GROUP 22 CASE PRESENTATION

INTRODUCTION

Group 22 of 2BSN6 from Pamantasan ng Lungsod ng Marikina will be conducting a

comprehensive interview for their NCM 107. The client would be a preschooler that will be
represented by his parent to be able to collect important information from the client. The
interview will be conducted virtually through google meet and the students will depend on the
availability of the mother of the client to conduct the interview. Every information will be kept
confidential within the group members and clinical instructor. The purpose of the interview is to
assess the current health status of the client.

DEMOGRAPHIC

SMN male and a 5 years old (preschool age). Lives in Antipolo City with his mother and
father and has a younger sibling, a girl with an age of 1 years old. His birthplace is San Mateo,
Rizal and date of birth is October 20, 2017. Their religion is Roman Catholic and all of them are
Filipino citizens but the preferred language of our client is english, as his mother claimed, it is
because the cartoons he likes to watch are mostly in english language. He is currently enrolled
in kinder 2, the school is near their place, and the school does implement face-to-face classes.

CHIEF COMPLAINT

The mother reports that the client had suffered from cough and cold last week because
the client has weak lungs. He often suffers from these illnesses caused by being hyper active of
the child or excessive physical activities such as playing like running.

PRESENT HEALTH HISTORY

The client complains of “weak lungs” related to previous diagnosis of primary complex at
the age of 2. The client describes symptoms as severe cough that requires medical intervention.
The complaints began after the diagnosis of primary complex when they were 2 years old. The
complaint mostly affects the respiratory system. Episodes of severe cough last for 3 days when
medication is administered. It is triggered whenever the client does excessive physical activity
and is only alleviated by medication as prescribed by pediatrician. Associated factors include a
bleeding nose when client is exposed to high temperatures. When symptoms arise, the client
becomes lethargic or quiet.
PAST HEALTH HISTORY

The client was born without problems or complications. The client developed a primary complex
at the age of 2. The client underwent medical procedures in response to the diagnosis of
primary complex which the mother of the client described as three medications within a span of
three months. The client is up to date and complete with vaccinations, has no history of
accidents and allergies yet complains of back pain, possibly related to cough. The child is
physically active although develops problems when activity is excessive. The client is socially
active with his peers with no reported attitude of tantrums but shows displeasure when attention
is towards his younger sibling.

FAMILY HEALTH HISTORY

DEVELOPMENTAL HISTORY

Based on the gathered data from the child’s mother, the child had his first word when he
was one year old and that first word was “JJ” which is a character from a media show known as
Cocomelon since the child is fond of watching it. The child had both his first crawl and learned to
sit by himself when he was eight months. The child learned to walk when he was ten months
and was able to have his first run when he was almost two years of age. The child is now
attending school and is a Kinder II student. He is active with peers and he always finishes his
homeworks first before playing with them. The child has never thrown tantrums and never
sucked his thumb unlike other children of his age, according to his mother.

PSYCHOLOGICAL HISTORY

Based on the findings and observation the child shows no presence of mental problems and the
child is normal and does not have any kind of problems.

THEORETICAL FRAMEWORK

VIRGINIA HENDERSON’S NURSING NEED THEORY

Psychological Aspects of Communicating and Learning

As a patient receives treatment and is on the road to recovery, it’s important that the
patient is able to take care of him or herself after being released from medical care. To that end,
nurses should be caring for the patient while, at the same time, helping the patient become
more independent and reach goals and milestones on the road to health. Virginia Henderson’s
Need Theory addresses this issue and helps nurses help patients so that they can care for
themselves when they leave the healthcare facility. (Henderson, 1960)

This theory is necessary for the study to assess how the child connects with their
parent. With pediatric nursing, it is essential that parents are aware about how their child is
feeling and interpret it in a more understandable way. The parent will also learn more about their
child and ensure that the child will be expressive about what they think and feel to their parents.
If a child can express their needs to their parents effectively, they may be considered as
independent in terms of communicating if there are times that they need to express their
complaints to other people.

Effective way of
Child’s Parents’ and
communicating
Guardians’
complaint Understanding
complaints to
others.
GORDON'S FUNCTIONAL HEALTH PATTERNS
1. HEALTH PERCEPTION

The medication he takes is Amoxicillin (powder for suspension) and salbutamol if needed or
after consultation. The mother contacts the child’s pediatrician whenever the child is having a
week-long cough or a cough that has phlegm; the reason for the mother is for her to know what
she must do when these scenarios happen. The child has no allergies. The child has complete
vaccines (i.e., polio, measles, hepatitis AB).
NUTRITION (Micah)

The client is a picky eater. He doesn't like eating vegetables and he likes to eat pasta and rice
that's high in carbohydrates. The client also likes drinking milk for breakfast and for night time.
He have a vitamin supplements ceelin plus and appebon

ELIMINATION (Audrie)

The mother of the client said that she wasn’t able to monitor the output of the client on a daily
basis, however she was able to provide some information about his latest stool and the
estimated urine frequency. Base on her statement, the client have estimated 6 or more times of
urine output when she’s around the client and he’s drinks a lot of water daily “pagmagkasama
kami siguro mga 6 or more times sya umiihi, and matubig naman sya”. The color of the urine
was not provided due to the client’s independence “marunong na kasi sya umihi mag-isa”. The
client doesn’t complain about pain when urinating and there’s also no complaint about having
constipation. She said that the client was regularly releasing stool, usually at afternoon and
before sleeping “wala naman syang complaint about jan regular naman yung pag poop nya.
Usually hapon and before nya mag sleep”. She describe the stool as a soft texture and on the
darker shade of green color. “Yung poop nya is tama lang hindi matigas and hindi naman
sobrang lambot. Last night darker green yung color ng poop nya”. My findings are normal since
the client have normal bowel movement and he drink a lot of water to sustain his needs as a
toddler.

4. ACTIVITY

The child is active doing physical activities, he does not have any problems sitting-up or
standing-up. The client likes to watch on TV but he is also active playing with his friends and
playing on his own with his toys. The child does not get tired easily, the mother claimed, when
his father is at home doing exercise the child also does it together with his father.

5. COGNITION
The client was already speaking fluently. His most common language used was english and
something tagalog he's currently on kinder 2 and excel on his grade. He's also able to make his
own Decision and action like when peeing he doesn't it on his own.
6. SLEEP AND REST

Based on the client's data, the client's sleep and rest patterns are inconsistent, and it only takes
him 15 minutes to fall asleep. It depends on how well the client sleeps at night and how he gets
out of bed each morning. Sometimes, the client refers to immediately falling asleep right away
when he gets home from school and before he goes to school. Midnight awakenings, in
particular, occur when a client feels that he is not holding his mother's or father's hand, which
may be enough to disrupt and wake him up from his sleep. At the age of 5-11, the client gets 9-
11 hours of sleep and rest each night, depending on how he spends his time just before bed.

7. SELF PERCEPTION

She described that the client is starting on writing and reading since the client is currently a
kinder 2 student. She also said that she doesn't want her son to be pressured to be good at it.
He has good communication with the people surrounding him. Since he is a toddler he always
wants to watch youtube and watch cartoons on tv. But there is a limitation when it comes to that.
They also tell their son that he can play outside.

8. ROLES AND RS

The client has a good relationship with his family and peers. Regarding to if ever he was lost the
mother taught him what he needs to do.

9. SEXUALITY

10. COPING AND STRESS

The client is an active and lively person and he hasn't exhibited any irritability with his family.
Their bonding as a family is doing groceries together. The client likes playing with toys outside
with his peers and he was hurt sometimes due to his hyperactivity.

11. VALUES AND BELIEF

The values and beliefs of the client’s family, they are all active and do participate in mass, they
all are roman catholic. The mother practices her children to respect people especially those
elderly, and also them, the parents. The family’s belief in life is trust, trust one another and she
also added that if there is no trust in the family then that is a problem. The mother shows great
positivity to her family, showing great care and understanding towards her children and her
husband.
 PHYSICAL ASSESSMENT

According to the mother of the client, the child had lumps in his head because of his
naughtiness, experiencing eye pain because of too much exposure in television and gadgets,
nose bleeds because of the hot temperature and eating candies cause of having toothache.
However, No other abnormalities were found during the assessment.

ANATOMY AND PHYSIOLOGY

The respiratory system is the network of organs and tissues that help you breathe. It includes
your airways, lungs and blood vessels. The muscles that power your lungs are also part of the
respiratory system. These parts work together to move oxygen throughout the body and clean
out waste gases like carbon dioxide.

DRUG STUDY

MECHANIS NURSING
SIDE ADVERSE CONTRAINDICATI
DRUG INDICATION M OF RESPONSIBILITI
EFFECTS EFFECTS ONS
ACTION ES

GENERIC 1. Assess lung

NAME: 1. To control -It relieves Uncontrolla -Palpitations -Hypersensitivity to sounds, PR and
-albuterol and prevent nasal ble shaking adrenergic amines BP before drug
reversible congestion of a part of -Angina administration and
DOSAGE: airway and the body -Hypersensitivity to during peak of
-5ml obstruction reversible -Arrhythmias fluorocarbons medication.
caused by bronchospa Nervousnes
FREQUENCY: asthma or sm by s -Hypertension 2. Observe
-BID for 5 days chronic relaxing the paradoxical
obstructive smooth Headache - spasms and
ROUTE: pulmonary muscles of Hyperglycemi withhold
-Inhaler disorder the Nausea a medication and
(COPD) bronchioles notify the
BRAND NAME: . The relief Vomiting -Hypokalemia physician if
-Salbutamol 2. Quick relief from nasal condition occurs.
-Proventil for congestion Cough
-Ventolin bronchospasm and 3. Administer PO
-Accuneb bronchospa Throat medications with
-Novo- 3. For the sm is made irritation meals to minimize
Salbutamol prevention of possible by gastric irritation.
-Proventil HFA exercise- the Muscle,
- Gen- induced following bone, or 4. Administer
salbutamol bronchospasm mechanism back pain medication
-Ventodisk that takes through inhalation,
-Ventolin HFA 4. Long-term place when allow at least 1
-Volmax control agent Salbutamol minute between
-VoSpira ER for patients is inhalation of
with chronic or administere aerosol
DRUG persistent d. medication.
CLASSIFICATIO bronchospasm
N 5. Advise the
Therapeutic: patient to rinse
Bronchodilator mouth with water
after each
Pharmacologic: inhalation to
adrenergics minimize dry
mouth.

6. Inform the
patient that
Albuterol may
cause an unusual
or bad taste.

MECHANIS NURSING
SIDE ADVERSE CONTRAINDICATI
DRUG INDICATION M OF RESPONSIBILITI
EFFECTS EFFECTS ONS
ACTION ES

GENERIC Dietary Appebon 1. Observe for the

NAME: supplement to Kid Gastrointest Drowsiness, Primary 10 Rights
b complex-lysine help provide contains inal effects, dry mouth, hemochromatosis,
children with Lysine, diarrhea or headache peptic ulcer, 2. Verify doctor's
DOSAGE: nutrients 100% RDA constipation regional enteritis or order
5 ml essential for of both , temporary ulcerative colitis.
energy and to Vitamin B staining of Children receiving 3. Advise patient
FREQUENCY: help improve Complex teeth, parenteral iron and to take medication
Once A Day appetite. and Iron darker blood transfusions. with full stomach
which are colored
ROUTE: clinically stools. 4. Take
Oral proven to medication as
help prescribed
BRAND NAME: children
Appebon® Kid gain a
healthy
DRUG appetite,
CLASSIFICATIO which is the
N foundation
Vitamins & for the
Minerals, child’s
Children overall
health and
energy.
 MECHANIS NURSING
SIDE ADVERSE CONTRAINDICATI
DRUG INDICATION M OF RESPONSIBILITI
EFFECTS EFFECTS ONS
ACTION ES
GENERIC These Ceelin® nausea and nausea, Hypersensitivity. 1. Observe for the
NAME: nutritional Plus vomiting vomiting, 10 Rights
Ascorbic Acid supplements provides are seen heartburn,
Zinc are used for children with doses abdominal 2. Verify doctor's
the prevention double of cramps, order
DOSAGE: and treatment protection elemental fatigue,
5ml of deficiencies against zinc flushing, 3. Advise patient
of vitamin C sickness greater than insomnia, and to take medication
FREQUENCY: and zinc. with the 30 mg. sleepiness with full stomach
Daily powerful
combinatio 4. Take
ROUTE: n of Vitamin medication as
Oral C and Zinc. prescribed
It is the
BRAND NAME: only brand
Ceelin® Plus made with
ZincPlus®
DRUG Technology
CLASSIFICATIO that
NVitamin/Mineral ensures the
stable
combinatio
n of these 2
ingredients
so that kids
get the full
dose they
need.

MECHANIS NURSING
SIDE ADVERSE CONTRAINDICATI
DRUG INDICATION M OF RESPONSIBILITI
EFFECTS EFFECTS ONS
ACTION ES
GENERIC 1. treatment of - It acts -skin rash - hives, Amoxil is 1. Watch for
NAME: infections due through -fever - difficulty contraindicated in seizures; notify the
Amoxicillin to susceptible inhibition of - sore breathing patients who have physician
(lactamase– cell wall throat - swelling of experienced a immediately if the
DOSAGE: negative) biosynthesi - burning your face, lips, serious patient develops
5ml isolates of s that leads eyes tongue, or hypersensitivity or increases
streptococcus to the death - skin pain throat reaction to other seizure activity.
FREQUENCY: species. of the - severe lactam antibiotics
BID for 5 days bacteria stomach pain, (penicillins and 2. Monitor signs of
2. in and cephalosporins). pseudomembrano
ROUTE: combination diarrhea that is us colitis, including
Oral with watery or diarrhea,
clarithromycin bloody abdominal pain,
BRAND NAME: plus - red or purple fever, pus or
Amoxil, Larotid, lansoprazole skin rash with mucus in stool,
Moxylor as triple blistering and and other severe
therapy, is peeling or prolonged GI
DRUG indicated for problems (nausea,
CLASSIFICATIO the treatment vomiting,
N of patients heartburn).
Penicillin with H. pylori
antibiotics infection and
duodenal ulcer
disease