Introduction

We are the second year students of Saint Joseph Institute of Technology exposed at the Butuan Medical Center, Pink Section <Pedia Ward>. To make our exposure to be more exciting, we are assigned to do case study and divided our group into two.

It was February 13 2010 that we started to gather information about our case study and find the most interesting case that will surely captured our minds about it. At room 207, we’ve notice a very young mother carrying her baby boy, a two months old with a complaint of having a fever, cough and cold for almost seven days. We see the baby boy pale, with mucus secretion on the nose and prolonged coughing. Baby boy is diagnosed with bilateral pneumonia by Dr. Burdeos as his physician. We chose bilateral pneumonia as our case to be study out of curiosity. This is also our first time to encounter this kind of case and because of that, we are willing to do this to challenge our minds in analyzing the problem and enhances our hidden knowledge, and also to gain new experiences which would bring new learnings for the rest of the group. At the end of the case study, our group will be able to understand what is pneumonia all about, and prevention/ treatment of the occurrence of the disease.

What is bilateral pneumonia or pneumonia? It is an inflammatory illness of the lungs. Frequently, it is described as lung parenchyma/alveolar inflammation and abnormal filling of fluids< consolidation and exudation>.

Alveoli are microscopic air- filled sacs in the lungs responsible for absorbing oxygen. Pneumonia can be result from a variety of causes including infection of bacteria, viruses, fungi or parasites and chemical or physical injury to the lungs. Its can be also officially described as idiopathic that is, unknown when infectious causes has been excluded.

Typical symptoms associated with pneumonia include cough, chest pain, fever and difficulty in breathing. Diagnostic tools include X-

rays and examination of the sputum. Treatment depends on the cause of pneumonia; bacterial Pneumonia is treated with antibiotics.

According to the International Union Against Tuberculosis and Lung Disease, Pneumonia kills more than any other condition affecting the lungs; it is a prime cause of death in young children. There are also 10 to 12 million deaths occur annually in children under 5 years of age over 90% are in the developing world. It is small children who are less than one year of age living in the poorest communities who most often suffer and die from this condition. Pneumonia is often a result of other infections such as measles and pertussis. The frequency of pneumonia in children could be reduced by 10- 20% through immunization with these vaccines. Many Developing countries have very low immunization rates due to funding and delivery problems.

According also to Butuan Medical Center there are fifteen cases of babies ages 2mos old and above that are reported to have pneumonia by year November 2009 to January 2010.

NURSING HEALTH HISTORY

Nursing Health History is the first part of the client’s health status, it is systematic collection of subjective data provided by the patient’s significant other’s verbalizations and supplemental by objective data gathered during Physical assessment. It is needed for solving and determining a patient’s problem and for the nurse to know what interventions to be applied and what may be the cause of the illness.

For the patient’s trust, privacy, dignity and respect we gave him and we decided to hide his name and called him Patient X.

Since our patient cannot really express much of himself due to he is still a baby, we chose to gather information from his mother whom is very close to him.

Patient X is an 2 months old baby. A Roman Catholic, with fair complexion and weighs about 4 lbs. He was born on December 9, 2009 through normal spontaneous delivery at Butuan Medical Center (BMC). He was the eldest and the only son. Patient X with her mother is living at Purok 2, Kinamlutan, Butuan City with his family, and has been used to the catholic traditions since his mother and grandparents are Catholics.

Upon interview, his mother told us that Patient X had its first immunization (BCG). He has also no other diseases from past. As the mother told us that Patient X has an allergies on talc powders such as Johnson and Johnson powder and some non- hypoallergenic powders.

Before the hospitalization in Butuan Medical Center, Patient X already suffers from fever, cough and colds. It was January 7, 2010 when the mother brought Patient X to the hospital for further medication. But then it was not accepted by the hospital because there is no vacancy on that time.

It was February 12 2010 when the mother of Patient X decided to admit Patient X at the BMC around 10:25 am immediately at the emergency room. Upon the admission, he was immediately assessed, taking its initial Vital signs of T = 38.3°C; P = 120 bpm; R = 18bpm. O2

inhalation administered at 1-2 lpm; CBC is requested at 10:55am; started IVF of D5 .3 NaCl 500 with solvent refilled with 100 cc at 16 cc/hr; for chest x- ray (APL) requested; LABORATORY RESULTS

Date Ordered: February 12, 2010Date Performed: February 12 2010

Salbutamol nebulation T nebule Generic Name: Salbutamol Brand Name: Pharmacia and Upjohn (marsman)Classification: Anti-Asthma

  Result NormalValues Interpretatin

Significance

RBC 4.23 4.5 – 6.0 x 10/L

Normal  

WBC 16.70 10.1 5 – 10 x 10/L

Increase Indicatespresence ofinfection

HgB 95 130 – 140 g/dl

Decrease Indicatesoccurrence ofanemia

Hct 0.30 0.30 normal

Platelets 317 150 – 400 x09/L Normal

 

Indications :Bronchospasm in bronchial Asthma of all types, chronic Bronchitis and Emphysema Contraindications: HypersensitivityPrecautions: Hyperthyroidism, diabetes mellitus,closed-angle glaucoma, cardiovascular disease, pregnancy and lactation. Patient Teaching: -Instruct patients on dosage and not -Shake the inhaler -Clear nasal passages and throat - Breath out,expelling as such air from lungs as possible

-Place mouthpiece well into mouth Nursing Consideration:

-Syrup maybe taken by children as young as age 2, contains no alcohol or sugar.

-Glue extended release tablets consciously to patients with gastro Intestinal narrowing.

-Aerosol form maybe used 15 minutes before exercise to prevent exercise induced.

; for npo; brought to ward as ordered by Dr. Burdeos.

During February 13 2010, Dr. Burdeos ordered to continue O2

inhalation; checked vital signs;

Cefuroxime 750 mg IVTT

Generic Name:Cefuroxime Axetil Brand Name:Ceftin Classification: Antibiotic Indication :For skin structure infection caused by streptococcus pneumoniaeContraindications: Contraindicated for patients hypersensitive to drugAdverse Reaction: Cardiovascular: Phlebitis ,thrombophlebitis

Gastrointestinal Tract: Pseudo membranous colitis, nausea, vomiting, diarrhea .Hematologic: Transient neutropenin , eosinophiln, hemolytic anemia, thrombocytopenia

Skin: Maculopopular and erythematous rashes, urticaria pain ,in duration , sterile obscesses , increase temperature , tissue sloughing at intra muscular injection site.

Nursing Consideration: -Use contiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics. Also use contiously in breastfeeding women and in patients with history of colitis.

-For intramuscular administration, inject deeply into a large muscle mass such as the gluteus maximus or the lateral aspect of the thigh.

-Absorption of cefuroxime axetil is enhanced by food.-Cefuroxime axetil tablets may be crushed fpr patients who can’t

swallow tablets .Tablets may be dissolves in small amount of juice. However the drug has a bitter taste that is difficult to mask even with food.

Patient’s Teaching:-Tell patient or patient’s significant other to take all of the drug as

prescribed even after he feels better.-Advised patient’s significant others whwn patient receiving drugs

intra venous through tubing to report discomfort at intra venous insertion site.

Cefaclor 50 mg/ml as medication

Generic Name: Cefaclor Brand Name: CeclorClassification: Antibiotic Indication: For respiratory , skin and soft tissue infectionsContraindication: Contraindicated in patients hypersensitivity to drug.Adverse Reaction :

Central Nervous System: Fever, seizures, dizziness, headaches.Gastro Intestinal Tract: Nausea, vomiting, diarrhea, dyspepsia,

abdominal cramps, pseudo membranous colitis, oral condidiasis.Skin: Maculopapular rash, dermatitis, pruritis, urticaria Respiratory: Dyspnea

Nursing Consideration:-Use contious in patients with hypersensitive to penicillin

because of the possibility of cross-sensitivity with other beta-lactam antibiotic. Also use contiously in breastfeeding women and in patients with history of colitis.

-If large doses are given, therapy is prolonged or patient is high-risk, monitor patient for super infection.

Patient Teaching:-Instruct patient or patient’s significant others to take drug

with food or milk to lessen gastro intestinal discomfort.

-Tell the patient or patient’s significant others to take the entire amount of drug exactly as prescribed even after the patient feels better.

-Advised patient or patient’s significant others to notify prescriber if rash or if signs and symptoms of super infection such as re occurring fever, chills, malaise.

Developmental MilestoneThe optimal development of children is considered vital to society

and so it is important to understand the social, cognitive, emotional, and educational development of children. Increased research and interest in this field has resulted in new theories and strategies, with specific regard to practice that promotes development within the school system. In addition there are also some theories that seek to describe a sequence of states that comprise child development. According to Freud’s theory,

an infant is categorized in oral phase where a child is seeking pleasure through his mouth. The most powerful urge is to seek immediate satisfaction of impulses such as hunger or discomforts. In relation to the child, When the mother breast-feeds the child, the child experiences oral pleasure and subsequently sucks his or her finger in order to recover this pleasure. The nature of the breast-feeding determines the kind as well as intensity of oral sexuality.

According to Erickson’s psychosocial trust vs. mistrust which is the foundation of all psychosocial tasks. Because an infant is utterly dependent, the development of trust is based on the dependability and quality of the child’s caregivers. If a child successfully develops trust, he or she will feel safe and secure in the world. Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of mistrust in the children they care for. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable. In relation to patient X, the child develops trust on the day that he was delivered and cuddled by his mother. Until the day that he was took cared.

According to piaget’s cognitive tasks, he categorized infants in sensory motor where they developed to have object permanence(infants learns that objects has identity of their own). Infants also begins to recognizes familiar faces, objects and sounds. In relation to Patient X, he had familiarize faces of his mother and other members of the family.With its motor development, at 1 month old he already lifts head temporarily, but generally, head must be supported, head sags. At 2 months old, he can carry hand or object to mouth at will reaches for objects but misjudges distances, step o dances reflexes fading, grasp, tonic reflexes, Moro reflexes fading.

GORDON’S HEALTH PATTERN

Psychological1. Self Perception-Self Concept PatternAs stated by the client’s mother as part of their health maintenance, he is always giving his child with supplements such as vitamins and giving him appropriate nutrients for his growth. He also brings his 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 PatternHe has a very close bond with his family especially with his mother since she takes care of him 24/7. He is the first and only child in his family.

3. Sexuality and Reproductive PatternPatient x is male, and yet a 2 mos old baby.

4. Cognitive Perceptual PatternBaby X can do its reflexes such as blink reflexes that are appropriate of his age. By touching his hand Baby X can hold strong.

5. Coping Stress Tolerance PatternHis mother said that he usually cry when something is wrong or when he is not feeling well.

6. Value Belief PatternHe is a Roman Catholic and her parents bring her to mass every Sunday. As much as possible patient X mother wanted her baby to be involved in believing in God. They also usually believe in quack doctors.

7. EliminationNormally consumed more than four diapers. The consumption of diapers before and during hospitalization is decreased. Patient X consumed only two diapers.

8.Rest and ActivityThe client sleeps approximately about 9-10 hours during night time. He has no problem in sleeping. He always take naps during morning and afternoon.

9. Activity-Exercise PatternAccording to the mother, PTA the client is “napaka likot” as verbalized by the mother. In the hospital the client is unable to move freely due to his health condition and his IV infusion. Because of his young age and his condition he requires assistance and supervision from his parents in all his daily activities.

10.Nutritional and Metabolic PatternPrior to hospitalization Patient X usual food intake are milk, cerelac. Prior to admission Patient X is ordered Npo. He is currently having +28cc solvent very slow IV push.

ANATOMY AND PHYSIOLOGY OF THE AFFECTED SYSTEM

RESPIRATORY SYSTEM

Physiology of Gas ExchangeEach branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over. Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients.

CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.How do the lungs normally work?The chest contains two lungs, one lung on the right side of the chest, the other on the left side of the chest. Each lung is made up of sections called lobes. The lung is soft and protected by the ribcage. The purposes of the lungs are to bring oxygen (abbreviated O2), into the body and to remove carbon dioxide (abbreviated CO2). Oxygen is a gas that provides us energy while carbon dioxide is a waste product or "exhaust" of the body.

Nostrils/Nasal CavityDuring inhalation, air enters the nostrils and passes into the nasal

cavities which the foreign are removed, the air is heated and moisturized before it is brought further into the body. It is the part of the body that houses the sense of smell.

Sinuses It is a small cavities that lined the mucous membrane within the

bones of the skull.

PharynxIt is a throat carries foods and liquids into the digestive tract and

carries air into the respiratory tract.

LarynxIt is also called voice box located between the pharynx and

trachea. It is the location of the adam’s apple, which in reality a thyroid gland and houses the vocal cords.

Trachea-The trachea begins immediately below the larynx (voicebox) and runs down the center of the front part of the neck ends behind the upper part of the sternum. Here it divides to form two branches which enter the lung cavities. The trachea (windpipe) forms the trunk of an upside-down tree and is flexible, like a vacuum tube, so that the head and neck may twist and bend during the process of breathing. The trachea, or windpipe, is made up of fibrous and elastic tissues and smooth muscle with about twenty rings of cartilage, which help keep the

trachea open during extreme movement of the neck. The lining includes cells that secrete mucus along with other cells that bear very small hairlike fringes. This mucus traps tiny particles of debris, and the beating of the fringes moves the mucus up and out of the respiratory tract, keeping the lungs and air passages free. In Russian folk medicine, there is the thought that rubbing the chest with pork fat will cure a cold. Mustard plasters and boiled snails in barley water were thought to be effective by others, and nobody knows what the ingredients were for early "cure-all tonics" and "snake oil" kits. It is now believed that the best medicine is to rest, keep warm, drink plenty of fluids, and eat good, digestible meals. Sounds good to me...and certainly better smelling.Lungs- Air, which is inhaled through the mouth and nasal passages, travels through the windpipe or "trachea" into two main air passages. These divide into smaller branches which separate into even smaller "twigs" like an upside-down tree. The respiratory system is mainly contained in two lungs. The little air sacs at the end of the twigs comprise the fruit of the tree, and through its thin walls gasses pass into and out of the blood. The right lung is made up of three compartments, each of which contain a branch and each of which stems off into smaller "twigs," which hold the air sacs (or "fruit" of the tree) that process the oxygen in the air to be released into the blood and expel carbon dioxide, which is exhaled through the nose and mouth. The left lung cavity contains only two sections (each with its own branches, twigs and fruit) and encloses the heart, which processes the oxygenated blood and returns deoxygenated blood into the lungs for exhalation. Breathing is an automatic process which comes from the brain stem and is so strong a force that the involuntary reflexes will not allow us to stop breathing for any length of time. The passageways in the respiratory system are lined with various types of epithelia to prepare the air properly for utilization and with hair-like fibers called cilia that move in a wave-like motion to sweep debris out of the lungs for expulsion. The women in ancient Greece and Rome wore corsets of linen to restrain their figures. The female waistline has been moved up and down over the passage of time, but this became a real health hazard when whalebone corsets came into use during the last part of the 19th and early part of the 20th centuries, because they constricted the vital organs in the body - especially those of the respiratory and digestive systems. Women with "wasp-like" waists fainted so often that those who were well-off purchased "fainting" couches; and when a woman "swooned," the cry, "Cut her laces!" often allowed her enough air to recover.

Bronchi- The bronchus is the air passage into the lungs. Each lung has one main bronchus, which begins at the end of the trachea or windpipe. The bronchus divides into smaller branches known as segmental bronchi, which then divide into bronchioles. (See "Bronchial Bulbs")Bronchioles- the small airways of the lung extending from the bronchi to the alveoli. The bronchioles become inflamed and constricted in asthma, causing breathing difficulties.Alveoli- The alveoli are the final branchings of the respiratory tree and act as the primary gas exchange units of the lung. The gas-blood barrier between the alveolar space and the pulmonary capillaries is extremely thin, allowing for rapid gas exchange. To reach the blood, oxygen must diffuse through the alveolar epithelium, a thin interstitial space, and the capillary endothelium; CO2 follows the reverse course to reach the alveoli.

There are two types of alveolar epithelial cells. Type I cells have long cytoplasmic extensions which spread out thinly along the alveolar walls and comprise the thin alveolar epithelium. Type II cells are more compact and are responsible for producing surfactant, a phospholipid which lines the alveoli and serves to differentially reduce surface tension at different volumes, contributing to alveolar stability.

Pathophysiology of Pneumonia

Predisposing Factor: Precipitating Factor:

Age- less than one year of age Bacteria: S. pneumoniaeDecrease resistance: general/ immune Environment:Virulent organism Psittacosis <pet bird>Defective clearance mechanism: Legionella <water>

Cough/ gag reflex: coma, paralysis, addiction Aspergillosis <air, water>Mucosal injury: smoking, aspiration, toxin Histoplasmosis < birdPulmonary edema: cardiac, ARDS dropping and Obstruction: tumor, foreign bodies bat caves>

Bronchialdilatation: as bronchiectasis

Organism enters to the lungs

Microorganism enters the lung parenchyema

Virulent Microorganism Streptococcus Pneumoniae

Sign and symptoms: Difficulty of breathing, Cough, colds, Shivering, Nausea and vomiting, Itchiness of the throat

Necrosis of pulmonary tissue

Bad prognosis

Overwhelming sepsis

Death

Alveolar collapse

Increase pyrogen in the body

Good prognosis:-Tepid sponge bath-Paracetamol,Mucolytics/bonchodilators/expectorants

Increase pyrogen in the body

Fever

Physical Assessment

Physical examination follows a methodical head to toe format in the Cephalocaudal assessment. This is done systematically using the techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer, sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure, I made every effort to recognize and respect the patient’s feelings as well as to provide comfort measures and follow appropriate safety precautions.

GENERAL APPARANCE AND BEHAVIOR

-on our visit, Patient X is lying on bed wearing a baby’s clothes colored white. Patient X is 2 months old, who weighs 4lbs. The baby is conscious when we took and recorded the vital signs as follows:

Temperature:38.3 CPulse Rate:120 bpmRespiratory Rate:18 bpm

Mental StatusPatient X is still a baby and can’t be questioned.

O>Motor Functionnot yet applicable

O>Assessment of the Head Head is round in shape. Hair is still short, straight and evenly distributed. Scalp is smooth and white in color, minimal lesions were noted. O>Assessment of the EyesHis eyes are symmetrical, white in color, almond shape. Pupils constricts when diverted to light and dilates when he gazes afar, conjunctivas are pink. Eyelashes are equally distributed and skin around the eyes is intact. The eyes involuntarily blink.O>Assessment of the MouthShe has yet complete set of teeth. Oral mucosa and gingival are pink in color, moist and there were no lesions nor inflammation noted. Tongue is pinkish and is free of swelling and lesions. Presence of uvula was noted and there is absence of swelling.

O>Assessment of the NeckLymph nodes noted. Neck has strength that allows movement back and forth, left and right. Patient is able to freely move her neck.O>Assessment of the Lungs and Thoracic RegionChest is symmetric in volume, no tenderness and masses. Rib cage is also symmetrical and full- lung expansion. He has difficulty in breathing.

O>Assessment of the HeartHeart was not assessed.

O>Assessment of the AbdomenHis abdomen is in uniform in color, not distended, rounded symmetric contour and movements upon respiration. The quadrant when auscultated for bowel sounds is normal and no rebounds tenderness for flatulence or gastric bubbles. There are no masses or tenderness noted.

O>Assessment of the Upper ExtremitiesSkin: White in color; presence of rashes in the arms, neck. Skin is smooth, moist and soft to touch.Hands: Medium in size with 5 fingernails in each side. Nails are short, small dusty particles are present. A capillary refill of 1-2 seconds was noted.Arms: Able to move through active ROM. Able to extend arms in front or push them out to the side.O>Assessment to the Lower ExtremitiesSize of the feet is undefined with lines on the sole, no presence of scars and lesions. Ten fingers are present. Nails are clean and short. No apparent painupon movement therefore indicates negative Homan’s sign. Patient can’t do ambulation.O>Assessment of the GenitourinaryPatient urinates 1-2times a day and has not defecated yet prior to admission.O>Assessment of the PerineumAbsence of lesions and swelling.

NURSING CARE PLAN No.1Date identified: February 13,2010S:”Init pa kaayo ning bata” as verbalized by the mother.O: -Increase body temperature (38.3oC) -Flushed skin -Warm to touch -Seizures noted -Weak Nursing Diagnosis: Hyperthermia related to ongoing disease process.Scientific Basis: Elevated temperature that results of depresses the hypothalamus. As a result of soaring body temperature increases the metabolic rate, which in turn, increases heat production.Nursing Goal: Within 2o of rendering nursing interventions, the patients temperature will decrease from 38.3oC to normal which is 36.5oC-37.5oCInterventions:

Independent Rationale1.) Assess the general condition of the patient.2.) Monitor patient’s temperature.

3.) Determine the recent environmental exposure of the patient.4.) Demonstrate Tepid Sponge Bath to the patient.5.) Instruct the patient’s significant others to let the baby wear loose clothing and bed linens.6.) Encourage the patient’s significant others to avoid the baby in noisy environment.7.) Advise the patient’s significant others to increase fluid intake or

-To gather baseline data of the patient.

-To determine if there’s any alteration of the temperature.-May help identify causative environmental factors.-May help to lower down temperature.

-To prevent from feeling cold and shivering.

-To have adequate rest and sleep.

-To meet the increased metabolic

breastfeeding as possible.8.) Advise the mother to provide cooling blanket.

demands and prevent dehydration.

-Used to reduce fever.

Collaborative Rationale1.) Administer antipyretics medication.

-To reduce fever by it’s central action on the hypothalamus.

Evaluation: After 2o rendering nursing intervention the, the patient’s body temperature was able to decrease from 38.3oC down to 37.5oC.

NURSING CARE PLAN No.2

S:”Dile kayo siya kaginhawa”as verbalized by the mother.O: -Decreased respiratory rate 18 cbpm. -Restless -Weak - Nonproductive Coughing noted -Pale looking Nursing Diagnosis: Ineffective airway clearance related to mucous secretions.

Scientific Basis: Inability to clear secretions from the respiratory tract to maintain a clear airway.Nursing Goal: Within 2o of rendering nursing interventions, the patient’s airway will be free from mucous obstruction/secretions.

Interventions Rationale1.) Assess the condition of the patient 2.) Monitor for the respirations and breath sounds of the patient.3.) Monitor the infant for feeding intolerance, abdominal distention and emotional stresses.4.) Observe for signs of respiratory distress.5.) Demonstrate the proper position of the patient elevate the head of bed.6.) Encourage patient’s significant others to let the patient have adequate rest and sleep7.) Instruct the mother to let the baby increase breastfeeding as possible.

-To identify the health needs of the patient.-To determine the alteration of respiratory rate.-May compromise airway.

-To help identify the cause of airway obstruction. -To take advantage of the relaxation on the diaphragm and enhancing ventilation.-To prevent fatigue of the patient.

-Can help liquefy viscous secretions.

Collaborative Rationale1.) Administer analgesic medication.

2.) Suction naso/tracheal/oral.

-To improve cough when pain is inhibiting effort.-To clear airway when viscous secretions are blocking airway.

Evaluation: After 2o of rendering nursing interventions the patient’s airway was able to free from mucous obstructions or secretions.

NURSING CARE PLAN No.3

S:”Maglisod siya og ginhawa” as verbalized by the mother.O: -Difficulty of breathing -Irritability -Restless -Weak -Pale looking -Crying noted Nursing Diagnosis: Impaired gas exchange related to ongoing disease process.Scientific Basis:Excess or deficit in oxygenation or carbon dioxide elimination at the alveoli-capillary membrane.Nursing Goal: Within 2o of rendering nursing intervention the patients tissues will have adequate oxygenation.

Interventions Rationale1.) Assess the vital signs especially respiratory rate2.) Auscultate breath sounds of the patient.3.) Elevate head of bed .4.) Maintain adequate intake output of the patient.5.) Emphasized the importance of nutrition to the patient’s significant others.6.) Encourage the patient’s significant others to maintain frequent position changes of the patient. 7.) Instruct the patient’s significant others to identify specific supplier for supplemental oxygen necessary the respiratory devices.

- To monitor any alteration

-To note areas of decreased adventitious breath sounds.-To maintain airway.-For mobilization of secretions.

-To improve stamina and reducing the work of breathing.

-To promote optimal chest expansion and drainage of secretions.

-To facilitate independency.

Collaborative Rationale1.) Administer medications as prescribed by the doctor such as antibiotic and bronchodilators.

-To treat underlying conditions.

Evaluation: After 2o of rendering nursing interventions, the patient’s tissues had adequate oxygenation.

NURSING CARE PLAN No.4

S:”Daghan lagi rashes sa iyang lawas”as verbalized by the mother.O: -Rashes noted on the scalp, neck and axilla. -Redness noted between the inguinal region. -Irritability -Restless -Weak Nursing Diagnosis: Impaired skin integrity related to skin irritation.Scientific Basis: Inflammatory condition of the skin, possible evidenced by disruption of skin surface and possibly altered circulation and altered nutritional state.

Nursing Goal: Within 8o of rendering nursing interventions, the patient will maintain optimal nutrition. Independent Rationale1.) Assess the blood supply of the affected area.2.) Inspect the patient’s skin frequently.

3.) Keep the area clean and dry.

4.) Advised patient’s significant others to use petroleum jelly or cream on the affected area.5.) Encourage the mother to stay the baby in safe and polluted-free environment.

-To evaluate actual for impairment of circulation.-To describe lesions characteristics and observe changes.-To stimulate circulation and assist bodies natural process.-To minimize redness and skin irritation.

-To prevent of acquiring of other infection.

6.) Instructed to use clean water and mild soap.7.) Emphasized the mother to have properly adequate breastfeeding per demand.8.) Encourage the mother to eat nutritious foods.

-To avoid skin irritation on the affected area.-Help to lessen acquiring any infections.

-Nutrients from the mother may take through breastfeeding.

Collaborative Rationale 1.) Administer medications as prescribed by the doctor if severe reactions occur including antihistamines.

-To prevent difficulty of treatment.

NURSING CARE PLAN No.5

S:”Ambot ani nga bata dile ko kasabot sige man hilak-hilak” as verbalized by the mother.O: -Irritability -Restless -Weak -Changes movements/uncoordinated movements. -Pale looking Nursing Diagnosis: Disorganized infant behavior related to lack of feeding tolerance.Scientific Basis: Disorganized physiological and neurobehavioral responses of the infant to the environment.Nursing Goal: Within 2o of rendering nursing intervention the patient will be able to satisfy her needs by identifying appropriate responses through breastfeeding.

Interventions: Independent Rationale

1.) Assess the general condition of the patient.2.) Discuss infant growth and development as appropriate.3.) Provide patient’s significant others the positive feedback for progressive parental involvement in care giving process.4.) Encourage parents to hold infant including skin to skin contact or kangaroo care as appropriate.5.) Support and encourage parents to be with infant and participate actively in all of care.6.)Let the mother eat more nutritious foods that are riched in vitamins and minerals.

-To determine his/her behavior properly.

-Augments parent’s knowledge of co-regulation.-To progress continuum as parents and increases to take on more complex care activities.

-May have a positive effect on infant development.

-Support may have enhance coping and strengthen attachment to the baby.

-May help the nutrients through breastfeeding.

Collaborative Rationale1.) Administer medication as prescribed by the doctor appropriately.

-

DISCHARGE PLANNING

Take the entire course of any prescribed medications. After a patient’s temperature returns to normal, medication must be continued according to the doctor’s instructions, otherwise the

pneumonia may recur. Relapses can be far more serious than the first attack.

Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse.

Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs.

Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected. It’s important to have the doctor monitor his progress.

Encourage the guardians to wash patient’s hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter one’s body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk.

Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.

Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed.

Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isn’t possible, a person can help protect others by wearing a face mask and always coughing into a tissue.

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