Professional Documents
Culture Documents
Patient Profile
a. Patient Data
1. Name: Baby Girl A
2. Date Admitted: September 01, 2013
3. Time of Admission: 5:25 am
4. Age: 1 month old
5. Gender: Female
6. Religion: Roman Catholic
Diet: NPO
7. Admitting Diagnosis: Pneumonia
b. Nursing History
1. Chief Complaint
5 days prior to confinement patient experienced coughing, gasping and mottling
appearance.
2. Present History
This is the first time patient was confined.
3. Past History
Not applicable
4. Personal and Social History
Not applicable
5. Obstetric History (Mother of patient)
G7P7 (T7P0A0L7), Delivered via Normal Spontaneous Delivery at JJASGEN
During pregnancy the mother only has four check-ups and not frequent and
consistent for the last trimester as it should be and there are no medications taken.
Mother is not a smoker and non-alcoholic. In addition, she only had one dose of
tetanus toxoid.
6. Developmental History
Theoretical
I. Piagets Stages of Cognitive
Development
a. Neonatal Reflex (1 month)
Stimuli are assimilated into the
beginning of mental images.
Behavior entirely reflexive.
b. Primary Circular Reaction
Hand-mouth and ear-eye
coordination develop
Findings
I. Piagets Stages of Cognitive
Development
Patient responses and spontaneously
move on every stimulus. Patient gazes in
the surroundings and objects. Can grip
onto things using the hand. Spontaneous
blinking.
7. Feeding History
Breast milk
8. Immunization History
Only BCG and one dose of Hepatitis B.
Gordons Functional Health Pattern
1. Nutritional and Metabolic Pattern
Prior to confinement patient feeds on breast milk. On confinement patient is on
NPO yet intravenous fluids are given to maintain hydration. Weight is 3.5 kg.
2. Elimination Pattern
Patient is able to urinate, yellowish in color and defecate, greenish in color and
soft. Consumes at least 3-4 diapers per day.
3. Activity-Exercise Pattern
Patient has spontaneous movement grips on to things and cries at times.
4. Sleep Rest Pattern
Patient can sleep but sometimes disturbed due to coughing out of secretions.
5. Coping-Stress Tolerance Pattern
Coping mechanism of patient is through crying.
6. Value-Belief Pattern
Patient was baptized as a Roman Catholic.
Physical Assessment
Date
Normal
September 01, 2013
Integumentary System Hair is well
distributed
Pink lips
Abdomen is protruded
Abnormal
Analysis
Dry skin
Poor skin turgor
Sharp long nails with
black deposit
Mottled Skin
Cardiovascular
System
Respiratory System
No significant
findings
Crackles upon
auscultation on both
lung fields
Use of accessory
muscles
Whitish & Scanty
secretions
Coughing
Use of accessory
muscles is a sign that
the patient is having
difficulty of breathing
September 02, 2013
Integumentary System Hair is well
distributed
Pink lips
Abdomen is protruded
Dry Skin
Poor Skin Turgor
Sharp Long Nail with
black deposit
Mottled Skin
Cardiovascular
System
Respiratory System
No significant
findings
Crackles upon
auscultation on both
lung fields
Use of accessory
muscles
Whitish & Scanty
secretions
eliminating the
secretions
Use of accessory
muscles is a sign that
the patient is having
difficulty of breathing
Dry Skin
Poor Skin Turgor
Sharp Long Nail with
black deposit
Mottled Skin
Respiratory System
O2 Saturation 99%
Spontaneous
breathing
Crackles upon
auscultation on both
lung fields
Use of accessory
muscles
Yellowish & Thick
secretions
Use of accessory
muscles is a sign that
the patient is having
difficulty of breathing
Cardiovascular
System
No significant
findings
Doctors order
Nursing
Responsibility
September 01, 2013 TPR q shift
Carry out doctors
Gasping
order accordingly
NPO
Mottling
Document vital signs
Intubated patient ET
Coughing
Monitor Intake and
size 4 at level 9
Output
Insert OGT
IVF: D50.3NaCl500cc, Administer
medications as
15cc/hr
Start Ampicillin 100
ordered
mg TIV q66
V/S q16
Gentamycin 25mg/IV
OD
I&O q shift
Refer
Salbutamol nebule
+ 1.5ml PNSS q46
For feasible
extubation this PM
IVF: D5IMB500cc x
Analysis
TPR & v V/S q16 are
ordered for continuous
monitoring because the
patient is experiencing
respiratory distress and
the patient is intubated
Patient is given IV
fluids to maintain
hydration
Gentamycin is given to
promote the inhibition
of microbial growth
I&O is ordered to
monitor if the patient is
experiencing any
deficits or excess in
their fluids.
Salbutamol is given to
15 cc/hr
o For feasible
extubation
tomorrow
o Repeat CXR tom
AM prior to
extubation
September 02, 2013 HAA 15mg IV q66
(+) Wheeze
Salbutamol nebule
+ 1.5ml PNSS q86
Hgt Monitoring q126
Increase Salbutamol 1
nebule q46
For CBC with PC
For ABG, if feasible
For Blood Culture &
Sensitivity
Hydrocortisone is
ordered because the
patient was assessed to
have wheeze this will
interact with mast cells
to prevent the release of
histamines and this is a
form of glucocorticoid
Hgt monitoring was
necessary if the patient
has enough glucose in
the blood, since glucose
is necessary of ATP
production and it is the
primary food of the
brain.
CBC was needed in
order to know the blood
count esp. the WBC to
know if there is an
infection present.
ABG was also ordered
to know the level of
blood gases.
Blood culture and
sensitivity was ordered
to be able to know what
type of infection the
(+) mottling
(+) bradycardia
(+) forceful
ambubagging
(+) thick secretions
per ET
II.
that are surrounded by connective tissue that contains arteries, lymphatics and nerves. It is
then branch into bronchioles which contains submucosal glands that produces mucus that
covers the lining of the airways and it also lined with cilia that creates a whipping motion
that propels mucus and foreign substances away from the lungs toward the larynx and
branches out into the terminal bronchioles. Terminal bronchioles are considered to be the
passageway between the conducting airways and the gas exchange airways.
Alveoli this is where oxygen and carbon dioxide
takes place. It has 3 types: Type I are
epithelial
cells that forms the alveolar walls, Type II are cells that secretes surfactant, a
phospholipid that lines the
inner surface and prevents alveolar collapse, Type III
are large phagocytic cells that ingest foreign matter
(e.g mucus, bacteria) that acts as a defense
mechanism.
Functions of the Respiratory System
Oxygen Transport oxygen is supplied to, and carbon
dioxide is removed from, cells by
way of the circulating
blood. Respiration process of gas exchange between the
atmospheric air and he blood and between the blood and
cells of the body. Ventilation movement of air
in and out of the airways that continually
replenished the oxygen and removes the carbon
dioxide from the airways and lungs.
Pulmonary Diffusion is the process by which oxygen
and carbon dioxide are exchanged at
the air-blood interface while Pulmonary Perfusion is
the actual blood flow through the
blood circulation.
Immature development has also an advantage lessened amount of smooth muscle in the airway
means that an infant does not develop bronchospasm. Therefore, wheezing may not be a
prominent finding in infants even when lumen of the airway is severely compromised.
III. Pathophysiology
Risk Factors Associated with PNEUMONIA
Age: 1 month old
NPO Status
Exposure to environment
Poor Hygienic Practices
Anatomical Presentation
Nasogastric Tubing
Exposure to sick individuals
Doctor ordered:
CBC with PC
Ineffective Airway
Clearance
Arterial Hypoxemia
III.
Laboratory Examinations
Result
PNEUMONIA
Normal
values
Clinical Significance
Clinical manifestation
Hemoglobin
134 g/L
125-168 g/L
Normal
None
Hematocrit
0.42
0.37-0.42
Normal
None
20.8
x109/L
5-10 x109/L
Fever
Platelet Count
593
x109/L
150-400
x109/L
Increased WBC;
indicative of an
infection
Increased in Platelet ;
indicative of
hypercoagulation
Increased Neutrophil;
signifies acute infection
Normal
Differential Count
Neutrophils
Lymphocytes
0.68
0.28
0.36-0.66
0.22-0.40
Fast coagulation
Fever
None
Nurs
Secure req
Ensure saf
Observe th
Notify the
are alterati
Monocytes
Eosinophil
Hgt Monitoring
Glucose
IV.
0.02
0.02
0.04-0.08
0.01-0.04
Normal
Normal
None
None
92mg/dL
70-110mg/dL
Normal
None
Ensure saf
Observe th
Notify the
are alterati
Drug Study
Generic
name
Gentamycin
Brand name
Classification
Action
Garamycin
Albuterol
Salbutamol
Hydrocortis
one
Hydrocorto
ne
Aminoglycosid Gentamicin is an
e
aminoglycoside that
binds to 30s and 50s
ribosomal subunits of
susceptible bacteria
disrupting protein
synthesis, thus
rendering the
bacterial cell
membrane defective.
Bronchodilator It relieves nasal
congestion and
reversible
bronchospasm by
relaxing the smooth
muscles of the
bronchioles. The
relief from nasal
congestion and
bronchospasm is
made possible by the
following mechanism
that takes place when
Salbutamol is
administered.
Glucocorticoid Hydrocortisone is a
corticosteroid used
Indication
Gram-negative
infections
Dosage/route/frequen
y
Pediatric:
22.5 mg/kg q 8 hr IM
or IV.
Infants and neonate
2.5 mg/kg q 8 hr.
Premature or full-term
neonates: 2.5 mg/kg
12 hr.
To control and
prevent
reversible
airway
obstruction
caused by
asthma or
chronic
obstructive
pulmonary
disorder (COPD)
Each actuation of
aerosol dispenser
delivers 90 mcg
albuterol; 2 inhalatio
q 46 hr; some
patients may require
only 1 inhalation q 4
hr; more frequent
administration or
larger number of
inhalations not
recommended.
Allergic states
severe or
Pediatric Patients:
IV, IM or
phosphate
Ranitidine
Zantac
H2-Blocker
Ampicillin
Ampicin
Antibiotic
incapacitating
allergic
conditions
subcutaneous
(hydrocortisone and
hydrocortisone sodiu
phosphate)
20240 mg/day
usually in divided
doses q 12 hr.
Inhibits acid
secretions
Tablets75, 150, 30
mg; effervescent
tablets and granules
25, 150 mg; syrup
15 mg/mL; injection
1, 25 mg/mL
Pediatric Patients
2550 mg/kg/day IM
or IV in equally
divided doses at 68
hr interval
Bactericidal action
against sensitive
organisms; inhibits
synthesis of bacterial
cell wall, causing cell
death.
Treatment of
infections
caused by
susceptible
strains of
Shigella,
Salmonella,
Escherichia coli,
Haemophilus
influenzae,
Proteus
mirabilis,
Neisseria
gonorrhoeae,
enterococci,
gram-positive
organisms
(penicillin G
sensitive
staphylococci,
streptococci,
pneumococci)
Dopamine
V.
Dopress
Inotropic
Sympathetic
precursor to
norepinephrine that
increases the heart
rate.
DOPAMINE
(dopamine
hydrochloride) is
indicated for the
correction of
hemodynamic
imbalances
present in the
shock syndrome
due to
myocardial
infarctions,
trauma,
endotoxic
septicemia, open
heart surgery,
renal failure, and
chronic cardiac
decompensation
as in congestive
failure.
Assessment
Objective:
Crackles upon
auscultation on both
lung fields
Use of accessory
muscles
Yellowish & thick
secretions
Mottling appearance
Alteration on oxygen
saturation
Productive Cough
Diagnosis
Ineffective Airway
Clearance related to
thick mucus secretions
in the alveoli sac
Planning
After 30 minutes of
nursing intervention
patients airway will be
free from secretion.
Intervention
Assess the need in
performing suctioning.
Assess oxygen
saturation; if O2 Sat. is
below 95%
hyperventilate using the
ambu bag.
Prepare suctioning
machine and catheter
Prior to suctioning
hyperventilate three
times.
Apply intermittent
suctioning.
Note the color,
consistency and amount
of the secretions.
After suctioning
Ev
Aft
nur
pat
fro
ventilate.
Administer Salbutamol
nebule to dilate the
bronchioles as ordered.
Reassess if there are still
secretions present
Assessment
Objective:
Crackles upon
auscultation on both
lung fields
Use of accessory
muscles
Yellowish & thick
secretions
Mottling appearance
Decreased oxygen
saturation of 84%
Productive Cough
Bradycardic, Heart rate
of 90 bpm
Assessment
Objective:
Flushed skin
Restlessness
Agitated
Warm to Touch with a
temperature of 38.16C
Increased in WBC
Diagnosis
Impaired Gas Exchange
related to thick mucus
secretions in the alveoli
sac
Planning
After 30 minutes of
nursing intervention
patients O2 will increase
to 99%
Intervention
Assess patient O2
Saturation.
Administer Dopamine to
increased cardiac rate as
ordered.
Apply continuous
ambubagging and
oxygenate patient to
10Lpm
Reassess patients status
Ev
Aft
nur
pat
to 9
Diagnosis
Altered
thermoregulation related
to presence of an
infection.
Planning
After 1 hour of nursing
intervention patients
temperature will be
reduce.
Intervention
Apply Tepid Sponge
Bath
Assess temperature
every 15 minutes
Keep patient safe on bed
Note for allergy prior to
giving antibiotics
Administer antibiotic
therapy round the clock
as ordered to maintain a
desired level of
Ev
Aft
inte
tem
fro