UNIVERSITY OF THE CORDILLERAS

College of Nursing
Governor Pack Road, Baguio City, Philippines 2600
(+6374) 442-3316, 442-2564, 442-8219, 442-8256
E-mail: webmaster@bcf.edu.ph
Website: www.bcf.edu.ph

PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA- C

WITH RULE OUT ACUTE GLOMERULONEPHRITIS

A Case Presented to the

College of Nursing

In Partial Fulfillment of the requirements in the Course

Care of the Mother, Newborn and Child at risk or with problems (ACUTE and Chronic)
NCM 109

Submitted by:
Bartido, Sophia Eriecka
Belly, Johanna Kate
Galamgam, Raditha Mae
Golocan, Xyla Zeen
Limmang, Clarissa Marie
Masigman, Shaira
Ofanda, Jezreel
Peg-ed, Janice
Salinas, Jojo
Soriano, Noreen Valerie
Tucyapao, Irish
Villanueva, Jayson

(Date: 19 -May- 2022)

Noted and Approved for Presentation:

Name of Case Presentation Adviser or Panel/s

__ Mitzy Sy__ __Jane Guzman_____

Signature of Adviser / Date Signature of Adviser / Date
 ABSTRACT

TITLE: Pediatric Community Acquired Pneumonia- C with Negative Acute Glomerulonephritis in Pedia
Ward
AUTHOR INFORMATION: Sophia Eriecka Bartido, Johanna Kate G. Belly, Raditha Mae N. Galamgam,
Xyla Zeen L. Golocan, Clarissa Marie P. Limmang, Shaira J. Masigman, Jezreel P. Ofanda, Janice P. Peg-ed,
Jojo U. Salinas, Noreen Valerie C. Soriano, Irish P. Tucyapao, and Jayson L. Villanueva. (alphabetical)
BACKGROUND: The case focuses on Pediatric Community Acquired Pneumonia- C on children and how it
is a very common and potentially dangerous infection in children that often requires hospitalization. CAP is
described as an infection of the pulmonary parenchyma in a patient who contracted the illness in the
community. CAP is a common, potentially fatal illness with a high rate of morbidity. The responsible of the
majority of CAP cases in children under the age of two are Viruses. After this period, bacteria such as
Streptococcus pneumoniae, Mycoplasma pneumoniae, and Chlamydia pneumoniae become increasingly
frequent. CAP symptoms are vague in younger infants, but cough and tachypnea are common in older children.
An x-ray of the chest can assist confirm the diagnosis. Most children can be treated empirically with oral
antibiotics as outpatients without the need for particular laboratory testing. Serious infections or symptoms that
persist or worsen necessitate more testing and may necessitate hospitalization. The diagnosis can also be made
based on the history and physical examination findings in children with fever and respiratory signs and
symptoms. The antibiotic choice and dosage should be based on the patient's age, the severity of the
pneumonia, and information of local antimicrobial resistance patterns. (shorten) (brief) (why this report
significant)
CASE DESCRIPTION: Patient X, a 3 year old toddler residing at Tinglayan, Kalinga was admitted at Bontoc
General Hospital Pediatric ward with a chief complaint of Cough, Fever, Edema and Vomiting. She was
admitted on May 5 2022 at 1:42 PM with an admission diagnosis of Pediatric Acquired Pneumonia- C rule out
acute glomerulonephritis. Approximately 4 days prior to admission, parents noticed facial edema and bipedal
edema with associated febrile episodes and were referred to go to the hospital. Right after admission, the
doctor ordered laboratory tests to make sure what is the condition of the toddler and some medications were
given to avoid progression of the disease.
CONCLUSION: This study will guide not only medical professionals, as well as parents of children who
have had pediatric community-acquired pneumonia in better managing the condition. This case has also
benefited us in acquiring knowledge that will help us improve our competency as future nurses. It has helped
us apply nursing processes, particularly in delivering appropriate nursing interventions to help patients in
managing their conditions. This case study will help everyone in the understanding and management of this
disease by proper health interventions and health teaching, guaranteeing a safe and healthy body among
children. (outcome of case , respond in treatment strength implication, future study)

2
 TABLE OF CONTENTS

I. Introduction ………………………………………………………………………………………….4
II. Statement of Objectives
A. General Objectives………………………………………………………………………..4
B. Specific Objectives …………………………………………………………………….….4
III. Patient’s Profile ……………………………………………………………………………….……..6
IV. Chief Complaint ……………………………………………………………………………….……6
V. Present History of Illness ……………………………………………………………………….…...6
VI. Past History of Illness ………………………………………………………………………………..6
VII. Family Health History ……………………………………………………………………………….6
VIII. Developmental History …………………………………………………………………………….6
IX. Social and Environmental History ………………………………………………………………..7
X. Lifestyle and Health Practices ……………………………………………………………………7
XI. Health Assessment ………………………………………………………………………………….7
A. General Survey ………………………………………..…………………………………...7
B. Head to Toe Assessment ……………………………………………………..…………..7
C. 13 Areas of Assessment …………………………………………………………..……....9
XII. Diagnostics …………………………………………………………………………………………13
XIII. Comprehensive Pathophysiology ……………………………………………………………..20
XIV. Treatment/Management
A. Drugs …………………………………………………………………………..……………22
B. IV Fluids ……………………………………………………………………………....…….37
C. Surgery …………………………………………………………………………..…………37
XV. Nursing Care Plans
A. Prioritization of Problems
A.1. List of Problems ……………………………………………………………………38
A.2. Basis for Prioritization ……………………………………………………...……...38
B. Nursing Care Plans
NCP 1 ……………………………………………………………………………...………41
NCP 2 ..…………………………………………………………………………………....43
NCP 3 ……………………………………………………………………..……………....45
NCP 4 ………………………………………………………………………..…………....47
NCP 5 ………………………………………………………………………..…………....49
C. Discharged Plan ……………………………………………………………………....….55
XVI. Learning Insights …………………………………………………………………………………...56
XVII. List of References …………………………………………………………………………...………59
XVIII. Appendices ……………………………………………………………………………………….....60
Appendix A: Approval/ Request Letter……………………………………………...……61

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 I. Introduction

The term "pneumonia" derives from the ancient Greek word "pneumon," which means "lung," so the
term "pneumonia" becomes "lung disease." Medically, it is an inflammation of one or both lungs' parenchyma
caused by infections more frequently, but not always, caused by it. Bacteria, viruses, fungi, and parasites are
among the various causes of pneumonia. The leading cause of morbidity and death is bacterial pneumonia.
There are four types of pneumonia, according to the new classification: community-acquired (CAP), hospital-
acquired (HAP), healthcare-associated (HCAP), and ventilator-associated pneumonia (VAP). Because this is
the condition of the chosen patient, this study focuses on Community-Acquired Pneumonia- C (CAP) in the
pediatric ward.

Community-acquired pneumonia- C is a potentially serious infection in children and often results in

hospitalization. It is a significant cause of respiratory morbidity and mortality in children, especially in
developing countries. Some common symptoms include, cough, tiredness (fatigue) and chest pain. It is the
leading cause of death in children younger than five years. The factors that increase the incidence and severity
of pneumonia in children include prematurity, malnutrition, low socioeconomic status, exposure to tobacco
smoke, and child care attendance. The diagnosis can be based on the history and physical examination results
in children with fever plus respiratory signs and symptoms. Chest radiography and rapid viral testing may be
helpful when the diagnosis is unclear. However, some types of pneumonia can be prevented with a vaccine,
good handwashing, and hygiene. Viruses cause a significant percentage of CAP infections, especially in
children younger than two years. The prevalence of viral pneumonia decreases with age. Respiratory syncytial
virus, influenza A, and parainfluenza types 1 through 3 are the most common viral agents. Other viral
pathogens include adenovirus, rhinovirus, influenza B, and enteroviruses. Human metapneumovirus has been
identified as a common cause of CAP in cases previously classified as virus-negative. The spectrum of illness
caused by metapneumovirus is similar to that of respiratory syncytial virus. Mixed viral and bacterial infection
accounts for 30 to 50 percent of CAP infections in children. The estimated worldwide incidence of
community-acquired pneumonia varies between 1.5 to 14 cases per 1000 person-years, and this is affected by
geography, season, and population characteristics. In the United States, the annual incidence is 24.8 cases per
10,000 adults with higher rates as age increases. The mortality rate is as high as 23% for patients admitted to
the intensive care unit. ( local cases in ph) ( bakit pinili itong cases) ( Citation ) (types of pneumonia ,
nationaly, localy, sign and symptoms)

II. Statement of Objectives

A. General Objectives
This case analysis aims to increase the understanding and knowledge of student nurses on how to
manage and care for pediatric patients with Community Acquired Pneumonia.

B. Specific Objectives
1. Define Community Acquired Pneumonia with negative acute glomerulonephritis: Fever, vomiting and
cough.
2. Illustrate the pathophysiology of Community Acquired Pneumonia with negative acute
glomerulonephritis and in relation to the signs and symptoms specifically observed in the patient.
3. Describe and identify the signs and symptoms of community acquired pneumonia.
4. Discuss the medical interventions for the management of community acquired pneumonia.
5. Formulate appropriate nursing care plans suited for the patient based on the assessment findings.
6. Identify care measures to be given to the patient and family to promote continuity of care and
independence after discharge.

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 III. Patient’s Profile:
Patient’s Name : Patient X
Age/sex : Female , 3 years old
Ward : Pedia
Occupation : N/A
Marital status : Single
Religion : Roman Catholic
Date of admission : May 02, 2022 at 1:42 PM
Admitting Diagnosis : Pediatric Community Acquired Pneumonia - C rule out acute
glomerulonephritis
Date of discharge : N/A
Final Diagnosis : N/A
Surgery (if any) : N/A
Date of Surgery : N/A

IV. Chief Complaint

Cough, Fever, Edema and Vomiting

V. Present History of Illness

Patient X, a 3-year-old was hospitalized due to facial edema . Approximately 4 days prior to
admission, the patient’s mother noticed facial edema and bipedal edema with associated febrile episodes.
Patient had also been persistently coughing (productive cough). According to the mother, no medications were
given to the patient prior to admission. After the symptoms persisted, the patient was referred to Bontoc
General Hospital for treatment. (clinic)

VI. Past History of Illness

The patient had no history of heart disease, allergies, kidney disease, accidents and or trauma, only
minor illnesses, such as cough, colds and fever and was remedied with water therapy with rest. Patient also has
no previous hospitalization record and previous operations.

VII. Family Health History

The patient’s mother reports that their family’s side has no history of Diabetes Mellitus, TB and other
illnesses mentioned upon assessment. ( Father )

VIII. Developmental History

The patient is a 3 year old female and according to Erik Erikson’s Developmental theory he belongs to
the second stage of psychosocial development which is autonomy vs. shame and doubt. In this stage, children
are learning to be self-sufficient in ways such as self-regulation, toileting, feeding, and dressing. The parents
stated that their child can feed herself and picks foods that interest her but needs assistance in dressing and
toileting. As a 3 year old who is very active her parents said that she always plays with other kids in their
neighborhood, loves to write and draw everywhere, and counts numbers from 1 to 3. She also loves to climb
and pick things from the floor. (autonomy)

IX. Social and Environmental History

Furthermore, the mother states that the patient has not come in contact with any harmful chemical
before admission. And only started feeling unwell 4 days prior to admission where unusual signs and
symptoms of illness were noticed by the mother. However, since the hospital is far from their house, they
chose to employ natural medicine and other common therapeutic practices to treat the patient. She claims that
they use it because it is effective at times, but also admits that it doesn’t always work. ( describe environment)

X. Lifestyle and Health Practices

The patient is mostly outside of their home since her parents take her where they work at. The patient has
complete nutrition by eating three complete meals a day with snacks included. The patient's food is mostly
prepared at home by her mother most of the time and seldomly has her parents buy meals from restaurants.
The patient drinks 6 glasses per day and mostly drinks packed juices as stated by her mother. The patient does

5
not drink supplement or vitamin tablets. (describe surounding )

XI. Health Assessment

A. General Survey
The patient was admitted for Community Acquired Pneumonia- C with negative acute
glomerulonephritis in the pediatric ward. The patient was received awake beside mother with productive
coughing along with yellowish to greenish sputum, afebrile with no nausea or vomiting. Upon monitoring the
patient, following the third day after admission, the patient’s vital signs were: T: 36.7, SPO2: 91%, PR: 105,
RR: 30, BP: 110/70. (recieved with intact heplock ) (height weight and BIM)

B. Head to Toe Assessment

1. Head Head is rounded, normocephalic, and symmetrical; no nodules or masses
and depressions upon palpation; hair well distributed and no parasites
noted; face appears smooth and has uniform consistency and with no
presence of nodules or masses and lesions. (edema )

2. Eyes The bulbar conjunctiva appeared transparent with few capillaries evident;
sclera is anicteric; palpebral conjunctiva is pale; no presence of edema or
tearing of the lacrimal gland; cornea is transparent, smooth and shiny and
the details of the iris are visible; pupils are black and equal round and
respond to light and accommodation; both eyes coordinately move in
unison with parallel alignment, and is able to follow the 6 cardinal fields
of gaze without difficulty. No color vision deficiency.

3. Ears The auricles are symmetrical and have the same color as her facial skin, it
is aligned with the outer canthus of the eye. Auricles are mobile, firm, and
not tender upon palpation. The pinna recoils when folded. During the
whisper test the client was able to hear in both ears and repeat the words
whispered.

4. Nose and Sinuses Nose appeared symmetrical, straight, and uniform in color. Client has
clogged nose, septum is located midline, no flaring noted. Client is unable
to distinguish different scents, and no episodes of epistaxis during the
shift, upon palpation there were no tenderness and lesions.

5. Mouth Lips are uniformly pink; moist, symmetric and have a smooth texture.
Client has 20 primary teeth present, and are pearly white in color, no
dental caries noted. Tongue is centrally positioned, pink in color, moist,
with presence of thin whitish coating. Oral mucosa is moist and pinkish,
no lesions noted, tonsils are not inflamed, uvula is located midline.

6. Neck ROM intact, able to change direction of head slowly and without
complaints of pain, carotid pulse are bilaterally symmetrical, full and
strong pulses, 2+ (remove), jugular vein is not distended, lymph nodes are
not palpable. Thyroid is not visible on inspection. The trachea is located
midline of the neck.

7. Chest Shape of the chest is normal, asymmetrical chest wall expansion noted.
Upon auscultation the client has harsh breath sounds, with adventitious
breath sounds such as wheezes and crackles at both lungs. (ok na daw)

8. Cardiac There were no visible pulsations on the aortic and pulmonic areas. No
presence of heaves or lifts.

9. Breast/Chest Skin color is similar with the rest of the body, areola is dark colored, no
lumps/masses, and discharges present.

10. Abdomen Abdomen is flat, color is consistent with the skin color of the body, no
abdominal distention noted. Upon palpation no masses and tenderness
noted.

11. Genitals According to the mother, there are no complaints when it comes to genital

6
 area. No lesions were noted and unusual discharges were reported. (wag
na ilagay kung hindi nakita)

12. Musculoskeletal Client is able to move with ease but needs minimal assistance from her
mother. Joints, muscles and bones are symmetrical, no presence of
swelling and redness upon palpation. (Accessory MUSCLE)

13. Integumentary Skin is pale; unblemished; and no visible open wounds were noted. She
has good skin turgor and skin is warm to touch. Hair is thick and evenly
distributed with no signs of lice infestation. Nails have the shape of a
convex curve, are intact with the epidermis, and are well trimmed.
Capillary refill is normal. No foul odor was noted. (edema)

7
 C. 13 Areas of Assessment

1. Psychosocial and Psychological Status

Patient X is a three-year-old female child from Dananao, Tinglayan Kalinga. She was taken to Bontoc
General Hospital at 1:41 p.m. together with her mother on May 2, 2022, with a two-day history of fever and
cough, edema on the face and lower extremities for four-days, and vomiting episodes. The admission diagnosis
was Pediatric Community Acquired Pneumonia-C Rule Out Acute Glomerulonephritis. During the interview,
the mother stated, "Kapag walang magbabantay sa anak namin, sinasama namin sa trabaho." "Lagi kami
naglalakad, sasakay lang kami ng jeep kung malayo yung pupuntahan namin," which she thinks is the source
of her daughter's sickness. (one reason)

Patient X belongs to Erik Erikson's second stage of psychosocial development, which is autonomy vs.
shame and doubt. At this age, children begin to acquire a sense of personal autonomy and control. They get a
sense of control over themselves and some basic confidence in their ability as they learn to accomplish things
for themselves.

2. Mental and Emotional Status

The patient is conscious and oriented about what is happening in her surroundings. She is lying in bed
asleep. Her clothes are fit and comfortable for her. She is shy but can respond to our questions.

3. Environmental Status
The patient has no complaints of uneasiness or discomfort concerning her environment. It is spacious
with other patients but no unnecessary noise. Her food and drinks are on her left side for easy access. She is
comfortably cuddled by her mom in the bed and has no problem sleeping. (saaang hospital)

4. Sensory Status
a. Visual Status
The patient's eyes are almond-shaped, with black irises, white sclera and able to move eyes without
tenderness, pain or difficulty. There are no optical devices noted being used by the patient. She was able to
follow the 6 cardinal eye gazes.
b. Auditory
Through a whisper test the patient can hear loud and soft sounds from a distance. The patient’s ears
have no visible lumps, discharges and lesions. No corrective auditory device noted being used by the patient.
c. Olfactory Status
Patient’s nose is symmetrical and no lesions or discharges are noted. There are no signs of birth
defects or congenital anomalies like cleft palate upon observation. Patient is unable to convey odor
distinctions, but as stated by the mother, the patient has an intact sense of smell. ( nosetril )
d. Gustatory Status
Patient’s lips are pinkish in color, dry, and symmetrical in shape. As verbalized by the mother, the
patient has no difficulties masticating and swallowing food.
e. Tactile Status
Facial sensations are symmetrical on both sides. She was able to perceive heat and cold, as well as
pain in proportion to stimulus. Patient has an intact body image.

5. Motor Status
Prior to hospitalization, the patient can walk and stand with no limitations. Upon assessment, the
patient is able to move on her own but still needs assistance from her mother. There is edema noted on the
lower extremities. (hindi nakakalakad kasi may edema)

6. Thermoregulatory Status

Date Time Temperature

05/5/22 10pm 36.7 Patient was afebrile and

2am 36.5 the temperature was
6am 36.7 within normal range.

8
 05/6/22 10pm 36.8 Patient was febrile and
2am 36.5 had an elevated body
6am 37.9 temperature

05/7/22 10pm 36.6 Patient was afebrile and

2am 36.9 the temperature was
6am 36.1 within normal range.
During the 3 days monitoring of the patient's temperature, there are no signs of hyperthermia, the
patient's axillary temperature is normal. During the assessment, the patient’s skin and extremities are warm to
touch. There are no signs of profuse sweats and irritability. The patient's room is well ventilated. (isali ang
elevated chuchu ) (normal range)

7. Respiratory Status

Date Time RR SPO2

05/5/22 10pm 35 91%

2am 28 95%
6am 25 94%

05/6/22 10pm 31 97%

2am 30 96%
6am 30 95%

05/7/22 10pm 23 94%

2am 30 95%
6am 27 97%
The patient has a respiratory rate of 30 however, patient experience above normal range during the
first day at 10pm and in normal range on the following day. Observed signs in difficulty in breathing.
Accessory muscle in use. Chest expansion is symmetric with each respiration.The normal value of respiratory
rate is 22-30 beats per minute. (normal rate ilagay)

8. Circulatory Status

Date Time CR Capillary Blood Pressure

05/5/22 8am 100 bpm 1- 2 second 110/80mmHg

2pm 98 bpm 1-2 second 110/70mmHg
6pm 99 bpm 1-2 second 110/80mmHg

5/6/22 8am 92 bpm 1-2 second 110/80

2pm 96 bpm 1-2 second 110/70
6pm 90 bpm 1 second 110/70

5/7/22 8am 100 bpm 1 second 110/80

2pm 95 bpm 1 second 110/80
6pm 92 bpm 1 second 110/70

The patient has a pulse rate of 95 bpm average , blood pressure of 110/70, and capillary refill of 1
second which are all normal. (capillary need) (normal range)

9. Nutritional status

9
 Upon assessment, the patient’s skin was not too dry and had a good skin turgor. She is on a low
protein and low salt diet as ordered. She still doesn’t have a good appetite and needs her mother’s help when
eating. There is no culture or religious dietary restriction reported by the patient’s mother. She can swallow her
food and medications well. (height and weight)

10. Elimination Status

As the patient stays in the hospital, she defecates 0 - 1 times a day and urinates 2-4 times a day. The
color of the urine is yellow, and the color of the stool is brown. The patient has no nausea and vomiting.

11. Sleep, Rest and Comfort Status

The patient sleeps for 6 to 8 hours each night. Her mother claims she doesn't experience insomnia and
shows no signs of sleep deprivation. She also takes a nap during the day for 1 hour. However, she wakes up
when peeing and defecating with the help of her mother. There is no medication provided to help the patient
sleep.

12. Fluid and Electrolytes Status

The patient was advised to increase her usual fluid intake to help her condition. Skin turgor is good,
the mucosa is moist, and capillary refill is normal. She is able to consume 7-8 glasses of water daily and also
urinates regulary (how many times). Mother denies the patient has the feeling of thirst.

13. Integumentary Status

Upon assessment, the patient’s skin is not too dry with no signs of jaundice, lesions or bruises, however
signs of pallor were noted. She has a good skin turgor and capillary refill of 1-2 seconds. Skin was warm to
touch and had a dark tone complexion. Her hair is black and thin with no parasites noted.
(facial expression , pag pinppisil)

10
XII. Diagnostics
Diagnostic Description of the
Procedure Procedure
Complete Blood A CBC is a procedure that
Count measures the different
components in the blood.
Doctors will measure
different blood cell levels
and compare them with the
expected levels for a person
of the same age and sex.
Any differences can
indicate a condition or
Significance/Purpose of Date of Significant Findings Implications
the Procedure Procedure
It is a very common test to May 2, 2022 Hemoglobin Low hemoglobin can be associated with
screen for problems or Normal range: certain illnesses and conditions, like
because a child isn't feeling 120 – 160 g/L anemia.
well. The levels of red blood Result:
cells, white blood cells, and 94
platelets can provide doctors
with information about
possible problems like
anemia, infections,
inflammation, and other
11
other problem. It may be conditions. Hematocrit Below normal, indicates that there is
part of a routine health Normal range: insufficient supply of healthy red blood
checkup, or a doctor may 35.0 – 40.0 cells (anemia).
order the test when a Result:
person shows symptoms of 28.0
an underlying health
condition. It can also help
monitor treatment or an
existing health problem.

WBC Within the normal range.

Normal range:
4.00 – 12.00 x 10^9/L
Result:
10.18

Lymphocyte Within the normal range.

Normal range:
20.0 – 60.0
Result:
40.2

12
Monocyte Within the normal range.
Normal range:
3.0 – 12.0
Result:
6.0

Neutrophils: Low neutrophil count indicates a

Normal range: condition called neutropenia. This makes
50.0 – 70.0 it harder for the body to fight off
Result: pathogens. As a result, the person is more
42.1 likely to get sick from infections.

RBC Within the normal range.

Normal range:
3.50 – 5.20 x 10^12/L
Result:
3.60

13
 Platelet count Above normal range indicates
Normal range: thrombocytosis, which can cause too
100 – 300 x 10^9 /L much clotting in the blood vessels. It
Result: could be a sign of immune system
372 problems or infections.

Diagnostic Description of the procedure Significance/ Purpose of the Date of Procedure Findings & Implications
procedure procedure

14
Urine Dipstick Strip A urine dipstick test is the
quickest way to test urine. It
involves dipping a specially
treated paper strip into a
sample of urine. This can be
done during an appointment
with the doctor, midwife, or
other health professional. The
results are usually available
within 60-120 seconds. A
sample doesn't need to be sent
to a laboratory for a urine
dipstick test, although if the
test is abnormal it might need
to do another sample to be sent
for further testing in a
laboratory.
Diagnostic Description of the procedure
procedure
Chest X-ray Chest radiography is the first
investigation performed to
assess pneumothorax because
it is simple, inexpensive, rapid,
and noninvasive; however, it is
This urine test is performed as
part of a medical examination
to discover early indications of
disease. It involves checking
the appearance, concentration,
and content of urine to detect
and manage a wide range of
disorders, including urinary
tract infections, kidney disease,
and diabetes.
Significance/ Purpose of the
procedure
It is used to determine the
severity of the patient’s
pneumothorax and to determine
the progress of his medical
management.
May 2, 2022 Physical Examination The color, pH, and specific gravity of the
Color: Yellow urine are all within normal range.
Transparency: Turbid Urine appears turbid, indicating a urinary
Ph: tract infection or mild dehydration, and a
Normal range: 5-7 large amount of protein is found in the urine
Result: 6.5 that may indicate kidney disease.
Chemical Examination
Protein: Positive (+++)
Specific Gravity
Normal range: 1002 - 1030
Result: 1010
Date of Procedure Findings & Implications
May 2, 2022 According to the anterior-posterior chest x-ray, the patient’s heart size is normal;
Pulmonary vascular markings are within normal; Both hemidiaphragm and
costophrenic angle are intact; and visualized osseous structures are unremarkable.
However, there are reticulohazed opacities seen in both lung parenchyma and
retrocharidac area. The final impression states that the patient has bilateral
15
 much less sensitive than chest
CT in detecting a small
pneumothorax, blebs, and
bullae.
Diagnostic Description of the procedure
Procedure
Ultrasound KUB Ultrasound refers to a
diagnostic medical imaging
technique of the abdomen and
stands for Kidneys, Ureters,
and Bladder, although in fact
the Ureters only show if they
are abnormally distended. A
KUB ultrasound is an
examination requested by
doctors to evaluate the urinary
tract (which includes the
kidneys, ureters, and urinary
bladder).
Significance/Purpose of the
procedure
A KUB Ultrasound may be
requested to look for changes
in the bladder wall, kidney size
or structure, to look for stones
in the urinary tract, to evaluate
reasons why you have recurrent
kidney infection, and to
identify the cause of renal or
pelvic pain.
pneumonia.
Date of procedure Findings and implications
According to the ultrasound of the Kidneys, Ureters, and Urinary Bladder; Both
May 2, 2022 kidneys are slightly enlarged with smooth borders but with slightly increased
parenchymal echopattern on the right. The cortical thickness are within normal. No
liathisis/mass noted. The perinephric regions are unremarkable. Both ureters are
undilated. Both psoas muscles are intact. The bladder is adequately filled with low
level internal echoes. No wall thickening nor thickness were observed. The
implications of this result is that there is a non-specific renal enlargement with mild
parenchymal disease on the right. The result also implies that although no wall
thickening in the bladder were noted, possibility of having cystitis cannot be totally
excluded.
Normal value of protien
chest xrya - ultrasound
cbc - urine stick
16
Antigen Test - need

17
XIII. Comprehensive Pathophysiology

XIV.

18
19
XV. Treatment/ Management
A. DRUGS

DRUG STUDY 1

DRUG NAME MECHANISMS OF ACTION INDICATIONS & ADVERSE EFFECTS NURSING RESPONSIBILITIES
CONTRAINDICATIONS

GENERIC: By binding to specific penicillin- INDICATIONs: CNS: BEFORE:

PENICILLIN binding proteins (PBPs) located For use in the treatment of severe seizures Dx:
G SODIUM inside the bacterial cell wall, infections caused by penicillin G- GI: a. Assess for history of allergies, particularly
BRAND: penicillin G inhibits the third and susceptible microorganisms when diarrhea, epigastric distress, nausea, penicillin, cephalosporins
PFIZERPEN last stage of bacterial cell wall rapid and high penicillin levels are vomiting, pseudomembranous
CLASS synthesis. Cell lysis is then required such as in the treatment of colitis b. Skin testing , dilute
THERAPEUTIC: mediated by bacterial cell wall septicemia, meningitis, pericarditis, GU:
BETA- autolytic enzymes such as endocarditis and severe pneumonia. interstitial nephritis. Tx:
LACTAM autolysins; it is possible that Derm: a. Monitor CBC, urinalysis, renal function tests
ANTIBIOTIC penicillin G interferes with an CONTRAINDICATION: rash, urticaria
PHARMACOLOG autolysin inhibitor. A history of hypersensitivity Hemat: EDx:
IC: (anaphylactic) reaction to any eosinophilia, leukopenia. Local: a. Educate patient to understand that
NATURAL SOURCE: penicillin pain at IM site, phlebitis at IV site hypersensitivity reaction may be delayed
PENICILLIN Benzylpenicillin: Uses, Misc:
DOSAGE: Interactions, Mechanism of Action| DRUG to DRUG allergic reactions including DURING:
DrugBank Online. (2015). anaphylaxis, serum sickness, and Dx:
ROUTE: Drugbank.com; DrugBank. Reaction chuchu superinfection a. Monitor signs of allergic reactions and
https://go.drugbank.com/drugs/ anaphylaxis, including pulmonary symptoms
INTRAVENOUS DB01053 (tightness in the throat and chest, wheezing, cough
dyspnea) or skin reactions (rash, prurits, urticaria)

Tx:
a. Observe closely for signs of toxicity

20
 EDx:
a. Educate patient on the side effects of the drug

AFTER:
Dx:
a. Monitor injection site for pain, swelling, and
irritation

Tx:
a. Instruct patient’s family to report untoward
signs and symptoms

EDx:
a. Educate patient’s family on the importance of
completing the dosage and frequency of the drug

DRUG STUDY 2

DRUG NAME MECHANISMS OF ACTION INDICATIONS & ADVERSE EFFECTS NURSING RESPONSIBILITIES
CONTRAINDICATIONS

GENERIC: Lagundi or Vitex negundo has been INDICATION: None were reported in the clinical BEFORE:
VITEX NEGUNDO traditionally used as herbal For the relief of mild to moderate trials of the syrup. Dx:

21
BRAND: medicine by Philippine and Indian
ASCOF folks. It;'s main health benefit is to
CLASS: ease respiratory complaints.
COUGH SUPRESSANTS Lagundi is generally used for the
AND EXPECTORANTS treatment of coughs, asthma
THERAPEUTIC: symptoms, and other respiratory
problems. Lagundi is also known
DOSAGE: for its analgesic effect that helps
5 mL alleviate pain and discomfort.
ROUTE:
ORAL SOURCE:
Lagundi / Vitex
NegundoHerbalMedicine,Health
Benefits,Uses, Side Effects.
(n.d.).Www.medicalhealthguide.co
m.http://www.medicalhealthguide.c
om/articles/lagundi.htm
cough due to common colds, flu and
mild to moderate acute bronchitis;
for relief of reversible mild to
moderate bronchospasm in adults
and children 2 years of age and
older with obstructive airway
disease such as asthma and chronic
bronchitis.
CONTRAINDICATION:
Hypersensitivity to the drug
a. Assess for possible contraindications and
cautions: any history of allergy to the drug;
persistent cough due to smoking, asthma, or
emphysema, which would be cautions to the use of
the drug; and very productive cough, which would
indicate an underlying problem that should be
evaluated.
Tx:
a. Perform a physical examination to establish
baseline data for assessing the effectiveness of the
drug and the occurrence of any adverse effects
associated with the drug therapy.
b. Monitor temperature to assess for underlying
infection.
c. Assess respiration and adventitious sounds to
evaluate the respiratory response to the drug
effects.
d. Monitor orientation and affect to monitor CNS
effects of the drug.
EDx:
a. Educate the client/so about the possible adverse
effects before taking the drug.
DURING:
Dx:
a. Verify the client's identity.
b. Administer the right drug in the right dose and
route at the right time.
22
Tx:
a. Advise the patient to take small, frequent meals
to alleviate some of the GI discomfort associated
with these drugs.

EDx:
a. Alert the patient that these drugs may be found
in OTC preparations and that care should be taken
to avoid excessive doses.

AFTER:
Dx:
a. Warn SO to prevent overdose of the drug.
Tx:
a. Monitor adverse effects.

EDx:
a. Provide thorough patient teaching, including the
drug name and prescribed dosage, measures to
help avoid adverse effects, warning signs that may
indicate problems, and the need for periodic
monitoring and evaluation, to enhance patient
knowledge about drug therapy and to promote
compliance.

23
DRUG STUDY 3

DRUG NAME MECHANISMS OF ACTION INDICATIONS & ADVERSE EFFECTS NURSING RESPONSIBILITIES
CONTRAINDICATIONS

GENERIC: Relaxes smooth muscles by INDICATIONS: CNS: BEFORE:

SALBUTAMOL stimulating beta 2 – receptors -To prevent and relieve dizziness, excitement, headache, Dx:
SULFATE thereby causing bronchodilation bronchospasm in patients with hyperactivity, insomnia a. Assessed and auscultated lung sounds
BRAND: and vasodilation reversible obstructive airway CV:
ASMACAIRE disease. Hypertension, palpitations, b. Monitored respiratory rate and oxygen
CLASS -To prevent exercise induced tachycardia, chest pain saturation
THERAPEUTIC: bronchospasm. EENT:
ANTI-ASTHMATIC conjunctivitis, dry and irritated c. Checked for signs of accessory muscle.
PHARMACOLOGIC: CONTRAINDICATIONS: throat, pharyngitis
BRONCHODILATOR Sensitivity to beta-adrenergic GI: Tx:
stimulants nausea, vomiting, anorexia, a. Assisted in a comfortable position. (Fowler’s
DOSAGE: SOURCE: Schnull, P.D. (2006). heartburn, GI distress, dry mouth Position)

24
 1mg/ 1mL (every many Nursing Spectrum Drug Handbook. METABOLIC:
hours) Second Edition. Hypokalemia b. Ensured safety by putting up the side rails.
www.nursesdrughandbook.com MUSCOLOSKELETAL:
ROUTE: Muscle cramps Edx:
INHALATION RESPIRATORY: a. Encouraged the mother of the patient to
Cough, dyspnea, wheezing, verbalize the concerns of the patient.
paradoxical bronchospasm
SKIN: b. Instructed the mother how to use the nebulizer.
pallor, urticaria, rash, angioedema,
flushing, sweating c. Educated the mother of the patient about the
OTHER: side effects of the drug.
tooth discoloration, increased
appetite, hypersensitivity reaction . DURING:

Dx:
a. Observed for irritable behavior.

b. Checked for difficulty of breathing.

c. Monitored oxygen saturation.

Tx:
a. Assisted in taking the drug.

EDx:
a. Educated the SO about the indication of the
drug.

b. Encouraged the SO to assist the patient at all

times.

AFTER:

25
Dx:
a. Monitored respiratory rate and oxygen
saturation.

b. Checked for signs of cough

c. Observed accessory muscle.

Tx:
a. Assisted in comfortable position (lying position)

b. Kept patient safety

EDx:
a. Encouraged SO that Salbutamol may cause
unusual or bad taste.

b. Instructed SO to tap the back of the

patient from up to down.

c. Encouraged SO to report any signs and

symptoms

d. Encouraged SO to check the color of the sputum

of the patient.

e. Encouraged the patient and the SO to increase

the fluid intake of the patient.

26
DRUG STUDY 4

DRUG NAME MECHANISMS OF ACTION INDICATIONS & ADVERSE EFFECTS NURSING RESPONSIBILITIES
CONTRAINDICATIONS

GENERIC: Produces a bacteriostatic effect on INDICATIONS: CNS: BEFORE:

CHLORAMPHENICOL susceptible organisms by inhibiting Serious infections for which no headache, confusion, delirium, Dx:
BRAND: protein synthesis, thus preventing other antibiotic is effective. depression, fever, peripheral a. Check the doctor's order.
CHLOROMYCETIN amino acids from being transferred neuropathy
CLASS to growing polypeptide chains. CONTRAINDICATIONS: CV: Tx:
DICHLOROACETIC Hypersensitivity to chloramphenicol gray syndrome in neonates a. As appropriate and ordered, obtain specimens
ACID or its components. EENT: for culture and sensitivity testing before starting
optic neuritis chloramphenicol therapy.
THERAPEUTIC: GI:
ANTIBIOTIC nausea, vomiting, diarrhea DURING:
HEME: Dx:
Dosage: aplastic anemia, bone marrow a. Assess the patient's condition.
10 ml ( every hours) SOURCE: Jones & Bartlett depression, granulocytopenia,
Learning. Nurse’s Drug Handbook, hypoplastic anemia, leukopenia, Tx:
Route: 2015. reticulocytopenia, thrombocytopenia a. Administer medication as prescribed on the
ORAL SKIN: right patient, right time, and right dosage.
rash
Others: AFTER:
anaphylaxis, angioedema Tx:
a. Inform patient or SO about the possible adverse

27
 effects of the drug.

EDx:
a. Instruct patient or SO to report severe or
prolonged GI problems.
b. Document accordingly.
DRUG STUDY 5
DRUG NAME MECHANISMS OF ACTION INDICATIONS & ADVERSE EFFECTS NURSING RESPONSIBILITIES
CONTRAINDICATIONS

GENERIC: Acts on the ascending loop of INDICATION: CNS: BEFORE:

FUROSEMIDE Henle in the kidney, inhibiting • Acute pulmonary edema dizziness, headache, vertigo, Dx:
BRAND: reabsorption of electrolytes sodium • Edema caused by heart failure weakness, lethargy, paresthesia, a. verify doctor’s order
LASIX and chloride, causing excretion of • hypertension drowsiness, restlessness, light- b. assess allergy to furosemide, sulfonamides,
CLASS: sodium, calcium, magnesium, headedness tartrazine
chloride, water, and some CV:
THERAPEUTIC: potassium; decreases reabsorption CONTRAINDICATION: hypotension, orthostatic Tx:
DIURETIC, of sodium and chloride and • Hypersensitivity to drug or other hypotension, tachycardia, volume a. do not mix parenteral solution with highly
ANTIYPERTENSIVE increases excretion of potassium in sulfonamides depletion, necrotizing angiitis, acidic solutions with ph below 3.5
the distal tubule of the kidney; • anuria thrombophlebitis, arrhythmias
PHARMACOLOGIC: responsible for slight EENT: b. do not expose to light, which may
SULFONAMIDE LOOP antihypertensive effect and DRUG-DRUG INTERACTION: Blurred vision, xanthopsia, hearing discolor tablets or solution
DIURETIC peripheral vasodilation. Increased risk of cardiac loss, tinnitus
arrhythmias with cardiac GI: EDx:
DOSAGE: glycosides; increased risk of nausea, vomiting, diarrhea, a. educate the patient about the purpose and
13 mg (13ml) x 12° ototoxicity with aminoglycoside constipation, dyspepsia, oral and importance of the drug
(lower than 90/60) antibiotics, cisplatin; decreased gastric irritation, cramping,
ROUTE: absorption of furosemide with anorexia, dry mouth, acute DURING:
INTRAVENOUS phenytoin; decreased GI absorption pancreatitis Dx:
with charcoal; may reduce effect of GU: a. check the patency of the IV site and IV line
insulin or oral antidiabetics because excessive and frequent urination,

28

SOURCE:
Linda Skidmore-Roth. (2014).
Mosby’s Drug Guide for Nursing
Students, 11th Edition St. Louise,
Missouri.
DRUG STUDY 6
blood glucose levels can become
elevated.
nocturia, glycosuria, bladder spasm,
oliguria, interstitial nephritis
HEMA:
anemia, purpura, leukopenia,
thrombocytopenia, hemolytic
anemia
HEPA:
jaundice
META:
hyperglycemia, hyperuricemia,
dehydration, hypokalemia,
hypomagnesemia, hypocalcemia,
hypochloremic alkalosis
MUSCO:
muscle pain, muscle cramps
SKIN:
photosensitivity, rash, diaphoresis,
urticaria, pruritus, exfoliative
dermatitis, erythema multiforme
OTHER:
fever, transient pain at I.M. site
b. give early in the day so that increased urination
will not disturb sleep
Tx:
a. administer the right dose at the right time
EDx:
• measure and record weight to monitor fluid
changes
AFTER:
Dx:
a. monitor blood glucose levels
Tx:
a. arrange to monitor serum electrolytes,
hydration, liver, and renal function
arrange for potassium-rich diet or supplemental
potassium as needed
EDx:
a. Instruct patient’s SO to report loss or gain of
more than 1.5kg in 1 day, swelling in the ankles or
fingers, unusual bleeding or bruising.
b. Document and record.
29
DRUG NAME MECHANISMS OF ACTION
GENERIC: Iron combines with porphyrin and
FERROUS SULFATE globin chains to form hemoglobin,
BRAND: which is critical for oxygen
IRON delivery from the lungs to other
Class tissues. Iron deficiency causes a
microcytic anemia due to the
THERAPEUTIC: formation of small erythrocytes
IRON PREPARATION with insufficient hemoglobin.
PHARMACOLOGIC:
IRON PREPARATION SOURCE:
Ferrous Sulfate.(2017, November
DOSAGE: 29). RxList; RxList.
10mg ( every hours) https://www.rxlist.com/consumer_f
errous_sulfate_slow_fe_fer-in-sol/
drugs-condition.htm
ROUTE:
ORAL
INDICATIONS &
CONTRAINDICATIONS
INDICATION:
Ferrous Sulfate is an essential body
mineral. Ferrous sulfate is used to
treat iron deficiency anemia (a lack
of red blood cells caused by having
too little iron in the body).
CONTRAINDICATION:
-iron metabolism disorder causing
increased iron storage
- an overload of iron in the blood
- a type of blood disorder where the
red blood cells burst called
hemolytic anemia
-an ulcer from too much stomach
acid
- a type of stomach irritation called
gastritis
- ulcerative colitis, an inflammatory
condition of the intestines
- diverticular disease
- excess iron due to repeated blood
transfusions
- problems with food passing
through the esophagus
ADVERSE EFFECTS
CNS:
CNS toxicity, acidosis, coma and
death with overdose
GI:
GI upset, anorexia, nausea,
vomiting, constipation, diarrhea,
dark stool, temporary staining of
teeth
NURSING RESPONSIBILITIES
BEFORE:
Dx:
a. Check the doctor’s order.
b. Assess for allergy to any ingredient;
hemochromatosis, hemosiderosis, haemolytic
anemias.
Tx:
a. Monitor blood studies.
EDx:
a. Confirm that client does have iron Deficiency.
DURING:
Dx:
a. Verify client’s identity
b. Administer the right drug in the right dose and
route at the right time
Tx:
a. Give drug with meals, avoiding milk, eggs,
coffee and tea.
b. Administer liquid preparation in water or juice
to mask the taste and prevent staining of teeth.
EDx:
30
a. Advice the client not take with antacids nor
tetracycline unless
prescribed.

AFTER:
Dx:
a. Warn patient that stool may be dark or green.

Tx:
a. Arrange for periodic monitoring of Hct and Hgb
levels.

EDx:
a. Report severe GI upset, lethargy, rapid
respiration and constipation.

b. Document and record.

31
B. IV Fluids

Name Classification Component/s Use & Effects

Nursing Responsibilities

1. n/a n/a n/a n/a n/a

C. Surgery

Procedure Description & Indication Nursing Care/Responsibilities

N/a N/a N/a

32
XVI. Nursing Care Plans
A. Prioritization of Problems
a.1. List of Problems
1. Ineffective Airway Clearance related to excessive mucus and retained secretions as manifested by crackle sounds and inability to cough out
secretions independently
2. Ineffective breathing pattern related to narrowing airways as evidenced by respiratory rate above normal range
3. Elevated body temperature related to inflammatory process secondary to PCAP C as evidenced by temperature of 37.9 degree Celcius
4. Risk for exacerbation of Infection related to compromised immune system secondary to Pediatric Community- Acquired Pneumonia-C
5. Risk for aspiration related to persistent coughing (3. Elevated body temperature related to inflammatory process secondary to PCAP C as evidenced by temperature of 37.9 degree
Celcius)

a.2. Basis for Prioritization

NURSING DIAGNOSES JUSTIFICATION

1. Ineffective Airway Clearance related to excessive
mucus and retained secretions as manifested by
crackle sounds and inability to cough out secretions
independently
This should be the top priority because It should be pointed out that ineffective
airway clearance, as well as other respiratory diagnoses, are usually priority
because they directly affect tissue oxygenation, requiring quick and resolutive
interventions. The human body has several mechanisms to keep the airway free
from occlusions such as the presence of microorganisms in the airway, the
presence of small hair in the nostrils, and the ability to cough to clear out
obstructions. In instances that these mechanisms are impaired, a risk for a
compromised airway arise. It is also important to acknowledge the signs and
symptoms associated with a compromised airway. (supporting factors)

2. Ineffective breathing pattern related to narrowing This should be the second priority because similar to ineffective airway
airways as evidenced by respiratory rate above clearance, ineffective breathing pattern requires quick and resolutive
normal range intervention. When the abdominal wall excursion during inspiration,

33

3. Risk for aspiration related to persistent cough
4. Risk for exacerbation of Infection related to
compromised immune system secondary to PCAP C
expiration or both do not maintain optimum ventilation for the individual, the
nursing diagnosis Ineffective Breathing Pattern is one of the issues nurses need
to focus on. It is considered the state in which the rate, depth, timing, rhythm,
or pattern of breathing is altered. When the breathing pattern is ineffective, the
body will likely not get enough oxygen to the cells. Respiratory failure may be
correlated with variations in respiratory rate, abdominal and thoracic patterns.
This should be the third priority because aspiration can lead to serious
complications, especially if the patient waits too long to see a doctor. The
infection may spread fast to other parts of the body. It can also enter the
bloodstream, which is extremely deadly. Lung pockets or abscesses can occur.
Pneumonia can induce shock or respiratory failure in rare circumstances.
Diseases that affect swallowing or generate additional inflammation may
worsen or prevent aspiration from healing adequately. Some serious infections
can cause long-term damage and scarring in the lungs and main airways.
This should be the fourth priority because if no action is taken, the severity of
the disease or its signs and symptoms will worsen. These flare-ups are often
linked to a lung infection caused by a virus or bacteria, such as a cold or some
other illness and since the immune system is compromised the body
is not able to fight off the bacteria, or virus very well which may lead to the
infection to worsen and cause the patient more trouble breathing or make more
noise when breathing. It is important to have a healthy immune system to
recover from pneumonia after treatment with antibiotics and rest.
34
5. Elevated body temperature related to
inflammatory process secondary to PCAP C as
evidenced by temperature of 37.9 degree Celcius
This should be the fifth priority because elevated body temperature is the
easiest to manage among the four nursing diagnosis. The only main goal is to
maintain the body temperature of the patients at the normal ranges by providing
necessary nursing interventions, and to prevent further complications and risks
related to elevated body temperature.
35
 B. Nursing Care Plans

NCP 1: Ineffective Airway Clearance related to excessive mucus and retained secretions as manifested by crackle sounds and inability to cough out secretions independently
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation

Subjective: Inability to clear secretions or STO: Dx: STO:

“Hindi niya kaya obstructions from the After 4-5 hours of effective • Monitored vital signs especially • To obtain baseline data and evaluate (Goal met)
palabasin yung plema respiratory tract to maintain a nursing interventions, the respiration rate degree of compromise After 4-5 hours of effective
niya. Umuubo naman pero clear airway. patient will be able to: nursing interventions, the
nalulunok niya lang yung a) demonstrate deep breathing • Indicatives of respiratory distress patient was able to
plema”, as verbalized by and coughing exercise; and • Assessed breath sounds and pattern and/or accumulation of secretions demonstrate deep breathing
pt’s mother SOURCE: Doenges, M., expectorate clear secretion and coughing exercise; and
Moorhouse, M.F., Murr, A., readily expectorate clear secretion
Objective: (2019). Readiness for Tx: • To gain patient’s trust and facilitate readily
• Patient has harsh breath enhanced Comfort. NANDA LTO: implementation of nursing care
sounds, with crackles on International: Diagnoses, After 3 days of effective • Administered bronchodilators as LTO:
both lungs upon Prioritized Interventions, and nursing interventions, the prescribed • To make breathing easier by relaxing After 3 days of effective
auscultation Rationales. 15th edition, p. 27. patient will be able to retain muscles in the lungs nursing interventions, the
• Uses accessory muscles F.A Davis Company airway patency and • Facilitated in nebulization q4 hours patient was able to retain
during respiration Philadelphia. demonstrate reduction of • Aids in relaxing the breathing airway patency and
• Persistent productive congestion as evidenced by muscles and permits air to flow more demonstrate reduction of
cough clear breath sounds, • Positioned client to an upright easily in and out of the lungs. It also congestion as evidenced by
• Patient is pale in position helps to loosen mucous in the lungs clear breath sounds,
appearance noiseless respirations, and
• Sp02: 91% • To take advantage of gravity improve oxygen exchange.
• RR: 35 cpm decreasing pressure on the diaphragm
• Assisted with deep breathing and enhancing drainage of/ventilation
Nursing Diagnosis: exercise of different lung segment
Ineffective Airway
Clearance related to

36
excessive mucus
production and retained
secretions as manifested
by crackle sounds and
inability to cough out
secretions
NCP 2: Ineffective breathing pattern related to narrowing airways as evidenced by respiratory rate above normal range
Assessment
Subjective:
“May mga oras na hirap
siyang huminga,” as
verbalized by the patient’s
mother.
Objective:
Explanation of the Problem
Ineffective breathing pattern is
defined as an inspiration or
expiration that does not
provide adequate ventilation.
When the breathing pattern is
ineffective, the body will
likely not get enough oxygen
Objective
STO:
Within 1-2 hours of effective
nursing interventions, the
patient will be able to:
a) perform diaphragmatic
pursed-lip breathing.
b) take part in medicines
• Demonstrated effective coughing • To maintain hydration status and to
exercise while in upright position mobilize secretions by liquefying
mucus
Edx:
• Educated mother on how to perform • Facilitates maximum expansion of the
bronchial tapping after every lungs and smaller airways.
nebulization.
• Coughing is a natural self cleaning
• Emphasized the need for the mother mechanism
to report any untoward signs and
symptoms observed.
• Encouraged increase of fluid intake • Chest physical therapy helps mobilize
at frequent intervals. bronchial secretions
• For prompt appropriate nursing
interventions to be performed and avoid
further complications
Nursing Intervention Rationale Evaluation
Dx: STO:
● Monitored for use of ● To be able to identify (Goal met)
accessory muscle increased in work of breathing Within 1-2 hours of effective
● Assisted client in the use of by retraction nursing interventions, the
relaxation technique ● To provide relief of causative patient performed
factors diaphragmatic pursed-lip
breathing; and tooks part in
37
 ● Pale in appearance to the cells. Respiratory
● Productive cough failure may be correlated with
observed variations in respiratory rate,
● Use of accessory abdominal and thoracic
muscles to breathe patterns.
● Restless
● SPO2: 91%
RR: 35 cpm
SOURCE: Doenges, M. E.,
Moorhouse, M. F., & Murr,
A. C. (2019). Nurse’s pocket
guide: diagnoses, prioritized
Nursing Diagnosis: interventions, and rationales
Ineffective breathing (15th ed.). F.A. Davis
pattern related to Company.
narrowing airways as Wayne, G. (2019). Ineffective
evidenced by respiratory Breathing Pattern – Nursing
rate above normal range Diagnosis & Care Plan.
Nurseslabs.
https://nurseslabs.com/ineffect
ive-breathing-pattern/
prescribed by the doctor and
treatment programs.
LTO:
Within 72 hours of effective
nursing interventions, the
patient will be able to:
a) remain a respiratory rate
within established limits.
b) maintain an effective
breathing pattern, as evidenced
by relaxed breathing at normal
rate and depth and absence of
dyspnea.
EDx:
● Observed for nasal ordered
Tx:
● Administered oxygen as
ordered
● Elevated the head of the
patient
● Administered prescribed
medications as ordered
● Demonstrated
diaphragmatic pursed-lip
breathing
● Instructed proper breathing
techniques
● Breathing may increased as medicines prescribed by the
lung compliance doctor and interventions
required.
LTO:
● Supplemental oxygen helps (Goal met)
reduce hypoxemia and relieve Within 72 hours of effective
respiratory distress nursing interventions, the
patient’s respiratory rate
remained within established
● To promote lung expansion, limits; and maintained an
opening airways, and improve effective breathing pattern.
circulation
● To manage the patient's
condition pharmacologically
● To maintain an effective
breathing pattern
● Proper breathing techniques
help get rid of the accumulated
stale air in the lungs and
increase oxygen levels as well
as get the diaphragm to return
to its job of helping you
breathe.
38
● Advised adequate rest ● This prevent fatigue and
periods in between daily reduces oxygen demand
activities

● Educated on the importance ● For the patient/ parent to gain

of taking the medication as more understanding about the
prescribed. medication and compliance
with the treatment

39
NCP 3 (POTENTIAL): Risk for aspiration related to persistent cough as evidenced by gagging

Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation

40
Objectives:
> Facial Grimace
> Gagging
> Productive Cough
Nursing Diagnosis:
Risk for aspiration related to
persistent cough as evidenced
by gagging
Aspiration occurs when food,
secretions, fluids, or other
substances enter the airways or
lungs. When you swallow, the
epiglottis should close over the
trachea which prevents food or
fluids from entering the
trachea (often called the
windpipe). If this mechanism
fails, unintended substances
can end up in the lungs which
can cause complications such
as aspiration pneumonia.
SOURCE:
Risk For Aspiration Nursing
Diagnosis & Care Plan. (2022,
February 18). NurseTogether.
https://www.nursetogether.co
m/risk-for-aspiration-nursing-
diagnosis-care-plan/
STO: Dx: STO
After 8 hours of effective nursing • Assess for gag reflex and • Impaired swallowing may After 8 hours of effective
intervention the patient will be swallowing. cause aspiration. nursing intervention the patient
able to : was able tol not experience
a) Patient will not Tx: aspiration as observed by clear
experience aspiration as
• Elevate the head of the bed or • To aid breathing and promotes lung sounds, unlabored
observed by clear lung upright position when eating. lung expansion. breathing, and oxygen saturation
sounds, unlabored within normal limits
breathing, and oxygen • Place patient on lateral • Reduces the risk of aspiration
saturation within normal
position or change the position. by allowing secretions to drain.
limits LTO
EDx: After 2 days of effective nursing
LTO : • Encourage pt. To drink fluids • To prevent blockage on the intervention the patient and SO
After 2 days of effective nursing when eating. passage of food. was be able to demonstrate
intervention the patient and SO appropriate techniques to
will be able to: • Instruct pt. To eat with small • To prevent obstruction on prevent aspiration, verbalized
a) Patient and/or caregiver amount of food. airway and aspiration. potential risk factors for
will demonstrate aspiration and was free from
appropriate techniques to aspiration and reduced the risk
prevent aspiration of recurrence
b) Patient and/or caregiver
will verbalize potential
risk factors for aspiration
c) Be free of aspiration and
reduce the risk of
recurrence
41
NCP 4 (POTENTIAL): Risk for exacerbation of Infection related to compromised immune system secondary to PCAP- C
Assessment Explanation of the Problem
Objective: Possibly evidenced by risk
● Shortness of factors of stasis of body
breath fluids, malnutrition and
● Weak looking associated condition of
chronic illness, decrease in
ciliary action,
Nursing Diagnosis: immunosuppression.
Risk for exacerbation of
Infection related to (paano nag manifest ung
compromised immune symptoms sa patient)
system secondary to
PCAP C
SOURCE:
Doenges, M., Moorhouse, M.,
& Murr, A. Nurse’s Pocket (SMART) 3 or more
Guide (p.1005)
Objective
STO:
Within 1 hr of nursing
intervention, the patient will be
able to achieve timely
resolution of current infection
without complications.
LTO:
Within 24 - 48 hrs of effective
nursing intervention, the
patient including SO will be
able to verbalize understanding
on how to prevent or reduce
risk of infection.
Nursing Intervention
• Assess immunization status and
history.
• Perform the proper handwashing
technique.
• Change position frequently and
provide good pulmonary hygiene.
• Administer prescribed antimicrobial
agents as ordered.
• Institute isolation precautions as
individually appropriate.
• Monitor effectiveness of
antimicrobial therapy.
• Encourage adequate rest balance
Rationale Evaluation
• Incomplete immunizations may not STO:
have sufficient acquired active Within 1 hr of nursing
immunity. intervention, the patient is
able to achieve timely
• This will prevent transmission and resolution of current
acquisition of infection. infection without
complications.
• Promotes expectoration, clearing of
infection. LTO:
Within 24 - 48 hrs of
effective nursing
• To prevent relapse of pneumonia, the intervention, the patient
patient needs a complete course of including SO is able to
antibiotics as prescribed. verbalize understanding on
how to prevent or reduce
• Dependent on the type of infection, risk of infection.
response to antibiotics, patient’s general
health, and development of
complications, isolation techniques may
be desired to prevent spread from other
infectious processes.
• Signs of improvement in condition
should occur within 24-48 hours. Note
any changes.
• Facilitates healing process and
42
 with moderate activity. Promote enhances natural resistance.
adequate nutritional intake.

• Encourage the patient to eat healthy

foods that can enhance the immune • It enhances the immune function of
function and take necessary vitamins the body.
needed.

NCP 5: Elevated body temperature related to inflammatory process secondary to PCAP- C as evidenced by temperature of 37.9 degree Celcius
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation

Subjective: Patient X was admitted at STO: Dx: STO:

“Awan ganas na ag ay Bontoc General Hospital Within 6-12 hours of effective ● Assessed for signs of ● Look for signs of dehydration, (Goal Met)
ayam, madi sa rikna na Pediatric Ward. (PCAP- C) nursing intervention the patient dehydration as a result of including thirst, furrowed Within 6-12 hours of
napudot pay suna” as Community-acquired will be able to: hyperthermia. tongue, dry lips, dry oral effective nursing

43
verbalized by the mother. pneumonia is a potentially
serious infection in children
Objective: and often results in
- Vital signs: hospitalization.It is a
Temp: 37.9 significant cause of
PR: 111 bpm respiratory morbidity and
RR: mortality in children,
SPO2: 96% especially in developing
BP: 110/70 countries. Some common
- Afebrile symptoms include, cough,
- Warm to touch tiredness (fatigue) and chest
- Irritable pain. It is the leading cause of
- Headache death in children younger than
- five years.
Hyperthermia is defined as
elevated body temperature due
to a break in thermoregulation
that arises when a body
Nursing Diagnosis: produces or absorbs more heat
Elevated body than it dissipates.
temperature related to
inflammatory process SOURCE:
secondary to PCAP- C as Stuckey-Schrock, K., Hayes,
evidence by temperature B. L., & George, C. M.
of 37.9 C (2012). Community-Acquired
Pneumonia in Children.
American Family Physician,
86(7), 661–667.
https://www.aafp.org/afp/201
2/1001/p661.html
(Hyperthermia – Nursing
Diagnosis & Care Plan, 2016)‌
a) maintain temperature within
normal limits.
LTO:
Within 2-3 days of effective
nursing intervention the patient
will be able to:
a) be free from hyperthermia
and experience no associated
complications.
● Monitored core temperature
by appropriate route (e.g.,
tympanic, rectal). Note the
presence of temperature
elevation (>98.6°F [37°C]) or
fever (100.4°F [38°C]).
● Noted the presence or
absence of sweating as the
body attempts to increase
heat loss by evaporation,
conduction,
● Monitored the patient’s heart
rate and blood pressure.
● Monitored respirations.
membranes, poor skin
turgor,decreased urine output,
increased concentration of
urine, and weak, fast pulse.
● Rectal and tympanic
temperatures most closely
approximate core temperature;
however, abdominal
temperature monitoring may be
done in the premature neonate.
● Evaporation is decreased by
environmental factors of high
humidity and high ambient
temperature,as well as body
factors producing loss of ability
to sweat or sweat gland
dysfunction (e.g., spinal cord
transection, cystic fibrosis,
dehydration, vasoconstriction).
● HR and BP increase as
hyperthermia progresses.
● Hyperventilation may initially
be present, but ventilatory
effort may eventually be
impaired by seizures or
hypermetabolic state (shock
and acidosis).
interventions, the patient
was able to maintain
temperature within normal
limits.
LTO:
(Goal Met)
Within 2-3 days of effective
nursing interventions, the
patient was able to
experienced no associated
complications and be free of
hyperthermia as manifested
by her temperature of 36.5,
no signs of discomfort, and
other vital signs are within
normal range.
After doing intervention and
shift.
44

● Checked and record all
sources of fluid loss such as
urine
Tx:
● Measured and documented
the client’s temperature every
hour or as frequently as
indicated, or when there is a
change in the client’s
condition.
● Provided blankets or
cooling blankets when
necessary.
● Oliguria and/or renal failure
may occur due to hypotension,
dehydration, shock, and tissue
necrosis
● Using a consistent temperature
measurement method, site, and
device will help make accurate
treatment decisions and assess
trends in temperature. Use two
modes of temperature
monitoring if necessary. All
non-invasive methods to
measure body temperature have
accuracy and precision
variances unique to each type
and method compared to core
temperature methods.
● Use cooling blankets that
circulate water when the body
temperature is needed to be
cooled quickly. Set the
temperature regulator to 1ºC
below the client’s current
temperature to prevent
shivering.
● A tepid sponge bath is a non-
45

● Provided a tepid bath or
sponge bath.
EDx:
● Encouraged the patient’s SO
to increase the patient’s fluid
intake
● Instructed the patient’s SO to
maintain bedrest.
● Recommended avoidance of
hot tubs/ saunas as
appropriate.
● Instructed the parents on
how to measure the child’s
temperature, at what body
temperature to give
antipyretic medications, and
pharmacological measure to
allow evaporative cooling. Do
not use alcohol as it can cool
the skin rapidly and may cause
shivering.
● To keep your urine pale yellow.
This helps to prevent
dehydration.
● To reduce metabolic
demands/oxygen consumption.
● Patients with cardiac conditions
may increase cardiac load.
● Fever may be treated at home
to relieve the general
discomfort and lethargy
associated with fever. Fever is
reportable, however, especially
in infants or very young
children with or without other
symptoms and in older children
or adults if it is unresponsive to
antipyretics and fluids, because
it often accompanies a treatable
infection (viral or bacterial).
● This indicates a need for
prompt intervention.
46
 what symptoms to report to
the physician.

● Reviewed signs/symptoms of
hyperthermia (e.g., flushed
skin, increased body
temperature, increased
respiratory and heart rate,
fainting, loss of
consciousness, seizures).

47
C. Discharge Plan

Health Teaching

Diet/Nutrition 1. Drink warm water and fruit juices

2. Take vitamin C tablets daily
3. Offer small amounts of food, but more often than
usual.

Activity 1. Avoid places where there is a lot of accumulation of

dust and smoke
2. Cover your nose and mouth when near people who
are sneezing or coughing
3. Get enough sleep
4. Wash hands often
5. Take deep breaths and cough
6. Breath warm, moist air

Medication 1. Take medicine as prescribed by physician

2. Don’t forget the time and always complete all
medication doses

48
XVII. Learning Insights
A. Bartido, Sophia
This case study taught me a lot and helps me as a student nurse to gain a better comprehension and
knowledge of the topic. In this case, I was able to enhance my knowledge regarding the pediatric community
acquired pneumonia c. And learn the most crucial function that nurses perform on a daily basis such as
determining the patient's condition which allows us to give the necessary care to avoid the illness/disease from
worsening. We are able to identify the primary problem through the effective evaluation using 13 areas of
assessment and by reviewing the diagnostics. By constructing a nursing care plan we are able to provide the
appropriate care for the patient, a nursing care plan that may also apply in the future with patients in similar
situations. For me as a student nurse, each case is a new learning experience that I will carry with me for the
rest of my career.

B. Belly, Johanna
Coming up with this study, we experienced ups and downs; with some having difficulty and others
completing their allotted assigned tasks on time. Despite the obstacles we faced, collaboration was vital.
Everyone in my group worked hard on every task that was given to them. Everyone also supported each other;
if one of our group members had difficulty completing this work, the other one fills it. I am thankful to have
been included in this group, and I am happy and proud to call them my groupmates. I've learned that in order
to produce a better result, there must be unity. Everyone must work together to make the study a success. One
of the features I observed in this group was the ability to lift each other up. I never witnessed someone in our
group keep someone alone or bring someone down. I wouldn't say we did very well, but I know we tried and
gave it our all. This study is difficult, but it is a good opportunity for us to expand our understanding of the
disease and, as a result, increase our capabilities in doing another case in the future. As to the study, I learned
that coughing, fever, and vomiting with edema are symptoms of pneumonia, which is an infection that causes
inflammation in the lungs. Pediatric pneumonia should not be underestimated since it can be fatal. Learning
about this disease will help us as student nurses in the future when we encounter patients with the same
condition and need to provide effective interventions and health teaching.

C. Galamgam, Raditha
I was able to see the patient on our second day of duty and helped in the assessment, so I learned to
communicate and how to get the trust of the patient and significant others. I have seen how hard it is to have
this illness, especially for children. However, as we went to her room to get her vital signs and others, we
chose to show our confidence and not our weaknesses. This case is challenging because it needs to be
monitored, especially her airways and breathing. We all know that these are the highest priorities. However,
even though we are aware that this is a complicated case, we chose to handle it through teamwork and
cooperation for patient recovery. I’m glad that my peers are cooperative and responsible. We learned a lot
about community pediatric-acquired pneumonia and how to effectively assess and care for patients through
case studies.

49
 D. Golocan, Xyla
Group work is more than simply a task; it is a means for students to learn together. It allows students
to learn about deep listening and engaging with different points of view. Learning and working together can
result in learning far more than learning alone. I gained a lot from this case presentation, including the value of
teamwork, patience, and trust. But most importantly, I learned from the case itself, which is about Community
Acquired Pneumonia.

E. Limmang, Clarissa
During the making of our case study presentation, I have learned a lot. But the most notable thing I’ve
learnt from this group is being able to learn from my groupmates’ insights and be productive as a group
member, which has helped me delegate tasks more easily and resulted in early completion deadlines. It has
influenced my own thinking and broadened my knowledge, and from our case presentation, I acquired new
ideas that will benefit me in the future as a nurse. I am thankful for the opportunity to work with and learn
from such kind and good people, as well as accommodating fellow learners!

F. Masigman, Shaira
As I did my part in making our case presentation, I’ve learnt that every individual’s participation in a
group work is crucial. I’ve learnt that we need each other’s help and cooperation. I’ve also learnt more about
community acquired pediatric pneumonia in a more detailed manner. Although I’m not fond of children, I’ve
developed patience and understanding towards them as they are unable to express themselves with what they
are feeling. This was my first time meeting a pediatric patient with PCAP and as we made this case
presentation, I was able to understand in a deeper depth the patient’s diagnosis. As I encounter more patients, I
bring my knowledge and understanding about PCAP.

G. Ofanda, Jezreel
While doing the case study, I have learned many things about the patient's diagnosis, pediatric
community acquired pneumonia, which is a very serious but common infection in children. We have to make
sure that the nursing intervention we perform is efficient and effective to boost their recovery and comfort.
Health teachings are also important to render to parents such as getting their children vaccinated to reduce the
incidence and severity of PCAP in children, and also proper hygiene to minimize the spread of infection.
Although it is pretty challenging doing this case study, I know that the knowledge and experience I have
gained will help me perform better in other nursing activities and as future nurses.

H. Peg-ed, Janice
What this case taught me about Community-Acquired Pneumonia was that even though it is quite
preventable, many children still develop it, and remains a common disease within their age group. This is
unfortunate because its consequences to their health may be fatal especially if complications arise.
Furthermore, I don’t like seeing the children go through what they do when they have pneumonia. It’s hard to
watch them having trouble breathing, see them cry when they are distressed about their medications; or listen
to their persistent coughing all night. That’s why I do hope that preventive measures against PCAP will be
more well known especially in places where cases are common. Things like immunization programs,
environmental remedies, hygiene, etc. can help lessen these cases. After all, we do believe that prevention is
always better than cure. That said, I did enjoy learning about PCAP despite the roadblocks our group
encountered during the case study.

I. Salinas, Jojo
During this case press I learned a lot and we need to be responsible in order to finish a good case. I
was not able to meet the patient too that’s why it’s very hard to get the pain scale but my groupmates help me
to finish my part on this case pres. Empathy is especially important for physicians and student nurses caring for
the littlest patients. This case pres is challenging because some of us was not able to meet the patient that’s
why i gathered my data through other groups that handle patient X because we need to work as one. I larned
that we can prevent pneumonia by having a good hygiene and practice a healthy lifestyle.

J. Soriano, Noreen
I was not able to meet the patient, but I was still able to contribute in making our case presentation
through the gathered data of my group mates during their duty. During the days that we made this case
presentation, I learned that teamwork will make doing activities a little less difficult to do. Different

50
 perspectives from other people will let others gain knowledge. Pneumonia can also be acquired outside of the
hospital. Parents should let their children play in clean environments that are away from dust, smoke and
people who cough and sneeze. They should also update their children’s immunization.

K. Tucyapao, Irish
Unity in diversity, as a student nurses with different perspectives and ideas we collaborated to be as
one in completing this case study. Although we had experienced difficulties through this journey we still
managed to contribute and finish every responsibility that was tasked. Here in the Philippines, pneumonia is
the third leading cause of death across all ages and is the most common cause of death among children<5 years
of age. During the process of our case study I realized and learned that good hygiene can help prevent
pneumonia by teaching children proper hand washing, covering mouth and nose when coughing and sneezing
and also immunization.

L. Villanueva, Jayson
I've learned that knowing about community acquired pneumonia, particularly its cause, is essential for
me to effectively provide proper nursing intervention and disease management, as well as appropriate health
teachings.

XVIII. List of References

● Aspiration from Dysphagia. (n.d.). Cedars-Sinai. Retrieved December 7, 2021, from
https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/aspiration-from-dysphagia.html
● Aspiration pneumonia: Treatment, complications, and outlook. (2018, June 10).
Www.medicalnewstoday.com. https://www.medicalnewstoday.com/articles/322091#complications
● Berce et al., The Usefulness of Lung Ultrasound for the Aetiological Diagnosis of Community-
Acquired Pneumonia in Children. 2019. retrieved from https://www.nature.com/articles/s41598-019-
54499-y
● Community Acquired Pneumonia. (2022). Retrieved from https://www.drugs.com/cg/community-
acquired-pneumonia-discharge-care.html
● Discharge Instructions - Pneumonia in children - discharge. (2017). Adam.com.
https://ssl.adam.com/content
● Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses,
Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
● Hariharan Regunath, & Oba, Y. (2021, August 11). Community-Acquired Pneumonia. Nih.gov;
StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430749/
● Penicillin G | Davis’s Drug Guide for Rehabilitation Professionals | F.A. Davis PT Collection |
McGraw Hill Medical. (2016). Mhmedical.com. https://fadavispt.mhmedical.com/content
● Stuckey-Schrock, K., Hayes, B. L., & George, C. M. (2012). Community-Acquired Pneumonia in
Children. American Family Physician, 86(7), 661–667.
https://www.aafp.org/afp/2012/1001/p661.html
Pediatric Pneumonia - Conditions and Treatments | Children’s National Hospital. (2022).
https://childrensnational.org/visit/conditions-and-treatments/airway-lungs/pneumonia
● Urine Dipstick Test. (n.d.). Patient.info. https://patient.info/treatment-medication/urine-dipstick-
test#nav-0
● Healthcare, B. (n.d.). Ultrasound of the Kidneys, Ureters & Bladder (KUB). Beehive Healthcare.
Retrieved May 15, 2022, from http://www.communityultrasound.co.uk/kub-ultrasound/

51
XVIII. Appendices

52
 Appendix A

Approval/Request Letter

To:

Thru: Juliet Avena

Clinical Coordinator

Dear Ma’am,

Greetings!

We, the Level II Section F Group C, would like to reserve the case with a diagnosis of PEDIATRIC
COMMUNITY ACQUIRED PNEUMONIA- C WITH NEGATIVE ACUTE GLOMERULONEPHRITIS IN
PEDIA WARD presentation this second semester of school year 2022-2023. This case was presented to us for
our virtual case presentation on May 19 2022. Our clinical instructors for the virtual case presentation are
Ma’am Mitsy Sy and Ma’am Jane Guzman .

We are glad to accept this case to further enhance our knowledge and management.

Thank you very much for your kind consideration and God Bless!

Respectfully yours,

__________________________ __________________________
Bartido, Spophia Belly, Johanna Kate

__________________________ __________________________

Galamgam, Raditha Mae Golocan, Xyla Zeen

__________________________ __________________________

Limmang, Clarissa Masigman, Shaira

__________________________ __________________________

Ofanda, Jezreel Peg-ed, Janice

__________________________ _________________________

Salinas, Jojo Soriano, Noreen Valerie

__________________________ __________________________
Tucyapao, Irish Villanueva, Jayson

53
54