JAMES ANDRE N.

RENDON
BSN 2A, GR.1

Case Scenario No. 1

Wambui is 8 months old. She weighs 6 kg. her length is 69 cm. Her temperature is 39°C.

Her father tells the health worker, "Wambui has had a cough for 3 days. She is having trouble breathing.
She is very weak." The health worker says, "You have done the right thing to bring your child today. I
will examine her now."

The health worker checks for general danger signs.

The mother says, "Wambui will not breastfeed. She will not take any other drinks I offer her." Wambui
does not vomit everything and has not had convulsions. Wambui is lethargic. She does not look at the
health worker or her parents when they talk.

The health worker counts 55 breaths per minute. He sees chest indrawing. He decides that Wambui has
stridor because he hears a harsh noise when she breathes in. He does not hear wheezing.

Disease:

 Cough
 Trouble breathing

General Danger Signs:

(-) Vomiting

(+) Lethargic

(-) Convulsions

(+) Chest Indrawing

(+) Harsh Noise

(-) Wheezing

Classifications:

 Very Severe Febrile Disease

 Severe Pneumonia
 Severe Dehydration
  Possible Bacterial Infection

Treatment/Management:

 Give first dose of an appropriate antibiotic.

 Treat the child to prevent low blood sugar.
 Give one dose of paracetamol in clinic for high fever (38.5° C or above).
 Refer URGENTLY to hospital.
 Give fluid for severe dehydration
 Advise the mother to continue breastfeeding.
 If child is 2 years or older and there is cholera in your area, give antibiotic for cholera.
 Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.

Diagnosis:

 Risk for Dehydration related to insufficient fluid intake

 Hyperthermia related to bacterial infection
 Ineffective breathing pattern related to pneumonia

FDAR

Date Focus Data, Action, Response

5/8/2023 Insufficient Fluid D- 8 months old baby girl, weighs 6 kg, length 69
Intake cm, T: 39 C, RR: 55 bpm, Will not breastfeed,
have cough, not taking other drinks offer, weak,
trouble in breathing

A- Observe and measure the urinary output, note

the color and amount of it, provide safety
measures, encourage to drink prescribed amount
of water to intake, assist position in every 2 hours,
promote proper ventilation and environment

R- The patient seen conscious and coherent and

was able to maintain fluid volume

Case Scenario No. 2

Pemba is 18 months old. He weighs 9 kg, his length is 70 cm, and his temperature is

37°C. His mother says he has had a cough for 3 days.

The health worker checks for general danger signs. Pemba's mother says that Pemba is able to drink
and has not vomited anything. He has not had convulsions. Pemba is not lethargic or unconscious.

The health worker counts the child's breaths. He counts 38 breaths per minute. The mother lifts the
child's shirt. The health worker does not see chest indrawing. He does not hear stridor or wheezing when
he listens to the child's breathing.

Disease:

 Cough

General Danger Signs:

(-) Not able to drink/eat
(-) Vomiting
(-) Convulsions
(-) Lethargic/Conscious
(-) Chest indrawing
(-) Stridor/wheezing

Classifications:

 No pneumonia: Cough or Cold

 No anemia or not very low weight

Treatment/Management:

 If child is less than 2 years old, assess the feeding and counsel the mother on feeding according to
the food box on the counsel the mother chart.
 If feeding problem, follow-up in 5 days
 Advise mother when to return immediately.
 If coughing more than 30 days, refer for assessment. Soothe the throat and relieve the cough with
a safe remedy.
 Advise mother when to return immediately.
  Follow-up in 5 days if not improving.

Diagnosis

 Ineffective Airway Clearance

 Imbalanced Nutrition


Date Focus Data, Action, Response

D- 18 months old baby boy, weighs 9 kg,
5/8/2023 Ineffective Airway Clearance length 70 cm, T-37 C, RR- 38 bpm,
cough for 3 days

A- Evaluate response for the activity,

administer medications, soothe the throat
and relieve the cough with a safe remedy,
allow the patient to have enough
relaxation intervals and emphasize the
value of cuddling to keep the child
comfortable, educate the mother about
proper coughing and deep breathing
exercises.

R- The patient will have greater air

exchange.