Far Eastern University

Institute of Nursing

Case Presentation
Submitted by: Maningding, Marvic Mislang, Angel Marie BSN 122/ group 87 Submitted to: Mr. Oliver Sanidad

I. Biographic Data Name: S.A.G Address: Marilao, Bulacan Age: 6 years old Gender: Male Religious Affiliation: Catholic Marital Status: single Room & Bed no.: 214 Chief complaint: Fever Provisional diagnosis: to consider acute tonsilopharyngitis pneumonia Attending physician: Dra. Alveza

II. Nursing History A. past health history Childhood illness: The patient had a tonsillitis and asthma. Immunization: The mother of the patient cannot remember some of the immunization. The mother said, ang naalala ko lang ay yung BCG nung 2 weeks siya tapos every month na yung pag immunization sa kanya. Meron ding Hepa B, polio vaccine pero wala siyang MMR. Allergies: (-) allergy to food/ drug Accidents: none Hospitalization: The child was brought to the hospital in January 11, 2010 and this was his first time he was confined to a hospital.

medications used or currently taken: paracetamol salbutamol for nebulization opigesic salbutamol tablet combivent for nebulization penicillin G Na Gentamicin foreign travel: none

B. History of present illness Five days prior to confinement, the patient began experienced cough and fever. Few hours prior to confinement, the patient experienced convulsion while having high grade fever followed by two episodes of vomiting hence consults.

C. Family History
GENOGRAM
R.A

V.G.

R.G

I.A (DM)

Son, 37 (asthma) Son, 35 Son, 33 Son, 31 Son, 29 Daught er, 25 Daught er, (asthm a Patient 6 y/o (Asthma)

Son, 35
Daught er, 29 Daught er 33 Daught er, 27 Daught er, 24

Legends

Male

Female

D. developmental history 2 months old- the incisor teeth are the first teeth appeared - the mother said that his child know them - the first word to say was tata 6 months the child started to eat celerac as his food 7 months the patient started to crawl - celerac is still the food that he eats 11 months started to walk with guide 1 years old started to eat solid foods - say the word mama and can identify his mom - started to walk fast and run 2 years old started to know his father 3 years old the child can identify pictures 4 years old started to go to school 5 years old started to read word by word 6 years old still reading word by word - the mother said that she is still the one who feeds her child though the child knows how to eat

Patterns of functioning

A. Psychosocial The patient has a good relationship with his parents. When their family has problems, first they talk about it and decide what action should be done. The child tells his parents what he wants but sometimes he cant get what he wants so he is nagdadabog. He was able to express his feelings to others whether he is happy, angry, or sad. As a family, they watch TV; go to mall, church together. They have time to bond with each other. The child says that he is a cheerful person. According to the mother of our client lageng nasa labas yan nakikipaglaro kay echo. The client verbalized that si echo kalaro ko sa labas bestfriends kame forever e tpos si shekaila un boss namin. His closest friends are echo and shekaila. He always plays with them, and he doesnt have any problems in school. The child doesnt feel isolated in their place because he has many playmates. When asked about the activity when inside the house the client verbalized naglalaro lang ng gameboy tska kumakaen.

Analysis: Six year old children play in groups, but when they are tired or under added stress, they prefer one-to-one contact. In a first grade classroom, students compete actively for a few minutes of special time with the teacher. At the end of the day, they enjoy time spent individually with parents. You may have to remind the parents this is not babyish behavior but of a typical 6 year old.

(Maternal and Child Health Nursing 5th Edition Vol. 2 page 919)

Interpretation: The childs behavior in his age is appropriate.

B. Elimination: The mother of the patient said that the child doesnt have any problems with regard to his urinary and bowel elimination. The mother said, Umiihi siya ng 5- 6 beses sa isang araw tska wala naman siyang nararamdaman na sakit. When asked about the odor of his urine. The child said, mapanghe po yung amoy.. his mother is the one who cleans him after he defecates. She said that his son defecates once a day and his stool is formed. Pero simula nung inadmit siya dito sa hospital, hindi pa siya nakakadumi. The mother said. The child doesnt experience excess perspiration and odor problems. Analysis: The school age childs elimination system reaches maturity during this period. The kidneys double in size between age 5 and 10 years. During this period, the child urinates 6-8 times a day. About 10% of all 6-year-old experience difficulty in controlling the bladder. Bed-wetting should not be considered a problem until after the age of 6.

(Fundamentals of nursing 8th edition Vol. 2 page 1288)

School age children and adolescent have bowel habits similar to those of adults. Patterns of defecation vary in frequency, quantity, and consistency. Some school age children may delay defecation because of an activity such as play.

(Fundamentals of nursing 8th edition Vol. 2 page 1326)

Interpretation: The child doesnt have problems with regards to his elimination except on the time when he is admitted to the hospital

C. Rest and sleep The child sleeps at 11:00 in the evening together with his parents, lage yang sumasabay sa amin sa oras ng pagtulog. Hapon pa naman pasok niya kaya ayos lang. the mother said. But before the child sleeps, he eats his midnight snacks which are milk and bread. The mother said, pag natulog nayan, hindi nay an gumigising sa madaling araw. dirediretso na. The child wakes up at 9:00 in the morning and doesnt take an afternoon nap because he is in school. But when the child is admitted in the hospital, the child needs to sleep earlier, para makapagpahinga siya at gumaling agad. Verbalized by the mother.

Analysis: Sleep needs vary among individual children. Younger school age children require 10-12 hours of sleep each night., and older school age children require about 8-10 hours. Most 6 year olds are too old for naps but do require a quiet time after school to get them through the remainder of the day. During school years, many children enjoy a quiet talk or a reading time at bedtime.

(Maternal and child health nursing 5th edition Vol. 2 page 923)

Interpretation: The child has a good sleeping pattern and doesnt have a problem with regards to sleep.

D. Sexuality The patient doesnt have any problems in expressing his sexuality. As a boy, he said that he plays his toys like cars and baril-barilan just like what other boys do. His mother said that he is not yet circumcised. The child doesnt talk too much regarding his genital organ, as his mother said,puro laro naman yan eh Analysis: Age 6-12, sexual development includes: has strong identification with parent of same gender tends to have friends of the same gender has increasing awareness of self increased modesty, desire for privacy continues self stimulating behavior learns the role and self concepts of own gender as part of the total self concept

(Fundamentals of nursing 8th edition Vol. 2 page 1020)

Interpretation: The child can express his sexuality in a way that he want. He is not shy in expressing it.

E. Oxygenation: The child has asthma and there are times that he cant breathe normally. The mother said that when this happens, she consults their doctor and nebulize the child. nung new year nagpaputok yan sa labas kasama yun daddy niya eh ang usok-usok sa labas buti hindi siya hinika. the mother said.

Analysis: Asthma is another chronic disease often identified in childhood. The airways of the asthmatic child react to stimuli such as allergens, exercise, or cold air by constricting, becoming edematous, and producing excessive mucus. Airflow is impaired, the child may wheeze as air moves through narrowed airpassages.

(Fundamentals of nursing 8th edition Vol. 2 page 1362)

Interpretation: due to his asthma, the child sometimes encounter problems but his parents take good care of him. F. Nutrition The child said that he like fried foods. The mother said, nakaka 5 baso ng tubig yan sa isang araw. The child doesnt have an idea when it regards to proper nutrition. His favorite foods are hotdog, bread, foods in jollibee. Our Client verbalized that paborito kong pagkaen ung sa jollibee hotdog pati chicken. According to the mother of the client Kumakaen yan tatlong beses sa isang araw ang takaw nga nyan e.our client verbalized that paborito ko din kumaen ng candy kasi masarap. He doesnt like to eat vegetables, as he said, mapait eh... he eats in the dining room together with his parents. Before hospitalization the mother stated that malakas kumaen ng ulam yan di siya gano mahilig sa kanin When the child is admitted to the hospital, he is in a soft diet. When the child has wound, his mother said that it heals fast. The child doesnt have any skin problems but he has dental problems. The tooth of the client is yellowish and has 26 teeth. The mother verbalized that hindi siya nagpapachek-up sa dentista.

3 Day Diet Recall 01/09/2010 Breakfast: bread, 2 bottle of mineral water, half bottle of Gatorade Lunch: spaghetti, 2 bottle of mineral water Dinner: milk, water but his mother said, patikim-tikim nalng siya nun. 01/10/2010 Does not eat until 5:30 pm Dinner: cup noodles but doesnt able to finish 01/11/2010 2 bottles of mineral water On a soft diet

Analysis: School age children need breakfast to provide enough energy to get them through active morning at school. Many children qualify for a free or reduced price school lunch and breakfast. A government regulated school lunch (type A) provides milk (8 oz), protein (2 oz), one starch serving, and vegetable ( cup). Servings vary according to age to provide one third of a childs nutrition requirements for a day. Whether they take lunch or buy it in school, school age children should know some elementary facts of nutrition so they do not trade a sandwich for a cake or choose only deserts in the cafeteria. Health care personnel should play an active role in nutrition education at health maintenance visits. Most children are hungry after school and enjoy a snack when they arrive at home. Because sugary foods may dull a childs appetite for dinner, urge parents to make the snack nutritious: fruit, cheese or milk rather than cookies and soft drinks.

(Maternal and child health nursing 5th edition Vol. 2 page 921-922)
Interpretation: The childs nutrition is not good because he is not eating nutritious foods and loves to eat candies thats why he has dental carries.

Activity of daily living

ADL Before hospitalization
mother stated that malakas kumaen ng ulam yan di xa gano mahilig sa kanin He doesnt like to eat vegetables, as he said, mapait eh... he eats in the dining room outside their house with his parents. Our Client verbalized that paborito kong pagkaen ung sa jollibee hotdog pati chicken. According to the mother of the client Kumakaen yan tatlong beses sa isang araw ang takaw nga nyan e.our client verbalized that paborito ko din kumaen ng
candy kasi masarap.

After hospitalization
the client will now eat nutritious foods and avoid eating too much candies as much as possible.

Interpretation & analysis

Analysis: Most school age children have good appetite, although any meal is influenced by the days activity. Help children who are hospitalized to select a diet that is enjoyable as well as nutritious.

1. Nutrition

(Maternal and child health nursing by Pilliteri 5th edition vol. 2 page 921 & 938 )
Interpretation: The client dont like to eat nutritious foods like vegetables, instead he loves candies that's why he has dental carries

ADL 2. Elimination

Before hospitalization.
The mother said, Umiihi siya ng 56 beses sa isang araw tska wala naman siyang nararamdaman na sakit. His mother is the one who cleans him after he defecates. She said that his son defecates once a day and his stool is formed.

After hospitalization
The client will still not experience problems in his elimination

Interpretation & analysis

Analysis: School age children and adolescent have bowel habits similar to those of adults. Patterns of defecation vary in frequency, quantity, and consistency. Circumstances of diet, fluid intake and output, activity, psychologic factors, lifestyle, medications, medical procedure and disease affect defecation.

(fundamentals of nursing by kozier and erbs 8th edition vol. 2 page 1326)
Interpretation: The client has a good elimination pattern

ADL
3. Exercise

Before hosp[italization
Before hospitalization when asked about his exercise the client verbalized thathindi aq nag eexcercise e he also stated that pag wala q ginagawa sa bahay naglalaro lang ako ng gameboy. He also stated that tinatawag ako ni echo tyaka shikaila para maglaro sa labas. The mother of the client stated that walang exercise yang batang yan puro kaen nga lang alam e.

After hospita;ization
When he is discahrge, the client will start to do some exercise to be strong.

Interpretation & analysis

Analysis: School age children need daily exercise. Although they go to school all day, they do not automatically receive much exercise because school is basically a sit-down activity. Exercise need not involve organized sports. It can come from neighborhood games, walking with parents, or bicycle riding. Urge them to participate in some daily exercise, or else obesity, or osteoporosis later in life can result.

(Maternal and child health nursing by Pilliteri 5th edition vol. 2 page 923)
Interpretation: The childs form of exercise is by playing outside his house with his playmates and walking with his parents when they go to mall and church.

ADL
4. Hygiene

Before hospitalization

After hospitalization
The child will now brush his teeth regularly and retain his good hygiene.

Interpretation & analysis

Analysis: Children of 6 or 7 age still need in regulating the bath water temperature and in cleaning their ears and fingernails. Boys who are uncircumcised may develop inflammation under the foreskin from increased secretions if they do not wash regularly.

When asked about the clients hygienic practices he stated that isang beses lang ako maligo sa isang araw he also stated that nagtotoothbrus h lang ako bago po matulog tsaka pag gising.

(Maternal and child health nursing by Pilliteri 5th edition vol. 2 page 923)
Interpretation: When the child is in the hospital, his hygiene is not that good because hes not able to take a bath, only sponge bath and doesnt brush his teeth.

ADL

Before hospitalization
The child sleeps at 11:00 in the evening together with his parents, lage yang sumasabay sa amin sa oras ng pagtulog. Hapon pa naman pasok niya kaya ayos lang. the mother said. But before the child sleeps, he eats his midnight snacks which are milk and bread. The mother said, pag natulog nayan, hindi nayan gumigising sa madaling araw. dirediretso na. The child wakes up at 9:00 in the morning

After hospitalization
The client will sleep comfortably in his house and can sleep together with his parents

Interpretation & analysis

Analysis: Sleep needs vary among individual children. Younger school age children require 10-12 hours of sleep each night., and older school age children require about 8-10 hours. Most 6 year olds are too old for naps but do require a quiet time after school to get them through the remainder of the day. During school years, many children enjoy a quiet talk or a reading time at bedtime.

5. Rest / Sleep

(Maternal and child health nursing 5th edition Vol. 2 page 923)
Interpretation: The child needs rest to recover from his condition so that he can continue doing the things that he is doing before.

V. Physical assessment Physical Assessment Findings Name of Client: S.A.G. Height: 107 cm Age: 6 y/o Weight: 24 kg Vital signs: BMI: 20.9 Temperature: 36.1 degrees celsius Pulse Rate: 93 bpm Respiratory Rate: 21 cpm

Blood Pressure: N/A

assessment Normal findings

Body built, height, and weight in relation to clients age,
Proportionate, varies with lifestyle and age (Fundamentals of nursing by kozier and erbs 8th edition p.572)

Actual findings
His weight is proportion to his height

analysis

Normal

Posture and gait, standing, sitting and walking

Relaxed, erect posture, coordinated movement (Fundamentals of nursing by kozier and erbs 8th edition p.572)

he has a relaxed erect posture, coordinated movement

Normal

Overall hygiene and grooming

Clean, neat (Fundamentals of nursing by kozier and erbs 8th edition p.572)

He has dandruff on his head and has breath odor

mother said that she just gave him a spongebath once a day and he is not brushing his teeth when he is in the hospital

Body Odor and breath odor in relation to activity level.

No body odor; no breath odor (Fundamentals of nursing by kozier and erbs 8th edition p.572)

He has no body odor but have breath odor

When he is in the hospital, he doesnt brush his teeth that is why he has breath odor.

Signs of distress in posture or facial expression

No distress noted (Fundamentals of nursing by kozier and erbs 8th edition p.572)
Healthy appearance (Fundamentals of nursing by kozier and erbs 8th edition p.572) Cooperative (Fundamentals of nursing by kozier and erbs 8th edition p.572)

When I look at him there is no sign of distress.

Normal

Signs of health or illness

The client looks healthy

Normal

Attitude

He is cooperative.

Normal

Mood; appropriateness of responses

Appropriate to situation (Fundamentals of nursing by kozier and erbs 8th edition p.572)

His mood is appropriate in the situation. Smiley face

Normal

Quantity of speech, quality and organization and functions of vagus nerve Relevance and organization of thoughts

Understandable, moderate pace, exhibits thought association (Fundamentals of nursing by kozier and erbs 8th edition p.572)

His quality and quantity of speech is in moderate pace and understandable.

Normal

Logical sequence; makes sense; has sense of reality (Fundamentals of nursing by kozier and erbs 8th edition p.572)

The relevance and organizations of his thought is in logical sequence and in the sense of reality

Normal

Skin color

Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive (Fundamentals of nursing by kozier and erbs 8th edition p.579)

skin

The color of his skin is brown

Normal

Uniformity of color Edema, if present Skin lesions

Generally uniform except in areas exposed to sun; areas of lighter pigmentation (Fundamentals of nursing by kozier and erbs 8th edition p.579)

There is no skin discoloration on his body

Normal

No edema (Fundamentals of nursing by kozier and erbs 8th edition p.579)

Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions (Fundamentals of nursing by kozier and erbs 8th edition p.579)

There no presence of edema

Normal

No abrasions or lesions

Normal

Skin moisture

Moisture in skin folds and the axillae(Fundamentals of nursing by kozier and erbs 8th edition p.579) Uniform; within normal range (Fundamentals of nursing by kozier and erbs 8th edition p.579)

It is Moist in skin folds

Normal

Skin temperature

His body temperature is slightly warm.

Normal

Skin turgor (fullness or elasticity)

When pinched, skin springs back to previous state (Fundamentals of nursing by kozier and erbs 8th edition p.58-)

When pinched, his skin springs back to its original state

Normal

nails
Fingernail plate shape
Convex curvature; angle of nail plate about 160 degrees (Fundamentals of nursing by kozier and erbs 8th edition p.583) Smooth texture(Fundamentals of nursing by kozier and erbs 8th edition p.583)

His nail has a convex curvature

Normal

Fingernail and toenail texture

His fingernail is smooth and it is not dirty His bed color is pink in color and it is highly vascular

Normal

Fingernail and toenail bed color

Highly vascular and pink in light-skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal steaks(Fundamentals of nursing by kozier and erbs 8th edition p.584)

Normal

Tissues surrounding nails

Intact epidermis(Fundamentals of nursing by kozier and erbs 8th edition p.583)

The tissues surrounding his nails are intact to his epidermis.

Normal

Blanch test of capillary refill

Prompt return of pink or usual color(Fundamen tals of nursing by kozier and erbs 8th edition p.584)

His blanch test return in its original color in 1 second

Normal

skull
Skull for size, shape, and symmetry
Rounded (Normocephalic and symmetrical, with frontal, parietal and occipital prominences); smooth skull contour (Fundamentals of nursing by kozier and erbs 8th edition p.585)

His skull is rounded (norm cephalic and symmetrical with the bone prominences) and has a smooth skull contour.

Normal

Skull for nodules or masses and depressions

Smooth, uniform consistency; absence of nodules or masses (Fundamentals of nursing by kozier and erbs 8th edition p.585)

There are no masses and nodules on his skull

Normal

scalp
Color and appearance of scalp Clean, smooth, white in color His scalp is white in color but with presence of dandruff

Normal

Areas of tenderness

No tenderness

There is no tenderness on his scalp

Normal

Hair
Evenness of growth, thickness Evenly distributed His hair is evenly hair, thick distributed and hair(Fundamental has a thick hair s of nursing by kozier and erbs 8th edition p.582)

Normal

Texture and oiliness over the scalp

Silky, His hair is resilient resilient(Fundame ntals of nursing by kozier and erbs 8th edition p.582)

Normal

face
Facial features . Symmetric or slightly asymmetric features; palpebral fissures equal in size; symmetric nasolabial folds(Fundamentals of nursing by kozier and erbs 8th edition p.585) He has a symmetrical face, even to his body Normal

Symmetry of facial movements and functions of facial nerve

Symmetric facial movements(Fundamentals of nursing by kozier and erbs 8th edition p.585)

He has symmetrical facial movements

Normal

eyes
Eyebrows for hair distribution and alignment and skin quality and movement
Eyelashes for evenness of distribution and direction of curl

Hair evenly distributed; skin intact(Fundamentals of nursing by kozier and erbs 8th edition p.588)
Equally distributed; curled slightly outward(Fundamentals of nursing by kozier and erbs 8th edition p.588) Skin intact; no discharge; no discolorationLids close symmetricallyApproximate ly 15-20 involuntary blinks per minute, bilateral blinkingWhen lids open, no visceral sclera above corneas, and upper and lower borders of cornea are slightly covered(Fundamentals of nursing by kozier and erbs 8th edition p.588) Transparent; capillaries sometimes evident; sclera appears white(Fundamentals of nursing by kozier and erbs 8th edition p.588)

his hair in the eyebrows are evenly distributed, skin intact, it is symmetrically aligned
His hair in the eyelashes is equally distributed and it is slightly outward

Normal

Normal

Eyelids for surface characteristics, position in relation to the cornea, ability to blink, and frequency of blinking and functions of trigeminal nerve

His skin is intact in the eyelids and there are no discharge, no discoloration, it closes symmetrically, no visible above corneas and the upper lower area of the cornea is slightly covered. Approximately 10-15 blinks/min.

Normal

Bulbar conjunctiva for color, texture, and the presence of lesions

His Bulbar conjunctiva is transparent, no lesions, sclera appears to be white

Normal

Palpebral conjunctiva for color, texture, and the presence of lesions

Shiny, smooth, and pinkish in color (Fundamentals of nursing by kozier and erbs 8th edition p.588)

His Palpebral conjunctiva is Shiny, smooth and pinkish in color.

Normal

Lacrimal gland

No edema or tenderness over lacrimal gland (Fundamentals of nursing by kozier and erbs 8th edition p.588)

No presence pf edema or tenderness over lacrimal galnd

Normal

Pupils for color, shape and symmetry of size

Black in color; equal in size; 3 to 7 mm in diameter; round, smooth border, iris flat and round (Fundamentals of nursing by kozier and erbs 8th edition p.590)

His pupil is black in color, equal in size, round In shape and has smooth borders.

Normal

Lacrimal sac and nasolacrimal duct

No edema or tearing (Fundamentals of nursing by kozier and erbs 8th edition p.588)

No presence of edema or tearing

Normal

Pupils direct and consensual reaction to light

Illuminated pupil constricts (direct response) Nonilluminated pupil dilates (consensual response)

When Illuminated his pupil constricts, Non illuminated his pupil dilates

Normal

Cornea for clarity and texture

Transparent, shiny, and smooth; details of the iris are visible (Fundamentals of nursing by kozier and erbs 8th edition p.589)

He has a transparent cornea and anterior chamber. His cornea is smooth and shiny

Normal

Pupils reaction to accommodation

Anterior chamber for transparency or depth

Transparent No shadows of light on iris Depth of about 3 mm

Transparent No shadows of light on iris Depth of about 3 mm

Normal

Pupils constrict when looking at near objects; pupils dilate when looking at far objects; pupils convergence when near object is moved toward nose

His pupil constricts when looking at near objects and his pupils dilate when looking at far objects; pupils convergence when near object is moved toward nose

Normal

Visual fields and extra ocular muscles

Peripheral visual fields to determine function of retina and neuronial visual pathways to brain and optic cranial nerve

When looking straight ahead, client can see objects in periphery (Fundamentals of nursing by kozier and erbs 8th edition p.591)

He can see objects in periphery

Normal

Six ocular movements to determine eye alignment and coordination and functions of oculomotor, trochlear and abducens nerve

Both eyes coordinated, move in unison, with parallel alignment (Fundamentals of nursing by kozier and erbs 8th edition p.592)

Both eyes coordinated, move in unison, with parallel alignment

Normal

Ears Auricles
Color, Symmetry of size, and position Color same as facial skinSymmetricalAuricle aligned with outer canthus of eye, about 10 degrees from vertical(Fundamentals of nursing by kozier and erbs 8th edition p.596) -his auricle is the same as his facial skin.- it symmetrical to his face.- his auricle is aligned with the other canthus of the eye Normal

Texture, elasticity, and areas of tenderness

Mobile, firm, and not tender; pinna recoils after it is folded(Fundamentals of nursing by kozier and erbs 8th edition p.596)

His ear is firm and not tender and after being folded it recoils

Normal

External ear canal

Distal ends contains hair follicles and glands; Dry cerumen, grayish-tan color; or sticky wet cerumen in various shades of brown

his eardrum have a dry cerumen, the distal has some hair follicles and glands.- No lesions, pus or blood In his eardrum.

Normal

Hearing Acuity Test

Response to normal voice tones Normal voice tones audible(Fundamentals of nursing by kozier and erbs 8th edition p.597) He can hear normal voice tones Normal

Watch tick test

Able to hear ticking in both ears(Fundamentals of nursing by kozier and erbs 8th edition p.597)

He is able to hear the ticking of the watch in both ears

Normal

Webers test

Sound is heard in both ears or is localized at center of the head(Fundamentals of nursing by kozier and erbs 8th edition p.597)

He can hear the sound in both ears

Normal

Rinnes test

Air-conduction hearing is greater than bone-conduction hearing (Fundamentals of nursing by kozier and erbs 8th edition p.598)

air conduction: 12 seconds bone conduction: 10 seconds

Normal

Nose
External Nose for nay deviations in shape, size and color and flaring, or dishcharge from the nares Symmetric and Straight; No discharge or flaring; Uniform Color(Fundamentals of nursing by kozier and erbs 8th edition p.600) -His nose is symmetrical and straight.- No discharge or flaring on his nose.- The nose is uniform in color. Normal

Palpate external nose to determine any areas of tenderness, masses, and displacements of bone and cartilage.

Not tender; no lesions(Fundamentals of nursing by kozier and erbs 8th edition p.600)

His nose is not tender and no presence of lesions

Normal

Patency of both nasal cavities

Air move freely as the client breathes through the nares(Fundamentals of nursing by kozier and erbs 8th edition p.600)

The air moves freely as he breath through the nares

Normal

Nasal Cavity and Facial Sinuses

Observe for any presence of redness, swelling, growths, and discharge. Mucosa pink, clear, watery discharge, no lesions,(Fundamentals of nursing by kozier and erbs 8th edition p.600) His nasal cavities are pink in color, clear, watery discharge Normal

Nasal Septum

Nasal septum intact and in midline(Fundamentals of nursing by kozier and erbs 8th edition p.600)

His nasal septum is intact and in the midline.

Normal

Palpate the Maxillary and Frontal sinuses for tenderness and functions of olfactory nerve

No tenderness, not palpable(Fundamentals of Nursing, 8th Ed.by Barbara Kozier Pp.600)

There are no tenderness in maxilla and frontal sinuses

Normal

MOUTH
Outer lips for symmetry of contour, color and texture Uniform pink color; soft; moist; smooth texture; symmetry of contour; ability to purse lips(Fundamentals of nursing by kozier and erbs 8th edition p.602) His lips is uniform, pink in color, moist, smooth in texture, has symmetric contour and his lips has the ability to purse. Normal

Inner lips and buccal mucosa for color, moisture, texture, and the presence

Uniform pink color; moist; smooth; soft; glistening, and elastic texture(Fundamentals of nursing by kozier and erbs 8th edition p.602)

His buccal mucosa is uniform in pink color, moist, soft, glistening and elastic in texture and has no lesions

Teeth and Gums

The Teeth and Gums Deciduous teeth are lost and permanent teeth erupt during the school age period. The average child gains 28 teeth between 6 and 12 years of age (maternal and child health nursing volume 2, 5th edition page 913) 26 teeth with dental carries and yellowish in color The child like to eat candies and doesnt have a dental check-up

TONGUE/FLOOR of the MOUTH

Surface of the Tongue for position, color, and texture Central position slightly rough; thin whitish coating; smooth; lateral margins; no lesions; raised papillae (Fundamentals of nursing by kozier and erbs 8th edition p.602) Moves freely; no tenderness (Fundamentals of nursing by kozier and erbs 8th edition p.602) His tongue is in central position, pink in color raised taste buds moist, slightly rough, thin whitish coating, lateral margins visible. Normal

Tongue Movement and functions of hypoglossal nerve

His tongue moves freely and there is no tenderness

Normal

Base of the Tongue, the mouth floor, and the frenulum

Smooth tongue base with prominent veins (Fundamentals of nursing by kozier and erbs 8th edition p.602) Smooth with no palpable nodules (Fundamentals of nursing by kozier and erbs 8th edition p.603)

His tongue is pink in color, smooth tongue base with prominent veins.

Normal

Palpate the tongue and floor of the mouth for any modules, lumps, or excoriated areas and functions of glosopharyngeal nerve

The tongue is smooth and there are no palpable nodules

Normal

PALATES and UVULA

Hard and Soft Palate, its color, shape, texture, and the presence of bony prominences Light pink, smooth, soft palate, lighter pink hard palate, more irregular texture (Fundamentals of nursing by kozier and erbs 8th edition p.603) His soft palate light pink in color and it is smooth while the hard palate is lighter pink in color and it is irregular in texture Normal

Uvula, its positioning, and mobility while examining the palates

Positioned in midline of soft palate (Fundamentals of nursing by kozier and erbs 8th edition p.603)

-his uvula is positioned midline. -it appears in pink and smooth and no discharge.

Normal

OROPHARYNX and TONSILS

The Oropharynx, its texture and color Pink and smooth posterior wall (Fundamentals of nursing by kozier and erbs 8th edition p.603) The color of his oropharynx is pink and it is smooth on posterior wall Normal

The Tonsils, its color, any discharges and size

Pink and smooth; no discharge; of normal size (Fundamentals of nursing by kozier and erbs 8th edition p.603)

The tonsils is pink and it is smooth and there are no discharge; Grade 1

Normal

Elicit gag reflex

Present

It is present

Normal

Neck
Lymph Nodes Not Palpable (Fundamentals of nursing by kozier and erbs 8th edition p.607) His lymph nodes are not palpable Normal

Trachea

Central placement in midline of neck; spaces are equal on both sides

His trachea is in central placement in the midline of the neck, spaces are equal on both sides.

Normal

Thyroid Gland; observe lower half of the neck overlying the thyroid gland for symmetry and visible masses.

Not visible on inspection (Fundamentals of nursing by kozier and erbs 8th edition p.608)

The thyroid gland is not visible on inspection

Normal

Palpate the Thyroid gland for smoothness and areas of enlargement, masses or nodules

Lobes may not be palpated; if palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing (Fundamentals of nursing by kozier and erbs 8th edition p.608)

The lobes are not palbable and it rise freely when he swallows

Normal

Posterior thorax
Shape, Symmetry, size and diameter of anteriorposterior thorax to transverse diameter Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric Normal

Spine alignment

Spine vertically aligned; Spinal column is straight, right and left shoulders and hips are at same height

His spine is vertically aligned, straight shoulders and hips are the same as the height.

Normal

Palpate the posterior thorax; for clients who have no respiratory complaints, rapidly assess the temperature and integrity of all chest skin

Skin intact, uniform temperature; chest wall intact; no tenderness; no masses

His thorax skin is intact, it uniform in temperature and there are no masses or lesions were seen in the thorax of the client.

Normal

Palpate the posterior chest for respiratory excursion

Full symmetric chest expansion; normally the thumbs separate 35 cm(1.5-2 in.) during deep inspiration

It is Full and symmetric chest expansion.

Normal

Palpate the chest for vocal fremitus

Bilaterally symmetry of vocal fremitus; fremitus is heard most clearly at the apex of the lungs

The vocal fremetus is bilaterally symmetrical and it is heard more clearly at the apex of the lungs

Normal

Percuss the posterior thorax

Percussion notes resonate, except over scapula; lower point of resonance is at the diaphragm

His posterior resonant sound will be heard during percussion.

Normal

Auscultate the posterior thorax

Vesicular and Bronchiovesicular breath sounds

During his auscultation on his thorax, there is a wheezing sound

Normal

ANTERIOR THORAX
Breathing patterns Quiet, rhythmic and effortless Quiet sound and effortless Normal

Palpate for temperature, tenderness, masses

Uniformly warm, no tenderness, no masses

His Anteriror thorax has uniform temperature, no tenderness and masses

Normal

Palpate the anterior chest for respiratory excursion

Full symmetric excursion; thumbs normally separate 3-5 cm (1.5-2 in)

he has a full symmetric chest expansion.

Normal

Palpate the vocal fremitus

Same as the posterior vocal femitus; fremitus is normally decreased over heart and breast tissue

He has bilateral symmetry of vocal fremetus.

Normal

Percuss the anterior thorax

Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscles and bone, dull on areas over the heart and the liver, and tympanic over the underlying

In percussing his thorax, there is a resonate down to the sixth rib at the level of the diaphragm but flat over the heavy muscle and bone, dull on the areas over the heart at the liver, tympanic over the underlying stomach.

Normal

Auscultate the Trachea

Bronchial and tubular breath sounds

There is a bronchial and breath sound on his trachea.

Normal

Auscultate the anterior thorax

Bronchiovesicular and vesicular breath sounds

During his auscultation on his thorax, there is a wheezing sound

The child has an asthma

CARDIOVASCULAR
Inspect and palpate the aortic and pulmonic areas No masses, no pulsations, no lift or heave(Fundamentals of nursing by kozier and erbs 8th edition p.621) No pulsation on his aortic area.No pulsation and no lift or heave. Normal

Inspect and palpate the tricuspid areas

No pulsations and no heaves or lift

No pulsations and no lift or heaves

Normal

Inspect and palpate the apical area

Pulsation visible 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL Diameter of 1 to 2 cm (1/3 to in.) No lift or heave

Pulsation is palpable

Normal

Auscultate the aortic, pulmonic, tricuspid and apical valves

S1:usually heard at all sitesUsually louder at apical areS2: usually heard at all sitesUsually louder at the base of the heartSystole: silent interval; slightly shorter duration than diastole at normal heart rateDiastole: silent interval; slightly longer duration than systole at normal heart rates

In auscultating his thorax, S1 is usually heard at all sites, S2 usually heard at all sites

Normal

Carotid artery and Jugular Vein

Carotid Artery Symmetric pulse volumes; pulse volumes; full pulsation, thrusting quality; quality remains same when client breaths; turns head, and changes from sitting to supine position; Elastic arterial wall; no sound heard on auscultation(Fundamentals of nursing by kozier and erbs 8th edition p.622) it has a full thrusting quality. there is no sound heard Normal

Jugular Vein

Veins not visible(Fundamentals of nursing by kozier and erbs 8th edition p.623)

His veins are not visible

Normal

Breast and Axillae

Breast size; symmetry; and contour or shape Males: Round, slightly unequal in size his breasts are rounded in shape slightly unequal in size; generally symmetric.-his breasts skin uniform in color. His skin is intact and smooth Normal

Inspect the skin of the breast for discolorations or hyper pigmentation, retraction or dimpling, localized hyper vascular areas, swelling or edema Inspect the Areola for size, shape, symmetry, color, surface characteristics, and any masses or lesions

Skin uniform in color; skin smooth and intact; diffuse symmetric horizontal or vertical vascular pattern in light-skinned people; striae; moles and nevi

his breasts skin uniform in color. His skin is intact and smooth

Normal

Round or oval and bilaterally the same; Color varies widely, from light to pink to dark brown; Irregular placement of sebaceous gland on the surface of the areola Round everted, and equal in size; similar in color; soft and smooth; both nipples point in same direction; no discharge, except from pregnant or breast feeding females; inversion of one or both nipples that is present from puberty

His areola is round and bilaterally the same. The color of his areola is brownish. He has an irregular placement of the sebaceous glands on the surface of the area. His nipples are round in shape everted and equal in size.similar in color. Both nipple point in the same direction -it has no discharge - his breasts nipples have no tenderness, masses or nodules.

Normal

Inspect the Nipples for size, shape, position, color, discharge and lesions

Normal

Palpate the axillary, subclavicular and supraclavicular lymph nodes

No tenderness, masses or nodules

There is no tenderness, masses or nodules on the axillary.

Normal

Palpate breasts for masses and tenderness

No tenderness, masses, nodules

There is no tenderness or masses around his breast

Normal

Palpate the nipples for tenderness and discharge

No tenderness, masses, nodules, or nipple discharge (Fundamentals of Nursing by Barbara Kozier,8th Ed. Pp.628630)

There is no tenderness masses, nodules or nipple discharge

Normal

ABDOMEN
Inspect the abdomen for skin integrity Unblemished skin; Uniform Color; Silver white striae or surgical scars His abdomen In skin is Unblemished in skin,has uniform in color,silver with striae or surgical scars Normal

Inspect the abdominal contour

Flat, rounded (convex), or scaphoid (convex)

It is rounded

Normal

Inspect for an enlarged liver or spleen

no evidence of enlargement of liver or spleen;

Not done

Not done

Assess the symmetry of contour while standing at the foot of the bed

symmetric contour

Not done

Observe abdominal movement associated with respiration, peristalsis, or aortic pulsation

Symmetric movement cause by respiration; Visible peristalsis in very lean people; Aortic pulsation in thin persons at epigastric area (Fundamentals of nursing by kozier and erbs 8th edition p.633) No visible vascular pattern

Symmetric movement cause by respiration; Aortic pulsation in thin persons at epigastric area

Normal

Observe vascular patternsAuscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs

No visible vascular pattern

Normal

Audible bowel sounds; Absence of Arterial bruits Absence of friction rub (Fundamentals of nursing by kozier and erbs 8th edition p.634) Tympany over the stomach and gas-filled bowels; dullness, especially overt the liver and spleen, or a full bladder

Audible bowel sounds are heard and absence of Arterial bruits and friction rub

Normal

Percuss several areas in each of the four quadrants to determine presence of tympany and dullness.

Tympany over the stomach and gas-filled bowels

Normal

Perform light/deep palpation first to detect areas of tenderness and/or muscle guarding

No tenderness; relaxed abdomen with smooth, consistent tension (Fundamentals of Nursing by Barbara Kozier,8th Ed. Pp.634636)

No tenderness and relaxed abdomen

Normal

MUSCULOSKELETAL SYSTEM
Inspect the muscle for size; compare the muscles on one side of the body to the same muscle on the other side Equal size on both sides of the body The muscles are equal in size on both sides of the body Normal

Inspect the muscle and tendons for contractures

No contractures

No contractures

Normal

Inspect the muscles for fasciculation and tremors

No fasciculation or tremors

No tremors or fasciculation

Normal

Palpate muscle tonicity

Normally firm

His muscles are firm

Normal

Test muscle strength (Neck)

Equal strength on each body part (Fundamentals of Nursing by Barbara Kozier,8th Ed. P. 640)

Cannot rotate his head on the left side, only in the right side

(+) torticollis

Test for muscle strength (Upper extremities)

Equal strength on each body part (Fundamentals of Nursing by Barbara Kozier,8th Ed. P. 640)

Equal strength on each body part

Normal

Test for muscle strength (Lower extremities)

Equal strength on each body part (Fundamentals of Nursing by Barbara Kozier,8th Ed. P. 640)

Equal strength on each body part

Normal

Bones and Joints

Inspect for normal bone structure and deformities No deformities (Fundamentals of Nursing by Barbara Kozier,8th Ed. P. 641) No deformities Normal

Palpate the bones to locate any areas of edema or tenderness

No tenderness or swelling

No tenderness or swelling

Normal

Inspect the joints for swelling, palpate each joint for tenderness, smoothness of movements, swelling, crepitation, Snodules

No swelling; no tenderness, swelling, or nodules; Joints move smoothly

There are no swelling of joints and it moves smoothly and there is no tenderness

Normal

Range of Motion
Upper Extremities (shoulder and Scapula) Can perform the range of motion in the shoulder and scapula Reference: (Fundamentals of nursing 8th edition Vol. 2 page 1108-1111) Can perform the range of motion in the elbows He can perform the range of motion in the shoulder and scapula Normal

Upper extremities (elbows)

He can perform the range of motion in the elbows

Normal

Upper Extremities (hands)

Can perform the range of motion in the hands

He can perform the range of motion in the hands

Normal

Lower Extremities (acetabulum/ inguinal area) Lower Extremities (popliteal)

Can perform the range of motion in the inguinal

He can perform the range of motion in the inguinal

Normal

Can perform the range of motion in the popliteal

He can perform the range of motion in the popliteal

Normal

Lower Extremities (ankles)

Can perform the range of motion in the ankles

He can perform the range of motion in the ankles

Normal

Laboratory and Diagnostic Examination

Urinalysis
Physical examination Color: yellow Reaction: acidic chemical examination: albumin: 1+ sugar: negative

Transparency: clear
Specific gravity: 1.025

Microscopic examination
Epithelial cells: rare
Pus cells: 0-2/hpf Red cells: 1-2/hpf N

amorphous urates: rare

amorphous phosphates: mucus threads: rare Bacteria: occasional

Hematology
Test N.M Hemoglobin M = 140170 F120-150 Hematocrit M = 0.410.54F = 0.37-0.47 Leucocytes 5-10 Erythrocyte M = 4.1s 5.4F = 4.35.5 units g/dl results 120

Vol%

0.36

X 10 g/l

8.3

Drug study
Generic/Trade
name Generic name: Salbutamol Trade name: Ventolin, Albuterol T neb every 6 hours Bronchodilato r Salbutamol is used in cases of bronchospas m in patients with reversible airway obstruction: mild and moderate attacks of dyspnea in patients suffering from bronchial asthma; mild and moderate bronchoobstr uction in patients with chronic bronchitis and lung emphysema. Hypersensitivt ty to agents -avoid use in uncontrolled arrythmias Headache,tremo r, tachycardia hypertension, anxiety. Rarely nausea, vomiting, and skin rash can be observed.

Dosage/Frequ ency

Classification

Indication

Contraindicati on

Side effects Nursing Responsibilities

-Assess pulse, respiration, lung sounds, and character of secretions before and throughout the therapy.

Generic Name: Opigesic(supp ository)

250 mg per rectum

Anti-pyretics

Symptomatic relief of fever associated w/ common childhood infections. Relief of minor pains eg headache, toothache & earache. Mild to moderate pain and fever.

Nephropathy.

Hematological reactions, rashes & other allergic reactions.

-Assess fever (note presence of associated symptoms diaphoresis, tachycardia and malaise)

Paracetamol Generic Name: Acetaminophe n Trade Name: Tempra, Tylenol

240 mg TIV EVERY 4 HOURS

Anti-pyretics

Contraindicate d in previous hypersensitivit y products containing alcohol,aspart ame,saccharin , sugar or tartrazine should be avoided in patients who have hypersensitivit y or intolerance in these compounds.

GI:hepatic necrosis(overdose )Derm: Rashes

-Assess fever (note presence of associated symptoms diaphoresis, tachycardia and malaise)

Salbutamol(ta blets) Albuterol

PO( 6-14 yrs old) 2 mg 3-4 times daily.

Bronchodilato r

Salbutamol tablets may be used in asthma, to relieve the narrowing of the airways. chronic bronchitis. emphysema

Hypersensitivity to adrenergic amines. Contraindicated during bronchospasm.

CNS: nervousness,restl essness.EENT: eye irritation, blurred vision.RESP: Pulmonary edema(tocolytic use of terbutaline).GI: Nausea and vomitingEndo: Hyperglycemia. Hypoglycemia.F and E: hypokalemia Severe allergic reactions, tightness in the chest, swelling of the mouth, face, lips, or tongue, chills,convulsions, decreased urination

-Assess pulse, respiration, lung sounds, and character of secretions before and throughout the therapy.

Penicillin G sodium

800,000iu/IV

Antibiotics

Treatment of severe infections caused by sensitive organisms, treatment of syphilis and gonococcal infections

Contraindicated with allergy to penicillins, cephalosporins, beta lactamase inhibitors and other allergens

-Assess fever (note presence of associated symptoms diaphoresis, tachycardia and malaise)

Combivent Generic name: ipratropium (inhalation) Trade name: Combivent, Duoneb

Two sprays of Combivent four times a day.

Bronchodilator

Management of reversible airway disease due to asthma

Hypersensitivit y to adrenergic amines, use cautiously in cardiac disesase, diabetes, bronchospasm

Nervousness, restlessness, pulmonary edema, hypertension, tachycardia.

-Assess pulse, respiration, lung sounds, and character of secretions before and throughout the therapy

Gentamicin

40 mg/ IV

antibiotic

Treatment of serious UTI, bacteremia, meningitis, cerebral ventriculitis, osteomyelitis, pneumonia, peritonitis & otitis caused by suspected gm-ve bacteria.

Hypersensitivit y to aminoglycosid es.

Neurotoxicity: Dizziness, tinnitus, vertigo, roaring in the ears, hearing loss. Peripheral neuropathy or encephalopathy: Numbness, skin tingling, muscle twitching, convulsions & myasthenia gravis-like syndrome. Resp depression, lethargy, confusion, depression, visual disturbances, decreased appetite, wt loss, hypotension & hypertension, rash, itching, urticaria, generalized burning, laryngeal edema, anaphylactoid reactions, fever, headache, nausea, vomiting, increased salivation, stomatitis, purpura, pseudotumor cerebri, acute organic brain syndrome, pulmonary fibrosis, alopecia, joint pain, transient hepatomegaly & splenomegaly.

Lab tests: Perform C&S and renal function prior to first dose and periodically during therapy; therapy may begin pending test results Draw blood specimens for peak serum gentamicin concentration 30 min1h after IM administration, and 30 min after completion of a 3060 min IV infusion. Draw blood specimens for trough levels just before the next IM or IV dose. Use nonheparinized tubes to collect blood.

Nursing Care Plan

Nursing problem cues

Ineffective breathing pattern related to Hyperventilation Subjective: The child has asthma and there are times that he cant breathe normally. The mother said that when this happens, she consults their doctor and nebulize the child. nung new year nagpaputok yan sa labas kasama yun daddy niya eh ang usok-usok sa labas buti hindi siya hinika. the mother said. Objective: >adventitious breath sounds (wheezes) upon auscultation >vital signs: T = 36.1C PR = 93bpm RR = 21cpm >nasal flaring

analysis Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or Bronchopneumonia . Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. (www.nursingcrib.c om)

Goal/objectives After 15 minutes of nursing intervention, the client will be able to breathe normally without obstruction

Nursing interventions
1. Assess the clients respiratory rate every 4 hours or more frequently as indicated. 2. Place the client comfortably in an upright or semiupright position. 3. Provide for a period of rest. 4. Assess and document pleuritic discomfort. Provide analgesic as ordered. 5. Provide reassurance when the client is experiencing respiratory distress. 6. Administer oxygen as ordered.

rationale
1. Tachypnea and diminished ar

evaluation Clients condition improved as manifested by breathing normally without difficulty

adventitious breath sounds may be early indicators of respiratory compromise. Early intervention can prevent atelectasis and significant tissue hypoxia 2. This position promotes lung expansion and ventilationas well as comfort 3. Rest is important to reduce fatigue and the work of breathing 4. Adequate pain relief minimizes splinting and promotes adequate ventilation 5. Hypoxia and respiratory diatress produce high levels of anxiety in the client, which tends to further increase tachypnea and fatigue and decrease ventilation.

7. Teach the client to use slow abdominal breathing.

8. Teach the client how to use relaxation techniques such as visualization and meditation.

6. Supplemental oxygen reduces hypoxia and associated anxiety

7. This promotes lung expansion 8. These techniques help reduce anxiety and slow the client's breathing pattern.

Nursing problem cues Impaired dentition related to ineffective oral hygiene Subjective: The tooth of the client is yellowish and has 26 teeth. The mother verbalized that hindi siya nagpapachek-up sa dentista. our client verbalized that paborito ko din kumaen ng candy kasi masarap. nagtotoothbrush lang ako bago po matulog tsaka pag gising the client verbalize Objective: halitosis excessive plaque missing teeth

analysis
Good oral hygiene results in a mouth that looks and smells healthy. This means: Your teeth are clean and free of debris Gums are pink and do not hurt or bleed when you brush or floss Bad breath is not a constant problem If your gums do hurt or bleed while brushing or flossing, or you are experiencing persistent bad breath, see your dentist. Any of these conditions may indicate a problem. Your dentist or hygienist can help you learn good oral hygiene techniques and can help point out areas of your mouth that may require extra attention during brushing and flossing. (www.colgate.com )

Goal/objectives After 2 weeks of nursing intervention the client would be able to learn essential knowledge about effective oral hygiene.

Nursing interventions Discuss to the significant other the proper way of effective oral hygiene Demonstrate the correct brushing of his teeth Encourage the client to brush his teeth every after meal Advice the client to avoid sweet foods Advice to eat foods that can help to clean the teeth Advice the significant other to bring his child to dentist every six months

rationale To provide knowledge to the client

evaluation The clients condition improves as manifested by doing proper oral care.

To guide the patient on the proper care of teeth

To be free from plaque on the surfaces of the teeth

To avoid frequent toothaches and fractured teeth To keep the teeth strong and clean To take advice from the professionals

Nursing problem cues Risk for infection related to decreased hemoglobin production Cues: Hematology: Hemoglobin = 120 Hematocrit = 0.36 Leucocytes = 8.3
vital signs: T = 36.1C PR = 93bpm RR = 21cpm

analysis
Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues to the lungs. Hemoglobin also plays an important role in maintaining the shape of the red blood cells. Abnormal Hemoglobin structure can, therefore, disrupt the shape of red blood cells and impede its function and its flow through blood vessels (http://www.medi cinenet.com/heog lobin/article.h m).

Goal/objectives After 2 hours of nursing intervention, the client will minimize sign of infection

Nursing interventions
Monitor vital signs Especially temperature Demonstrate to the client and significant other Thorough Hand washing Encourage frequent position changes/ ambulation, coughing, & deep breathing exercises Promote adequate fluid intake Obtain specimen For culture/ sensitivity as indicated (http://nursingdepart ent.blogspot.com/200 /08/nursing-care-plan risk-for-infection.html)

rationale Reflective of inflammatory process/ infection requiring evaluation & treatment Prevents cross contamination/ bacterial colonization Promotes ventilation of all lung segments and aids in mobilizing secretions to prevent pneumonia

evaluation Patient was able to minimize the sign of infection

Assist in liquefying respiratory secretions to facilitate expectoration & prevents stasis of Body fluids
Verifies presence of infection, identifies specific pathogens& influences choice of treatment

Anatomy and physiology

The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in and disposing of those gases. Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body. Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.

Respiratory system

Pathophysiology of Pneumonia
Droplets S. Pneumoniae aspirated into the lungs Inflammatory response initiated

Alveolar Edema

Exudate Formation

Alveoli and respiratory bronchioles fill with serous exudate, blood cells, fibrin, and bacteria

Consolidation of lung tissue

Pnemonia
Signs and symptoms: high fever , shaking chills, cough with sputum production, shortness of breath

Discharge plan
Medicine:
Take the entire course of any prescribed medications. After a patients temperature returns to normal, medication must be continued according to the doctors instructions, otherwise the pneumonia may recur. Relapses can be far more serious than the first attack.

Exercise:
>Walk or jog >Dancing, Aerobics, Gymnastics, Stretching ... >Swimming >Do not exhaust yourself ! >Do not exercise with full stomach ! (You may take a walk!)

Treatment:
Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse. Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs.

Health Teaching:
Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g. smoke). Smoking damages ones lungs natural defenses against respiratory infections.

Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isnt possible, a person can help protect others by wearing a face mask and always coughing into a tissue. Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed. Encourage the guardians to wash patients hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter ones body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk.

Out- patient referral:

Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected. Its important to have the doctor monitor his progress.

Diet:
Eat nutritious foods like fruits and vegetables to recover well.