Case Scenario:

A twelve year old boy named Corbido Fandemica, comes in accompanied by his mother, with a complaint of
coughing for 2 weeks. Coughing is present every night. He has also had a mild fever, but his temperature has not
been measured at home. His parents have been using a decongestant/antihistamine syrup and albuterol syrup
which were left over from a sibling. Initially the cough improved but it worsened over the next 2 days. He is noted
to have morning sneezing and nasal congestion. There are colds going around their community. He has had similar
episodes in the past, but this episode is worse. He has no known allergies to food or medications.

His past history is notable for eczema and dry skin since infancy. He is otherwise healthy and he is fully
immunized. His family history is notable for a brother who has asthma. In his home environment, there are no
smokers or pets.

Upon Examination: VS T 38.1, P 100, RR 24, BP 85/65, oxygen saturation 99% in room air. He is alert and
cooperative in minimal distress if any. His eyes are clear, nasal mucosa is boggy with clear discharge, and his
pharynx has moderate lymphoid hypertrophy. He has multiple small lymph nodes palpable in his upper neck. His
chest has an increased AP diameter and it is tympanitic (hyperresonant) to percussion. Rhonchi and occasional
wheezes are heard on auscultation, but there are no retractions. Heart is in a regular rhythm and no murmurs are
heard. His skin is dry, but not flaky, inflamed or thickened.

He is initially diagnosed to have moderately persistent asthma and possible asthmatic bronchitis. He is initially
treated with nebulized albuterol and nebulized corticosteroids for bronchospasm and bronchial inflammation. He is
also treated with an antihistamine at night to reduce his morning allergy symptoms. In follow-up, his cough has
improved a bit & he is not running a fever(T 36.8C ). A chest X-ray is obtained, but no radiographic evidence of
pneumonia is present. His cough persists, but only with exercise and drinking cold juice.

Activity:

1. Make a Nursing care Plan following the NCP format given to you. List down all the objective
assessments you could find in the case scenario. Formulate at least 3 Nursing Problems and prioritize it
according to high, medium and low level priority, Write one short-term and one long term goal, Make at
least 2 Nursing Interventions each for Independent, Dependent and one nursing intervention as health
teaching.

2. Make a Drug Study for Nebulized Albuterol & Nebulized Corticosteroids mentioned in the case scenario.
Follow our Drug Study Format.

3. You are the assigned nurse of this patient in Rm. 301 Pediatric Medical Wing of P. Orata Medical Center.
Your nurse supervisor asks you to make an F-DAR Charting for your 3-11PM shift.

4. Accomplish the hospital Forms that is needed for this patient: TPR Sheet, Nurses Notes, etc.
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