V.

LABORATORY RESULT AND DIAGNOSTIC EXAMINATION

Name of Test Hematology Date Done Indication Blood tests such as CBC and APC can be used to find out what is happening in many parts of the body. Testing blood is easier than obtaining a tissue sample. Any test designed to discover abnormalities in a sample of blood to determine blood groups. (Merk Manual of Medical Normal Value Actual Result Significance of Result

September 14, 2013

WBC

5-9 x 109/L

11.3

Increased Leukocytosis occurs in acute infections (Pneumonia), in which the degree of increase of leukocytes depends on severity of the infection, patient's resistance, patient's age, and marrow efficiency and reserve. (A Manual of Laboratory and Diagnostic Tests by Frances Fischbach pp.80). On the date of admission, the client is febrile with a temperature is 37.6 C which indicates infection. Thats why when a blood sample was taken for a CBC test, the WBC count was above normal.

Information p.888).

Hemoglobin 120 190 g/L 119

Decreased May occur in anemia, a condition in which there is a reduction in the number of circulating erythrocytes, the amount of Hemoglobin, or the volume of packed cells (Hct). (A Manual of Laboratory and Diagnostic Tests by Frances Fischbach pp.70). The hemoglobin decreased because the maternal iron in the infant starts to decreased at 6 months.

Hematocrit

0.40-0.454 g/L

0.36

Decreased Decreased in anemias. (Medical-Surgical Nursing 10th ed. By Brunner and Suddarth pp.2215) The hematocrit decreased because the maternal iron in infant starts to decreased at 6 months Decreased Decreased RBC values occur in anemia. Anemia is associated with cell destruction, blood loss, or dietary insufficiency of iron or

RBC

4.5-5.5 x 1012/L

3.96

of certain vitamins that are essential in the production of RBCs. (A Manual of Laboratory and Diagnostic Tests by Frances Fischbach pp.75) The RBC decreased because the maternal iron in infant starts to decreased at 6 months

Neutrophils

0.55-0.65

0.60

Normal Increased A lymphocytosis indicates viral infections of the upper respiratory tract (pneumonia). (A Manual of Laboratory and Diagnostic Tests by Frances Fischbach pp.61)

Lymphocytes

0.25-0.35

0.40

Name of Test

Date Done

Indication This is used to examine soft and bony tissues of the body.

Chest X-ray

September 16, 2013

Normal Value Appearing and normally positioned chest, bony thorax (all bones present, aligned, symmetrical and normally shaped), soft tissues, mediastinum, lungs, pleura, heart and aortic arch.

Actual Result Hazy infiltrates are noted in both lungs. Both lungs fields are hyperaerated. Heart and great vessels are within normal size and configuration. Other chest structures are not remarkable.

Significance of Result Pneumonitis, bilateral with pulmonary hyperaeration. Abnormal Abnormal chest x-ray results indicate the following lung conditions: Presence of foreign bodies Lobar pneumonia Bronchopneumonia Aspiration pneumonia Viral pneumonia

IX. DRUG STUDY

Drug name Generic Name: Gentamicin Sulfate Brand name: Garamycin

Action

Broad-spectrum aminoglycoside antibiotic derived from Micromonospora purpurea. Action is Contraindication usually bacteriocidal. History of hypersensitivity to or toxic reaction with any aminoglycoside antibiotic. Safe use during pregnancy (category C) or lactation is not established

Indication Contraindication Indication For bacterial and viral infection

Side effects Adverse effect Side Effect skeletal muscle weakness, apnea hypotension or hypertension Nausea, vomiting Adverse Effect ototoxicity (vestibular disturbances, impaired hearing), optic neuritis, neuromuscular blockade:, respiratory paralysis hepatomegaly, splenomegaly. Increased or decreased reticulocyte counts; granulocytopenia, thrombocytopenia anemia.

Nursing responsibilities Monitor for signs of renal toxicity including unusual appearance of urine (dark, cloudy) intake and output ratio, and the presence of edema Monitor for evidence of ototoxicity, including headache, dizziness or vertigo, nausea or vomiting with motion, ataxia, nystagmus, tinnitus, roaring noises, sensation of fullness of ears, and hearing impairment. Observe for signs and symptoms of bacterial overgrowth due to drugs effect to kill all bacteria, even normal flora that can lead to superinfection.

Drug name Generic Name: Ampicillin Brand name: Rimacillin

Action These antibiotics all have a similar mechanism of action. They stop bacteria from multiplying by preventing bacteria from forming the walls that surround them. The walls are necessary to protect bacteria from their environment and to keep the contents of the bacterial cell together. Bacteria cannot survive without a cell wall. Penicillins are most effective when bacteria are actively multiplying and forming cell walls.

Indication Contraindication Indication Treatment of bronchitis, uncomplicated community-acquired pneumonia

Side effects Adverse effect Side Effect rash, headache, fever and hives, nausea, soreness of the tongue, inflammation in the mouth, oral candidiasis, vomiting, Contraindication enterocolitis, diarrhea Hypersensitivity to penicill tooth discoloration. ins. Infectious mononucleosis. Use Adverse Effect cautiously with renal Severe allergic disorders reactions pseudomembranous colitis Anaphylactic shock, redness of skin, skin inflammation, hives and inflammation of blood vessels.

Nursing responsibilities Take this drug around-theclock. Take the full course of therapy; do not stop taking the drug if you feel better. Take the oral drug on an empty stomach, 1 hr before or 2 hr after meals; the oral solution is stable for 7 days at room temperature or 14 days refrigerated. Report pain or discomfort at sites, unusual bleeding or bruising, mouth sores, rash, hives, fever, itching, severe diarrhea, difficulty breathing.

Drug name Generic Name: Salbutamol + Ipatropin

Action

Used as bronchodilator to control and prevent reversible airway obstruction caused by Brand Name: asthma Combivent

Indication Contraindication Indication Used as a quiet relief agent for acute bronchospasm Contraindication Hypersensitivity to adrenergic amines. Hypersensitivity to fluorocarbons.

Side effects Adverse effect Side Effect headache, insomnia Adverse Effect chest pain, arrhythmias, palpitations nervousness, restlessness, tremor

Nursing responsibilities Assess lung sound, pulse and blood pressure before administration and during peak of medication. Observe for paradoxical bronchospasm Allow at least 30 minutes intervals between nebulization. Provide dose as soon as remembered spacing remaining doses at regular intervals. Avoids double dose as increase of dosage. Provide albuterol first before using other inhalation medication. Advise patient to rinse mouth with water after each inhalation dose to prevent dry mouth.

Drug name Generic name: Cefuroxime Brand name: Zinnat

Action Interferes with bacterial cell-wall synthesis and division by binding to cell wall, causing cell to die. Active against gramnegative and grampositive bacteria, with expanded activity against gram-negative bacteria.

Indication Contraindication Indication Treatment of respiratory tract infection Contraindication Hypersensitivity to cephalosporin Serious hypersensitivity to penicillins.

Side effects Adverse effect Side Effect nausea, vomiting pain at IV site phlebitis Adverse Effect cramps rashes

Nursing responsibilities Use cautiously with renal impairment Assess patient for infection. Obtain culture and sensitivity. Provide skin test Keep epinephrine as antidote for anaphylactic reaction Provide medicine around the clock and to finish the medication completely even patient feeling better.

Drug name Generic Name: Paracetamol

Action

Unclear. Pain relief may result from inhibition of prostaglandin Brand Name: synthesis in CNS, with Ileosone subsequent blockage of pain impulses. Fever reduction may result from vasodilation and increased peripheral blood flow in hypothalamus, which dissipates heat and lowers body temperature.

Indication Contraindication Indication Fever, pain Contraindication Hypersensitivity to products containing alcohol, aspartame saccharin, sugar or tartrazine.

Side effects Adverse effect Side Effect rash and urticarial Adverse Effect renal failure,

Nursing responsibilities Use cautiously with hepatic and renal disease. Assess for the over all health status. Assess fever; note presence of associated signs ( diaphoresis, tachycardia and malaise) Keep acetylcysteine as an antidote for overdose Avoid giving excess amount more than recommended dose Advise patients and caregivers to assess concentration of liquids preparatory.

X. INTRAVENOUS FLUIDS
IVF NAME D5 0.3 NaCl 500cc INDICATION AND SIDE EFFECT AND CONTRAINDCATION ADVERSE EFFECT Indication Side Effect Replacement therapy in Phlebitis on the IV site isotonic solution particularly in pediatrics. Adverse Effect Hypokalemia Contraindication Hypotonic dehydration DM Hypokalemia Severe acidosis NURSING RESPONSIBILITIES Assess the IV site for phlebitis or possible infection. Regulate properly the IVF as prescribed. Monitor serum electrolyte especially Potassium

IVF NAME D5 IMB 500cc

INDICATION AND SIDE EFFECT AND CONTRAINDCATION ADVERSE EFFECT Indication Side Effect Maintenance of fluid and Phlebitis on the IV site electrolyte balance and supply of calories Adverse Effect Hyperphosphatemia Contraindication Shock Water intoxication DM

NURSING RESPONSIBILITIES Assess the IV site for phlebitis or possible infection. Regulate properly the IVF as prescribed. Monitor serum electrolyte especially Phosphate

XI. OXYGEN THERAPY

THERAPY Oxygen INDICATION AND SIDE EFFECT AND CONTRAINDCATION ADVERSE EFFECT Indication Side Effect For decrease paO2 in the tachycardia blood Adverse Effect Contraindication Respiratory alkalosis Respiratory alkalosis NURSING RESPONSIBILITIES Assess the patency of nasal cannula, the oxygen tank

Regulate properly the level of the oxygen as prescribed. Monitor for adverse effect.

XII. PRIORITIZATION OF THE PROBLEM

Date September 16, 2013 Nursing Diagnosis Ineffective Airway Clearance related to bronchial inflammation as evidenced by adventitious sounds (rales and crackles) Cues Subjective Nahihirapan siyang huminga. verbalized by the grandmother Objective Presence of O2 tank at the bed side VS T 37.6 oC, RR 44 cpm, CR 138 bpm Parameters Chest x-ray result: Hazy infiltrates are noted in both lungs. Both lungs fields are hyperaerated O2 of 1-2 lpm Impaired Gas Exchange Subjective related to altered delivery Nahihirapan siayng huminga of oxygen as manifested by verbalized by the grandmother tachycardia Objectives Weak in appearance Bed rest Presence of O2 at bed side VS T 37.6 oC, RR 44 cpm, CR 138 bpm Justification According to the As Emergency Priority, airway is the priority problem in the setting.

September 16, 2013

As

According to the Emergency Priority, breathing is the next priority problem in the setting.

Parameters O2 of 1-2 lpm RBC 3.96 x 1012/L

Hbg 119g/dL Hct 0.36 g/dL

September 16, 2013

Activity Intolerance related to imbalance between oxygen supply and demand as evidenced by tachypnea and weak in appearance.

Subjective Hindi pa rin siya kagaya noong dati bago siya ma-ospital. Dati kasi nagagawa niyang makipag-laro. As verbalized by the grandmother Objectives Weak in appearance Bed rest Presence of O2 at bed side VS T 37.6 oC, RR 44 cpm, CR 138 bpm Parameters O2 of 1-2 lpm RBC 3.96 x 1012/L Hbg 119g/dL Hct 0.36 g/dL

After ABC and LOC, Maslows Hierarchical Needs is the last priority problem.

XI. NURSING CARE PLAN

NURSING DIAGNOSIS Subjective Ineffective Nahihirapan Airway siyang Clearance huminga. As related to verbalized by bronchial the inflammation grandmother as evidenced by adventitious Objective sounds (rales Presence of and crackles) O2 tank at the bed side VS T 37.6 oC, RR 44 cpm, CR 138 bpm ASSESSMENT PLANNING After 3 days of nursing interventions, the client will be able to display patent airway (RR within normal range of 20-30 cpm) with clear breath sounds; absence of dyspnea. INTERVENTIONS Independent >Assess rate/depth of respirations and chest movement. RATIONALE EVALUATION

After 3 days of >Tachypnea, shallow nursing respirations, and interventions, asymmetric chest the client was movement are frequently able to display present because of patent airway discomfort of moving with the chest wall and/or fluid in absence of lung. dyspnea. >Rhonchi, wheezes indicate accumulation of secretions/inability to clear airways that may lead to use of accessory muscles and increased work of breathing. >Tachycardia is usually present as a result of fever/dehydration but may represent a response to hypoxemia. >High fluid intake helps thin secretions, making them easier to expectorate. Subjective Mas maganda na ang pakiramdam niya kasi nakikipaglaro na siya at nakakatawa na ng malakas. As verbalized by the grandmother Objective Able to laugh and sit on the lap of his grandmother

>Assess respiratory function, e.g., breathe sounds, rate, rhythm, and depth, and use of accessory muscles.

Parameters Chest x-ray result: Hazy infiltrates are noted in both lungs. Both lungs fields are hyperaerated

>Monitor heart rate/rhythm every hour.

>Encourage increase fluid intake of at least 2500 mL/day

O2 of 1-2 lpm

>Position client in semior high-Fowlers position by placing pillows to support the posterior portion of the body.

>Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open atelectatic areas and promote movement of secretions into larger airways for expectoration.

VS T 36.5oC, RR 25 cpm, CR 135 bpm Parameters O2 discontinued Goal partially met because the client still has adventitious sounds and no repeat chest xray ordered.

>Assist patient with frequent deep-breathing exercises. Demonstrate/help patient learns to perform activity, e.g., splinting chest and effective coughing while in upright position.

>Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. >Accumulation of secretions in the airway can impair oxygenation of vital organs and tissues.

>Evaluate change in level of mentation. Note cyanosis and/or change in skin color, including mucous membranes and

nailbeds. DEPENDENT >Provide humidify inspired air/oxygen.

>Prevents drying of mucous membranes; helps thin secretions. >Facilitates liquefaction and removal of secretions >Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness. >Fluids are required to replace losses (including insensible) and aid in mobilization of secretions. >Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery.

>Assist with/monitor effects of nebulizer treatments. >Suction as indicated (e.g., frequent or sustained cough, adventitious breath sounds, desaturation related to airway secretions). >Provide supplemental fluids, e.g., IV, humidified oxygen, and room humidification.

>Administer medications as indicated: Bronchodilators (Salbutamol Neb 1neb + 2cc NSS)

Corticosteroids (Hydrocortisone )

>May be useful in presence of extensive involvement with profound hypoxemia and when inflammatory response is lifethreatening. >Repeat Chest X-ray may reveal clearance of the lungs from the previous infection.

COLLABORATIVE >Assist for repeat Chest X-ray, if possible.

NURSING DIAGNOSIS Subjective Impaired Gas Nahihirapan Exchange siayng related to huminga As altered delivery verbalized by of oxygen as the manifested by grandmother tachycardia ASSESSMENT Objectives Weak in appearance Bed rest Presence of O2 at bed side VS T 37.6 oC, RR 44 cpm, CR 138 bpm

PLANNING After 3 days of nursing interventions, the client will be able to demonstrate an improved ventilation and oxygenation of tissues by discontinuing of the O2and with the absence of symptoms of respiratory distress.

INTERVENTIONS INDEPENDENT

RATIONALE

EVALUATION After 3 days of nursing interventions, the client was able to demonstrate an improved ventilation and oxygenation of tissues by discontinuing of the O2and with the absence of symptoms of respiratory distress. Subjective Mas maganda na ang pakiramdam niya kasi nakikipaglaro na siya at nakakatawa na ng malakas. As verbalized by

>Assess respiratory Manifestations of rate, depth, and ease. respiratory distress are dependent on/and indicative of the degree of lung involvement and underlying general health status. > Assess mental status. Restlessness, irritation, confusion, and somnolence may reflect hypoxemia/ decreased cerebral oxygenation. > Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral). > Cyanosis of nailbeds may represent vasoconstriction or the bodys response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (warm membranes) is indicative of systemic hypoxemia.

Parameters O2 of 1-2 lpm RBC 3.96 x 1012/L Hbg 119g/dL Hct 0.36 g/dL

> Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills, e.g., addition/removal of bedcovers, comfortable room temperature, tepid or cool water sponge bath. > Maintain bedrest. Encourage use of relaxation techniques and diversional activities such as toys and fine motor activities. DEPENDENT > Administer oxygen therapy by appropriate means, e.g., nasal prongs, mask, Venturi mask.

> High fever (common in bacterial pneumonia and influenza) greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.

the grandmother Objective Able to laugh and sit on the lap of his grandmother VS T 36.5oC, RR 25 cpm, CR 135 bpm Parameters O2 discontinued Goal partially met because the client still has adventitious sounds and no repeat chest xray ordered.

> Prevents overexhaustion and reduces oxygen consumption/demands to facilitate resolution of infection.

> The purpose of oxygen therapy is to maintain PaO2 above 60 mm Hg. Oxygen is administered by the method that provides appropriate delivery within the patients tolerance.

COLLABORATIVE > Monitor ABGs, pulse > Follows progress of

oximetry, possible

CBC,

if disease process and facilitates alterations in pulmonary therapy.

ASSESSMENT Subjective Hindi pa rin siya kagaya noong dati bago siya maospital. Dati kasi nagagawa niyang makipag-laro. As verbalized by the grandmother Objectives Weak in appearance Bed rest Presence of O2 at bed side VS T 37.6 oC, RR 44 cpm, CR 138 bpm

NURSING DIAGNOSIS Activity Intolerance related to imbalance between oxygen supply and demand as evidenced by tachypnea and weak in appearance.

PLANNING After 3 days of nursing interventions, the client will be able to demonstrate increase in tolerance to activity (able to sit on own) with absence of dyspnea and vital signs within patients acceptable range (RR 2030 cpm, CR 80-140 bpm Temp. 36.537.5).

INTERVENTIONS INDEPENDENT >Assess childs usual level of activity, taking into account age and developmental level (. >Assess patients response to activity. Note reports of dyspnea, increased weakness/ fatigue, and changes in vital signs during and after activities. >Monitor response to activity including pulse, respiratory rate, skin color, and behavior. >Determine usual sleep/rest routine and bedtime rituals/security objects such as safety pillows and milk prior to sleep. Plan care with adequate rest periods.

RATIONALE >Establishes baseline, in order to determine needed interventions and to assess progress of recovery. >Establishes patients capabilities/needs and facilitates choice of interventions.

EVALUATION After 3 days of nursing interventions, the client was be able to demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs within patients acceptable range. Subjective Mas maganda na ang pakiramdam niya kasi nakikipaglaro na siya at nakakatawa na ng malakas. As verbalized by

>Helps identify/monitor degree of fatigue and potential for complications. >Attempting to maintain usual sleep routines promotes rest and maximizes energy and endurance.

Parameters O2 of 1-2 lpm RBC 3.96 x 1012/L

Hbg 119g/dL Hct 0.36 g/dL

>Provide a quiet environment and limit visitor. >Encourage use of diversional activities such as blocks and fine motor puzzles.

>Reduces stress and excess stimulation, promoting rest. >Reduces stress and excess stimulation, promoting rest.

the grandmother Objectives Able to sit on the lap of the grandmother VS T 36.5oC, RR 25 cpm, CR 135 bpm

DEPENDENT > Provide supplemental oxygen as indicated.

> Maximizing oxygen transport to tissues improves ability to function. >May be needed to improve tolerance to activity, treat underlying cause for fatigue. > Identifies deficiencies in RBC components affecting oxygen transport and treatment needs/response to therapy. >Maximizes nutrient intake without undue fatigue/energy expenditure from eating large meals

COLLABORATIVE >Provide/monitor response to oxygen therapy and medications. > Monitor laboratory studies, e.g., Hb/Hct and RBC count

Parameters Discontinue O2. Goal met.

>Encourage small, frequent meals with foods according to age group such as milled rice (am).