NURSING PROCESS

A Group Nursing Process

In Partial Fulfillment of the Requirements

For RLE class

Submitted by:

Castillo, Mary Grace O.

Castro, Marion G.

Contreras, Mary Ann Mae R.

Cuneta, Justine Joy D.

Daño, Charles Kevin R.

De Paz, Angelyne

De Vera, James Matthew

BSN II – A-01

Submitted to:

Ms. Lorna Melosantos, RN, MAN

Date Submitted:

February 15, 2011

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

Nursing Process
I. Assessment

A. General Data

Patient's Initials: P.J.P.M. Informant: Mother of patient

Address: Caloocan City Date of Admission: 02/07/2011
Age: 1 ½ yrs old Order of Admission: Ambulatory
Sex: Female No. of days in the hospital: 3 days
Date of Birth: July 26, 2009
Civil Status: N/A
Occupation: N/A

B. Chief Complaints

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

C. History of present illness

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

D. Past History

1. Childhood Illness: bronchopneumonia

2. Adult Illness: N/A
3. Immunization: complete EPI immunization
4. Previous hospitalization: 02/07/2011
5. Operations: none
6. Injuries: None
7. Medication taken prior to confinement: Cefuroxime, Gentamicin, Ranitidine,
Metoclopromide, Paracetamol
8. Allergies: none

E. Family Assessment

Name Relation Age Sex Occupation Educational

Attainment
L.M Mother 29 F Check-out College
team leader graduate
J.M father 27 M driver College
undergraduat
e

F. Heredo

Maternal: Diabetes
Paternal: None

G. Developmental Theory

Theorist Ag Task Patient’s Description

e
 Erik Erikson 1½ Trust  The patient’s mother said that her
son would always cry if someone he
doesn’t know carries him or
approaches him.
 Sigmund 1½ Oral  The patient’s mother said that her
Freud son sometimes suck on his thumb,
and likes to put things in his mouth.
 Jean Piaget 1½ Sensory Motor  According to the mother of the
Stage patent, the child is able to imitate
(Coordination of the observed behaviors of other.
Reactions) The child also begins to recognize
certain objects like the rattle.
 James 1½ Undifferentiated  The child doesn’t cries when only
Fowler the relative is present and her
mother is not around.

I. Anthropometric Measurements

• Head Circumference: 47cm

• Chest Circumference: 95cm
• Abdominal Circumference: 49cm

Vital Signs:

T: 37.9
RR: 34
PR: 156
Physical Assessment:

Skin

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

Nails

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

Hair

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

Skull and face

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

Eyes

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

Ears

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

Nose

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

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

Neck

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

Thorax and Lung

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

Abdomen

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

Genitals

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

II. Environmental History:

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

IV. Pediatric history

Birth history

Birth date: July 26, 2009

Hospital: Cabarles lying-in
Birth weight: 2.6kg
Type of Delivery: NSD

VI. Pathophysiology

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

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

Was observed
via physical
examination

Chief Complaint
 VII. Laboratory Result

Laboratory Normal Value Result Interpretations

(date)

02/07/2011
Hemoglobin 10.3-12.4 g/dl 12.58 The patient's hemoglobin is above
the normal range

RBC Count 4.1-5.0 x106/µL. 3.95 The patient's RBC count is below
the normal range

Hematocrit 37 The patient's hematocrit is within

30.9-37.7% the normal range

WBC Count 12.0 The patient's WBC count is above

5-10 g/dl the normal range

Platelet count 286 The patient's platelet count is

219–452 x10³/µL. within the normal range

Lymphocyte 23% The patient's lymphocyte is within

20-40% the normal range

VIII. Drug Study

Drugs Indication Action Side Nursing Patient

effect/adverse Consideration Teaching
effect

Date:02/07/1 -Short-term Competitively -CNS: headache, - Administer oral • Patient

1 treatment of inhibits the malaise, drug with meals should not run
Generic active, benign action of dizziness, and at bedtime. or do
Name: gastric ulcer histamine at somnolence, -. Decrease doses physicalactiviti
Ranitidine - Treatment of the H2 insomnia, vertigo in renal and liver es/ hazardous
Hydrochloride heartburn, acid receptors of -CV: tachycardia, failure. activities until
Brand indigestion, the parietal bradycardia - Provide he knows how
Name: sour stomach cells of the -Dermatologic: concurrent drug affects
Zantac stomach, rash, alopecia antacid therapy to concentration
Dosage: inhibiting basal -GI: constipation, relieve pain. and alertness.
0.5cc/IVP, q6 gastric acid diarrhea, nausea - Arrange for • Tell mother of
secretion and and vomiting, regular follow-up the patient that
gastric acid abdominal pain, including blood smoking may
secretion that hepatitis test, to evaluate decrease drug
is stimulated -GU: impotence or effects. effects.
by food, decreased libido - Monitor BP
insulin, carefully during IV
histamine, -GI: nausea and administration.
cholinergic diarrhea - Monitor diabetic
agonists, patients, arrange
gastrin and for alterations in -instruct the
pentagastrin. insulin dose or mother to let
timing if diabetic her son take
 control is the meds. 30
compromised by minutes before
-Disturbances alterations in meals.
of GI motility CNS: restlessness, timing of food - Instruct the
Generic -Nausea and drowsiness, absorption. mother to
Name: vomiting fatigue, insomnia, report
Metocloprami -Metabolic Blocks dizziness, anxiety -Determine involuntary
de diseases dopamine history of movements of
Brand receptors by -CV: transient hypersensitivity face, eyes, or
Name: disrupting CNS hypertension reactions to limbs.
Maxolon chemoreceptor cephalosporins, - Patient should
Dosage:0.5cc trigger zone, -GI: nausea and penicillins, and not do run or
increasing diarrhea history of do physical
peristalsis and allergies, activities until
promoting particularly to drug's effects
gastric drugs, before are known.
emptying therapy is
initiated.

-Report onset of
loose stools or
For the diarrhea.
treatment of CNS: Dizziness,
headache, Although
many different pseudomembrano -Teach mother
types of fatigue, to recognize
paresthesia, us colitis.
Generic bacterial signs and
name: infections such fever, chills, symptoms of
confusion
Cefuroxime as bronchitis, Inhibits superinfection.
Brand sinusitis, bacterial GI: Diarrhea, Instruct him to
nausea, -Monitor I&O rates
Name: tonsillitis, ear wall synthesis, report these
Zinacef, infections, skin rendering cell vomiting, and pattern: right away.
anorexia, Especially
Ceftin infections, wall - Advise mother
Dosage: gonorrhea, and osmotically glossitis, important in to report CNS
bleeding, severely ill
2.2cc q8 urinary tract unstable, changes.
infections leading increased AST, patients receiving
ALT, high doses.
to cell death by
binding to cell bilirubin, LDH, Report any
alkaline significant
wall
membrane phosphatase, changes.
abdominal pain, Monitor for S&S
loose stools, of: hepatotoxicity,
flatulence, even with
heartburn, moderate
stomach cramps, acetaminophen
To relieve mild colitis, jaundice doses, especially -Do not self-
to moderate in individuals with medicate
pain due to poor nutrition. children for
things such as pain more than
Generic headache, Side effects are 5 d without
rare with
name: muscle and consulting a
Paracetamol joint pain, Paracetamol paracetamol physician.
when it is taken
Dosage: backache and possesses -Do not use for
5 ml, q4 period pains. It prominent at the fever persisting
-Assess for Lab
recommended
is also used to antipyretic and tests: Perform longer than 3
bring down a analgesic doses. Skin d, fever over
C&S and renal
 high effects.. The rashes, blood 39.5° C (103°
temperature. mechanism of disorders and function prior to F), or recurrent
Paracetamol is action is acute first dose and fever.
often included related to inflammation of periodically -Do not give
in cough, cold depression of the pancreas during therapy; children more
and flu the have occasionally therapy may than 5 doses in
remedies. prostaglandin occurred in begin pending 24 h unless
synthesis by people taking the test results. prescribed by
inhibition of the drug on a regular Determine physician.
specific cell basis for a long creatinine
cyclooxygenas time. clearance and
e, and serum drug
depression of concentrations at
the frequent intervals,
thermoregulato particularly for
ry center in the patients with
medulla impaired renal
oblongata. function, infants -Advise mother
(renal to report signs
Gentamicin is immaturity), older and symptoms
Generic an adults, patients of ototoxicity
name: aminoglycoside receiving high (hearing loss,
Gentamycin antibiotic, doses or therapy ringing in ears,
Dosage: which is used beyond 10 d, vertigo).
0.5cc/IVF, q8 to treat patients with -Instruct
infections Destroys gram- Nephrotoxicity fever or extensive patient to drink
caused by negative occurs and is burns, edema, plenty of fluids
aerobic gram- bacteria by related to the obesity. to ensure
negative irreversibly length and adequate urine
bacteria. binding to 30S dosage of -Repeat C&S if output.
Gentamicin in subunit of gentamicin. The improvement -Tell mother to
combination bacterial initial toxic effects does not occur in monitor urine
with penicillin ribosomes and are renal failure 3–5 d; reevaluate output and
has synergetic blocking that causes therapy. report
antibacterial protein serious effects. significant
effects against synthesis, Gentamicin may changes.
gram positive also cause -Draw blood
resulting in specimens for -patient should
cocci. misreading of irreversible not run or do
ototoxicity that peak serum
genetic code gentamicin physical
and separation may lead to activities until
hearing loss. concentration 30
of ribosomes min–1h after IM he knows how
from administration, drug affects
messenger and 30 min after concentration
RNA completion of a and alertness.
30–60 min IV
infusion. Draw
blood specimens
for trough levels
just before the
next IM or IV
dose. Use
nonheparinized
tubes to collect
blood.
 XI. List of Priority Problems:

1. Altered body temperature

2. Risk for infection
3. Impaired gas exchange

X. Nursing Care Plan

Cues Nursing Rationale Goal and Intervention Rationale Evaluation

diagnosis Objective
S: “ Altered body Bacterial -After 2 Independent -To determine After 2
Nilalagnat temperature microorganismsGoalshours
and of : if the Pt’s hours of
ang Cues
anak Diagnosis
related to Rationale
(e.g. Objective
pulmonary Nursing Intervention -Monitor Pt’s Rationale
temperature is Evaluation
Nursing
ko” as bacterial pathogens) Intervention Temperatur Above the Intervention,
verbalized invasion in enter , the Pt’s e normal body Afterthe30 goal was
byS:the Risk for
the Bacterial
the airway -Aftertemperature
30 Independent:
q1 hr - To improve
temperature minutesmet.ofThe
O:
mother’s infection
lungs as microorgani
These minutes
willof the -Allows the health Pt’s
-
patient (spread) r/t
manifested sms health
bacteria/viruses decrease -Teach the understanding
patient to teachings, the
temperature
Presence broncho-
by (e.g.
infects the teachings,
from 37.9 mother of the of the mother
- Encourage recuperate goal was
decreased
O:of pneumonia
body pulmonary
lung/s the °C to normal pharmaco-Pt to rest on why her
physical partially
frommet.
37.9 °C
- infection as
temperature pathogens) patient’s
Inflammation of range dynamics of son’s strength Health
to normal
-
tachypnea evidenced
higher than enter
the lung/s mother will - 37.5
(36.6 her son’s medications teaching
rangewas
Antibiotic
-febrile by the
normal, the airway
Signs and know of
°C) therapeutic are important
-To maintain interrupted
(36.6 - 37.5
therapy
-T= 37.9 C presence of
tachypnea, ↓symptoms of the drugs -Encourage hydration due to
°C)the
-RR=34 current
(+) crackles These
Pneumonia importanc Pt to - To avoid
status and patient was
cpm infection bacteria/vir e
(e.g.temperatur of strictly -Advise increase skipping of gagging.
increased fluid Drug
-(+) uses
e following patient’s dosesintake
fluid intake pharmaco-
crackles infects
may bethe her son’s
greater mother to -Sponge bathdynamics
lung/s
than medication make a - to hasten the
with warm were not
↓37.5°C), regime schedule for
-Encourage recovery
waterof the explained
Inflammatio
tachypnea, son’s the Pt’s patient
evaporates properly, but
ncoughs
of the with medications
guardian to off his skin, the
lung/s
greenish do tepid thus, cooling medication
secretions -Advise sponge bath off the Pt schedule was
Source: mother to advised.
medical-
sources: strictly follow
dictionary.
www.healthline the
thefreedic
.com/ medication
tionary.co
channel/ order
m/broncho
bronchopneum
pneumoni
onia.
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 Cues Diagnosis Rationale Goals and Interventions Rationale Evaluation
Objectives

S: Independent:
“Nahihirapa Impaired Bacterial - For the For the whole
n sya gas microorganis whole - Observe - for shift, the
huminga exchange ms shift, the patient for immediate patient was
paminsan” r/t (e.g. patient’s coughing action on the under
as broncho- pulmonary difficulty to and any sign problem observation but
verbalized pneumonia pathogens) breathe of difficulty showed no
by the as enter will be in breathing signs of
mother of evidenced the airway relieved and: difficulty of
the patient by gasping ↓ > Shift the > Promote breathing. The
O: to breathe These -After 30 child’s optimal chest mother was
- Diagnosis and bacteria/virus minutes of position and expansion advised to let
of broncho- restlesness es health elevate the the child
pneumonia infects the teachings, head of the continue to rest
- Patient is lung/s the bed and carry the
restless and ↓ patient’s > Let the > helps limit child on her
constantly Inflammation mother will child oxygen shoulder while
sits up and of the lung/s know of continue to needs/consum patting his
starts to ↓ simple rest ption back lightly
gasp Gas interventio when he
continuously exchange is ns to aid -Advise coughs.
- impaired her child. patient’s - To promote
Tachycardia mother to the
Source: shift her mobilization of
medical- child’s secretions
dictionary.t position
hefreedictio frequently
nary.com/br and rub her
onchopneu child’s back
monia when he
 coughs, as
well as keep
the child’s
fluid intake
adequate

DISCHARGE PLANNING

M- Medication

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

E- Exercise

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

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

H- Health Teaching

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

O- Out patient follow-up

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

D- Diet

Diet as tolerated. Instruct the mother to give nutritious food intended for respiratory
problems. Instruct the mother to increase the fluid intake of the patient
Cues NURSING BACKGROUND PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE INTERVENTIONS
S> “Ayaw Imbalance Bacteria or virus After 4 > Assess for > The After 4 hours of
nyang d attacks the hours of recent consequence Nursing
kumain, Nutrition lung/s Nursing changes in s Intervention,
yung gatas due to ↓ Intervention physiological of the Pt
sinusuka frequent weakened , the status malnutrition started taking
lang vomiting immune Pt will start that may interfere can foods
naman and not systems taking with nutrition lead to a which he
nya,” and eating the ↓ foods which further usually eat
“Mas payat usual foods Pneumonia he decline in the (crackers)
sya taken ↓ usually eat patient's After 4 hours of
ngayon, as Symptoms of (rice, condition Nursing
dati ang manifested Pneumonia: crackers, that then Intervention,
lakas by nausea or chicken becomes the Pt didn’t
naman decreased vomiting, may breast,etc) self- vomit anymore
kumain” weight, experience After 4 perpetuating the
as food profound hours of if ingested milk
verbalized aversion, weakness w/c Nursing not
by the Pt’s and lasts Intervention recognized
mother. weakness. for a long time. , the > Provide and
O> vomits Pt will not companionship at treated.
ingested vomit mealtime to > Often
milk anymore encourage toddlers will
Food the nutritional intake eat more
aversion ingested food if other
Decreased milk people are
wt > Determine present at
weakness healthy body mealtimes.
weight for age and > Protein-
height calorie
malnutrition
most
often
> Assess client's accompanies
ability to obtain a
and use essential disease
nutrients. process
> Cases of
vitamin D
deficiency
have been
reported
among
darkskinned
toddlers who
were
exclusively
breast fed
and were
not given
supplemental
vitamin