide
SPIRITUALITY:
Evaluation: