Case Study of a 1-year-old Infant with

Severe Pneumonia

Presented to

CHINESE GENERAL HOSPITAL COLLEGES

In Partial Fulfillment

of the Requirements for the Course

N-109 MCN 2 RLE

By:

Masangkay, Christine Darla V.

BSN-2C

Submitted to:

Ms. Ma. Cristabelle Denofra

MARCH 03, 2023

 1. ASSESSMENT
A. CLIENT’S PROFILE
I. GENERAL INFORMATION
CLIENT’S INITIALS: JJSD DATE OF ADMISSION: FEBRUARY 22, 2023
AGE: 1 Y.O. HOSPITAL/INSTITUTION: CGHMC
SEX: MALE WARD/AREA AND BED NUMBER: COP CHARI-PD04
Source of Information (if client is child): REPRESENTATIVE’S INITIALS: MJS
RELATIONSHIP TO CLIENT: MOTHER

FOR NEONATES/INFANTS:
BIRTH DATE: JULY 18, 2021
BIRTH PLACE: CALOOCAN
MANNER OF DELIVERY: CESAREAN DELIVERY
AGE OF GESTATION UPON BIRTH: 37 WEEKS AOG
BIRTH WEIGHT: 2.9 kg
FOR PEDIATRIC CLIENTS (18 YEARS OLD AND BELOW):
NUMBER OF SIBLINGS: 1
AGES OF EACH SIBLING: 3 Y.O. (MALE)
ORDINAL POSITION IN THE FAMILY: SECOND CHILD
IMMUNIZATION STATUS:
Vaccine Dose

BCG 1

HEP B 1

DTWP/DTAP 3

OPV/IPV 3

HiB 3

PnCV 3

Measles 1

Influenza 1

IPV 1

OCCUPATION: N/A
CIVIL STATUS: SINGLE
 II. MEDICAL DIAGNOSIS
A 1-year-old male patient was diagnosed with Pediatric Community
Acquired Severe Pneumonia.
III. OPERATION (if any)
No medical operation was performed for health management.
IV. CHIEF COMPLAINT
Chief Complaint: Cough
V. BRIEF HISTORY OF PRESENT HOSPITALIZATION
Apparently, the patient was well 3 days prior to hospitalization. Patient
was said to have undocumented low grade fever without other associated
symptoms noted such as vomiting, cough and colds, loss of appetite. The patient
was given Paracetamol drops at an unidentified dose and no consultation was
done.
2 days prior to hospitalization, the patient experienced resolved fever, but
was noted with a productive cough with cold associated with no other symptoms
such as vomiting, loss of appetite, and difficulty of breathing. Patient was given
self-medicated Carbocisteine (RobiKids) which provided no resolution, and no
consultation was done.
Few hours prior to client’s admission, persistent cough with notable
difficulty of breathing, subcostal retractions, pallor, and circumoral cyanosis was
present and observed. Patient was sent to the nearest hospital where
administration of Salbutamol nebulization was given every 15 minutes for 3 doses
offering no relief. Patient was advised to transfer to tertiary hospital, hence
admission.

B. NURSING HISTORY (narrative format per health pattern)

I. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

Mrs. MJS, mother of Patient JJSD, stated that her son has never been
hospitalized before for any reason, thus this is his first hospitalization. She also
claimed that there was no history of illness in their family. Patient JJSD did not
have any illnesses or known allergies in the past 6 months. When asked what she
does to maintain her son’s health, Mrs. MJS said that her son takes vitamin
supplements, specifically Growee, Ceelin, and Tiki-Tiki. The use of cigarettes,
alcohol, and drugs were prohibited. Patient’s mother also affirmed that it is easy
for them to follow all of the doctor's suggestions and there were no beliefs and
practices followed when it comes to their health management.
 II. NUTRITION AND METABOLIC PATTERN
Milk, rice, bread, and biscuits make up Patient JJSD’s typical diet, which
he consumes 2 to 3 times a day. Patient JJSD also drinks yakult and chuckie. Mrs.
MJS also added that she supplements her son’s daily diet with vitamins like
Growee. She claimed that client JJSD consumed 1 to 2 glasses of water each day.
The patient’s appetite is noted to be good. Patient JJSD had no discomfort in
eating or drinking except now that he was ordered of NPO (Nothing by mouth)
due to endotracheal intubation. His weight is 8.5 kilograms and his height is 2’7
feet and 31.5 inches. Patient JJSD’s BMI is unidentified as the body mass index of
children below 2 years old cannot be calculated (CDC, 2022).

III. ELIMINATION PATTERN

Patient JJSD defecates twice per day, depending on how much he ate for
that specific day. According to Mrs. MJS, her son’s feces has a paste-like
consistency, color green but most often occurs light brown. She also stated that
client JJSD did not have any discomfort or complaint about his usual pattern of
bowel movement. Prior to admission, the patient was able to regularly eliminate,
but during hospitalization he was not able to defecate since admission. Patient
JJSD saturates 8 to 10 diapers per day. His usual urine appears light yellow in
color. He did not have any discomfort when urinating as per his mother's
statement. Mrs. MJS also stated that her son experiences excess expiration.
Patient has no odor problems.

IV. ACTIVITY-EXERCISE PATTERN

The patient’s daily routine activities include playing, running, and walking
around the house. Patient JJSD was active and had enough energy to complete
such activities. One of his leisure activities is to watch and play with his older
brother. These activities include social play and his favorite toys to play with are
stuffed toys and puzzles.

V. SLEEP-REST PATTERN

According to Mrs. MJS, prior to confinement, patient JJDS sleeps at 12

midnight as he waits for his parents to finish work and wakes up at 9:00 in the
morning. His afternoon nap is at 2 pm. Patient has 9 hours of sleep and has no
nightmares; able to get enough rest. During hospitalization, client JJDS usual
pattern of sleep was disturbed because there were few procedures that needed to
be performed to monitor him from time to time. He is sometimes irritable so he
can only sleep every 2 hours.
 VI. COGNITIVE-PERCEPTUAL PATTERN
As per Mrs. MJS, patient JJDs has no deficit in hearing and vision.
Patient’s visual acuity was last checked around December to January according to
her mother’s statement.

VII. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

Mrs. MJS described patient JJDS as playful and active before

hospitalization. She also stated that her son recently experienced weight loss.
Client JJDS frequently feel angry, annoyed or frustrated when playing. Patient
JJDS had been inactive since admission due to intubation.

VIII. ROLE-RELATIONSHIP PATTERN

Patient JJSD lives with his mother, father, brother, and his father’s sibling
(brother). According to Mrs. MJS statement, she doesn’t experience any difficulty
when handling family problems. If there are family problems, she and her partner
usually handle it by communicating effectively and thoroughly with each other.
When asked about how she feels about her son’s hospitalization, she stated that
she felt sad and hurt, but it doesn’t hinder her from trusting the doctors and the
nurses. Patient’s representative also stated that she has close friends to rely on.

IX. HOME AND ENVIRONMENT

Patient JJSD lives in a two-storey house with two bedrooms, living room,
dining room and a business room. It is a mixed type of house composed of wood
and cement, moderate or medium in size. Patient JJSD lives in a neighborhood
beside a Christian church, so it is usually normal to have a busy and quite loud
environment especially on weekends.

X. SEXUALITY-REPRODUCTIVE PATTERN
Sexuality-reproductive pattern is not applicable as the client is a
1-year-old pediatric patient.

XI. COPING-STRESS TOLERANCE PATTERN

Mrs. MJS, patient JJSD’s representative, affirmed that there have been no
big and significant changes in their life in the past year since hospitalization.
During times of stress, coffee usually helps her. To be able to handle and solve
problems, she and her husband communicate.
 XII. VALUE-BELIEF PATTERN
Mrs. MJS stated that the most important things in her life are her children.
Roman Catholicism is their religion and they go to church every weekend,
specifically Sunday, to attend mass and worship God which she said helps them
when difficulties arise.
XIII. OTHERS
Mrs. MJS, the mother of patient JJSD, stated that she hopes for her baby’s
fast recovery.

C. PHYSICAL EXAMINATION (narrative format per organ system)

I. VITAL SIGNS/ANTHROPOMETRIC MEASURES
Temperature 36.4 degrees Celsius Respiratory Rate 36 breaths per minute
oral, axilla, rectal regular, irregular
afebrile, febrile Blood Pressure 100/70 mm Hg
Heart/Pulse Rate 124 beats per minute right arm, left arm
regular, irregular lying, sitting, standing
strong/bounding, weak/faint, absent

symmetrical, asymmetrical
warm to touch, cold to touch
Height (for infants, indicate length) = 80 cm; 2’7 feet; 31.5 inches
Weight = 8.5 kg

During physical examination, patient JJSD’s temperature is 36.4 degrees celsius. His
heart rate counts 124 beats per minute noted with regular, strong and bounding heart sounds. The
patient was observed to have a regular respiratory rate of 36 breaths per minute, and blood
pressure of 100/70 mm Hg obtained from his right arm in a supine lying position.

FOR CHILDREN:
Is height and weight appropriate for age? See growth chart.
Growth and Development milestones
THEORY FINDINGS

Physical The patient’s weight upon birth is 2.9 kg (normal) and

gained weight, which is currently 8.5 kg at the age of 1.
His height upon birth is 51 cm (normal) and his current
height is 80 cm. In head circumference, upon birth it is
35 cm and it is currently 46 cm. His chest
circumference upon birth is 34 cm, while the current
CC of DJJ is 50 cm. His abdominal circumference is 34
cm and now, it is 51 cm. DJJ usually sleeps 12 at
midnight and wakes up at 9 in the morning. He also
sleeps in the afternoon, usually 2 pm.
Psychosexual (Freud) According to the mother of DJJ, he starts thumb
sucking at the age of 3 months. Sometimes, he puts
toys in his mouth or some things that he finds
interesting. He is usually in his diaper even in their
house. Sometimes, he gets irritable when wearing
diapers, especially when it is hot.

Psychosocial (Erikson) The mother stated that the patient started to

demonstrate awareness or familiarity of faces at the age
of 4 months. He cries when someone he doesn’t know
tries to hold him. His first social smile was observed by
the mother at the age of 2 months. Sometimes, DJJ
cries or gets angry when someone takes away his toy.
He also cries when someone is mad. He smiles or
giggles when someone is talking to him in a playful
voice. At the age of 1 year old, he prefers to feed
himself than letting others do it for him. He is active
and very playful. He likes to play, run, and walk around
the house. He rarely gets mad or gets tantrums when
things don't go his way.

Cognitive (Piaget) According to the mother, DJJ doesn’t throw his toys
when he throws a tantrum, which he rarely do
(tantrums). He likes to share his toys and play with his
brother.

Moral (Kohlberg) The mother stated that DJJ often follows what his
parents tell him what to do. He knows what is good and
bad based on what his parents say. He didn’t adapt
some bad behaviors that his other playmates display,
such as hurting or getting mad with playmates.

II. GENERAL APPEARANCE

Patient JJSD’s body frame is small. His head circumference measures 46 cm with
chest circumference of 50 cm and abdominal circumference of 51 cm. The patient’s
posture is upright with normal and coordinated gait. As for dress, grooming, and hygiene,
the patient is notably appropriately well-groomed with good body and breath odor. No
obvious physical deformities are noted.

III. MENTAL STATUS

Upon examination, the patient is conscious and oriented especially with the
people around him. Patient JJSD’s emotional status is cooperative, irritable and resistive
from time to time. Language and communication was not applicable as no words were
noted, only mumbles.

IV. SKIN
Upon examination, patient JJSD’s skin color is normally pinkish and symmetrical
all throughout his body. His skin was warm to touch, dry, intact and smooth in texture
 with notable good skin turgor. Hair is thick and evenly distributed. No significant lesions
and edema was observed.

V. HEAD AND FACE

Patient JJSD’s head is normocephalic and appears to be proportionate with his
body size. Upon inspection, there are no tenderness, lesions, visible or palpable masses,
depressions noted. The patient’s hair has normal texture, smooth, shiny and evenly
distributed. Facial symmetry and movement are observed symmetrical.

VI. EYES
Upon examination of the eyes, the condition is straight normal. Eyebrows and
eyelashes appear to be intact, long and thick, and eyelids are symmetrical. There is no
edema or any discoloration observed in the periorbital region. Patient JJSD’s blink
response is spontaneous. Eyeballs are symmetrical, conjunctivae are pinkish and sclerae
are white. Pupils are symmetrical in size, and are reactive to light and accommodation
(PERRLA). Visual acuity and peripheral vision appears to be normal, and six ocular
movements are coordinated.

VII. EARS
Patient JJSD’s ear color is the same as the facial skin, external pinnae are
symmetrical in position, mobile, firm, and non tender. External canal contains hair
follicles and there are no lesions, nor discharge. The client was able to hear normal voice
sounds symmetrically with both ears.

VIII. NOSE
The patient’s nasolabial fold is symmetric, and septum appears to be intact and
located at the midline. Mucous membrane is pink and there are no lesions. The client was
able to smell and air moves patently as the client breathed through the left and right
nostril. No tenderness on the sinuses, no masses and pain was noted.

IX. MOUTH
Patient JJSD’s lips appear to be soft but dry. The patient’s tongue is pink and is
located at the midline with no nodules and lumps. His teeth are intact and continue to
grow. Gums are pink with no swelling and lesions. The patient’s speech is noted to be
mumbling.

X. PHARYNX
The patient’s uvula is located at the midline and is light pink in color. Hard and
soft palate appears to be soft, intact, and at the midline. Tonsils are moist and no
inflammation was observed. Upon assessment, gag reflex is present.
 XI. NECK
Patient JJSD’s head movement is coordinated with normal muscle strength.
Lymph nodes are non palpable and non tender. The trachea is located at the midline,
symmetrical with no visible masses or enlargement.

XII. BREAST AND AXILLAE

The patient’s breast size and symmetry is equal, contour is flat, and there is no
redness or edema observed in the skin. Breast and axillae appear to be non tender. Nipple
and areola are symmetrical in size, shape and color which seems to be normal.

XIII. CHEST AND LUNGS

Upon the assessment of the chest and lungs, the patient’s inspiration-expiration
ratio is 1:2. Breathing pattern is regular with respiration rate within the normal values.
Antero-posterior-lateral ratio is symmetrical, no bulges or tenderness was noted and
observed. Chest expansion is symmetrical upon inspiration and expiration. Upon
examination and auscultation, adventitious breath sounds are present, specifically
wheezes.

XIV. HEART
The patient’s precordial area is flat. The point of maximal impulse, apical pulse, is
regular and strong, palpable and audible upon palpation and auscultation. Heart sounds
are strong and bounding with no extra heart sounds.

XV. ABDOMEN
Upon inspection of patient JJSD’s abdomen, there are no scars, rashes or any
lesions observed. His abdomen is symmetrical in configuration. There are no palpable
masses or tenderness upon palpation and bowel sounds are normal upon percussion. The
umbilicus appears to be sunken.

XVI. GENITALIA AND ANUS

No pubic hair is present, penis is not retracted and testes appear to be descended.
There are no tenderness, nodules, and masses in the rectum and anus upon examination.

XVII. BACK AND EXTREMITIES

Patient JJSD’s peripheral pulses are symmetrical and regular. Joints are non
tender, and there is no swelling and redness observed. Nail plate shape is normal, nail bed
color is pink, and good capillary refill is notable. Muscle tone and strength of the upper
and lower extremities are equal in size, have normal tone and strength. No significant
lesions and deformities, pain in dorsiflexion, and phlebitis were observed. Spine is
located at the midline.
 2. ANATOMY AND PHYSIOLOGY
Patient JJSD was diagnosed with pediatric community-acquired pneumonia. Pneumonia
has varieties of etiologies, as per this case, the etiological factor is environmental. Hence, the
anatomical and physiological scope primarily focuses on the respiratory system, particularly the
lower respiratory tract.

Countless cells in the body require vast and continuous oxygen supply to perform their
vital functions. A human cannot last without oxygen even for a short period of time as humans
can do without food or water. Hand in hand with the cardiovascular system, the respiratory
system works to supply the body with oxygen and dispose of carbon dioxide, a waste product
that the body must eliminate. The respiratory system oversees gas exchange between the blood
and the environment. Blood as the transporting vehicle, delivers respiratory gasses between the
lungs and the cells in the body. If failure occurs either of the systems mentioned, cells begin to
expire from oxygen deprivation and accumulation of carbon dioxide.

Nose, pharynx, larynx, trachea, bronchi and its smaller branches, and the lungs
containing alveoli or air sacs, are the organs of the respiratory system. Gas exchange mainly
occurs only in the alveoli of the lungs; other respiratory system structures act as passageways to
carry oxygen through the lungs. The passageways from the nose to the larynx are the upper
respiratory tract, and from the trachea to the alveoli are the lower respiratory tract (Marieb &
Keller, 2018). The lungs are the major organs of the respiratory system that occupy the thoracic
cavity. Each of these lungs houses the structure of conducting and respiratory zones. Each lung is
divided into lobes by fissures whereas the left has two lobes, and the right has three. As the gas
enters the lungs, the main bronchi subdivide into secondary and tertiary branches ending in the
smallest conducting passageways, the bronchioles. This branching and rebranching of respiratory
passageways within the lungs forms a network called the bronchial or respiratory tree that has
reinforcing cartilage in their walls. The terminal bronchioles lead to respiratory zone structures
including the bronchioles, alveolar ducts, alveolar sacs and alveoli where gas exchange occurs.
The surface of the alveoli is covered with pulmonary capillaries which makes up the respiratory
membrane where air and blood flows. Gas exchange happens by diffusion through the
respiratory membrane; oxygen enters capillary blood from the alveolar air, and carbon dioxide
exits the blood to the alveoli (Marieb & Keller, 2018). With the alveoli being infected by
pathogens, inflammation and filling up of fluid or pus occurs, a condition called Pneumonia.
3. PATHOPHYSIOLOGY
 4. DIAGNOSTIC AND LABORATORY STUDY
Patient’s Initials: JJSD Clinical Area: Pedia Charity Ward

Medical Diagnosis: Pediatric Community Acquired Pneumonia Patient’s Age and Sex:1 Y.O. Male
(Severe)

Date of Test Name of Indication of Test Actual Findings or Conclusion Based on Nursing Implications
Diagnostic/Laboratory Results of Test Findings/ Results
Test

February 22, 2023 Molecular Pathology The most widely used ASSAY: NEGATIVE (-) Health teaching to the parents
Test diagnostic technique for SARS-CoV-2 because patient JJSd is just 1 year
severe acute respiratory The SARS-CoV-2 RNA old, regarding the signs and
SARS-CoV-2 RNA syndrome coronavirus 2 INTERPRETATION: RT-PCR Test of the symptoms of Covid-19 and the
(Ribonucleic Acid) (SARS-CoV-2) infection NEGATIVE (-) patient was indicated importance of following health
RT-PCR TEST is real-time reverse negative (-), meaning that protocols for Covid-19 such as
(CARTRIDGE-BASED) transcriptase-polymerase the patient has no properly wearing masks and
chain reaction (RT-PCR). CoVid-19. avoiding going to places with many
Ribonucleic acid people.
extraction is performed
using the RNA Extraction
Kit. Sars-Cov-2 viral N
Gene, ORF Gene or M
gene, S gene amplification
and detection were dont
with Real-Time PCR
machine with internal,
positive and negative
controls included to
confirm validity and
accuracy of the results.

This test is intended to be

used to achieve qualitative
detection of Sars-Cov 2
which is the causative
agent of COVID-19,
 extracted from
nasopharyngeal swabs or
oropharyngeal swabs or
of the patient.

February 22, 2023 Complete Blood Count A Complete Blood Count WBC – 11.6 (High) HIGH High WBC and decreased
(CBC) (CBC) is a common blood RBC – 4.60 neutrophil count are at high risk for
test that is often a part of a HGB – 124 The patient's WBC count, developing infection, the nurse
routine checkup which HCT – 0.377 which is 11.6 compared to should carefully monitor WBC
measures different MCV – 81.9 the normal range of 6.0 to count and assess for any signs of
components of blood like: MCH – 26.9 11.0, is abnormal. infection.
Red Blood Cells (RBC), MCHC – 328
White Blood Cells RDW – 15.4 An increased number of Health teaching about how a proper
(WBC), Hemoglobin, PLATELET – 199 WBCs is one of the diet and getting enough rest and
Hematocrit, Platelets, MPV – 9.33 indicators that a bacterial sleep can regulate the levels of
Mean Corpuscular infection, including white blood cells.
Volume (MCV), and DIFFERENTIAL Pneumonia, may be
Mean Platelet Volume COUNT: present. (File, 2022)
(MPV). Segmenters – 0. 82 (High)
Lymphocytes – 0.12 The patient's segmenters
CBC can help detect a (Low) (neutrophils) are high
variety of disorders Monocytes – 0.05 (0.82), and his
including infections, Eosinophils – 0.01 lymphocytes are low
anemia, diseases of the (0.12).
immune system, and Comments:
blood cancers. Machine Count only. When there are high
neutrophils and low
lymphocytes, the NLR
(Neutrophil to
Lymphocyte Ratio) is
high. An elevated NLR
ratio may be an indicator
of severe infection,
inflammatory disorder,
chronic disease or cancer.

February 22, 2023 Sodium (Na), Potassium A sodium blood test, also SODIUM: NORMAL Health teaching regarding the
(K) known as a serum sodium 138 mmol/L importance of having normal
test, is a routine test that The sodium levels in the values of Sodium and Potassium
can be used to assess a POTASSIUM: blood were within the levels in the blood.
patient's overall health. It 3.9 mmol/L normal range of 136 to
enables the doctor to 146 mmol/l. The patient's Eating more fresh vegetables and
determine the amount of sodium level is 138, fruits which are naturally high in
sodium in the patient's which means it is within potassium and low in potassium are
blood. It can be used to the usual range. His good for the body avoiding
detect and monitor potassium level, which possible feelings of losing energy,
conditions that affect the was 3.9, was also within drowsiness and fatigue.
body's fluid, electrolyte, the usual range. Blood
and acidity balance. potassium levels should
be between 3.5 and 5.1
This test was also done to mmol/L.
check for hyponatremia
which is relatively
common in patients
admitted with pneumonia.

The potassium blood test

determines the level of
potassium in the blood.
Potassium is classified as
an electrolyte. Electrolytes
are electrically charged
minerals that help regulate
fluid levels and the
acid-base balance (pH
balance) in the body. They
also help to control
muscle and nerve activity,
among other things. Even
minor changes in the
amount of potassium in
the blood can cause
serious health problems.
This test is frequently part
of a group of routine
blood tests called an
electrolyte panel
(including Na Test).
 This test was ordered to
check for hyperkalemia
which is prevalent in
patients with Covid-19
pneumonia.

February 22, 2023 Ionized Calcium (iCa) Calcium is a vital mineral Result: NORMAL Health teaching regarding why it is
that the body utilizes in 1.19 mmol/L important to maintain calcium
numerous ways. It The Ionized Calcium levels within a normal range.
strengthens the bones and normal value levels in
teeth and aids the function blood is 1.12 to 1.32 Patient JJDS is still an infant so it
of our muscles and nerves. mmol/L. The patient’s iCa is vital to consume the right
The total calcium in the result was 1.19 mmol/L amount of calcium which helps to
blood is measured by a which indicates that it is form and maintain healthy teeth
serum calcium blood test. within the normal range. and bones. Having enough calcium
Ionized calcium is one of levels in the body over a lifetime
several types of calcium can help prevent osteoporosis.
found in blood. The most
active form of calcium is
ionized calcium, also
known as free calcium.
Each of free calcium and
bound calcium accounts
for roughly half of your
body's total calcium. An
imbalance may indicate a
serious health problem.
Low free calcium levels
can cause your heart rate
to slow or speed up,
muscle spasms, and even
coma.

February 22, 2023 C-Reactive Protein A C-reactive protein Result: NORMAL Examine the client for any
(CRP) (CRP) test determines the 0.3 mg/dL indications of an infection.
amount of c-reactive The normal C-Reactive
 protein (CRP) in a blood Protein (CRP) levels in Give the mother of patient JJDS a
sample. CRP is a protein blood is less than 0.1 health lesson on how to keep her
produced by the liver. mg/dL. The patients\’s child healthy by ensuring that
Normally, our blood CRP level is within the client JJDS receives a balanced
contains low levels of normal range with the meal as well as appropriate rest and
c-reactive protein. When value of 0.3 mg/dL. sleep. Having enough water is also
there is inflammation in vital.
the body, the liver releases
more CRP into the
bloodstream. High CRP
levels may indicate a
serious health condition
that causes inflammation.

A CRP test can determine

whether and how much
inflammation occurs in
the body and to monitor
inflammation in acute or
chronic conditions
including lung diseases
such as pneumonia.

February 22, 2023 Complete Blood Count The immature platelet Rapid ESR (Erythrocyte HIGH Conduct a health teaching to the
(CBC) + Immature fraction (IPF) measures Sedimentation Rate): mother of patient JJDS on how she
Platelet Fraction (IPF) the reticulated platelets 30 mm/hr The normal value of can keep her baby healthy by
which are the platelets Rapid ESR for patient’s having a proper diet and enough
containing mRNA in under the age of 50 years rest and sleep.
peripheral blood. IPF old is less than 15 mm/hr.
reflects the bone marrow The patient’s age is 1 year Assess for any signs of infection
thrombopoietic activity, old and the result of his that the client may manifest.
increasing when platelet Rapid ESR is 30 mm/hr
production rises and which is not within the
decreasing when normal range.
production falls.
A high or a faster ESR
According to Er et.al rate may indicate higher
(2020), immature platelet levels of inflammation.
fraction may have an early
predictive role in the
diagnosis of congenital
pneumonia.
 5. DRUG ANALYSIS
Patient’s Initials: JJSD Clinical Area: Pedia Charity Ward

Medical Diagnosis: Pediatric Community Acquired Pneumonia Patient’s Age and Sex:1 Y.O. Male
(Severe)

Name of Drug Desired Dosage, Mechanism of General Contraindications General Nursing

Route, and Action Indications Side/Adverse Responsibilities
Frequency Effects

Generic Name: 15 mg, IV, OD Reduce stomach Symptomatic Contraindicated in CNS: asthenia, Use cautiously in patients
Omeprazole acid production by GERD without patients hypertensive to dizziness, with hypokalemia and
combining with esophageal lesions these drugs or their headache respiratory alkalosis and in
Brand Name: hydrogen, components. patients on a low sodium
Prilosec, PrilosecOTC potassium, and Duodenal ulcer GI: abdominal diet
adenosine (short-term pain, constipation,
triphosphate in treatment) . diarrhea, May increase risk of
parietal cells of the flatulence, nausea, osteoporosis-related bone
stomach to block Short-term vomiting, acid fractures and CDAD. Use
the last step in treatment of active regurgitation the lowest effective dose
gastric acid benign gastric ulcer for the shortest duration.
secretion. Musculoskeletal:
Dyspepsia back pain, May increase risk of GI
weaknesses infections,
hypomagnesemia and with
Respiratory: prolonged use, vitamin
cough, URI B12 deficiency.

Skin: rash False-positive results in

diagnostic investigations
for neuroendocrine tumors
Specific Side/Adverse may occur due to
Indications to Effects increased CgA level.
Client Experienced Temporarily stop
None omeprazole treatment at
least 14 days before
assessing
CgA level and consider
repeating the test if initial
CgA level is high. If serial
tests are performed
(e.g., for monitoring), the
same commercial lab
should be used for testing,
as reference ranges
between tests may vary.

Long-term therapy may

cause vitamin B12
absorption problems.
Assess patient for signs
and
symptoms of
cyanocobalamin
deficiency (weakness,
heart palpitations,
dyspnea, paresthesia,
pale skin, smooth tongue,
CNS changes, loss of
appetite).

Because risk of fundic

gland polyps increases
with long-term use,
especially beyond 1 year,
use
drug for shortest duration
appropriate to the
condition being treated.

Periodically assess patient

for osteoporosis.

Monitor patient for signs

and symptoms of acute
interstitial nephritis. If
suspected, discontinue
drug and evaluate patient.

Drug increases its own

bioavailability with
repeated doses. Drug is
unstable in gastric acid;
less
drug is lost to hydrolysis
because drug increases
gastric pH.

Gastrin level rises in most

patients during the first 2
weeks of therapy.
Alert: Prolonged use of
PPIs may cause low
magnesium levels.
Monitor magnesium levels
before starting treatment
and periodically thereafter.
Alert: Monitor patients for
signs and symptoms of
low magnesium level,
such as abnormal
HR or rhythm,
palpitations, muscle
spasms, tremors, or
seizures. In children, an
abnormal HR
may present as fatigue,
upset stomach, dizziness,
and light-headedness.
Magnesium
supplementation or drug
discontinuation may be
required.

Look alike–sound alike:

 Don’t confuse Prilosec
OTC with Plendil,
Prevacid, prednisone,
Pristiq, Prozac, prilocaine,
or Prinivil. Don’t confuse
omeprazole with
aripiprazole,
esomeprazole, or
fomepizole.

Generic Name: 140 mg, IV, Q6H Produce analgesia Mild pain or fever Contraindicated in CNS: agitation Use caution when
Paracetamol PRN for Fever ≥ by inhibiting patients hypersensitive (IV), anxiety, prescribing, preparing, and
37.8°C prostaglandin and to drug. IV form is fatigue, headache, administering IV
Brand Name: other substances Mild to moderate contraindicated in insomnia, pyrexia. acetaminophen to avoid
Biogesic that sensitize pain pain; mild to patients with severe dosing errors leading to
receptors. Drugs moderate pain with hepatic impairment or CV: HTN, accidental overdose and
may relieve fever adjunctive opioid severe active liver hypotension, death. Be careful not to
through central analgesics; fever disease. peripheral edema, confuse dose in
action in the periorbital edema, milliGRAMS and dose in
hypothalamic Use cautiously in tachycardia (IV). milliLITERS. Be sure to
heat-regulating patients with any type base dose on weight for
center. of liver disease, G6PD GI: nausea, patients weighing less than
deficiency, chronic vomiting, 50 kg, to properly program
malnutrition, severe abdominal pain, infusion pump, and to
hypovolemia diarrhea, ensure that total
(dehydration, blood constipation (IV). daily dose of
loss), or severe renal GU: oliguria (IV). acetaminophen from all
impairment (CrCl of sources doesn’t exceed
30 mL/minute or less). Hematologic: maximum daily limit.
hemolytic anemia,
Use cautiously in leukopenia, Consider reducing total
patients with long-term neutropenia, daily dose and increasing
alcohol use because pancytopenia, dosing intervals in patients
therapeutic doses cause anemia. Hepatic: with hepatic or
hepatotoxicity in these jaundice. renal impairment.
patients. Patients with
chronic alcoholism Metabolic:
shouldn’t take more hypoalbuminemia
than 2 g of (IV),
 acetaminophen every hypoglycemia,
24 hours. hypokalemia,
hypervolemia,
hypomagnesemia,
hypophosphatemia
(IV).

Musculoskeletal:
muscle spasms,
extremity pain
(IV).

Respiratory:
abnormal breath
sounds,
dyspnea, hypoxia,
atelectasis, pleural
effusion,
pulmonary edema,
stridor, wheezing
(IV). Skin:
rash, urticaria;
infusion-site pain
(IV), pruritus.

Specific Side/Adverse
Indications to Effects
Client Experienced

PRN for fever ≥ None

37.8°C

Generic Name: 270 mg, IV, OD Aminoglycosides Septicemia; Contraindicated in CNS: Due to increased risk of
Amikacin are bactericidal. postoperative, patients hypersensitive neuromuscular ototoxicity, evaluate
They bind directly pulmonary, to these drugs. blockade. patient’s hearing before
Brand Name: and irreversibly to intra-abdominal, and during therapy if
Amikacide 30S ribosomal and urinary tract Aminoglycosides are EENT: ototoxicity. patient will be receiving
subunits, infections; associated with the drug for longer than 2
inhibiting bacterial skin, soft-tissue, significant GU: azotemia, weeks. Notify prescriber if
protein synthesis. bone, and joint nephrotoxicity and nephrotoxicity, patient has tinnitus,
They’re active infections; aerobic ototoxicity. Toxicity increase in vertigo, or hearing loss.
against many gram-negative may develop even with urinary excretion Boxed Warning Weigh
aerobic bacillary meningitis conventional doses, of casts. patient and review renal
gram-negative and not particularly in patients function studies before
some aerobic susceptible to other with Respiratory: and periodically
gram-positive antibiotics; serious prerenal azotemia or apnea. during therapy.
organisms and can staphylococcal, impaired renal
be used with other Pseudomonas function. Evidence of Correct dehydration
antibiotics for short aeruginosa, renal function before therapy because of
courses of Klebsiella, impairment or increased risk of toxicity.
therapy. and Acinetobacter ototoxicity requires
infections; drug discontinuation or Monitor serum amikacin
enterococcal appropriate dosage peak and trough
infections; adjustments. When concentrations
nosocomial possible, monitor periodically during
pneumonia; TB; serum drug therapy. Peak drug levels
initial concentrations, renal greater than 35 mcg/mL
empirical therapy in function, and eighth and trough levels greater
patients who are nerve function. Avoid than 10 mcg/mL may
febrile and use with be linked to a higher risk
leukopenic other ototoxic, of toxicity.
neurotoxic, or
nephrotoxic drugs. Due to increased risk of
Specific Aminoglycosides can Side/Adverse nephrotoxicity, monitor
Indications to cause fetal harm when Effects renal function: urine
Client given during Experienced by output,
pregnancy. Safety of Client specific gravity, urinalysis,
Severe Pneumonia treatment lasting longer BUN and creatinine
than 14 days hasn’t None levels, and CrCl. Report
been established. evidence of declining
renal function to
Use cautiously in prescriber. Safe use for
patients with longer than 14 days hasn’t
neuromuscular been established.
disorders and in those
taking neuromuscular Watch for signs and
blockers. symptoms of
superinfection (especially
Use at lower dosages in of upper respiratory tract),
patients with renal such as
impairment. continued fever, chills,
and increased pulse rate.
Use cautiously during
pregnancy. Safety Neuromuscular blockade
hasn’t been established and respiratory paralysis
with breastfeeding. In have been reported after
neonates and infants aminoglycoside
born prematurely, the administration, especially
half-life of in patients receiving
aminoglycosides is anesthetics,
prolonged because of neuromuscular
immature renal blockers, or massive
systems. In infants and transfusions of
children, dosage citrate-anticoagulated
adjustment may be blood. If blockade occurs,
needed. Older adults calcium
have an increased risk salts may reverse these
of nephrotoxicity and phenomena, but
commonly need a mechanical ventilation
lower dose and longer may be necessary. Monitor
dosage patient closely.
intervals; they’re also
susceptible to Therapy usually continues
ototoxicity and for 7 to 10 days. If no
superinfection. response occurs after 3 to
5 days, stop therapy
and obtain new specimens
for culture and sensitivity
testing.

Look alike–sound alike:

Don’t confuse amikacin
with anakinra.
Generic Name: 1800 mg + 30 cc Inhibits cell-wall Adjust-a-dose (for Contraindicated in GI: If large doses are given,
Ceftriaxone PNSS, IV, OD synthesis, all indications): In patients hypersensitive pseudomembranou therapy is prolonged, or
promoting osmotic patients with to drug or other s colitis, diarrhea. patient is at high risk,
Brand Name: instability; usually significant renal cephalosporins. Hematologic: monitor patient for signs
Numetrax bactericidal. disease and hepatic • Use cautiously in eosinophilia, and symptoms of
dysfunction, patients hypersensitive thrombocytosis, superinfection.
maximum dose is 2 to penicillin because of leukopenia. Skin:
g/day. In patients possibility of pain, induration, Monitor PT and INR in
receiving cross-sensitivity tenderness at patients with impaired
intermittent with other beta-lactam injection site, rash. vitamin K synthesis or low
hemodialysis, no antibiotics. Other: vitamin K stores.
dosage adjustment • To reduce hypersensitivity Vitamin K therapy may be
is necessary as drug development of reactions, serum needed.
is poorly dialyzed. drug-resistant bacteria sickness,
and maintain anaphylaxis. Monitor patients for
Uncomplicated effectiveness of superinfection, diarrhea,
gonococcal antibacterial and anemia and treat
vulvovaginitis drugs, use drug only to appropriately.
treat or prevent
UTI; lower infections proven or Look alike–sound alike:
respiratory tract, strongly suspected to Don’t confuse drug with
gynecologic, bone be caused by other cephalosporins that
or joint, bacteria. sound alike.
intra-abdominal, Alert: May cause
skin, or skin- superinfection and mild
structure infection; to fatal CDAD. If
septicemia suspected, manage
appropriately;
Complicated discontinue drug if
infections may needed.
require longer
treatment. Alert: May cause
hemolytic anemia,
Meningitis which can be fatal. If
anemia develops
Perioperative during therapy,
prophylaxis stop drugs until cause
is determined.
Acute otitis media • Use cautiously in
 patients with history of
colitis, renal
Specific insufficiency, or GI or Side/Adverse
Indications to gallbladder Effects
Client disease. Experienced by
Dialyzable drug: No. Client
Severe Pneumonia
None

Generic Name: 1 neb + 2 ml PNSS, Relaxes bronchial, To prevent or treat CNS: tremor, • Contraindicated in
Salbutamol Q6H uterine, and bronchospasm in nervousness, patients hypersensitive to
vascular smooth patients with headache, drug or its ingredients.
Brand Name: muscle by reversible hyperactivity, • Use cautiously in
Ventolin stimulating beta2 obstructive airway insomnia, patients with CV disorders
receptors. disease dizziness, (including coronary
weakness, CNS insufficiency and HTN),
Regular use for stimulation, hyperthyroidism, or
maintenance malaise. CV: diabetes mellitus and in
therapy to control tachycardia, those who are unusually
asthma symptoms palpitations, HTN, responsive to adrenergics.
isn’t recommended. chest pain, • Use extended-release
lymphadenopathy, tablets cautiously in
To prevent edema. patients with GI
exercise-induced EENT: narrowing.
bronchospasm conjunctivitis,
otitis media, dry
Adjuvant therapy and irritated nose
for acute treatment and throat (with
of moderate to inhaled form),
severe nasal
hyperkalemia congestion,
epistaxis,
hoarseness,
pharyngitis,
rhinitis. GI:
nausea, vomiting,
heartburn,
anorexia,
altered taste,
 increased appetite.
GU: UTI.
Metabolic:
hypokalemia.
Musculoskeletal:
muscle cramps,
back pain.
Respiratory:
bronchospasm,
cough, wheezing,
dyspnea,
bronchitis,
increased sputum.
Other:
hypersensitivity
reactions, flu like
syndrome, cold
symptoms.

Specific Side/Adverse
Indications to Effects
Client Experienced by
client
Severe Pneumonia
None
 NURSING CARE PLAN PRIORITY 1
Student’s Name: Masangkay, Christine Darla V. Year, Section, Group: 2C-3

Patient’s Initials: JJSD Clinical Area: Pedia Charity Ward

Medical Diagnosis: Pediatric Community Acquired Pneumonia (Severe) Patient’s Age and Sex:1 Y.O. Male

Assessment Nursing Diagnosis Inference Goal and Objectives Nursing Rationale Evaluation
Interventions

Subjective: Impaired spontaneous Ineffective Airway Goal: Independent: After 24 hours of nursing
“Napansin ko na hirap siya ventilation related to Clearance Within 24 hours of Monitor vital signs, Vital signs monitor and intervention, the
huminga or parang naghahabol endotracheal Ineffective airway nursing intervention, respiration and breath detect health deviations or client/patient:
ng hininga” as verbalized by the intubation clearance is the inability to the client will have and sounds noting rate and problems. Assessment of
patient’s mother maintain a clear airway sounds (auscultate) respiration, SpO2 and Goal Met:
maintain a patent and
auscultation of breath sounds The patient displays
due to secretions or clear airway free of indicates respiratory distress improved gas exchange as
obstructions in the excessive secretions and accumulation of evidenced by normal
respiratory tract (NANDA and obstructions. secretions (NANDA 16th respiration rate and no
16th Edition, 2022). Edition, 2022). Changes of adventitious breath sounds.
Objective: Breathing is spontaneous Objectives: these vital signs outside
(+) Wheezes and inherently comes to 1. The client normal ranges may indicate Goal Met:
everyone. Thus, a patent respiratory compromise. The patient was able to
(+) Bilateral crackles will Adventitious breath sounds maintain a patent airway
(+) Deep subcostal retraction airway is vital to life. demonstrate can be heard as both fluid as evidenced by absence of
(+) Tachycardic rate Cough, a natural airway and mucus accumulate signs of respiratory
absence or
(+) Generalized pallor clearance mechanism, indicating ineffective airway distress and compromise.
(+) Cold extremities reduction of
occurs to aid in removing clearance (Wayne, 2022).
mobilize secretions when congestion Goal Met:
Vital Signs as follows airway is obstructed. In evidenced The patient displays relief
T: 36.4 degrees celsius the lower respiratory tract by normal Observe signs of Airway obstruction calls for of chest congestion as
SpO2: 99% respiratory distress an increase in respiratory rate evidenced by normal
involving bronchioles and breath and rhythm, cyanosis, breath sounds after
RR: 36 RPM alveoli, mechanisms such sounds and grunting, nasal flaring, chest suctioning.
HR: 124 BPM as the mucociliary system, retraction, etc. as
improved
BP: 100/70 mm Hg macrophages, and the compensatory responses
gas
lymphatics take place for (Wayne, 2022). Monitoring
Dx exchange. signs of respiratory distress is
patency of the airway
Severe Pneumonia 2. The client important to accurately
(Wayne, 2022). However,
will be free diagnose, intervene, and
risk for compromised manage for a positive
airway is present once of outcome (Johns Hopkins
these mechanisms are aspiration. Medicine, 2019).
oppressed by increased 3. The client Position head Body, especially the head,
production of secretions in
will appropriately for age appropriately positioned
conditions such as and condition allows open airway and
demonstrate
pneumonia. better lung expansion during
According to NANDA improved
at-rest and for compromised
16th Edition, Ineffective air exchange individuals (NANDA 16th
Airway Clearance is as Edition, 2022). Positioning
characterized by the evidenced mobilizes secretions and aids
in promoting drainage of
following: by normal secretions, ventilation of lung
● Adventitious vital signs segments, thereby preventing
breath sounds especially atelectasis, and improving
(crackles and gas exchange (Wayne, 2022).
oxygen
wheezes)
saturation
● Abnormal
respiratory rate, level and Dependent: Hydration improves ciliary
respiratory Administer action for the removal of
rhythm and
intravenous therapy secretions and reduction of
depth rate. its viscosity as coughing
● Excessive thinner secretions is easier to
secretions mobilize (Wayne, 2022).
● Hypoxemia/cyan
osis Administer Amikacin Antibiotics are used to treat
270 mg IV OD bacterial infection such as
● Cyanosis;
pneumonia (MIMS, 2020).
hypoxemia
● Subcostal Administer
retraction Ceftriaxone 1800 mg + Antibiotics are used to treat
● Nasal flaring 30 cc PNSS IV OD bacterial infection such as
● Difficulty pneumonia (MIMS, 2020).
verbalizing
Administer Salbutamol Salbutamol provides
1 nebule + 2 ml PNSS short-acting bronchodilation
Endotracheal Intubation Q6H with an immediate onset in a
Endotracheal intubation is reversible airways
a medical procedure that obstruction (Electronic
involves endotracheal tube Medicines Compendium,
(ETT) insertion to provide n.d.).
oxygenation and
ventilation. Endotracheal
tube (ETT), a tube made
of polyvinyl chloride, is Perform suction as Suctioning is used to aspirate
placed in the larynx or ordered by the retained or excessive
vocal cords through the physician. secretions from lower
trachea with an inflated respiratory airways. The
cuff. Endotracheal frequency of suctioning
intubation secures a patent should be in accordance with
airway allowing oxygen to the client’s clinical status,
pass to and from the lungs and not a routine as over
as indicated for inability to suctioning stimulates vagus
maintain clear airway, nerves, hypoxia, and injury
failure to ventilate and to the tissues of the lungs and
oxygenate, and in such bronchioles (Wayne, 2022).
case of deteriorating
condition which may lead
to respiratory failure
(Ahmed & Boyer, 2022).

Ineffective Cough
Cough is a spontaneous
airway clearance reflex
which mobilizes air and
particles out of the lungs.
Throat and lungs naturally
produce mucus to keep the
airway moist and acts as a
protective barrier against
irritants as inhaled. An
ineffective cough
compromises patency of
the airway and prevents
secretions from being
expelled (American Lung
Association, n.d.).

Pneumonia
Pneumonia is an acute
respiratory infection that
inflames the alveoli or the
lungs’ air sacs. The lungs
have small sacs called
alveoli, which is filled
with air as a person
inhales. In pneumonia, the
alveoli are filled with fluid
or pus resulting in
difficulty breathing and
limited oxygen intake
(World Health
Organization, 2022).
According to the World
Health Organization,
pneumonia is the leading
infectious cause of child
mortality worldwide.
 NURSING CARE PLAN PRIORITY 2
Patient’s Initials: JJSD Clinical Area: Pedia Charity Ward

Medical Diagnosis: Pediatric Community Acquired Pneumonia (Severe) Patient’s Age and Sex:1 Y.O. Male

Assessment Nursing Diagnosis Inference Goal and Objectives Nursing Rationale Evaluation
Interventions

Subjective: Risk for Infection Infection Goal: Independent: After 24 hours of nursing
3 days prior to admission (secondary) related to Infection is the invasion Within 24 hours of nursing Encourage the client, Handwashing is the intervention, the
Patient noted to have invasive procedure as and proliferation of intervention, the client will family members, and first-line defense client/patient:
undocumented low grade fever site for organism pathogenic remain free of any staff to practice against infectious
invasion microorganisms proper hand washing diseases.
2 days prior to admission including bacteria,
(secondary) infection upon
between activities
Goal Met:
Fever was resolved, but patient viruses, fungi or assessment. and handling of The patient’s vital signs
is noted to have productive parasites which enter clients. remained stable and there
cough and colds the body, grow and were no signs and
multiply interfering symptoms of infection
Few hours prior to admission with the normal Monitor vital signs Deviation of vital were observed.
Patient noted to have persistent physiologic functions. signs outside normal
cough with notable difficulty of These microorganisms range signal early
breathing, subcostal retractions may enter the body signs of infection.
(indrawing of abdomen below anywhere and spread
rib cage), pallor, circumoral through causing Observe for Signs and symptoms,
cyanosis (blue discoloration of cellular, signs/symptoms of often including fever,
the mouth or lips) immunological, and infection are indicative of
systemic response infection varying
Objective: against these foreign Objectives: depending on the
Endotracheal intubation and infective 1. The client will causative agent of the
suction microorganisms infectious diseases.
(Harvard Health remain free of
Publishing, 2021). infection as
evidenced by
Vital Signs as follows Endotracheal Monitor/document Chest x-rays produce
T: 36.4 degrees celsius normal range
intubation procedures such as images of organs
SpO2: 99% Endotracheal intubation vital signs. serial chest x-rays including the heart,
RR: 36 RPM is a medical procedure 2. The client will lungs, and bones. The
HR: 124 BPM that involves remain free of condition of the lungs
BP: 100/70 mm Hg endotracheal tube can be revealed as
signs and
(ETT) insertion to medical conditions
provide oxygenation symptoms of such as infection
Dx
Severe Pneumonia and ventilation. infection such as manifesting lungs to
Endotracheal tube fever, and pain as collapse can be
(ETT), a tube made of detected with the
polyvinyl chloride, is evidenced by images it produces.
placed in the larynx or zero numeric
vocal cords through the pain assessment. Dependent:
trachea with an inflated Administer Paracetamol is an
cuff. Endotracheal Paracetamol 140 mg analgesic and
intubation secures a IV Q6H PRN for antipyretic drug used
patent airway allowing fever ≥ 37.8°C to relieve mild to
oxygen to pass to and moderate pain and
from the lungs as reduce high
indicated for inability to temperature (fever).
maintain clear airway,
failure to ventilate and Collaborative:
oxygenate, and in such Encourage early Early termination of
case of deteriorating removal of endotracheal
condition which may endotracheal tube intubation allows for
lead to respiratory mobilization of
failure (Ahmed & respiratory secretions
Boyer, 2022). and to prevent further
respiratory infections
Suction and aspiration
Suction is known as the (NANDA 16th
mechanical aspiration Edition, 2022).
of retained or excessive
secretions from lower
respiratory airways. Assist with weaning According to NANDA
Suctioning is used to from mechanical (2022), Weaning of
aspirate secretions ventilator as soon as oxygen reduces risk of
when cough possible ventilator-associated
mechanisms are pneumonia,
ineffective or absent destruction of lung
and if there is increased tissues and collapse
mucus production in (atelectasis).
such conditions. A
suction catheter is
inserted via
endotracheal or
tracheostomy tube to
the trachea to aspirate
the lower respiratory
tract, especially for
patients with artificial
airway who cannot
spontaneously expel
due to impaired
mechanisms.
 NURSING CARE PLAN PRIORITY 3
Patient’s Initials: JJSD Clinical Area: Pedia Charity Ward

Medical Diagnosis: Pediatric Community Acquired Pneumonia (Severe) Patient’s Age and Sex:1 Y.O. Male

Assessment Nursing Diagnosis Inference Goal and Objectives Nursing Rationale Evaluation
Interventions

Subjective: Imbalanced Nutrition: Imbalanced nutrition Goal: Independent: After 24 hours of nursing
“Baka mangayayat o mag Less than Body Imbalanced nutrition is Within 24 hours of Provide indicated or Parenteral nutrition is intervention, the
bawas ng timbang kasi nga requirements related to the intake of nutrients nursing intervention, ordered dietary and supply of nutrients client/patient:
hindi nakakakain” as altered ability to ingest that are deficient to the client will meet the nutritional intravenously, through an IV
verbalized by the patient’s meet the metabolic catheter, bypassing the Goal Met:
body’s metabolic needs modifications such as
mother needs of the body digestive system. Enteral The patient was able to
(NANDA 16th Edition, and tolerate earlier parenteral or tube nutrition is the use of the maintain normal body
2022). Nutrition is a initiation of enteral feeding. gastrointestinal tract to weight.
physiological process of feeding upon deliver nutrients either by
consuming and utilizing termination of mouth or through a feeding Goal Met:
nutrients needed by the endotracheal intubation. tube. Parenteral feeding and The patient was able to
body for growth, enteral tube feeding are both tolerate parenteral/enteral
maintenance, and indicated for patients who tube feeding as a source of
development. Right are unable to take food to nutrients to meet the body's
Objective: kind and adequate
Objectives: meet body metabolic needs metabolic needs.
Endotracheal intubation amounts of nutrients 1. The client per orem.
found in foods ingested will Dependent:
Vital Signs as follows are essential to meet the maintain a Administer Omeprazole is used to treat
T: 36.4 degrees celsius body’s metabolic Omeprazole 15 mg IV gastric or duodenal
normal OD
SpO2: 99% demands. conditions with
RR: 36 RPM average characterized excess
HR: 124 BPM Ingestion weight upon stomach acid.
BP: 100/70 mm Hg The process of assessment.
digestion begins with
ingestion, the act of 2. The client
Weight: 8.5 kg taking food by mouth will
where it is broken down promptly
Dx by mastication and tolerate
Severe Pneumonia swallowing.
enteral
nutrition
Endotracheal (EN)
intubation
feeding
Endotracheal intubation following
is a medical procedure discontinuati
that involves
endotracheal tube on of
(ETT) insertion to endotracheal
provide oxygenation intubation.
and ventilation.
Endotracheal tube
(ETT), a tube made of
polyvinyl chloride, is
placed in the larynx or
vocal cords through the
trachea with an inflated
cuff. Endotracheal
intubation secures a
patent airway allowing
oxygen to pass to and
from the lungs as
indicated for inability to
maintain clear airway,
failure to ventilate and
oxygenate, and in such
case of deteriorating
condition which may
lead to respiratory
failure (Ahmed &
Boyer, 2022).
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