NURSING PROCESS

A Group Nursing Process

In Partial Fulfillment of the Requirements

For RLE class

Submitted by:

Castillo, Mary Grace O.Castro, Marion G.

Contreras, Mary Ann Mae R.Cuneta, Justine Joy D.

Daño, Charles Kevin R.De Paz, Angelyne

De Vera, James MatthewBSN II – A-01

Submitted to:

Ms. Lorna Melosantos, RN, MAN

Date Submitted:

February 15, 2011

Introduction

Pneumonia is an infection of the lung that can be caused by nearly any class of organism known to cause human infections. These include bacteria, amoebae, viruses, fungi, and parasites. Pneumonia is also the most common fatal infection acquired by already hospitalized patients. In developing countries, pneumonia ties with diarrhea as the most common cause of death. Even in nonfatal cases, pneumonia is a significant economic burden on the health care system.

Nursing Process

I. Assessment

A. General Data

Patient's Initials: P.J.P.M. Informant: Mother of patientAddress: Caloocan City Date of Admission: 02/07/2011Age: 1 ½ yrs old Order of Admission: AmbulatorySex: Female No. of days in the hospital: 3 daysDate of Birth: July 26, 2009Civil Status: N/AOccupation: N/A

B. Chief Complaints

"Limang araw nang inuubo at sinisipon may kasamang lagnat ang anak ko, tapos nahihirapan syang huminga”. As verbalized by the mother of the patient.

C. History of present illness

5 days prior to admission, patient had DOB due to non productive cough and cold accompanied with fever and body malaise. Patient consulted at the Cabarles lying-in clinic and was given a paracetamol for on/off fever. He was then advised to undergo an x-ray examination. Few hours prior to admission, the patient experienced an episode of vomiting. The x-ray result showed that the patient has bronchopneumonia and thus opted consult at the Queensberry Hospital.

D. Past History

1. Childhood Illness: bronchopneumonia2. Adult Illness: N/A3. Immunization: complete EPI immunization4. Previous hospitalization: 02/07/20115. Operations: none6. Injuries: None7. Medication taken prior to confinement: Cefuroxime, Gentamicin, Ranitidine, Metoclopromide, Paracetamol8. Allergies: none

E. Family Assessment

Name Relation Age Sex Occupation Educational Attainment

L.M Mother 29 F Check-out team leader

College graduate

J.M father 27 M driver College undergraduat

e

F. Heredo

Maternal: DiabetesPaternal: None

G. Developmental Theory

Theorist Age

Task Patient’s Description

Erik Erikson 1½ Trust The patient’s mother said that her son would always cry if someone he doesn’t know carries him or approaches him.

Sigmund Freud

1½ Oral The patient’s mother said that her son sometimes suck on his thumb, and likes to put things in his mouth.

Jean Piaget 1½ Sensory Motor Stage

(Coordination of Reactions)

According to the mother of the patent, the child is able to imitate the observed behaviors of other. The child also begins to recognize certain objects like the rattle.

James Fowler

1½ Undifferentiated The child doesn’t cries when only the relative is present and her mother is not around.

I. Anthropometric Measurements

Head Circumference: 47cm Chest Circumference: 95cm Abdominal Circumference: 49cm

Vital Signs:

T: 37.9RR: 34PR: 156

Physical Assessment:

Skin The patient’s skin is light brown, with a few dark spots scattered on his arms. Skin on the sides of the patient’s toes was dry and broken. The patient’s skin temperature is warm to touch. His skin recoils quickly when pinched.

NailsThe patient’s nails have a convex curvature and are smooth. The nail beds are pale pink. After performing the blanch test, the nail returns to its color in approximately two seconds.

HairThe patient’s hair is thin and is distributed evenly on his scalp. No infestations were seen.

Skull and faceThe skull of the patient is round. His facial features are symmetrical. There are no observable deformities on the child’s face.

EyesThe patient’s eyebrow hair is distributed evenly. Eyebrows are aligned to the upper part of the ear. Dark bags are present under the patient’s eyes. The patient’s eyelids close simultaneously.

EarsThe patient’s auricles have the same color with his facial skin. They are symmetrical and are aligned with the outer canthus of the eye. His auricles are firm and the pinna recoils quickly when folded.

NoseThe patient’s nose is in midline and is straight. His nostrils sometimes flare when he coughs. There are also no visible lesions on the nasal mucosa. The air passing through the client’s left and right nares are unequal. Nasal septum is placed in the midline and is intact.

Mouth and OropharynxThe patient’s lips are pink and have chapped skin. The patient’s lips have a symmetrical contour. The inner part of the mouth was not examined because the patient coughs frequently and was restless.

NeckThe patient’s neck held his head properly positioned in the center. Lymph nodes on the neck were palpable. Patient showed no signs of tenderness on the nodes upon palpation.

Thorax and LungThe patient’s chest is somehow bloated. Spine is aligned vertically and the spinal column is straight. When breathing sounds were auscultated, rattling sounds were heard on both sides with varying sound intensities.

AbdomenThe patient’s abdomen is slightly enlarged. The patient did not show signs of tenderness when the abdomen was lightly palpated. Auscultation for borborygmic sounds was not performed due to the patient’s restlessness.

Genitals

Inspection was the only procedure done because the patient’s genital was encased in a detachable plastic container that catches the patient’s urine. The skin on the genital is intact, and there were no observable lesions.

II. Environmental History:

According to the mother of the patient, their house is located at the side of the road. Sometimes they get disturbed on the noise made from the vehicles passing by the road. Their house has only one floor with two windows. The family has many plants and trees on their garden. All houses are far from each other so the place does not look crowded.

IV. Pediatric history

Birth history

Birth date: July 26, 2009Hospital: Cabarles lying-inBirth weight: 2.6kgType of Delivery: NSD

VI. Pathophysiology

Pneumonia is an illness that can affect the lungs and respiratory system of children. In pneumonia, the alveoli, small sacs within the lungs that provide gas exchange, become inflamed and filled with fluids, preventing them from functioning properly.

A. Theoretical Based:

B. Client Based: From 2nd page of The theoretical based

VII. Laboratory Result

Was observed via physical examination

Chief Complaint

Laboratory(date)

Normal Value Result Interpretations

02/07/2011Hemoglobin

RBC Count

Hematocrit

WBC Count

Platelet count

Lymphocyte

10.3-12.4 g/dl

4.1-5.0 x106/µL.

30.9-37.7%

5-10 g/dl

219–452 x10³/µL.

20-40%

12.58

3.95

37

12.0

286

23%

The patient's hemoglobin is above the normal range

The patient's RBC count is below the normal range

The patient's hematocrit is within the normal range

The patient's WBC count is above the normal range

The patient's platelet count is within the normal range

The patient's lymphocyte is within the normal range

VIII. Drug Study

Drugs Indication Action Side effect/adverse

effect

Nursing Consideration

Patient Teaching

Date:02/07/11Generic Name: Ranitidine HydrochlorideBrand Name: ZantacDosage: 0.5cc/IVP, q6

-Short-term treatment of active, benign gastric ulcer- Treatment of heartburn, acid indigestion, sour stomach

Competitively inhibits the action of histamine at the H2

receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin and pentagastrin.

-CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo-CV: tachycardia, bradycardia-Dermatologic: rash, alopecia-GI: constipation, diarrhea, nausea and vomiting, abdominal pain, hepatitis-GU: impotence or decreased libido

-GI: nausea and diarrhea

- Administer oral drug with meals and at bedtime.-. Decrease doses in renal and liver failure.- Provide concurrent antacid therapy to relieve pain.- Arrange for regular follow-up including blood test, to evaluate effects.- Monitor BP carefully during IV administration.- Monitor diabetic patients, arrange for alterations in insulin dose or timing if diabetic control is

• Patient should not run or do physicalactivities/ hazardous activities until he knows how drug affects concentration and alertness.• Tell mother of the patient that smoking may decrease drug effects.

-instruct the mother to let her son take the meds. 30

Generic Name: MetoclopramideBrand Name: MaxolonDosage:0.5cc

Generic name:CefuroximeBrand Name: Zinacef, Ceftin Dosage:2.2cc q8

Generic name:ParacetamolDosage:5 ml, q4

-Disturbances of GI motility-Nausea and vomiting-Metabolic diseases

For the treatment of many different types of bacterial infections such as bronchitis, sinusitis, tonsillitis, ear infections, skin infections, gonorrhea, and urinary tract infections

To relieve mild to moderate pain due to things such as headache, muscle and joint pain, backache and period pains. It is also used to bring down a high

Blocks dopamine receptors by disrupting CNS chemoreceptor trigger zone, increasing peristalsis and promoting gastric emptying

Inhibits bacterialwall synthesis,rendering cell wallosmoticallyunstable, leadingto cell death bybinding to cell wallmembrane

Paracetamol possesses prominent antipyretic and analgesic effects.. The

CNS: restlessness, drowsiness, fatigue, insomnia, dizziness, anxiety

-CV: transient hypertension

-GI: nausea and diarrhea

CNS: Dizziness,headache, fatigue,paresthesia, fever, chills, confusionGI: Diarrhea, nausea,vomiting, anorexia,glossitis, bleeding,increased AST, ALT,bilirubin, LDH, alkaline phosphatase, abdominal pain, loose stools, flatulence, heartburn, stomach cramps, colitis, jaundice

Side effects are rare with paracetamol when it is taken at the recommended doses. Skin rashes, blood

compromised by alterations in timing of food absorption.

-Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated.

-Report onset of loose stools or diarrhea. Although pseudomembranous colitis.

-Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes. Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition.

-Assess for Lab tests: Perform C&S and renal function prior to

minutes before meals.- Instruct the mother to report involuntary movements of face, eyes, or limbs.- Patient should not do run or do physical activities until drug's effects are known.

-Teach mother to recognize signs and symptoms of superinfection. Instruct him to report these right away.- Advise mother to report CNS changes.

-Do not self-medicate children for pain more than 5 d without consulting a physician. -Do not use for fever persisting longer than 3 d, fever over

Generic name:GentamycinDosage:0.5cc/IVF, q8

temperature. Paracetamol is often included in cough, cold and flu remedies.

Gentamicin is an aminoglycoside antibiotic, which is used to treat infections caused by aerobic gram-negative bacteria. Gentamicin in combination with penicillin has synergetic antibacterial effects against gram positive cocci.

mechanism of action is related to depression of the prostaglandin synthesis by inhibition of the specific cell cyclooxygenase, and depression of the thermoregulatory center in the medulla oblongata.

Destroys gram-negative bacteria by irreversibly binding to 30S subunit of bacterial ribosomes and blocking protein synthesis, resulting in misreading of genetic code and separation of ribosomes from messenger RNA

disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for a long time.

Nephrotoxicity occurs and is related to the length and dosage of gentamicin. The initial toxic effects are renal failure that causes serious effects. Gentamicin may also cause irreversible ototoxicity that may lead to hearing loss.

first dose and periodically during therapy; therapy may begin pending test results. Determine creatinine clearance and serum drug concentrations at frequent intervals, particularly for patients with impaired renal function, infants (renal immaturity), older adults, patients receiving high doses or therapy beyond 10 d, patients with fever or extensive burns, edema, obesity.

-Repeat C&S if improvement does not occur in 3–5 d; reevaluate therapy.

-Draw blood specimens for peak serum gentamicin concentration 30 min–1h after IM administration, and 30 min after completion of a 30–60 min IV infusion. Draw blood specimens for trough levels just before the next IM or IV dose. Use nonheparinized tubes to collect blood.

39.5° C (103° F), or recurrent fever. -Do not give children more than 5 doses in 24 h unless prescribed by physician.

-Advise mother to report signs and symptoms of ototoxicity (hearing loss, ringing in ears, vertigo).-Instruct patient to drink plenty of fluids to ensure adequate urine output.-Tell mother to monitor urine output and report significant changes.-patient should not run or do physical activities until he knows how drug affects concentration and alertness.

XI. List of Priority Problems:

1. Altered body temperature2. Risk for infection3. Impaired gas exchange

X. Nursing Care Plan

Cues Nursing diagnosis

Rationale Goal and Objective

Intervention Rationale Evaluation

S: “ Nilalagnat ang anak ko” as verbalized by the mother’s patient

O: -tachypnea-febrile-T= 37.9 C-RR=34 cpm-(+) crackles

Altered bodytemperaturerelated to bacterialinvasion in thelungs asmanifested bybody temperaturehigher thannormal, tachypnea,(+) crackles

Bacterialmicroorganisms(e.g. pulmonarypathogens) enterthe airwayThese bacteria/virusesinfects the lung/sInflammation of the lung/sSigns andsymptoms ofPneumonia(e.g.temperaturemay be greater than37.5°C), tachypnea,coughs withgreenish secretions

sources:www.healthline.com/channel/bronchopneumonia.html

-After 2 hours of NursingIntervention, the Pt’s temperaturewill decreasefrom 37.9 °C to normal range(36.6 - 37.5 °C)

Independent:-Monitor Pt’sTemperature q1 hr

- Encourage Pt to rest

-Encourage Pt to increase fluid intake

-Encourage the Pt’s guardian to do tepidsponge bath

-To determine if the Pt’s temperature isAbove the normal bodytemperature-Allows the patient torecuperate physical strength

-To maintainhydration status andincreased fluid intake-Sponge bath with warm water evaporatesoff his skin, thus, cooling off the Pt

After 2 hours of NursingIntervention, the goal was met. The Pt’s temperaturedecreasedfrom 37.9 °C to normal range(36.6 - 37.5 °C)

Cues

S:O: - Presence of infection- Antibiotic therapy

Diagnosis

Risk for infection (spread) r/t broncho-pneumonia as evidenced by the presence of current infection

Rationale

Bacterialmicroorganisms(e.g. pulmonarypathogens) enterthe airway↓Thesebacteria/virusesinfects the lung/s↓Inflammation of the lung/s

Source: medical-dictionary.thefreedictionary.com/bronchopneumonia

Goals and Objective

-After 30 minutes of health teachings, the patient’s mother will know of the importance of strictly following her son’s medication regime

Intervention

Independent:

-Teach the mother of the pharmaco-dynamics of her son’s therapeutic drugs

-Advise patient’s mother to make a schedule for son’s medications

-Advise mother to strictly follow the medication order

Rationale

- To improve the understanding of the mother on why her son’s medications are important

- To avoid skipping of doses

- to hasten the recovery of the patient

Evaluation

After 30 minutes of health teachings, the goal was partially met. Health teaching was interrupted due to the patient was gagging. Drug pharmaco-dynamics were not explained properly, but the medication schedule was advised.

Cues Diagnosis Rationale Goals and Objectives

Interventions Rationale Evaluation

S:“Nahihirapan sya huminga paminsan” as verbalized by the mother of the patientO: - Diagnosis of broncho-pneumonia- Patient is restless and constantly sits up and starts to gasp continuously- Tachycardia

Impaired gas exchange r/t broncho-pneumonia as evidenced by gasping to breathe and restlesness

Bacterialmicroorganisms(e.g. pulmonarypathogens) enterthe airway↓Thesebacteria/virusesinfects the lung/s↓Inflammation of the lung/s↓Gas exchange is impaired

Source: medical-dictionary.thefreedictionary.com/bronchopneumonia

- For the whole shift, the patient’s difficulty to breathe will be relieved

-After 30 minutes of health teachings, the patient’s mother will know of simple interventions to aid her child.

Independent:

- Observe patient for coughing and any sign of difficulty in breathing and:> Shift the child’s position and elevate the head of the bed> Let the child continue to rest

-Advise patient’s mother to shift her child’s position frequently and rub her child’s back when he coughs, as well as keep the child’s fluid intake adequate

- for immediate action on the problem

> Promote optimal chest expansion

> helps limit oxygen needs/consumption

- To promote the mobilization of secretions

For the whole shift, the patient was under observation but showed no signs of difficulty of breathing. The mother was advised to let the child continue to rest and carry the child on her shoulder while patting his back lightly when he coughs.

DISCHARGE PLANNING

M- Medication

Instruct and explain to the patient’s mother that the medication is very important depending on the duration of the doctor’s order.

E- Exercise

Advice the mother to let her child have much rest because this will provide relief his body and prevent it from getting fatigued, which is one of the common symptoms of the disease. The patient can also play but for a short time only.

T- Treatments

Advice the mother to keep her baby relaxed in order to recover from present condition. Instruct the mother to minimize the exposure of the patient to various environmental conditions such as dusty and smoky areas where pathologic airborne microorganisms may be present.

H- Health Teaching

Encourage and explain the patient’s mother that it is important to maintain proper hygiene to prevent further infection. Instruct the mother to bathe her baby every day. Instruct the mother to clean their house every day.

O- Out patient follow-up

Regular consultation to the physician can be a factor for recovery and to assess and monitor the patient’s condition.

D- Diet

Diet as tolerated. Instruct the mother to give nutritious food intended for respiratory

problems. Instruct the mother to increase the fluid intake of the patient

Cues NURSINGDIAGNOSIS

BACKGROUNDKNOWLEDGE

PLANNING NURSINGINTERVENTIONS

RATIONALE EVALUATION

S> “Ayaw nyangkumain, yung gatassinusuka lang namannya,” and“Mas payat sya ngayon,dati ang lakas namankumain”as verbalized by the Pt’smother.O> vomits ingestedmilkFood aversionDecreased wtweakness

ImbalancedNutrition due tofrequent vomitingand not eating theusual foods takenas manifested bydecreased weight,food aversion, andweakness.

Bacteria or virusattacks the lung/s↓weakened immunesystems↓Pneumonia↓Symptoms ofPneumonia:nausea orvomiting, mayexperienceprofoundweakness w/c lastsfor a long time.

After 4 hours ofNursingIntervention, thePt will start takingfoods which heusually eat (rice,crackers, chickenbreast,etc)After 4 hours ofNursingIntervention, thePt will not vomitanymore theingested milk

> Assess for recentchanges inphysiological statusthat may interferewith nutrition

> Providecompanionship atmealtime toencouragenutritional intake

> Determinehealthy bodyweight for age andheight

> Assess client'sability to obtainand use essentialnutrients.

> The consequencesof malnutrition canlead to a furtherdecline in thepatient's conditionthat then becomesself-perpetuating ifnot recognized andtreated.> Often toddlers willeat more food if otherpeople are present atmealtimes.> Protein-caloriemalnutrition mostoften accompanies adisease process> Cases of vitamin Ddeficiency have beenreported among darkskinnedtoddlers whowere exclusivelybreast fed and werenot givensupplemental vitamin

After 4 hours of NursingIntervention, the Ptstarted taking foodswhich he usually eat(crackers)After 4 hours of NursingIntervention, the Pt didn’tvomit anymore theingested milk