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Case Study in Pediatric Intensive Care Unit

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.

Spends much time looking at objects


and separating self from them
Infant brings thumb to mouth for a
purpose to suck it.
II. Freuds Psychoanalytic Theory
Oral Stage: Child explores the world by
using mouth, especially the tongue.
III. Eriksons Theory of Psychosocial
Development

I. Freuds Psychoanalytic Theory


Patient spontaneously opens and closes
mouth.

II.Eriksons Theory of Psychosocial


Development
Development task is form a Sense of Trust
vs. Mistrust.
Patients needs are given yet not all are
given such as feeding, bathing, &
cuddling due to illness

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

Dry skin & Poor skin


turgor; Indicates that
the patient has
inadequate fluids in
the body.
Sharp long nails are
actually normal but
the presence of the
black deposits in the
nails may result to
another infection if
the patient
accidentally scratches
itself.
Mottled skin is caused
by arterial hypoxemia
meaning the patient
has mixed oxygenated
and unoxygenated
blood due to poor
pulmonary diffusion
of oxygen of the
blood.

Cardiovascular
System
Respiratory System

Heart Rate: 120 bpm


O2 Saturation 99%
Spontaneous
breathing

No significant
findings
Crackles upon
auscultation on both
lung fields
Use of accessory
muscles
Whitish & Scanty
secretions
Coughing

Crackles is the sign


that the lumen is
narrowing caused by
mucus secretions
Coughing is a way of
eliminating the
secretions

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

Dry skin & Poor skin


turgor; Indicates that
the patient has
inadequate fluids in
the body.
Sharp long nails are
actually normal but
the presence of the
black deposits in the
nails may result to
another infection if
the patient
accidentally scratches
itself.
Mottled skin is caused
by arterial hypoxemia
meaning the patient
has mixed oxygenated
and unoxygenated
blood due to poor
pulmonary diffusion
of oxygen of the
blood.

Cardiovascular
System
Respiratory System

Heart Rate: 135 bpm


O2 Saturation 99%
Spontaneous
breathing

No significant
findings
Crackles upon
auscultation on both
lung fields
Use of accessory
muscles
Whitish & Scanty

Crackles is the sign


that the lumen is
narrowing caused by
mucus secretions
Coughing is a way of

secretions

eliminating the
secretions
Use of accessory
muscles is a sign that
the patient is having
difficulty of breathing

September 03, 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

Dry skin & Poor skin


turgor; Indicates that
the patient has
inadequate fluids in
the body.
Sharp long nails are
actually normal but
the presence of the
black deposits in the
nails may result to
another infection if
the patient
accidentally scratches
itself.
Mottled skin is caused
by arterial hypoxemia
meaning the patient
has mixed oxygenated
and unoxygenated
blood due to poor
pulmonary diffusion
of oxygen of the
blood.

Respiratory System

O2 Saturation 99%
Spontaneous
breathing

Crackles upon
auscultation on both
lung fields
Use of accessory
muscles
Yellowish & Thick
secretions

Crackles is the sign


that the lumen is
narrowing caused by
mucus secretions
Coughing is a way of
eliminating the
secretions

Use of accessory
muscles is a sign that
the patient is having
difficulty of breathing
Cardiovascular
System

Heart Rate: 135 bpm

No significant
findings

Course in the Ward


Date/Assessment

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

make the airway patent


for oxygenation
Chest X-ray is ordered
to assess if the patient
can breathe on its own
by checking for the
amount of consolidated
mucus.
Carry out doctors
order accordingly
Send request from the
lab
Administer
medications as
ordered

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

September 03, 2013


(+) mottling

Start Dopamine 0.5cc


+ D5W 99.5cc= 100cc
x 5 cc/hr
Suction secretion PRN

(+) mottling
(+) bradycardia
(+) forceful
ambubagging
(+) thick secretions
per ET

II.

Carry out doctors


order accordingly
Administer
medications as
ordered

Instill 1cc of PNSS


prior to suctioning q46,
gently
Continuous dopamine
Continuous present
management
Refer

doctors are dealing with


in order to administer a
more potent antibiotic
for the patient.
Dopamine was ordered
because the patient
experienced
bradycardic episode,
this will further
increase the heart rate
of the patient however;
this may also cause
bradycardia an adverse
effect.
Suctioning in order to
clear the airway
Instillation of 1cc
PNSS was necessary
because the secretions
of the patient are thick
and this will further
dissolve the mucus.

Review of Anatomy and Physiology


The Respiratory center is the medulla of the brain. The Respiratory System has two divisions
namely: The Upper Respiratory Tract and Lower Respiratory tract.
UPPER RESPIRATORY TRACT
Nose it serves as a passageway for air to pass to and from the lungs. It filters impurities and
humidifies and warms the air as it is inhaled.
Paranasal Sinuses These are spaces that are lined with nasal mucosa and ciliated
pseudostratified columnar epithelium. These are connected by series of ducts that drain into the
nasal cavity. Sinuses are named by their location: Frontal, Ethmoidal, Sphenoidal and Maxillary.
The function of the sinuses is to serve as a resonating chamber in speech and it is also a common
site for infection.

Pharynx or throat, is a tubelike structure that connects the


nasal and oral cavity to the
larynx. The nasopharynx is
located posterior to the nose and

above the soft palate. The


oropharynx houses the faucial,
or palatine, tonsils. The
laryngopharynx extends from
the hyoid bone to the cricoid
cartilage.
The
pharynx
functions as a passageway for
the respiratory and digestive tract.
Larynx it is the voice organ that connects the pharynx and trachea. Major function is for
vocalization and protects the airway from foreign substances and facilitates coughing. Epiglottis
is a valve flap of cartilage that covers the opening of the larynx during swallowing.

LOWER RESPIRATORY TRACT


Lungs is the major organ of the respiratory system, which is a paired lung elastic structure that
enclosed in the thoracic cage and this is where gas exchange transpires.
Pleura it is a serous membrane that lines the lungs and wall of the thorax. The pleura have
small amounts of fluid that lubricates the thorax and lungs to permit smooth motion of the
lungs within the thoracic cavity with each breath.
Bronchi & Bronchioles has several divisions of the bronchi. Lobar bronchi (3 in right
lung; 2 in the left lung) and it is divided into segmental bronchi (10 on the right; 8 on the l
eft lung), which is a structure identified when choosing the most effective postural drainage
position for a given patient. Segmental bronchi are then divided into subsegmental bronchi

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.

Respiratory Difference in Children


Ethmoidal and Maxillary sinuses are present at birth; frontal sinuses and sphenoid sinuses do not
develop until the age of 6 and 8.
Respiratory mucus function in newborn produces little amounts of mucus, which makes them
more susceptible to respiratory infections.
In infants, the walls of the airways have less cartilage thus there are not so strong and it collapses
every exhalation.

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

Impairment of Hosts Defense against


Microorganism
Doctor ordered:
Blood Culture & Sensitivity

Staphylococcus aureus; Streptococcus


pneumoniae colonizes the lower respiratory tract
Signs & Symptoms:
Elevated WBC
Elevated Neutrophil

Inflammatory reaction in the alveoli

Signs & Symptoms:


Fever of 38.16 C
Flushed Skin
Warm to Touch

Producing exudates that interferes with the


diffusion of oxygen and carbon dioxide

Doctor ordered:
CBC with PC

Signs & Symptoms:


Production of secretions
Auscultatory Rales

Impaired Gas Exchange

White blood cells (neutrophils) migrates in


the alveoli

Production of Secretions and Mucosal Edema


occurs
Doctor ordered:
Chest X-ray
Signs & Symptom
Consolidation

Ineffective Airway
Clearance

Partial / Total Occlusion of the alveoli

Decrease in alveolar tension

Venous blood entering the pulmonary circulation passes


through the under ventilated area and travels to the left side of
the heart poorly oxygenated. The mixing of oxygenated and
oxygenated or poorly oxygenated blood

Arterial Hypoxemia

III.

Signs & Symptoms:


Mottling
Alteration of O2 Sat
Restlessness
Irritability

Laboratory Examinations

Complete Blood Count with Platelet Count


Lab Exams

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

White Blood Cell

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

for its antiinflammatory and


immunosuppressive
effects. Its antiinflammatory action
is due to the
suppression of
migration of
polymorphonuclear
leukocytes and
reversal of increased
capillary
permeability.

incapacitating
allergic
conditions

subcutaneous
(hydrocortisone and
hydrocortisone sodiu
phosphate)
20240 mg/day
usually in divided
doses q 12 hr.

Inhibits acid
secretions

For patients with


hyperacidity,
gastric
ulcerations and
duodenal ulcers

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.

IV- The recommende


initial dose is 1-5
mcg/kg/min, up to 510 mcg/kg/min
according to patient's
response.

Nursing Care Plan

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

effectiveness of the drug


Assess for adverse
reactions of the drug

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