COLLEGE OF HEALTH SCIENCES

Related Learning Experience

CASE ANALYSIS FORMAT

Name: Dulnuan Wilfred D. Date: 3/11/2023

Year Level: ____________
Name of Healthcare Facility: Panopdopan, District, Hospital Unit/Ward: Pediatric
Course Code and Title: MCN 109B Score: ________

Group members
Name of student Assigned topic

A. Introduction/Overview of the case:

 Presentation of the case scenario including patient’s profile
- Patient MB 1 year old baby male born onw Jan. 15, 2023, Filipino a resident of
barangay Hapid, Lamut, Ifugao. The patient is the son of Mrs. BD. he is admitted at
Panopdopan District Hospital on March 2, 2024 at 3:00pm with chief compliant of fever,
cold extremities, and seizure she was admitted by Dr. ASB with an admitting diagnosis
of pediatric community acquired Pneumonia-Moderate Risk, Benign Febrile Convultion.
 Admitting diagnosis
- Community acquired pneumonia is defined as pneumonia that is acquired outside the
hospital the most common identified pathogens are streptococcus pneumoniae,
Haemophilus influenzae, atypical bacteria, chlamydia pneumoniae, and viruses. PCAP
causes the lungs air sac to become inflamed and fill up with puss or fluid that can make
it hard to breath in to get into the blood stream the symptoms can range from mild to
severe it includes shortness of breath, fever, chills and cough.
Patient information: (Do not use any real names – Data Privacy Act)
Name: MB Age: 1year old Gender: Male
Room/Bed number: Room 11 bed no. 3 Attending Physician/Surgeon: M
Chief complaints: The mother of the patient is complaining that his child is having fever, his
extremities are cold and his having a seizure.
Diagnosis: Pediatric Community Acquired Pneumonia-Moderate Risk, Benign Febrile
Convulsion.

B. Client’s Health History (5 pts.)

 History of Past and present illness.
- In the last first week of February the patient has a runny nose and in the following days
the patient had a seizure for 6 times in the 6th time they went to hospital and the patient
was diagnosed with Community Aquired Pneumonia.
 Social History, Family History
-The grand mother of the patient had also suffered Pneumonia.
- The patient is active and plays together with the kids in their place.

Vital Signs: PR: 100 RR: 60 Temp: 38.7 Oxysat: 96%

Known Allergies: Non
_____________________________________________________________
 C. Pathophysiology (may use concept mapping/diagram) (20 points

Streptococcus Pneumoniae

D. The Nursing Process

I. Assessment (15 pts)
a. Physical Assessment (Head to Toe assessment performed by the nurse)
General Description

Integumentary Light brown skin, with marks of insects bite, and no rashes.

Head (EENT) Head is symmetrical there are no presence of masses or lesions, Eyes:
pupils are equally round and reactive to light and accommodation. Ears are
big, half heart shaped, symmetric and aligned with the eyes. Neck: no
rashes, nodules or masses found. Throat I wasn’t able to see.
Neck No rashes, nodules or masses found.

Respiratory 32 breaths per minute It’s on the normal range.

Cardiovascular 122 beats per minute its on the normal range.

Urinary Yellow and clear

Hematologic Hemoglobin: 11.90, Hematocrit: 0.35, WBC: 9.40, Neutrophils 67,

Lymphocytes 33,
Psychosocial Active, and play full.
 b. Diagnostic Procedures/Laboratory Tests
Name of the Date Ordered Normal Values Results Interpretation
Procedure/Tests and Analysis
HEMATOLOGY March 2, 2024

a. Hemoglobin Male: 14-17g/dL 11.90 LOW

Female:12-14g/
dL
b. Hematocrit Male: 0.47-0.50 0.35 LOW
Female 0.37-
0.47
c. WBC 5-10 x10/L 9.40 NORMAL
d. Neutrophils 50-70% 67 NORMAL
e. Ionized calcium 1.10- 1.35 1.02 LOW
mmol/L
f. Platelet Count 150,000- 291,000 NORMAL
450,000
g. Potassium 3.50- 3.91
5.50mmol/L
h. Sodium 135- 145 mmol/L 139.52 NORMAL
i. Chloride 96- 110 mmol/L 101.73 NORMAL
f. Lymphosytes 25-35 33 NORMAL
URYNALYSIS March 2, 2024

a. Color YELLOW
b. Transparency CLEAR
c. Glucose NEGATIVE
d. Pus Cells 1-3/HPF
e. Epithelial Cells RARE
f. pH 6.0
g. Specific Gravity 1.030
h. Protein NEGATIVE
i. Red cells 0-1/HPF
j. Bacteria FEW

II. Planning (20 pts)

a. List of nursing diagnoses (in order of priority)
Nursing Diagnosis Number of Priority Supporting Data Justification
ST
In effective airway 1 Increased sputum Presence of excessive
clearance production yellowish phlegm
 b. Nursing Care Plan (in order of priority)
Assessment/ Nursing Outcomes* Implementation Rationale Evaluation
Data Diagnosis

Subjective: Ineffective Short term INDEPENDENT INDEPENDENT Short term

 “May plema airway goal: after NURSING 1. To gain trust goal met.
pa” as clearance 30 mins of INTERVENTION and Patient was
stated by related to nursing 1. Establishing cooperation. able to let
rapport.
the mother increased intervention 2.To determine some
2. Assessment
 “Wala na sputum the a. Inspection
the under lying excessive
syang fever” production excessive b. Auscultation issues. phlegm out.
as stated by as phlegm 3. Vital signs 3.To check the
the mother evidenced would be monitoring. level of physical
by relieved. 4.Instructed the functioning to Long term
Objective: excessive mother to do obtain base line goal met.
 Coughing yellowish Long term chest physio data. Patient was
 Excessive phlegm goal: After therapy after 4. To help in able to
yellowish coming out nursing nebulization. removing breathe
phlegm in the intervention excess mucus comfortably
DEPENDENT:
 Normal lung mouth of the patient from respiratory without any
1. Assisted in
sound the patient would be medication
passage and difficulties
 Good when he is able to therapy of improve and the
appetite coughing. breath Salbutamol NEB. breathing. patient was
 Vital signs comfortably +2cc NSS as discharged.
PR: 142 without any prescribed. DEPENDENT:
RR: 39 difficulties. 1. It relaxes the
TEMP: 36.7 breathing
SpO2: 97 muscles and
permits air to
flow more easily
in and out of the
lungs also helps
to loosen
mucous in the
lungs
* Outcomes should include STG and LTG and should be SMART
III. Implementation (Medical/ Collaborative Management) (10 points)
a. Drug Study
Drug/ Dose, Route Mechanism of Side Effects Nursing
Classification and action Responsibilities
Frequency of
administratio
n
Generic Dose: The primary Common Side 🔹 Dosage
Name: 400 mg mechanism of Effects: Calculation:
Gentamicin action is generally - Nausea, Accurately
Frequency: accepted the ability vomiting calculate the
Brand Name: Once a day of ribosomes to - Ototoxicity appropriate dosage
discriminate on (auditory and based on the
Route: proper transfer vestibular child's weight, as
Drug IV RNA and dysfunction) gentamicin
Classification messenger RNA - Nephrotoxicity dosages are often
: interactions. (especially with weight-dependent.
Typically if an prolonged use),
- Antibiotic incorrect tRNA -Neuro 🔹 Patient
- Aminoglyco pairs with an muscular blockade Assessment:
side Antibiotic mRNA codon at - Allergic Perform a thorough
aminoacyl site of reactions (rash, assessment of the
the ribosome, fever) pediatric patient's
adenosines 1492 - Super health status,
and 1493 are Infections including kidney
excluded from the function, prior to
interaction and CNS: Headache, administering
retract signaling Dizziness, gentamicin.
the ribosome to Confusion
reject the amino Seizures (rare), 🔹 IV Site
acylated tRNA: Tingling or Assessment:
Elongation factors numbness (rare), Ensure a proper
Thermo- unstable Tremors, Vertigo and functioning IV
complex. site, checking for
CV: Irregular signs of infiltration
heartbeats or irritation, before
(arrhythmias), administering
Hypotension (low gentamicin
blood pressure), intravenously.
Hypertension
(high blood 🔹 Monitoring Vital
pressure), Signs: Regularly
Tachycardia (fast monitor the child's
heart rate), vital signs,
Bradycardia (slow including heart rate,
heart rate) blood pressure,
and respiratory
EENT: Hearing rate, during and
loss (ototoxicity), after gentamicin
Tinnitus (ringing in administration.
the ears),
Vestibular damage, 🔹 Renal Function
Vertigo, Ear pain or Monitoring: Monitor
discomfort, renal function
Blurred vision, through laboratory
Diplopia (double tests, as
vision) gentamicin can be
nephrotoxic. Report
GI: Nausea, any significant
Vomiting, changes promptly.
Diarrhea,
Abdominal pain, 🔹 Hydration Status:
Anorexia Ensure adequate
hydration to
RESP: support renal
Difficulty breathing, function and help
Respiratory minimize the risk of
distress, nephrotoxicity
Bronchospasm, associated with
Cough gentamicin.

SKIN: 🔹 Administration
Skin rash, Itching Rate: Administer
(pruritus), gentamicin at the
Erythema prescribed rate to
(redness), Urticaria prevent adverse
(hives) effects, and avoid
Photosensitivity, rapid infusion to
Dermatitis, reduce the risk of
Hyperpigmentation ototoxicity.
, Alopecia (hair
loss) 🔹 Prevent Cross-
Contamination:
Follow strict aseptic
techniques during
preparation and
administration to
prevent
contamination and
ensure patient
safety.

🔹 Patient
Education: Educate
the child's
caregivers about
the importance of
completing the
entire course of
gentamicin, even if
symptoms improve,
to prevent antibiotic
resistance.
 🔹 Monitoring for
Adverse Reactions:
Be vigilant for signs
of adverse
reactions such as
allergic reactions,
ototoxicity, or
neurotoxicity, and
report any
concerns to the
healthcare team
promptly.

Name of drug/ Dose, Route, Mechanism of Side Effects Nursing

drug and Action Responsibilities
classification frequency of
administratio
n
Generic Dose: Paracetamol has a CNS: Headache, 🔹Calculate Correct
Name: 100 mg central analgesic Dizziness, Dosage: Accurately
Paracetamol effect that is Insomnia, Fatigue, calculate the
Route: mediated through Tremors, Agitation, dosage based on
Brand Name: IV activation of Nervousness. the child's weight
descending and follow
Frequency: serotonergic CV: prescribed
Drug q 4 hours pathways. Debate Hypotension (low guidelines to avoid
classification: exists about its blood pressure), under- or
Analgesics and primary site of Palpitations, Chest overdosing.
antipyretics action, which may pain, Flushing,
be inhibition of Edema. 🔹Check Allergies:
prostaglandin (PG) Ensure the child is
synthesis or RESP: not allergic to
through an active Respiratory paracetamol and
metabolite depression (in high review the medical
influencing doses), Dyspnea, history for any
cannabinoid Tachypnea, contraindications.
receptors. Hyperventilation,
Respiratory 🔹Verify
distress, Nasal Prescription:
congestion, Confirm the
Cough. physician's
EENT: prescription and
Tinnitus (ringing in check expiration
the ears), Blurred dates on the
vision, Diplopia medication to
(double vision), Dry maintain safety and
eyes, efficacy.
Conjunctivitis,
Epistaxis 🔹Select
(nosebleed), Sore Appropriate
throat, Rhinitis, Formulation:
Otitis media. Choose the correct
formulation (e.g.,
GI: liquid, suppository)
Nausea, Vomiting, suitable for the
Abdominal pain, child's age and
Anorexia, ability to swallow.
Constipation,
Diarrhea, Gastric 🔹Administer
bleeding (in Timely: Administer
overdose), paracetamol on
Gastrointestinal schedule or as
ulcers. needed for fever or
pain, adhering to
SKIN: prescribed intervals
Rash (allergic to maintain
reaction), Pruritus therapeutic levels.
(itching), Erythema
Urticaria (hives), 🔹Monitor Vital
Photosensitivity, Signs: Regularly
Sweating, monitor the child's
Dermatitis. vital signs,
especially if there's
MS: a concern about
Myalgia (muscle potential adverse
pain), Back pain, reactions.
Muscle weakness,
Arthralgia (joint 🔹Educate
pain), Parents/Caregivers
Osteoporosis : Provide clear
(prolonged use), instructions to
Joint swelling. parents/caregivers
on proper
administration,
potential side
effects, and when
to seek medical
attention.

🔹Document
Administration:
Thoroughly
document the
administration
details, including
time, dosage, and
any observed
reactions.

🔹Assess
Effectiveness:
Monitor the child's
response to
 paracetamol,
assessing whether
there is a reduction
in fever or
alleviation of pain.

🔹Report Adverse
Events: Promptly
report any adverse
reactions or
unexpected events
to the healthcare
team.

🔹Maintain
Hydration:
Encourage fluid
intake to prevent
dehydration,
especially if the
child is
experiencing fever.
Name of drug/ Dose, Route, Mechanism of Side Effects Nursing
Drug and Action Responsibilities
classification frequency of
drug
administratio
n
Generic Dose: Salbutamol, also CNS: 🔹Verify the correct
Name: known as albuterol, Nervousness, dosage based on
Salbutamol is a bronchodilator Tremors, the child's weight
Route: commonly used to Dizziness, and prescribed
Brand Name: treat conditions like Insomnia, guidelines.
asthma and Restlessness,
Frequency: chronic obstructive Irritability, 🔹 Ensure proper
Drug pulmonary disease Headache, Sleep inhaler or nebulizer
classification: (COPD). In a disturbances. technique to
Beta-2 patient with PCAP optimize drug
adrenergic (presumed RESP: delivery.
agonists or community- Cough, Throat
bronchodilator acquired irritation, 🔹 Monitor vital
pneumonia), Respiratory signs before,
Salbutamol can infections, during, and after
help relieve Bronchitis, administration.
bronchoconstrictio Increased sputum
n and improve production, 🔹Assess the child's
airflow by binding Dyspnea respiratory status,
to beta-2 (shortness of including breath
adrenergic breath), Chest sounds and
receptors in the tightness, respiratory rate.
airway smooth Wheezing,
muscle. Nasopharyngitis 🔹Educate parents
 on the correct
This binding CV: administration
activates adenylate Increased heart technique and
cyclase, leading to rate (tachycardia), potential side
an increase in Palpitations, Chest effects.
intracellular cyclic discomfort,
AMP (cAMP). Hypertension, 🔹Document the
Elevated cAMP Fluctuations in time, dosage, and
levels result in the blood pressure, any observed
relaxation of Rapid heartbeat, effects or adverse
smooth muscle Irregular heartbeat, reactions.
cells, leading to Vasodilation,
bronchodilation. Arrhythmias, 🔹 Collaborate with
While Salbutamol Increased blood the healthcare
addresses airway pressure. team to coordinate
constriction, it’s care and address
important to note EENT: concerns.
that antibiotics are Dry or irritated
typically the throat, Nasal 🔹Watch for signs of
primary treatment congestion, systemic effects
for pneumonia. Rhinorrhea (runny such as increased
nose, Pharyngitis, heart rate or
Oropharyngeal tremors.
edema, Epistaxis
(nosebleeds), 🔹Be aware of
Taste contraindications or
disturbances, precautions for
Blurred vision, Eye specific pediatric
irritation. conditions.

GI: 🔹 updated on any

Nausea, Vomiting, changes in the
Upset stomach, child's medical
Diarrhea, history that may
Gastrointestinal impact salbutamol
discomfort, Dry administration.
mouth, Gastro
esophageal reflux,
Abdominal pain,
Constipation,
Stomach cramps.

MS:
Muscle cramps,
Muscle tremors,
Muscle weakness,
Back pain, Joint
pain.

SKIN:
Skin rash, Urticaria
(hives), Pruritus
 (itching), Sweating,
Erythema
(redness),
Dermatitis, Dry
skin.

Name of drug/ Dose, Route, Mechanism of Side Effects Nursing

drug and action responsibilities
Classification frequency of
drug
administratio
n
Generic Dose: Ampicillin works by CNS: When
Name: 400mg inhibiting the Headache, administering
Ampicillin synthesis of Dizziness, Ampicillin to
bacterial cell walls. Confusion, pediatric patients,
Route: It interferes with Hyperactivity, nurses should
Brand Name: IV the formation of Insomnia, Vertigo adhere to several
peptidoglycan, a Nervousness key responsibilities:
crucial component
Drug Frequency: of bacterial cell CV: 🔹Assessment:
Classification q 12 hours walls, leading to Hypotension (low Perform a thorough
Beta-lactam the weakening and blood pressure), assessment of the
antibiotic and eventual rupture of Tachycardia (rapid child's medical
is classified as the bacterial cell. heart rate), history, allergies,
aminopenicillin This mechanism of Palpitations, Chest and current health
action makes pain, Flushing status to ensure
ampicillin effective Peripheral edema Ampicillin is
against a wide appropriate.
range of bacteria, MS:
and it is often used Arthralgia (joint 🔹Dosage
to treat pediatric pain), Myalgia Calculation:
infections caused (muscle pain), Accurately
by susceptible Back pain, Muscle calculate and
organisms. weakness, Joint administer the
swelling, correct dosage
Tendonitis. based on the
child's weight, age,
Skin: and the specific
Rash, Itching condition being
(pruritus), treated.
Erythema,
Photosensitivity, 🔹Patient
Dermatitis, Education: Educate
Angioedema parents or
caregivers about
EENT: the medication,
Conjunctivitis, including proper
Blurred vision, administration
Tinnitus, Taste techniques,
disturbances, Dry potential side
eyes, Sore throat, effects, and the
Dysphonia importance of
completing the full
RESP: course of
Dyspnea (difficulty treatment.
breathing),
Bronchospasm, 🔹Allergy
Cough, Wheezing, Screening: Confirm
Nasal congestion, the absence of
Hemoptysis known allergies to
(coughing up penicillins or
blood), Respiratory cephalosporins
distress before
administering
GI: Ampicillin, as it can
Nausea, Vomiting lead to severe
Diarrhea, allergic reactions.
Abdominal pain,
Anorexia. 🔹Intravenous (IV)
Administration: If
administering via
IV, ensure proper
dilution and
infusion rates are
followed to prevent
complications such
as phlebitis or
infiltration.

🔹Monitoring:
Regularly monitor
vital signs,
especially if there is
concern about
adverse reactions,
and observe for
any signs of allergic
reactions or side
effects during and
after administration.

🔹Blood Tests:
Consider ordering
appropriate blood
tests to monitor for
potential adverse
effects on liver and
kidney function,
especially during
prolonged use.

🔹Reconstitution
Guidelines: If
 required, follow
proper
reconstitution
guidelines for oral
suspension or IV
administration to
maintain the drug's
efficacy.

🔹Patient Comfort:
Ensure the child is
comfortable during
the administration,
using age-
appropriate
techniques to
minimize anxiety
and discomfort.

🔹Documentation:
Thoroughly
document the
administration,
including dosage,
route, time, and
any observed
reactions or
responses. Keep
clear and accurate
records for
continuity of care.

🔹Hydration:
Encourage fluid
intake unless
contraindicated, as
ampicillin may
cause dehydration.

b. IV Therapy/Blood Transfusion
Current IV therapy/Blood Product D5 0.3 Na CI
Drip Rate 32 ugtts /min

Level received (mls) 300ml

Level to endorse 100ml

Nursing Intervention Regulate and monitor the IV fluid and line

ISBAR.
Good afternoon, Nurse X this is Student

I
nurse Wilfred Dulnuan calling from the
pediatric ward. For endorsement of Patient
MB 1 year old boy in the pediatric ward.

I am calling for endorsement for patient MB

S
in the room 11 bed no.3 with a diagnosis of
PCAP, with an IV fluid of D5 0.3Nacl
remaining 100ml.

Patient MB is a 1year old male born on

B
Jan.15 2023 a resident of Hapid, Lamut,
Ifugao diagnosed wit Pediatric Community
Acquired Pneumonia.

The patient has no fever and have a cough

A
with a presence of excessive yellowish
phlegm and a ineffective air way clearance.

Pls monitor patient MB’s Vital signs also

R
together with his IV line cause sometimes it
stops dropping. Kindly assist during his
nebulization and do chest physio therapy. I
wish the patient would be able to breath
comfortably.

c. NURSES NOTES.

March 4, 2024 Received a baby patient 1 year old male laying down together with her
 8:00 AM mother drinking bottle milk with an ongoing IV fluid of Dextrose 5% 0.3
Sodium chloride in his right foot. Patient’s mother said that his son has a
yellowish phlegm.
Monitored Vital signs.
PR:142 bpm
RR:39b pm
TEMP:36.7
OxSat:96%
(-) fever
(+) cough
Good appetite
Regulated the IV fluid.
Assisted in nebulization instructed the mother to do chest physio therapy.
Promoted rest.
After nebulization patients breaths comfortably with out any signs of
difficulties.

d. Health Promotion/Discharge Plan.

-Health teaching about the diets of the patient together with the mother and father
encourage them to let their child eat nutritional foods like citrus for vitamin C and stronger
immune system then continue taking the prescribed medication in the right time and right
dose until there’s nothing left and as told by the doctor, they will go for follow up checkups.

E. Ethical, legal & moral considerations (may use table format) (2 pts)

Beneficence The nurses and doctors did their

assessment, interventions and gave
medication to treat the disease of the patient
and it benefited him a lot.
Non maleficence The nurses and doctors did their job
cautiously they monitored the patient and
gave all the medications in the right route
right dose and right time.
Autonomy The nurses respected the decisions of the
patient’s mother.
F. Review of Related Literature (3 pts)
Community acquired pneumoniae is common in childhood. Viruses account for most cases of CAP
during the first two years of life. After this period, bacteria such as Streptococcus pneumoniae,
Mycoplasma pneumoniae and Chlamydia pneumoniae become more frequent. CAP symptoms
are nonspecific in younger infants, but cough and tachypnea are usually present in older
children. Chest x-ray is useful for confirming the diagnosis. Most children can be managed
empirically with oral antibiotics as outpatients without specific laboratory investigations. Those
with severe infections or with persistent or worsening symptoms need more intensive
investigations and may need admission to hospital. The choice and dosage of antibiotics
should be based on the age of the patient, severity of the pneumonia and knowledge of local
antimicrobial resistance patterns. The Canadian Pediatric Society recommends the use of the
heptavalent conjugate pneumococcal vaccine, which is efficacious in reducing chest x-ray
positive pneumonia by up to 20%.
Keywords: Childhood, Community-acquired, Diagnosis, Pneumonia
Community-acquired pneumonia (CAP) is a lower respiratory tract infection occurring in a child
who has not resided in a hospital or health care facility in the preceding 14 days. In a recent
study, the incidence of first episode pneumonia in unimmunized children younger than five
years of age was 55.9 per 1000 person-years. It has been estimated that there are 41,000
Canadian children younger than five years of age with non-hospitalized CAP, while another
9600 are hospitalized annually. While the etiology of the pneumonia is not often easy to
ascertain in the clinical setting, the greatest clue is the age of the child.
Reference:
Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-
acquired pneumonia in adults. Clin Infect Dis. 2000;31:347–82. [PMC free
article] [PubMed] [Google Scholar]
2. Black SB, Shinefield HR, Ling S, et al. Effectiveness of heptavalent pneumococcal conjugate vaccine
in children younger than five years of age for prevention of pneumonia. Pediatr Infect Dis
J. 2002;21:810–5. [PubMed] [Google Scholar]