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KHYBER PUKHTUNKHWA, PESHAWAR
Portfolio
Subject; Pediatric nursing
Case topic; pneumonia
Student; Tasleem tahir
Faculty; Anis Fatima
Semester; 5th
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Patient name Hamdan
Ward Children B
Bed No# 04
Age 1 year
Sex Male
Address Peshawar
Table of the contents
01 History Page NO 03
02 Assessment 04
03 Milestones 05
04 Lab investigations 05
05 Treatment 06
06 CM(concept map) 06
07 Diagnosis and interventions 08
08 Nursing care plane 09
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HISTORY
C/C
Difficulty in breathing 03 days
Fever 03 days
O/E
Irritable
Febrile
Difficulty in breathing
Present History
According to the mother of the baby, he was all right three days back when he develops
difficulty in breathing. It was not associated with cough. He also develops high grade fever,
which was not associated with rigors and chills.
Past History: no previous hospitalization
Socio – Economic history: satisfactory (the father of the baby working as a teacher)
Birth History: Spontaneous veginal delivery (SVD) with no
complications:
Feeding History: breast feeding, in 8month weaning was started.
Surgical History: NA (not applicable)
Vaccination History: Vaccination is done.
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Family History: Mother age; 22y Father age; 33y Baby age 1year
22 33
01
ASSESSMENT
Subjective data
Difficulty in breathing ---from 3 days
High grad fever not associated with rigors and chills.
Objective data
A one year old baby was admitted on April, 26, 2014.
He was lying on bed on 04 with his own cloth with IV cannula on the right foot.
The color of the baby was pale and her mod was unpleasant.
Physical Examination:
The following sings are found in a pneumonia patient.
Expansion: Expansion reduced on the affected side.
Vocal fremitus: increased on the affected side.
Percussion: dull, but not stony dull.
Breath sounds: bronchial, if the airways are open.
Additional sounds: medium, creps as the pneumonia resolves.
Vocal resonance: increased.
Pleural rub: may be present
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Vital signs:
Temp; 102f
Pulse; 80beats/mint
Res; 23/mint
MILESTONES
Age Language Movement Teething Eating Positive\Negative
Birth cries Kicks legs, _ Positive
trashes arms.
6month Babbles, Rolls over back _ Positive
Responds to to stomach.
name
12month Don’t say Start crawling _ Picks up Negative
anything clearly spoon by
handle
LAB INVESTIGATIONS
X-ray
BLOOD TEST
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FBC
HB 11.3g/dl normal…………….in men 14-18
TLC 20,500/cmm normal…………….4000-11000/cmm
Platelet’s 366000cmm normal…………….250, 000-500,000
DLC
N 80% normal………….40-75%
L 18% normal………….20-45%
M 01% normal…………..2-10%
E 01% normal…………….1-3%
RBS 4.45mg/dl. Normal…………….in men 4.5-6.5
TREATMENT
Drugs Dose MOA Side effects
Inj Rocephin 250 mg It results from Vomiting, nausea,
I\V BD the inhibition dizziness, fatiqe.
(Ceftriaxone)
of bacterial cell
wall synthesis.
Panadol liquid 1TSF BD It inhibits Side effects of
prostaglandin paracetamol are rare but
(paracetamol)
synthesis in the hypersensitivity including
central skin rashes may occur.
nervous
system.
O2 inhalation SOS
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Pneumonia
Inflammation of the pulmonary parenchyma is common in childhood but occurs more
frequently in infancy and early childhood.
Pneumonia may occur either as a primary disease or as a complication of another illness.
Types of Pneumonia:
There are two main types of pneumonia
1) Lobar pneumonia:
Lobar pneumonia initially affects one lobe of a lung.
2) Bronchopneumonia:
In Bronchopneumonia inflammation initially starts in the bronchi and bronchioles (airways)
Causative Organism:
Streptococcus pneumonia
Other bacteria that cause pneumonia in children (staphylococcus aureus, and Haemophilus
influenza).
Signs and Symptoms:
Fever
Malaise
Cough
Chest pain
Anorexia
Vomiting
Diarrhea
Abdominal pain.
Diagnostic Test:
Physical exam
Chest X-rays
Blood and mucus tests.
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Therapeutic Management:
Antibiotics therapy
Bed rest
Oral intake of fluid
Antipyretic
IV fluid and oxygen is required if the child is in respiratory distress.
Nursing Diagnosis:
Ineffective Airway Clearance related to inflammation, the accumulation of secretions.
Impaired Gas Exchange related to alveolar capillary membrane changes.
Fluid Volume Deficit related to inadequate oral intake, fever, and tachypnea.
Hyperthermia related to inflammatory processes.
Nursing Interventions:
Monitor respiratory status every 2 hours; assess the increase in respiratory status and
abnormal breath sounds.
Observation of level of consciousness, respiratory status, and cyanosis signs every 2
hours.
Give oxygen according to the program.
Record intake and output of fluids. Encourage the mother to continue giving fluids orally
and avoid the condensed milk / drink cold or cough inducing.
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NURCING CARE PLANE
Assessment Diagnose Planning Nursing Evaluation
Interventions
Subjective: Fever related Short Term: 3) Administer After nursing
to After 3-4 of antipyretic interventions
According to the nursing
inflammation drugs. the patient
mother of the baby, interventions
of the lungs 4) Cold sponging. fever is relived
he was all right the patient
secondary to 5) Administer and his
three days back fever will be
pneumonia. the prescribe condition is
when he develops decrease.
Long Term:
medications: better than the
difficulty in
After 6) Administer previous and he
breathing. It was
hospitalization oxygen lying on the bed
not associated with
and proper therapy as in semi-fowler
cough. He also
medication the ordered. position.
develops high grade
patient will get 7) Place the
fever, which was full recovery patient in
not associated with from fever. semi-fowlers
rigors and chills.
position to
Objectives: breath easily.
A one year old baby
was admitted on
April, 26, 2014.
He was lying on bed
on 04 with his own
cloth with IV
cannula on the right
foot. The color of
the baby was pale
and her mod was
unpleasant.
Vital signs:
Temp; 102f
Pulse;
80beats/mint
Res; 23/mint
