A GRAND CASE PRESENTATION OF A 1-YEAR-OLD CHILD

DIAGNOSED WITH BRONCHIAL ASTHMA IN ACUTE EXACERBATION

Presented to the Faculty of the College of Nursing

Xavier University - Ateneo de Cagayan

In Partial Fulfillment of the Requirements of

NCM 109 Care of Mother, Child, at Risk or

with Problems (Acute and Chronic)

Related Learning Experience

Submitted to

Jennifer O. Asio, RN, MN

Roviech John M. Echeveria, RN, MAN

Ivy Royo Go, RN, MAN, DScN

Clinical Instructors

April 30, 2021

 Submitted by

BSN - 2 NF

Acut, Louella B.

Ali, Sittie Jobaisah T.

Banaag, Ma. Venus Caress T.

Bantol, John Louise T.

Banza, Khrisna Nymph P.

Carlos, Jude Mariano Jr. A.

Cubillas, Franczhes A.

Danseco, Danna Francesca S.

Datu-Ramos, Dimapuno T.

Del Rosario, Carylle M.

Ebio, Dynn M.

Famacion, Kyra Bianca R.

Go, Clarke Nathaniel Sean E.

Laid, Althia Crizza J.

Langeras, Howard S.

Mah, Chloe Gwyneth R.

Maribao, Dylan Sean Ezekiel

Miñoza, Ana Rose Anthony E.

Nagac, Ailene Grace C.

Olarita, Venisse A.

Ragpala, Fide Lynn C.

Ravacio, Earl Christoffer C.

Romorosa, Christine Marie Pauline C.

Samoya, Abigail Kim T.

Sio, Zoe Nicole C.

 Telow, Jered Brae V.

Torion, Zenn Pauline M.

Torre, Carlos Joseton Paolo S.

Vallecer, Matthew Orlando IV V.

Waga, Mikayla Martina C.

Yongco, Sheila Adrianne S.

ACKNOWLEDGEMENT

The Block NF would like to express their sincere appreciation and indebtedness to

the people who made the completion of this case study possible. The development and

success of this paper would not have been possible without the contributions of the following

people:

To Mrs. Jennifer O. Asio, RN, MN, Mr. Roviech John M. Echeveria, RN, MAN,

and Mrs. Ivy R. Go, RN, MAN, DScN, the Clinical Instructors for NCM 109 RLE, for

providing proper guidance, dedication and patience to the student nurses throughout the

entire preparation of this case presentation. Their passion and commitment towards being a

Clinical Instructor for the student nurses has brought them to their fullest potential and

expanded their capabilities as a student nurse.

To Mrs. Mary Grace M. Paayas, RN, MAN, Dean of the College of Nursing, for

being a true inspiration to every student nurse, for leading the Clinical Instructors to be

competent in all aspects and to be the true example of a dedicated nurse.

To the patient and parents, for their trust in allowing the Clinical Instructors to use

the patient's documents as a tool for student nurses to learn through the procedures that

have been made. The student nurses commend them for taking this into consideration as

this is a major part for the student nurses in expanding their knowledge and becoming a

better version of themselves.

To the Maria Reyna - Xavier University Hospital, for entrusting the data to the

student nurses which is handled with confidentiality. The private documents they provided

were essential for the completion of this paper.

To the Block NF, the researchers of this case study, for their dedication and

commitment to produce a competent paper with the best of their abilities. The time and

effort spent from Block F was very much appreciated.

 To the 3rd year nursing students, for giving advice and guiding the student nurses

on what is expected to come. The goals would not have been achieved without their help

and support, they are very much appreciated and the researchers are very grateful to have

them on their side.

To the families of the researchers, for their unwavering support throughout their

children’s nursing career. The financial and spiritual support they provided were greatly

appreciated.

To the peers and friends of the researchers, for providing the student nurses good

advice and being an inspiration to them. They are indeed an example of a good influence.

Lastly, to God the Almighty Father, for the gift of knowledge and wisdom He has

bestowed upon the student nurses for the completion of this paper.
 TABLE OF CONTENTS

Page Number

Acknowledgements

I. General Objectives………………………………………………………………………..1

II. Specific Objectives ……………………………………………………………………….2

III. Significance of the Study…………………………………………………………………4

IV. Scope and Limitations…………………………………………………………………….6

V. Definition of Terms………………………………………………………………………...7

VI. Introduction………………………………………………………………………………...11

VII. ASSESSMENT…………………………………………………………………………….13

a. Narrative Assessment………………………………………………………...13

b. Assessment Tool………………………………………………………………16

VIII. Laboratory Results………………………………………………………………………...22

IX. Anatomy and Physiology…..……………………………………………………………..28

X. Pathophysiology…………………………………………………………………………...34

a. Narrative Pathophysiology…………………………………………………..34

b. Schematic Diagram…………………………………………………………..39

XI. Drug Study………………………………………………………………………………….44

XII. Nursing Care Management……………………………………………………………….60

a. Nursing Care Plan 1………………………………………………………….60

b. Nursing Care Plan 2………………………………………………………….65

c. Nursing Care Plan 3………………………………………………………….68

d. Nursing Care Plan 4………………………………………………………….71

e. Nursing Care Plan 5………………………………………………………….74

XIII. Discharge Plan…………………………………………………………..………………...77

XIV. Prognosis…………………………………………………………………………………...80
 XV. Conclusion………………………………………………………………………………....84

XVI. Recommendation………………………………………………………………………….86

XVII. BIBLIOGRAPHY…………………………………………………………..………………88

XVIII. APPENDICES……………………………………………………………………………..93

A. Doctor’s Orders………………………………………………………………93

B. Nurse’s Notes………………………………………………………………...96

C. Consent……………………………………………………………………….97
I. GENERAL OBJECTIVES

At the end of the grand case presentation, the group will be able to provide a

detailed and thorough discussion of the physiologic processes involved in the

disease state of the client along with its related factors. They will be capable of

applying basic nursing skills with ease and competence as well as demonstrate the

requisite positive and desirable attitudes. In this grand case presentation, the

researchers will be able to gather significant information and exhibit expertise related

to the patient's health condition, as well as improve critical thinking skills to become

competent and patient-centered healthcare professionals in the future. Effective

communication with the group will be established in order to efficiently manage time,

create teamwork and unity among student nurses, and improve competence in

handling potential cases. The student nurses will also be able to uphold and embody

the Ignatian values of becoming men and women for others and doing all things for

the greater glory of God.

1
II. SPECIFIC OBJECTIVES

At the end of the 2 hours of the grand case presentation, the group will be

able to:

Knowledge

● Describe the illness condition of the patient and interpret its general

manifestations;

● Thoroughly discuss the pathophysiology of the condition of the patient to fully

understand the etiology, methods of prevention, pathologic processes, signs

and symptoms, and the appropriate treatment and nursing interventions;

● Identify the priority problems in the respective nursing care plan formulated

based on the assessment findings of the patient;

● Explain the relevance and rationale of the nursing interventions presented

with regards to alleviating the condition of the patient;

● Discuss the importance and indications of the medications through the

presentation of the drug study and other therapeutic managements

prescribed by the physician;

● Interpret the patient’s laboratory and diagnostic tests results and determine its

relation to the client’s health state;

● Explain the final prognosis based on the categories that the patient is being

evaluated; and

● Provide recommendations for further case studies prior to concluding the

presentation

2
Skills

● Exercise proper time management in the presentation of the case;

● Constructively introduce the case and diagnosis of the patient in a manner

that it can be easily understood;

● Present the information of the patient and the complete data gathered in the

case in an organized and systematic manner;

● Apply the knowledge learned in class in determining the priority problem and

the appropriate nursing interventions for the patient; and

● Exemplify mastery and comprehension of the case through answering the

questions with confidence and competence

Attitude

● Display confidence and assertiveness throughout the case presentation;

● Maintain decency and professionalism throughout the presentation;

● Show a sense of collaboration and teamwork throughout the program; and

● Show a positive attitude towards constructive criticism and comments given

by the panel

3
 III. SIGNIFICANCE OF THE STUDY

The aim of this research is to provide knowledge and understanding about bronchial

asthma in acute exacerbation. The results will help people at all stages in addressing this

issue in order to have a healthy future. Furthermore, the findings of this analysis can be seen

as a learning aid, which would be beneficial to the following groups:

Patients with bronchial asthma especially to those who inherit this genetic

makeup. There is a wide range of environmental factors, such as virus infections,

environmental tobacco smoke and pollutants, to initiate tissue damage and aberrant repair

responses that are translated into remodelling of the airways. While candidate gene

association studies have revealed polymorphic variants that influence asthmatic

inflammation, positional cloning of previously unknown genes is identifying a high proportion

of novel genes (S. T. Holgate and etc). In this way we can supplement new ideas and

knowledge since it is considered as a common condition. The study can give patients an

overview about the disease predisposing and precipitating factors, its treatment, as well as

some important measures in controlling and monitoring asthma signs and symptoms during

an attack or exacerbation.

Level two nursing students. This could improve their critical thinking skills in order

for them to become competent and patient-centered health care professionals in the future.

They can apply all their learnings throughout their journey as student nurses. Doing further

research and study about this disease, its processes, and pathophysiology would ultimately

lead to new ideas and solutions that could guide them in caring for their patients.

For the healthcare team, this could provide new knowledge and methods on how to

render care to patients of similar situations. There is also an enhancement of skills and

abilities in providing care, as well as attitude when working with patients like this in different

areas of duty.

4
 As to our Clinical Instructors, this may be an excellent ground for inquiry, study,

and interpretation that can also be introduced to their students who benefit from their

experiences.

For the future nursing students, this could be a source of additional research that

could be used to further subsequent studies. Since illnesses progress with time, future

nursing students are encouraged to stay ahead of the curve in order to improve people's

lives as what they are sworn to do.

Lastly, for the community, this could raise awareness and provide more knowledge

for them to properly assess and treat these certain diseases. Moreover, it plays an important

role in discovering new treatments, and making sure that we use existing treatments in the

best possible ways. Research can find answers to things that are unknown, filling gaps in

knowledge and changing the way that healthcare professionals work.

5
 IV. SCOPE AND LIMITATION

The study focuses on a 1-year and 3-months-old male child who had a final

diagnosis of Bronchial Asthma in Acute Exacerbation with a chief complaint of cough, who

was brought to ER at exactly 3:30pm then was officially admitted at Maria Reyna - Xavier

University Hospital, Inc. (MRXUHI) last December 1, 2020 at 11:27 pm to December 4, 2020

at 6 pm. Different Instruments were used in the data gathering of the said study as follows:

Personal Data, Travel History, Emergency Room Admission Sheet, Consent for Admission,

Hospital Care, Diagnostic Procedures and Collection and Processing of Personal

Information, Vital Signs Sheet, Intake and Output Sheet, Physician’s Notes, Doctor’s Order,

Nurse’s Notes, Laboratory Result, Medication Sheet, Intravenous Fluid Sheet. This study’s

data is limited only to the instruments mentioned due to the arising pandemic and general

community quarantine. The students were not able to personally assess and evaluate the

patient and the information available is limited to what the hospital has given. Nonetheless,

the students were able to uphold solidly notice and regard the patient’s right to privacy and

confidentiality.

6
 V. DEFINITION OF TERMS

Acute. Disease or condition characterized by the rapid onset of severe symptoms.

Airway Obstruction. A type of respiratory dysfunction that produces reduced airflow,

usually on expiration; the obstruction can be localized or generalized.

Allergic Rhinitis. An inflammation of the nasal passages caused by allergic reaction to

airborne substances.

Asthma. Asthma is a chronic disease that causes the airways of the lungs to swell and

narrow. It leads to breathing difficulty such as wheezing, shortness of breath, chest

tightness, and coughing.

Aspiration. Pulmonary aspiration is the medical term for a person accidentally inhaling an

object or fluid into their windpipe and lungs. This can lead to coughing, difficulty breathing,

discomfort, and sometimes choking.

Bilateral Rales. It refers to the presence of crackles in both lungs.

Bronchial Asthma. Bronchial asthma is a medical condition which causes the airway path

of the lungs to swell and narrow. Due to this swelling, the air path produces excess mucus

making it hard to breathe, which results in coughing, shortness of breath, and wheezing.

Bronchial Hyperresponsiveness. An increase in sensitivity to a wide variety of airway

narrowing stimuli. In asthma, in particular, this hypersensitivity is accompanied by excessive

degrees of airway narrowing.

Bronchitis. Bronchitis is an inflammation of the air passages between the nose and the

lungs, including the windpipe or trachea and the larger air tubes of the lung that bring air in

from the trachea (bronchi).

7
Bronchoconstriction. Bronchoconstriction is a condition in which the smooth muscles of

the bronchus contract. The bronchus is the pathway that moves air to and from your lungs.

This muscle contraction causes the bronchus to narrow and restrict the amount of air

passing into and out of your lungs.

Chest X-RAY. A chest radiograph, called a chest X-ray, or chest film, is a projection

radiograph of the chest used to diagnose conditions affecting the chest, its contents, and

nearby structures.

Complete Blood Count (CBC). The complete blood count (CBC) is a group of tests that

evaluate the cells that circulate in blood, including red blood cells (RBCs), white blood cells

(WBCs), and platelets (PLTs). The CBC can evaluate your overall health and detect a variety

of diseases and conditions, such as infections, anemia and leukemia.

Cyanosis. A bluish color of the skin and the mucous membranes due to insufficient oxygen

in the blood.

Dyspnea. Breathlessness or shortness of breath; labored or difficult breathing. It is a sign of

a variety of disorders and is primarily an indication of inadequate ventilation or of insufficient

amounts of oxygen in the circulating blood.

Edema. Edema is a condition of abnormally large fluid volume in the circulatory system or in

tissues between the body's cells (interstitial spaces).

Exacerbation. It refers to an increase in the severity of a disease or its signs and symptoms.

Hypercarbia. Hypercapnia, or hypercarbia, is when you have too much carbon dioxide

(CO2) in your bloodstream. It usually happens as a result of hypoventilation, or not being

able to breathe properly and get oxygen into your lungs.

8
Hypoxemia. An abnormally low amount of oxygen in the blood, the major consequence of

respiratory failure, when the lungs no longer are able to perform their chief function of gas

exchange.

Hypoxia. Deficiency in the amount of oxygen delivered to the body tissues.

Interrupted Family Processes. A normally supportive family experiences or is at risk to

experience a stressor that challenges its previously effective functional ability.

Mucosal Edema. Mucosal edema or swelling is the build-up of edema (tissue fluid) within

the mucosa, the layer of tissue that lines the body’s interior.

Nebulization. The conversion of a liquid into a fine mist or spray, especially for inhalation

therapy; also called atomization.

Non-productive Cough. A dry cough and does not produce sputum.

Parental Stress. Perceptions of an imbalance between the demands of parenting and

available resources, is one of the many factors that contribute to the effectiveness of

parenting.

Pulse Oximetry. A noninvasive method of indicating the arterial oxygen saturation of

functional hemoglobin, using a pulse oximeter.

Retraction. The area between the ribs and in the neck sinks in when a person with asthma

attempts to inhale. Retractions are a sign someone is working hard to breathe.

Urinalysis. A test of urine. A urinalysis is used to detect and manage a wide range of

disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves

checking the appearance, concentration and content of urine.

9
Ventilation-Perfusion Mismatch. Defects in total lung ventilation perfusion ratio. It is a

condition in which one or more areas of the lung receive oxygen but no blood flow, or they

receive blood flow but no oxygen due to some diseases and disorders.

Wheezing. A high-pitched whistling sound made while breathing.

10
VI. INTRODUCTION

Asthma is a chronic inflammatory disease of the airways, characterized by recurrent

episodes of airflow obstruction resulting from edema, bronchospasm, and increased mucus

production. Seasonal allergies (allergic rhinitis) and eczema (atopic dermatitis) are

commonly associated and these three conditions form what is known as the atopic triad.

Patients who have asthma can have a variety of respiratory problems, including wheezing,

shortness of breath, coughing, and chest tightness. The severity and frequency of symptoms

vary, but untreated asthma and acute exacerbations may result in respiratory failure and

death (Lizzo & Cortes, 2020).

Asthma is one of the most prevalent non-communicable disorders, and for many, has

a significant impact on many people's quality of life. It is ranked 16th among the leading

causes of years lived with disability and 28th among the leading causes of burden of

disease, as measured by disability-adjusted life years. Patterns in asthma incidence and

prevalence differ between children and adults. It is well-known that asthma often begins in

childhood but can occur at any time throughout life (Dharmage et al., 2019).

According to Philchest (2017), there are approximately 300 million people worldwide

who are affected with asthma, and accounts to 250,000 deaths per year. In the Philippines,

the prevalence of asthma is 8.7% and 1 in 11 Filipinos have asthma. According to the data

released by WHO in 2018, asthma deaths in the Philippines reached 12, 479 or 2.05% of

total deaths, where the country ranks 14th worldwide. Almost 250,000 people die

prematurely each year from asthma, where most of the deaths are preventable. Globally,

death rates from asthma in children range from 0 to 0.7 per 100,000 people (Serebrisky &

Wiznia, 2019).

In the nursing profession, pediatric nursing is a specialization where the focus of

medical care and attention is to the children, from infancy to teenage years. It is a vital field

as the health of children is different from adults due to the development that occurs during

the course of childhood (Smith, 2019).

11
 This study is intended for the case of a 1 year and 3 month old patient admitted with

chief complaints of cough with a final diagnosis of Bronchial Asthma in Acute Exacerbation.

The patient is male and is a resident of Cagayan de Oro City. He is a Roman Catholic and

his nationality is Filipino. He was admitted in the emergency room on December 01, 2020 at

11:27P.M. Patient had a non-productive cough with clear nasal discharge 1 day prior to

admission and was given salbutamol syrup for self medication. The role of the pediatric

nurse was to assess vital signs, collaborate with other health care professionals, administer

prescribed medications, and provide safety and comfort to the patient during their course of

stay in the hospital.

12
VII. ASSESSMENT

a. Narrative Assessment

Patient X is a 1-year-and-3-month-old male infant from Indahag, Cagayan de Oro

City. On December 1, 2020, at 11:27 PM, Patient X was admitted to Maria Reyna - Xavier

University Hospital with a chief complaint of cough and colds and an admitting diagnosis of

pediatric community-acquired pneumonia with asthma.

Upon physical examination, the patient was conscious and was not lethargic nor

drowsy. His vital signs upon admission were a temperature of 36.6 degrees Celsius,

respiratory rate of 44 breaths per minute, heart rate of 188 beats per minute, and oxygen

saturation of 97%. Rales were heard in both lungs upon auscultation and intercostal

retraction was evident. Upon assessment, he weighed 11.5 kilograms and was noted to be

formula-fed. He was delivered via normal spontaneous delivery (NSD) without any

complications at JRB Hospital, Cagayan de Oro City. Immunizations received by Patient X

include BCG, DPT 3, OPV 3, and HIB 3. The mother is the primary caregiver. At 1 year old,

the patient is able to walk alone and able to say “mama” and “papa.” Patient X has a family

history of bronchial asthma from the maternal side. In the past two weeks, Patient X

presented with the following symptoms: vomiting, dry cough, runny nose, and shortness of

breath. His RT-PCR test result came in negative for COVID-19 Infection.

One day prior to admission, Patient X had a sudden onset of a non-productive cough,

with clear nasal discharge; but without fever, LBM, and vomiting. He was given salbutamol

syrup (self-medicated) 0.5mL x 3 doses. Morning prior to admission, Patient X had a

recurrence of symptoms associated with fast breathing, with decreased appetite and

decreased milk formula intake (6oz from normal intake of 18oz), and post-tussive vomiting.

On the day of admission, he was seen by the attending physician, which prompted

admission.

13
 On the second day of admission, December 2, 2020, upon assessment at 6:30 AM,

Patient X was afebrile, had decreased tachypnea with a respiratory rate of 50-52 breaths per

minute, and decreased intercostal retractions. Rales were still heard upon auscultation.

Heart rate was 150 beats per minute and oxygen saturation was at 97%. Patient X was

reported to be eating better. Diet for age was allowed but with strict aspiration precaution

and continuation of medications was ordered. At 3:00 PM, IVF rate was ordered to be

decreased to a rate of 50 cc/hr with an additional order of IVF to follow D5IMB (balanced

multiple maintenance solution) at 50 cc/hr in cycles until further notice. At 7:40 PM, Patient X

remained afebrile with a respiratory rate of 50 beats per minute. Heart rate was 120 beats

per minute and oxygen saturation was at 98%. Bilateral rales were still heard upon

auscultation and chest retraction was still present with an occasional wheeze. Chest tapping

after every nebulization was then instructed along with the continuation of his treatment with

Ceftriaxone D1.

On December 3, 2020, Patient X was placed safely at the center of the bed, with side

rails raised. The mother was instructed not to leave the patient unattended due to

medications given, kept watch for any unusualities. At 9:40 AM, assessment of Patient X

revealed that he was afebrile and had a good appetite. His vital signs that time were: heart

rate - 110, respiratory rate - 20, SPO2 - 98% - room air (RA), tolerated well. Bilateral rales

were still positive upon auscultation and audible wheeze was still present, however, there

were no observable retractions upon examination. He continued his course of antibiotic

therapy (Ceftraixone D1+1). Patient X’s oxygen was ordered to be discontinued with the

order to refer if with desaturation (<95% sat). His IV fluid was ordered to be decreased to a

rate of 45cc/hr with IV fluid to follow (D5IMB at 45 cc/hr). Nebulization interval was

decreased to q4. At 4:00 PM, Patient X’s follow-up assessment revealed that the audible

wheeze was still present, however, no retractions were observed. His vital signs were: blood

pressure - 90/60 mm/Hg, heart rate - 114 bpm, respiratory rate - 30 cpm, and SPO2 - 99% at

room air.

14
 On the last day of admission, December 4, 2020, at 9AM, no wheezing was noted

upon auscultation and retractions were not evident. His vital signs were as follows: blood

pressure - 90/60, heart rate - 114 BPM, respiratory rate - 28-38 CPM, and oxygen saturation

- 98%. Patient was advised to do chest tapping every after nebulization and was encouraged

to increase oral fluid intake (OFI). At 11 AM, Patient X was afebrile, no wheezing and

retractions were noted, and oxygen saturation was at 97% at room air (RA). Patient was

ordered to consume the remaining ceftriaxone 600 mg and was ordered to shift to

co-amoxiclav (Natravox) 250 mg/62.5 mg every 5 mL, 2.5 mL TID. The physician instructed

not to reinsert IV line once dislodged. IVF rate was decreased to 30cc/hour and salbutamol +

ipratropium was discontinued. Salbutamol was increased to 1 nebule q4h and

hydrocortisone was continued. At 11:30 AM, Patient X was discharged with the final

diagnosis of bronchial asthma in acute exacerbation. The following were the take-home

medications: salbutamol 1 nebule q6h for 5 days, co-amoxiclav 250 mg/62.5 mg, prednisone

20mg/5mL, and phenylpropanolamine HCl + Brompheniramine maleate (Nasatapp) drops 1

mL OD. Patient X was instructed to have a follow-up check-up on December 14, 2020 in

Maria Reyna Xavier University Hospital clinic at 12 NN.

15
b. Assessment Tool

16
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18
19
20
21
VIII. LABORATORY RESULTS

Legend:

Below normal range

Above normal range

HEMATOLOGY
Date of Result: 12-02-2020

Examination Normal Range Actual Result Interpretation

White Blood Cell 6.00 — 17.00 11.6 x10^9/L This indicates a normal number
Count x10^9/L of White Blood Cells in the
bloodstream.

Red Blood Cell 3.69 — 5.90 4.33 x 10^12/L This indicates a normal number
Count x10^12/L of Red Blood Cells in the
bloodstream.

Platelets 150 — 390 352 x10^9/dL This indicates a normal platelet

x10^9/dL count in the bloodstream.

Hgb 10.50 — 13.50 10.9 g/dL This indicates a normal number

g/dL of hemoglobin in the
bloodstream.

22
 Hct 33.00 — 39.00 % 32.2% (Low) Hematocrit measures how much
of the blood is made up of red
blood cells. Low hematocrit levels
may indicate conditions like blood
disorders, nutritional deficiency
(iron, vitamin B12, folate) or other
medical conditions. Iron is
important for the production of
hematocrit which is the protein is
the transferrin that binds to iron
and transports it throughout the
body; prior to admission, the
patient experienced decreased
appetite and decreased milk
formula intake, (6 oz) from usual
intake of 18 oz, during the last
two weeks which indicates a risk
for iron and vitamin B12
deficiency.

Neutrophils 37.00 — 72.00% 65% This indicates a normal number

of neutrophils in the bloodstream.

Lymphocytes 20.00 — 50.00% 26% This indicates a normal number

of lymphocytes in the
bloodstream.

23
Monocytes 8.00 — 14.00% 6% (Low) Monocytes are a major part of the
inflammatory system. Low levels
of monocytes may indicate
medical conditions such as bone
marrow disorder and infection
that reduces the total white blood
cell count that weaken the
immune system. Respiratory
infection includes cough/colds
that can affect the lungs when
having asthma, which can cause
inflammation (swelling) and
narrowing of the airways. The
patient’s medication,
hydrocortisone, is indicated for
reducing inflammation in the lung,
which may cause monocyte level
reduction.

Eosinophils 0.00 — 6.00% 0% This indicates a normal number

of eosinophils in the bloodstream.

Basophils 0.00 — 1.00% 0% This indicates a normal number

of basophils in the bloodstream.

RDW 11.50 — 14.50 % 15.7% (High) The red blood cell distribution
width indicates the size and
volume of the red blood cells in
the system. High levels of RDW
may indicate nutrient deficiency
such as iron, folate, and vitamin
B12. These results could also
indicate macrocytic anemia, a
condition in which the body does
not produce sufficiently normal
red blood cells and the cells it
does produce are larger than
normal which can be due to a
deficiency of folate or vitamin
B-12.

24
Interpretation:

The table shows Patient X’s hematology test done last December 2, 2020. Results

show low levels of hematocrit and monocyte count. An implication for low hematocrit count

may be due to nutrient deficiency, specifically iron, folate and vitamin B12 in which the

patient was noted to manifest the condition. An implication for the low monocyte count may

be due to the presence of infection that triggered the asthmatic condition of the patient. On

the other hand, there is a high level of RDW count which may indicate nutritional deficiency.

Prior to the admission, Patient X experienced decreased appetite, and decreased milk

formula intake which indicate the risk for deficiency of the following nutrients (iron, folate and

vitamin B12).

25
 URINALYSIS

Date of Result: 12-02-2020

Examination Reference Range Results Interpretation

Color Yellow Light Yellow This indicates a typical,

healthy urine.

Transparency Clear Clear Although normal, this may

indicate excess water intake

Specific Gravity 1.003 - 1.030 1.030 This indicated that the urine
gravity is within the normal
range

pH 4.5 - 8.0 6.0 This indicates a normal urine

acidity.

Sugar NEGATIVE NEGATIVE This indicates negative test

result which means that
there is no detectable amount
of sugar in the urine at the
time of testing

Protein NEGATIVE NEGATIVE This indicates negative test

result which means that
there is no detectable amount
of protein in the urine at the
time of testing

WBC 0-11 6 This indicates a normal WBC

count in the urine

RBC 0-11 6 This indicated a normal RBC

count in urine

26
 Epithelial Cells 0-11 RARE This indicates that the urine
has a small amount of
epithelial cells which is
considered as normal.

Bacteria 0-11 RARE This indicates that the the

urine has a small amount of
bacteria which is still
considered as normal

Interpretation:

The table shows Patient X’s urinalysis test results done last December 2, 2020. The

results are generally unremarkable which indicates that the patient has absence of infection

and a normal renal function. A urinalysis test is usually administered to rule out renal

dysfunction or determine the presence of an infection.

27
IX. ANATOMY AND PHYSIOLOGY

Anatomy of the Respiratory System

One of the primary functions of the respiratory system is breathing. Breathing or

respiration is essential for homeostasis. It provides the body with oxygen and eliminates

carbon dioxide. The respiratory system also performs other functions, such as: regulation of

the blood pH level, production of chemical mediators, voice production, olfaction and

protection (VanPutte et al., 2019).

Upper Respiratory Tract

The upper respiratory tract or the upper airways consists of structures that provide

major passageways for respiration. It functions in cleaning, warming, and humidifying the air

we breathe. Also, due to the presence of mucous membrane linings, it confines foreign

particles such as smoke and pollutants, before the air travels down to the lower respiratory

tract (VanPutte et al., 2019).

A. Nose

The nose comprises the external nose and the nasal cavity. The visible structure that

makes up the prominent feature in the face is the external nose, which is composed of

hyaline cartilage and a bone. These structures are covered by connective tissue and skin.

The external openings of the nose are called the nares or commonly called nostrils

(VanPutte et al., 2019).

B. Nasal Cavity

The nasal cavity is the structure between the nares and choanae which is divided

into left and right parts by the nasal septum. The hard palate forms a division of the nasal

cavity from the oral cavity which allows both cavities functioning at the same time. This

structure also consists of conchae, which are bony ridges at the walls of the nasal cavity

which functions in increasing its surface area allowing air to be cleansed, humidified, and

warmed (VanPutte et al., 2019).

28
 C. Pharynx

The pharynx opens to both the digestive system and the rest of the respiratory

system. It receives air, food, and fluid from the oral cavity and receives air from the nasal

cavity. There are three regions of the pharynx: nasopharynx, oropharynx, and

laryngopharynx (VanPutte et al., 2019).

D. Larynx

The larynx, also called the voice box, is a pathway for air between the pharynx and

trachea. Because of this, it is held open at all times by an outer casing of nine cartilages

(thyroid cartilage, epiglottis, cricoid cartilage, paired arytenoid cartilages, paired corniculate

cartilages, paired cuneiform cartilages, pair). It performs important functions that are vital to

maintaining air movement. Its cartilages maintain an open pathway, prevention of swallowed

material from entering the lower respiratory tract, production of sound, and mucus production

that moves debris to the pharynx (VanPutte et al., 2019).

29
Lower Respiratory Tract

The lower respiratory tract mainly functions in the conduction of gas exchange and

movement particularly the oxygen and carbon dioxide. These structures are also responsible

for the gas transport in the blood and tissues generating adequate amounts of gases in and

out of the body in order to achieve homeostasis (VanPutte et al., 2019).

A. Bronchi

From the trachea, it divides into two parts which is called the left and right main

bronchi connecting to the left and right lungs. The left main bronchi is structured more

horizontally than the right main bronchi due to the placement of the heart on the left side.

This causes the right main bronchus which is more vertical, wider, and shorter, to be more

susceptible to lodging of foreign objects. The main bronchi linings consist of pseudostratified

ciliated columnar epithelium and are supported with C-shaped pieces of cartilage (VanPutte

et al., 2019).

B. Lungs

The lungs are the vital organs of respiration. These are cone-shaped structures with

its base resting on the diaphragm and its apex extending slightly above the clavicle. The

right lung has three lobes (superior, middle, inferior), while the left lung has two lobes

(superior and inferior). The tracheobronchial tree is made up of the main bronchi and its

branches. From the main bronchi, it branches out into lobar bronchi which enters to the

respective lungs. This functions in conducting air to each lung lobe. From the lobar bronchi,

it divides into segmental bronchi leading to bronchopulmonary segments of the lungs. This

continues to branch out until it reaches the bronchioles which are subdivided into terminal

bronchioles, and then subdivided into respiratory bronchioles forming the alveolar ducts.

This opens into alveoli which are air- filled chambers where the air and blood creates close

contact. The respiratory membrane which consists of two layers of simple squamous

epithelium, alveolar fluids, and separating spaces, serves as the area where gas exchange

between the air and blood takes place (VanPutte et al., 2019).

30
Physiology of the Respiratory System

Respiration Process

A. Ventilation and Respiratory Volumes

Ventilation, or breathing, is the process of moving air into and out of the lungs. There

are two phases of ventilation: (1) Inspiration, or inhalation, is the movement of air into the

lungs; (2) expiration, or exhalation, is the movement of air out of the lungs. Ventilation is

regulated by changes in thoracic volume, which produce changes in air pressure within the

lungs (VanPutte et al., 2019).

At the end of a normal, quiet expiration, the respiratory muscles are relaxed. During

quiet inspiration, muscles of inspiration contract to increase the volume of the thoracic cavity.

Contraction of the diaphragm causes the top of the diaphragm to move inferiorly. Contraction

of the external intercostals also elevates the ribs and sternum to increase thoracic cavity

volume. The largest change in the thoracic cavity volume is due to contraction of the

diaphragm (VanPutte et al., 2019).

There are two physical principles that govern the flow of air into and out of the lungs:

(1) changes in volume result in changes in pressure, which means that as the volume of a

container increases, the pressure within the container decreases; and (2) air flows from an

area of higher pressure to an area of lower pressure, which means that if the pressure is

higher at one end of a tube than at the other, air or fluid flows from the area of higher

pressure toward the area of lower pressure (VanPutte et al., 2019).

There are two factors that keep the lungs from collapsing: (1) surfactant, which is a

mixture of lipoprotein molecules produced by secretory cells of the alveolar epithelium; and

(2) pressure in the pleural cavity, wherein the pleural pressure in less than alveolar pressure,

the alveoli tend to expand (VanPutte et al., 2019).

31
 B. Gas Exchange

Gas exchange between the air and blood occurs at the respiratory membrane of the

lungs. It is the diffusion of gases between the alveoli and the blood in the pulmonary

capillaries. The exchange of gases across the respiratory membrane is influenced by three

factors: (1) thickness of the membrane; (2) total surface area of the respiratory membrane;

and (3) partial pressure of gases across the membrane. Gas exchange does not occur in

other areas of the respiratory passageways, such as the bronchioles, bronchi, and trachea

(VanPutte et al., 2019).

C. Gas Transport in the Blood

O2 and CO2 are transported in the blood by diffusion through the respiratory

membrane and cells where it is produced respectively. For O2 transport, about 98.5%

combines reversibly with the iron-containing heme groups of hemoglobin after it diffuses. In

the lungs, PO2 normally is sufficiently high so that hemoglobin holds as much O2 as it can.

In the tissues, PO2 is lower. Therefore, hemoglobin releases O2 in the tissues. O2 then

diffuses into cells which use it in cellular respiration. At rest, approximately 23% of the O2

picked up by hemoglobin in the lungs is released to the tissues. With regards to CO2

transport, it is delivered in three ways: (1) 7% dissolved in plasma; (2) 23% bound to blood

proteins, primarily hemoglobin; and (3) 70% in the form of bicarbonate ions (VanPutte et al.,

2019).

D. Rhythmic Breathing

Rhythmic breathing is generated by neurons in the medullary respiratory center

found in the medulla oblongata which stimulates the muscles of respiration to create the

basic rhythm of breathing. This medullary respiratory center consists of the dorsal respiratory

group, which stimulates the diaphragm, and the ventral respiratory group, which stimulates

the intercostal and abdominal muscles. There is also the pontine respiratory group which

controls switching between inspiration and expiration. These groups, when stimulated, work

together to generate rhythmic breathing. Rhythmic breathing is generated by stimuli that

32
start and stop inspiration. Inspiration starts when a combination of different input or stimuli

from various sources (blood gas levels, blood temperature, muscle and joint movement,

voluntary respiratory movement, or emotions) stimulate the neurons in the medullary

respiratory center to stimulate the respiratory muscles. These neurons also spontaneously

establish the basic rhythm. After inspiration has begun, there is continual increase as more

neurons, and consequently, respiratory muscles are stimulated, all of which lasts around two

seconds. The same neurons that stimulate the respiration in the medullary respiratory center

are responsible for stopping inspiration once they reach a threshold. They receive input from

the pontine respiratory group which inhibit the neurons that are stimulating the respiratory

muscles. This causes relaxation of the muscles which results in expiration, which lasts

approximately 3 seconds. This cycle repeats and continues to produce rhythmic breathing

(VanPutte et al., 2019).

33
X. PATHOPHYSIOLOGY

a. Narrative Pathophysiology

Bronchial asthma is an inflammatory disease with manifestations of recurrent attacks

of breathlessness and wheezing. It is due to the inflammation of the air passages in the

lungs and affects the sensitivity of the nerve endings in the airways so they become easily

irritated. When an attack occurs, the lining of the passages swell which causes the airways

to narrow thus reducing the flow of air in and out of lungs. Episodes are variable in severity,

and the changes in airflow are often reversible (WHO, 2020).

In the case of Patient X, we identified the following predisposing factors. The patient

has a family history of bronchial asthma specifically from his maternal aunt. In addition, the

patient is 1 year old and 3 months at an age where asthma is more vulnerable and it starts to

develop at the age of 3 and below (Sharma, 2021). Having a family member with asthma

increases the risk of developing the disease. Gender may also play an important role as

childhood asthma occurs more frequently in boys than in girls. It is unknown why this occurs,

although some experts find a young male's airway size smaller compared to the female's

airway, which may contribute to increased risk of wheezing after a cold or other viral infection

(Trivedi & Denton, 2019).

For the precipitating factors, the child’s environment is a big factor in asthma onset

and exacerbation. Patient X may have been exposed to triggers in his environment such as

allergens, dusts, chemical fumes and vapors, molds, cold air, tobacco smoke, and

environmental contamination (WebMD, n.d.), especially since his home is located in an

urban area. All of these may provoke allergic reactions or irritate the airways. Another factor

is upper respiratory infections. Respiratory tract infections caused by viruses, Chlamydophila

or Mycoplasma have been hypothesized to have significant roles in the pathogenesis of

asthma. Particular viruses associated with infantile wheezing have been theorized to lead to

the inception of the asthmatic phenotype and those children who experience severe viral

34
respiratory infections in early life are more likely to have asthma later in childhood (Guilbert

& Denlinger, 2010).

The strongest risk factors for developing asthma are a combination of genetic

predisposition with environmental exposure (WHO, n.d.). This leads to atopy or the tendency

to develop allergic response and allergic diseases such as allergic rhinitis, asthma and

atopic dermatitis (eczema). Atopy is typically associated with heightened immune responses

to common allergens, especially inhaled allergens and food allergens.

Once there is a trigger or stimulus such as upper respiratory tract infections (URTIs)

or inspiration of animal dander, cigarette smoke, drugs, weather, and allergens, this initiates

the airway inflammatory response in asthma. After inspiration of the stimuli, the response

results in the sensitization of helper T cells which further causes the stimulation of B-cells to

produce Immunoglobulin E (IgE). There are two types of T helper cells (Th lymphocytes)

designated Th1 and Th2. Th1 cells tend to promote cell-mediated immune responses by

producing interferon-gamma, interleukin-2, and TNF-β. In contrast, Th2 cells promote

humoral immunity which includes the production of IgE antibodies by producing IL-4 and

IL-13. These are interleukins that act on B lymphocytes (B cells) to promote the production

of IgE antibodies to a specific antigen. People who are atopic are believed to have a higher

ratio of Th2 to Th1 cells which is an important factor in their tendency to produce

allergy-mediating IgE antibodies (LaMorte, 2017). The production of IgE causes its

cross‐linking on the mast cell surface. The increased levels of inflammatory and

bronchoconstrictive mediators then arise.

The principal cells involved in this process include mast cells, eosinophils, epithelial

cells, macrophages, and activated T lymphocytes. Activated Helper T-cells play a role in

regulating airway inflammation through the release of cytokines. Cytokines induce

maturation of the granular white blood cells. A type of white blood cell called eosinophils are

then stimulated to migrate into the airways. Eosinophils are proinflammatory and they play a

35
part in the body’s inflammatory processes. Their migration to the airways results in

bronchoconstriction.

Mast cells are allergy-causing cells that release histamine, leukotrienes, and other

inflammatory mediators, which causes nasal stuffiness, airway constriction, and itchiness in

skin allergy. The production of these mediators leads to airflow obstruction which can be

caused by a variety of physiologic changes, including acute bronchoconstriction, airway

inflammation, chronic mucus plug formation, and airway remodeling. The increased amount

of the inflammatory mediators results in mucus plug formation accumulated in the goblet

cells at the mucosa which causes the goblet cell hyperplasia, leading to increased mucus

secretion. As part of the inflammation process which is caused by the inflammatory

mediators, dilation of vessels at the lower respiratory tract then occurs. This happens during

the inflammatory process in order to allow increased blood flow to the affected area

(Seladi-Schulman, 2018). As a result, the vasodilation produces airway edema that further

contributes to the airway obstruction.

Another consequence of the inflammatory process is airway remodelling which

occurs as there are structural changes to the shape on the pathway of air such as the

pharynx, trachea, primary, secondary, and tertiary bronchi, bronchioles and alveoli (Morris, et

al., 2020). It is due to long-standing inflammation and may profoundly affect the extent of

reversibility of airway obstruction.

Chronic inflammation of the airways is associated with increased bronchial

hyperresponsiveness, which leads to bronchospasm. With triggered bronchospasm, there

will be unequal alteration of airflow resistance that results in uneven distribution of air. Along

with this, the hyperinflation occurs as compensation for airflow obstruction but it causes

increased intra-alveolar pressure which results in changes in circulation (Morris, et al.,

2020). All of this leads to ventilation-perfusion mismatch.

36
 Following the disease process, the main signs and symptoms of asthma were

present in the assessment of Patient X. He had shortness of breath, tightness of chest,

tachypnea, wheezing, excessive coughing, bilateral rales, and positive intercostal

retractions. These are all indicative of the diagnosis of bronchial asthma in acute

exacerbation.

Diagnostic procedures were performed in order to diagnose bronchial asthma. These

include chest x-ray, complete blood count (CBC), and urinalysis. A chest X-ray is the initial

imaging evaluation of bronchial asthma, which reveals any complications or any causes of

wheezing in the diagnosis of asthma and its exacerbations. CBC is performed to evaluate

blood cells and provide information on infection and inflammation. Lastly, urinalysis is done

to rule out infection and ensure that the level of medication received helps manage the

illness better and prevent future exacerbations.

Immediate medical treatment was done to address Patient’s X condition. He is

prescribed salbutamol through a nebulizer to control and prevent any airway obstruction

caused by asthma. Phenylpropanolamine HCl + brompheniramine maleate drops were also

given for the relief of nasal congestion and hypersecretion. Hydrocortisone was prescribed to

reduce airway inflammation. Early treatment of ceftriaxone is initiated in the case that

bacterial infection is suspected.

Main medical management provided for Patient X is oxygen therapy (oxygen at 2

LPM via cannula) in order to elevate blood oxygen levels (Gil, 2019). Due to ineffective

breathing patterns related to swelling and spasms, chest physiotherapy is indicated after

every nebulization for the removal of retained or profuse airway secretions (Spader, 2020).

Oxygen therapy is also increased to 3 LPM from 2 LPM with nothing by mouth. As Patient X

is at risk for aspiration, a chest X-ray is acquired in order to determine any pulmonary

infiltrates on the chest, which would indicate some level of aspiration (Wayne, 2017). He is

also placed on a diet for his age with strict aspiration precaution to reduce said risk.

37
 Nursing interventions done to alleviate Patient X’s condition included close

monitoring and assessment of his respiratory status, such as respiratory rate, depth, breath

sounds, peak flow and pulse oximetry. Any changes in respiratory status must be dealt with

immediately as these could suggest retention of secretions, which could lead to airway

obstruction (Doenges, et al., 2010). Effective coughing and deep breathing is encouraged to

mobilize secretions and clear the airway, and nasotracheal suctioning may be performed if

necessary. Suctioning is performed, especially if coughing alone is ineffective. Measures of

comfort, such as elevating the head of the bed, and safety, such as raising the rails of the

bed, are provided for comfort, safety, better chest expansion, and ventilation. As fatigue is

common with the increased work of breathing, periods of rest for Patient X are planned.

Family dynamics in handling their ill child is assessed, including the facilitation of

communication between members of the family. Stable and secure family relationships

better the consistency in the disease management (Berkowitz, et al., 2001). Health

education is also provided for various breathing techniques, relaxation techniques,

medication education, and proper positioning. These measures allow for full participation of

Patient X’s parents in maintaining health status and improving condition.

38
 b. Schematic Diagram

CONCEPT MAP/PATHOPHYSIOLOGY OF BRONCHIAL ASTHMA

A pediatric case of a 1 year and 3 month old patient admitted with chief complaints of cough and a final diagnosis of Bronchial Asthma in Acute

Exacerbation. The patient is male and is a resident of Cagayan de Oro City.

Patient’s Name: Patient X Age: 1 year and 3 months Sex: Male

Patient’s Diagnosis/ Impression: Bronchial asthma in acute exacerbation

39
40
41
42
43
XI. DRUG STUDY

Generic Name Date/Time Classification Indications Mechanism of Action Side Effects Nursing Considerations
(Brand Name) Ordered,
Dosage,
Timing
and Route

Ceftriaxone 12/1/20 Pharmacologic Treatment of the It binds to 1 or more CNS: Seizures ● Assess for infection (vital
(Viatrex) 5 PM Class: following penicillin-binding (high doses), signs,sputum, urine, and
600 mg, x Third- infections proteins inhibiting the headache. stool; WBC) at beginning
1 hr q12h, generation caused by final transpeptidation CV: of and throughout
IV drip cephalosporin susceptible step of peptidoglycan Hypotension, therapy
NST organisms: skin synthesis in bacterial palpitations, ● Before initiating therapy,
Therapeutic and skin cell wall, leading to chest pain, obtain a history to
Class: structure bacterial cell lysis and vasodilation determine previous use
Anti-infectives infections, death. EENT: Hearing of and reactions to
urinary and loss penicillins or
gynecologic GI: cephalosporins. Persons
infections, Pseudomembran with a negative history of
respiratory tract ous colitis, penicillin sensitivity may
infections (from diarrhea, still have an allergic
bronchial nausea, response.
asthma and vomiting, ● Obtain specimens for
colds). cholelithiasis, culture and sensitivity
Intra-abdominal cramps. before initiating therapy.
infections and Hemat: First dose may be given
septicemia. Agranulocytosis, before receiving results.
bleeding, ● Observe patients for
eosinophilia, signs and symptoms of
hemolytic anaphylaxis (rash,
anemia, pruritus, laryngeal
lymphocytosis, edema, wheezing) , do
neutropenia, necessary preparations

44
thrombocytopeni and actions (discontinue
a, drug, notify physician
thrombocytosis. immediately, keep
GU: Hematuria, epinephrine and
vaginal resuscitation equipment
moniliasis. close by).
Local: Phlebitis ● Assess newborns for
at IV site. jaundice and
Misc: Allergic hyperbilirubinemia as it is
reactions contraindicated.
including ● Monitor injection site
anaphylaxis and frequently for phlebitis
serum sickness, (pain, redness, swelling).
superinfection, Change sites every
chills, fever. 48-72 hrs. Dilute in at
least 1 g/10 mL. Avoid
direct IV administration.
Do not use preparations
containing benzyl alcohol
for neonates.
● Instruct parents of
patients to take
medication around the
clock and to finish the
medication completely,
even if feeling better.
Take missed doses as
soon as possible unless
almost time for the next
dose; do not double
doses.
● Advise parents of
patients to report signs of
superinfection (furry

45
 overgrowth on the
tongue, vaginal itching or
discharge, loose or
foul-smelling stools) and
allergy.
● Instruct parents of the
patient to notify
healthcare professional if
fever and diarrhea
develop, especially if
stool contains blood, pus,
or mucus. Advice to not
treat diarrhea without
consulting a healthcare
professional.

Co-amoxiclav 12/4/20 Amoxicillin Treatment of a Amoxicillin inhibits CNS: Reversible ● Assess for infection (vital
(Natravox) 4 AM Pharmacologic variety of transpeptidase, hyperactivity, signs; appearance of
250mg/62. Class: infections preventing dizziness, wound, sputum, urine,
5mg/5ml, Aminopenicillins including: Skin cross-linking of headache and and stool; WBC) at
2.5ml, TID, Therapeutic and skin bacterial cell walls and convulsions (high beginning of and
PO Class: structure leading to cell death. doses). throughout therapy.
Anti-infectives, infections, otitis Addition of clavulanate GI: ● Obtain a history before
antiulcer agents media, sinusitis, increases the drug's Pseudomembran initiating therapy to
respiratory tract resistance to ous colitis, determine previous use
Clavulanic Acid infections, GU beta-lactamase. diarrhea, of and reactions to
Pharmacologic tract infections. indigestion, penicillins or
Class: Beta nausea, gastritis, cephalosporins. Persons
lactamase stomatitis, with a negative history of
inhibitors glossitis, black penicillin sensitivity may
Therapeutic “hairy” tongue, still have an allergic
Class: vomiting and response.
Anti-infectives mucocutaneous ● Observe for signs and

46
candidiasis. symptoms of anaphylaxis
GU: Soreness, (rash, pruritus, laryngeal
discharge edema, wheezing).
Hemat: ● Obtain specimens for
Transient culture and sensitivity
leukopenia, prior to therapy. First
thrombocytopeni dose may be given
a, hemolytic before receiving results.
anemia, ● Monitor bowel function.
prolongation of Diarrhea, abdominal
bleeding time cramping, fever, and
and prothrombin bloody stools should be
time. reported to a health care
Derm: Skin professional promptly as
rashes, urticaria. a sign of
Respiratory: pseudomembranous
Wheezing. colitis. May begin up to
several weeks following
Misc: cessation of therapy.
Superinfections ● Instruct parents of
(oral and rectal patients that medication
candidiasis), should be taken round
fever, the clock and to finish the
anaphylaxis. drug completely as
directed, even if feeling
better.
● Advise parents of
patients to report the
signs of superinfection
(furry overgrowth on the
tongue, vaginal itching or
discharge, loose or
foul-smelling stools) and
allergy.

47
● Instruct parents of
patients to notify health
care professionals
immediately if diarrhea,
abdominal cramping,
fever, or bloody stools
occur and not to treat
with antidiarrheals
without consulting health
care professionals.
● Instruct parents of
patients to notify health
care professionals if
symptoms do not
improve or if nausea or
diarrhea persists when
drug is administered with
food.
● Teach parents to
calculate and measure
doses accurately.
Reinforce the importance
of using measuring
devices supplied by
pharmacies or with
products, not household
items.

48
 D5 0.3 NaCl 12/1/20 Therapeutic It is used for It is more concentrated CV: Tachycardia ● Monitor for possible
(dextrose + 5 PM Class: Mineral replacement or than extracellular fluid. Bradycardia, intravascular fluid volume
sodium 500 cc and electrolyte maintenance of It allows movement of Thrombophlebitis overload and pulmonary
chloride) 65cc/hr, IV replacements/s fluid and fluid from cells into the , Phlebitis. edema.
upplements electrolytes. bloodstream, causing Respi: Breathing ● Monitor serum
the cells to shrink thus difficulties, electrolytes and assess
increasing the pulmonary for signs and symptoms
extracellular fluid edema. of hypervolemia.
volume. Derm: Damage ● Assess for IV site
to skin and tissue irritation and damage,
around IV site, also for thrombosis of
itching around blood vessels.
area of IV site. ● Instruct parents to notify
nurses if an infant has
breathing difficulties or
very fast heart beat.

D5LR 12/1/20 Therapeutic It is indicated in Sodium takes control of CNS: Headache, ● Assess for any
(dextrose + 5 PM Class: Mineral adults and water distribution, fluid anxiety. hypersensitivity
sodium lactate 1L and electrolyte pediatric patients balance and osmotic CV: Bradycardia, reactions.
solution) 60cc/hr, replacements/s as a source of pressure of body fluids. tachycardia, ● Frequency laboratory
TF D5 0.3 upplements electrolytes, hypotension. determinations and
NaCl, IV calories, and Potassium functions in Respiratory: clinical evaluation are
water for carbohydrate utilization Respiratory essential in monitoring
hydration. and protein synthesis distress, the changes in the blood
and it is a critical part of laryngeal edema, glucose and electrolyte
nerve conduction and
sneezing. concentrations, and fluid
muscle contraction,
GI: Nausea, and electrolyte balance.
specifically in the heart.
abdominal pain, ● If adverse reaction
Chloride deals with the diarrhea, throat occurs, discontinue the
metabolism of sodium irritation, infusion and evaluate the
and changes in the hypoaesthesia patient. Facilitate
oral, dysgeusia. appropriate therapeutic

49
 acid-base balance of the Local: Phlebitis, countermeasures and
body. Calcium, when in extravasation,inf have the remainder of
ionized form, is ection. the fluid examined if
essential in the Misc: necessary.
mechanism of blood Hypervolemia, ● Hypertonic solutions
clotting, normal cardiac hyperkalemia, should be administered
function, and regulation hypernatremia. peripherally and it must
of neuromuscular be slowly infused through
irritability. a small bore needle.
● Before administering
parenteral drug products,
Sodium lactate is a
racemic salt containing
it should be inspected
both the levo form, visually for any particular
which is oxidized by the matter or discoloration.
liver to bicarbonate, and ● Frequent monitoring of
the dextro form, which is the electrolyte levels is
converted to glycogen. significant since
symptoms may result
Dextrose provides a from an excess or deficit
source of calories and of one or more ions
when it is readily present in the solution.
metabolized, it may ● Rate of administration
decrease losses of body should be adjusted
protein and nitrogen, according to tolerance
promotes glycogen since rapid infusions of
deposition and hypertonic solutions may
decreases or prevents cause local pain and
ketosis if sufficient venous irritation.
doses are provided.

It produces a metabolic
alkalinizing effect.

D5IMB 12/2/20 Therapeutic Treatment in Since it is a hypertonic CNS: Headache. ● Assess patient’s vital
(balanced 3 PM Class: Mineral replacing solution, it has a Respiratory: signs, lung sounds, heart

50
 multiple 50 cc/hr, and electrolyte electrolytes, to greater concentration Tachypnea. sounds, and edema
maintenance IV replacements/s treat hypotonic of solutes around 375 GI: Diarrhea. status before infusion.
solution in 5% upplements dehydration, mEq/L or greater than Local: Phlebitis. ● Monitor and observe the
dextrose) 12/3/20 and, to treat plasma. It causes fluids Misc: patient during
9:40 AM certain types of to move out of the cells Hypervolemia, administration.
45 cc/hr, shock. and into the hyperglycemia, Hypertonic solutions
IV extracellular fluid in cramping, should be administered
order to normalize the edema. only in high acuity areas
concentration of with constant nursing
particles between two surveillance for potential
compartments. With complications.
this effect, the cells will ● Verify the order. The
shrink and may disrupt specific hypertonic fluid
their function. that needs to be infused
should be stated in the
They draw water out of prescription along with
the intracellular space the total volume to be
which will lead to an infused, the infusion rate
increasing extracellular and the length of time to
fluid volume. continue the infusion.
● Assess health history.
Patients with heart or
kidney disease and those
who are dehydrated
should not receive
hypertonic IV fluids.
● Prevent fluid overload.
Ensure that the
administration of
hypertonic fluids does
not result in a fluid
volume excess or
overload.
● Monitor blood glucose

51
 closely. Rapid infusion of
this type of solution can
lead to hyperglycemia.

Hydrocortisone 12/1/20 Pharmacologic Management of Inhibits accumulation CNS: ● Assess patients for signs
5:25 PM Class: adrenocortical of inflammatory cells at Depression, of adrenal insufficiency
45 mg, Corticosteroids insufficiency, inflammation sites, euphoria, (hypotension, weight
now then (systemic) anti-inflammator phagocytosis, headache, ICP loss, weakness, nausea,
q6h, IVTT Therapeutic y, and it is lysosomal enzyme (Children only), vomiting, anorexia,
Class: immunosuppres release, synthesis personality lethargy, confusion,
Corticosteroids sive. In terms of and/or release of changes, restlessness) before and
topical mediators of psychoses, periodically during
management, it inflammation. This fatigue, therapy.
is used to treat prevents/suppresses restlessness, ● Monitor intake and output
inflammatory cell-mediated immune insomnia. ratios and daily weights.
dermatoses, reactions and CV: Arrhythmias Observe patients for
adjunctive decreases/prevents (from peripheral edema, steady
treatment of tissue response to hypokalemia), fat weight gain,
ulcerative colitis, inflammatory process. embolism, heart rales/crackles, or
atopic dermatitis, failure, dyspnea. Notify health
inflamed hypertension, care professionals if
hemorrhoids. hypotension, these occur.
thromboembolis ● Children should have
m, periodic evaluations of
thrombophlebitis. growth.
GI: Abdominal ● Monitor daily pattern of
distention, bowel activity, stool
hiccups, consistency.
increased ● Monitor electrolytes, B/P,
appetite, nausea, weight, serum glucose.
pancreatitis, ● Monitor for hypocalcemia
peptic ulcer, (muscle twitching,
rectal cramps), hypokalemia
abnormalities (weakness, paresthesia,

52
(bleeding, nausea/vomiting,
blistering, irritability, EKG changes).
burning, itching, ● Assess for emotional
or pain (rectal status, and ability to
form)), ulcerative sleep.
esophagitis, ● Corticosteroids cause
vomiting. immunosuppression and
GU: Glycosuria, may mask symptoms of
perineal burning infection. Instruct parents
or tingling. of patients to avoid
Hemat: people with known
Thromboembolis contagious illnesses and
m, to report possible
thrombophlebitis, infections immediately.
easy bruising, ● Report fever, sore throat,
leukocytosis. muscle ache, sudden
Metab: Weight weight gain, swelling,
gain. visual disturbances, and
Derm: Acne, behavior changes.
decreased ● Do not take aspirin or
wound healing, any medication without
ecchymoses, consulting a physician.
fragility, ● Do not cover or use
hirsutism, occlusive dressings
petechiae. unless ordered by a
MS: Muscle physician; do not use
wasting, tight diapers, plastic
osteoporosis, pants, and coverings.
aseptic necrosis
of joint, muscle
pain.
Misc:
Anaphylaxis,
hypocalcemia,

53
 hypokalemia,
hypokalemic
alkalosis,
impaired wound
healing.

Paracetamol 12/1/20 Therapeutic Used for the Inhibits the synthesis of GI: Hepatic ● Assess overall health
(Tempra) 5 PM Class: treatment of prostaglandins that failure, status before
1.2 mL Antipyretics, fever, headache, may serve as hepatotoxicity administering
drops, q4h nonopioid muscular aches mediators of pain and (overdose). acetaminophen. They
PRN, PO analgesics & pain, fever, primarily in the GU: Renal failure are at higher risk of
toothache, colds, CNS. Has no (high developing hepatotoxicity
and ear ache significant doses/chronic with chronic use of usual
anti-inflammatory use). doses of this drug.
Mild pain. Fever. properties or GI Hemat: ● Assess amount,
toxicity. It leads to Neutropenia, frequency, and type of
analgesia and pancytopenia, drugs taken in patients
antipyresis. leukopenia. self-medicating,
Derm: Rash, especially with OTC
urticaria. drugs. Prolonged use of
acetaminophen
increases the risk of
adverse renal effects. For
short-term use,
combined doses of
acetaminophen and
salicylates should not
exceed the
recommended dose of
either drug given alone.
● Fever: Assess fever, note
presence of associated
signs (diaphoresis,
tachycardia, and

54
 malaise).
● When combined with
opioids do not exceed
the maximum
recommended daily
dose.
● Administer with a full
glass of water. Must be
taken with food or on an
empty stomach.
● Advise parents of
patients to check
concentrations of liquid
preparations. Errors have
resulted in serious liver
damage.
● Caution parents to check
labels on all OTC
products. Advise to avoid
taking more than one
product containing
acetaminophen at a time
ato prevent toxicity.

Phenylpropano 12/1/20 Phenylpropanol Indicated for The antihistamine CNS: ● Assess allergy symptoms
lamine HCl + 5 PM amine allergic and action of Drowsiness, (rhinitis, conjunctivitis,
Brompheniram 1 mL Pharmacologic vasomotor or brompheniramine sedation, hives) before and
drops, class: other reduces or diminishes dizziness, periodically throughout
ine maleate
TID, PO Sympathomimet hyperactive the allergic response of excitation (in therapy.
(Nasatapp) ic Agent nasal disorders nasal tissues. It is children), ● Monitor pulse and blood
(Nonselective and acute complemented by the lassitude, pressure before initiating
adrenergic coryza, relief of mild vasoconstrictor giddiness, and throughout IV
receptor agonist nasal congestion action of increased therapy.
and and phenylpropanolamine, irritability and ● Assess lung sounds and

55
norepinephrine hypersecretion. which provides a nasal excitement, character of bronchial
reuptake Relief of nasal decongestant effect. headache, secretions.
inhibitor) congestion in Therefore, this insomnia ● Inform parents of
Therapeutic infants up to combination reduces EENT: Blurred patients that drowsiness
class: children 12 excessive vision, Mydriasis may occur.
Decongestant years of age. nasopharyngeal CV: ● Instruct the parents of
and appetite secretion and Hypertension, the patient to contact a
suppressant diminishes arrhythmias, health care professional
inflammatory mucosal hypotension, if symptoms persist.
edema and congestion palpitations.
Bromphenirami in the upper respiratory GI: Dry mouth,
ne tract. constipation,
Pharmacologic obstruction,
class: Phenylpropanolamin nausea
H1-receptor-blo e: Acts directly on GU: urinary
cking agent alpha- and, to a lesser retention and
Therapeutic degree, hesitancy.
class: beta-adrenergic Derm: Sweating.
Antihistamine receptors in the
mucosa of the
respiratory tract.
Stimulation of
alpha-adrenergic
receptors produces
vasoconstriction,
reduces tissue
hyperemia, edema,
and nasal congestion,
and increases nasal
airway patency. PPA
indirectly stimulates
beta-receptors,
producing tachycardia
and a positive inotropic

56
 effect.

Brompheniramine: As
an antihistamine,
competes w/ histamine
for H1-receptor sites on
effector cells and
therefore provides
symptomatic relief of
allergic symptoms
(rhinitis, urticaria)
caused by histamine
release.

Salbutamol 12/1/20 Pharmacologic Used as a Binds to beta CNS: ● Assess lung sounds,
5 PM Class: bronchodilator to 2-adrenergic receptors Nervousness, pulse, and blood
1 neb, now Adrenergics control and in airway smooth restlessness, pressure before
then q4h, Therapeutic prevent muscle, leading to tremor, administration and during
nebulizatio Class: reversible airway activation of adenylyl headache, peak of medication. Note
n Bronchodilators obstruction cyclase and increased insomnia (occurs amount, color, and
caused by levels of cyclic-3’, more frequently character of sputum
5:25 PM asthma or 5’-adenosine in young children produced.
1 neb x 2 COPD. Used as monophosphate than adults), ● Monitor pulmonary
doses, a quick-relief (cAMP). Increases in hyperactivity in function tests before
now, agent for acute cAMP activate kinase, children. initiating therapy and
nebulizatio bronchospasm which inhibits the CV: Chest pain, periodically during
n and for phosphorylation of palpitations, therapy to determine
prevention of myosin and decreases angina, effectiveness of
8:25 PM exercise-induced intracellular calcium arrhythmias, medication.
1 neb, bronchospasm. therefore relaxes hypertension. ● Observe for paradoxical

57
 q3h, smooth muscle GI: Nausea, bronchospasm
nebulizatio airways. vomiting. (wheezing). If a condition
n Endo: occurs, withhold
Hyperglycemia. medication and notify
10:40 PM F and E: physician or other health
1 neb, Hypokalemia. care professional
alternatew/ Neuro: Tremor. immediately.
salbutamol ● Protect solution from
+ipratropiu light. Store unused vials
m q3h, in a foil pouch.
nebulizatio ● Instruct parents of
n patients to contact a
health care professional
12/4/20 immediately if shortness
11 AM of breath is not relieved
1 neb, by medication or is
q4h, accompanied by
nebulizatio diaphoresis, dizziness,
n palpitations, or chest
pain.

Salbutamol + 12/1/20 Salbutamol Used as adjunct Salbutamol:activates CNS: Headache ● Assess patient’s history
Ipratropium 10:40 PM Pharmacologic treatment to adenylyl cyclase, the Eye: Mydriasis, for hypersensitivity to
1 neb, Class: anti-inflammator enzyme that stimulates blurred vision, atropine, soybean,
q3h, Adrenergics y therapy & the production of cyclic narrow-angle peanuts (aerosol
alternate bronchodilators adenosine-3’,5’-monop glaucoma, eye perspiration).
with Therapeutic in asthma to hosphate (cAMP). pain. ● Assess patient’s history
salbutamol Class: prevent Increased cAMP leads CV: Palpitations, for acute
, Bronchodilators exacerbations. to activation of protein tachycardia. bronchospasms,
nebulizatio Also in kinase A, which inhibits GI: Dry mouth, narrow-angle glaucoma,
n Ipratropium maintenance phosphorylation of nausea. prostatic hypertrophy,
Pharmacologic treatment of myosin and lowers bladder neck obstruction,
12/4/20 Class: COPD including intracellular ionic pregnancy, lactation.
11 AM Anticholinergics chronic calcium ● Assess for skin color,

58
discontinu bronchitis & concentrations, lesions, texture,
e Therapeutic emphysema. resulting in smooth orientation, reflexes,
Class: muscle relaxation bilateral grip strength,
Bronchodilators affect, ophthalmic
Ipratropium: Causes examination, pulse,
bronchodilation by blood pressure,
blocking the action of respiration, adventitious
acetylcholine-induced sounds, bowel sounds,
stimulation of guanylyl normal output, prostate
cyclase, hence palpation.
reducing formation of ● Assess lung sounds,
cyclic guanosine pulse, and blood
monophosphate pressure before
(cGMP) at administration and during
parasympathetic site. peak of medication. Note
amount, color, and
character of sputum
produced.
● Monitor pulmonary
function tests before
initiating therapy and
periodically during
therapy to determine
effectiveness of
medication.
● Observe for paradoxical
bronchospasm
(wheezing). If a condition
occurs, withhold
medication and notify
physician or other health
care professional
immediately.
● Protect solution from

59
 light. Store unused vials
in a foil pouch.
● Use a facemask instead
of a mouthpiece as this is
more appropriate for the
pediatric patient.
● Instruct parents of
patients to contact a
health care professional
immediately if shortness
of breath is not relieved
by medication or is
accompanied by
diaphoresis, dizziness,
palpitations, or chest
pain.

60
XII. NURSING CARE MANAGEMENT

Nursing Care Plan 1

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

(cite sources)

Subjective cues: Ineffective airway Short Term: Independent: Short Term:

(none) clearance r/t At the end of 30 [Link] [Link] in At the end of 30
bronchospasms, minutes, client will berate and depth; note respirations, use of minutes:
Objective cues: increased pulmonary able to: ease of breathing. accessory muscles,
secretions, ineffective Auscultate breathand pres- >Patient’s respiratory
+ rales bilateral cough, mucosal >Return to normal sounds. Investigate ence of crackles or rate is at 40cpm -
+ wheezing edema secondary to respiratory rate restlessness, dys- wheezes suggest 12/02/20 4AM
+ retraction,IC disease condition (20-40cpm). pnea, andretention of
Dry,non-productive AEB wheezing, development of
secretions. >Patient was able to
cough changes in >Maintain clear, open cyanosis. Airway obstruction maintain clear open
Shortness of Breath respiratory rate, airways as evidence (even partial) can airways as evidenced
Runny nose cough, dyspnea, and by normal breath lead to ineffective by normal breath
RR:44cpm - on retained secretions sounds. breathing patterns sounds.
admission and impaired gas
02 sat - 94% taken >Have the ability to exchange, resulting >Patient had the
on 10:00 PM - effectively cough up in ability to effectively
12/02/2020 secretions after complications, such cough up secretions
treatments and deep as pneumonia and after treatments and
breaths. respiratory arrest deep breaths.
(Doenges, et al.,
>Return to normal 2010). >O2 sat returned to
O2 saturation rate normal range (98%) -
(95%-100%). [Link] head of [Link] drainage 12/02/20 4AM
bed 30 to 45 of secretions, work of
Long Term: degrees. breathing, and lung ● Goals were
At the end of 48 Expansion (Doenges, partially met
hours, client will be et al., 2010).

61
able to: [Link] nasal [Link] Long Term:
cannula, as accumulation of At the end of 48
>Classify methods to indicated. Instruct secretions and thick hours:
enhance secretion client’s parents in mucous plugs from
removal. cleaning procedures. obstructing the
airway (Doenges, et >Client’s parents
>Recognize the al., 2010). were able to classify
significance of methods to enhance
changes in sputum to [Link] [Link] is secretion removal
include color, nasotracheal needed when
character, amount, suctioning as patients are unable to >Client’s parents
and odor. necessary, especially cough out secretions were able to
if cough is ineffective. properly due to recognize the
weakness, thick significance of
>Identify and avoid mucus plugs, or changes in sputum to
specific factors that excessive or include color,
inhibit effective tenacious mucus character, amount,
airway clearance. production (Doenges, and odor.
et al., 2010).
>Patient’s parents
[Link] [Link] of were able to identify
>Maintain normal environmental allergic type of and avoid specific
respiratory rate and pollution from respiratory reactions factors that inhibit
02 saturation with no sources such as that can effective airway
assistance of oxygen dust,smoke, and trigger or exacerbate clearance.
administration. feather pillows to a onset of acute
minimum according episode. >Patient’s respiratory
to individual situation. rate was 38cpm,
O2sat is 98% with no
Collaborative: assistance of oxygen
[Link] [Link] administration.
supplemental physiological (nasal
humidification, such passages) means of ● Goals were all
as compressed air filtering and met

62
or oxygen mist collar. humidifying air are
bypassed.
Supplemental
humidity decreases
mucous crusting and
facilitates coughing
or suctioning of
secretions (Gil,2019).

[Link] and [Link] the

monitor oxygen amount of oxygen
therapy (Oxygen at 2 your lungs receive
LPM via cannula) as and deliver to your
ordered by the blood (Gil,2019).
physician.

[Link] [Link] that

administration as medications are
prescribed by the given safely,
physician. accurately and to
avoid any additional
complications
(Doenges, et al.,
2010).

[Link] with a [Link]

respiratory therapist physiotherapy
for chest includes the
physiotherapy and techniques of
nebulizer postural drainage
management as and chest percussion
indicated. to mobilize secretions
from smaller airways
that cannot be

63
 eliminated by means
of coughing or
suctioning (Gil,2019).

Nursing Care Plan 2

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

64
 (cite sources)

Subjective cues: Ineffective breathing Short Term: Independent: Short Term:

None pattern r/t swelling At the end of 30 [Link] 1. Manifestations of At the end of 30
and spasm minutes, client will be
respirations: quality, respiratory distress minutes, client:
Objective cues: secondary to disease able to: rate, rhythm, depth, are indications of the
● V/S 8:25 PM condition AEB and any use of degree of lung >Showed improved
12/1/2020: non-productive >Show improved accessory muscles. involvement. Rapid, respiratory rate (RR
RR = 60 cpm cough, tachypnea, respiratory rate (RR shallow breathing = 50 cpm) with
use of accessory = <60 cpm) with patterns and decreased
● + SL/IC retractions muscles decreased hypoventilation retractions.
retractions. directly affects gas
● Patient had exchange. Flaring of Long Term:
non-productive Long Term: the nares, dyspnea, At the end of 3 days,
cough At the end of 3 days, use of accessory the client:
the client will be able muscles, tachypnea
to: and/or apnea are all >Maintained optimal
signs of severe breathing pattern, as
>Maintain optimal respiratory distress evidenced by relaxed
breathing pattern, as that require breathing, normal
evidenced by relaxed immediate respiratory rate or
breathing, normal intervention (Vera, pattern (RR = 28-38
respiratory rate or 2020). cpm), and absence of
pattern (RR = <60 retractions.
cpm), and absence of 2. Perform chest [Link]
retractions. tapping every after physiotherapy is a >Remained
nebulization. group of physical respiratory rate within
techniques that established limits.
>Remain respiratory
improve lung function
rate within
and help you breathe
established limits.
better. Chest PT, or
CPT expands the
> Show feelings of lungs, strengthens > Showed feelings of
comfort when breathing muscles, comfort when

65
breathing. and loosens and breathing.
improves drainage of
thick lung secretions
(Spader, 2020).

3. Assist the patient 3. These measures

to a full fowler’s promote comfort,
position. chest expansion, and
ventilation of basilar
lung fields (Padula,
C.A., et al., 2009).

4. Continue to strictly 4. This can be a sign

monitor retractions of a blocked airway,
every 30 minutes. which can quickly
become life
threatening (Delgado,
2019).

[Link] 5. Restlessness,
restlessness, and irritation, confusion,
changes in level of and somnolence may
consciousness. reflect hypoxemia
and decreased
cerebral oxygenation
(Vera, 2020).

Collaborative:
1. Increase oxygen 1. Supplemental
therapy to 3 LPM oxygen helps reduce

66
 from 2 LPM via hypoxemia and
cannula as ordered relieve respiratory
by the physician. distress (Padula,
C.A., et al., 2009).

2. Nothing by mouth 2. The patient will

as ordered by the have difficulty eating
physician. when he is in
respiratory distress.

[Link] 3. Ensuring that

administration as medications are
ordered by the given safely,
physician. accurately and to
avoid any additional
complications.

Nursing Care Plan 3

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

(cite sources)

67
Subjective cues: Impaired gas Short Term: Independent: Short Term:
(None) exchange r/t At the end of 6 hours, [Link] >Manifestations of At the end of 6 hours,
ventilation-perfusion client will be able to: respirations: quality, respiratory distress client:
Objective cues: imbalance AEB - Show improved rate, rhythm, depth, are indications of the (12/03/2020 at 4am)
V/S upon admission: SaO2 <95%, oxygenation (SaO2 and any use of degree of lung
HR:188 bpm dyspnea, tachypnea >95%) with less accessory muscles. involvement. Rapid, Showed improved
RR: 44 cpm and tachycardia symptoms of shallow breathing oxygenation O2 sat
O2 saturation: 97% respiratory distress: patterns and (99%) with less
less wheezing, RR hypoventilation symptoms of
Shortness of breath < 40 cpm, HR directly affects gas respiratory distress:
Wheezing <140bpm, SaO2 exchange. Flaring of occasional wheezing,
>95% after the nares, dyspnea, RR 34 cpm, HR 121
V/S 10:00 PM - providing nursing use of accessory bpm, SaO2 99%.
12/02/2020 interventions. muscles, tachypnea - Understood proper
RR: 40cpm - Understand proper and/or apnea are all nebulization
HR: 140 bpm nebulization signs of severe technique and
O2 saturation: 94% technique and respiratory distress performed with
perform with that require some guidance
guidance from the immediate from the nurse.
nurse. intervention (Vera,
2020).
Long Term:
Long Term: [Link] to strictly >To follow disease At the end of 2 days,
At the end of 2 days, monitor oxygen progression. Pulse client:
client will be able to: saturation; pulse Oximetry: SaO2
- Maintain adequate oximetry every 2 should be >95% - Exhibited adequate
gas exchange hours. (Prenhall, 2021). gas exchange
(oxygen saturation maintained at a
>95%) with no normal level: O2
supplemental [Link] assess > When oxygenation sat (97%) with no
oxygen therapy and for cyanosis; observe and perfusion supplemental
show absence of skin color, mucous weaken, peripheral oxygen therapy and
symptoms of membranes, and nail tissues become showed absence of
respiratory distress. beds. cyanotic. Cyanosis of symptoms of

68
- Fully understand nail beds (peripheral respiratory distress:
proper nebulization cyanosis) may no wheezing, RR
technique and can indicate 38 cpm, HR 108
properly give vasoconstriction or a bpm.
medicine through response to - Fully understood
nebulization without fever/chills; however, proper nebulization
need for guidance. cyanosis of the technique and
mucous membranes, properly gave
and skin around the medicine through
mouth (circumoral/ nebulization without
central cyanosis) need for guidance.
indicates systemic
hypoxemia (Vera,
2020).

[Link] to monitor >Tachycardia is a

heart rate and present as a
rhythm. response to
hypoxemia (Vera,
2020).

[Link] >Restlessness,
restlessness, and irritation, confusion,
changes in level of and somnolence may
consciousness. reflect hypoxemia
and decreased
cerebral oxygenation
(Vera, 2020).

[Link] parents on >Prevents over

how to maintain the exhaustion which
patient in a depletes oxygen
comfortable, rested demand to facilitate
state: elevate upper resolution of

69
 body or an upright decreased oxygen
position. level (Vera, 2020).

[Link] parents >Promotes maximum

proper positioning to chest expansion
ensure the patient's which improves
head is elevated. ventilation (Vera,
2020).

[Link] parents how > Children who are

to give the patient’s unable to cooperate,
medicine with proper will not keep the
nebulization mask on their face, or
technique; who cry during
preparation, treatment may not
administration, how get a proper dose of
to familiarize the their medicine. This
patient with the can make an asthma
nebulizer, and attack more likely
incorporating it into (Navas, 2018).
daily routine.

Collaborative:
[Link] and >Supplemental
monitor oxygen oxygen improves gas
therapy as ordered exchange and
by the physician: oxygen saturation
oxygen at 2 LPM via (RNLessons, 2021).
cannula.

Nursing Care Plan 4

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

70
 (cite sources)

Risk for aspiration r/t Short Term: Independent: Short Term:

Subjective cues: decreased ability to At the end of 3 hours, At the end of 3 hours,
(none) clear airway the patient will be 1. Assess airway >Maintaining an open client:
able to: patency and clear airway is
secretions secondary
Objective cues: vital to retain airway >Showed improved
Chief complaint: to disease condition >Show less clearance and reduce respiratory function.
Cough and colds symptoms of risk for aspiration
respiratory distress; (Wayne, 2017). >O2 sat maintained
V/S upon admission: maintain a good at a normal level
T: 36.6°C SpO2: >95% and >Signs of aspiration (>95%).
HR:188 bpm have a respiratory [Link] respiratory should be identified
RR: 44 cpm rate of less than 40 rate, depth, and as soon as possible At the end of 2 hours,
SpO2: 97% cpm. effort. Note any signs to prevent further the family of the
of aspiration such as aspiration and to patient was able to:
V/S 12/2/20 10:00pm At the end of 2 hours, dyspnea, cough, initiate treatment that
T: 36.2°C the family of the cyanosis, wheezing, can be life-saving >Explain and return
HR: 140 bpm patient will be able to: or fever. (Wayne, 2017). demonstrate the
RR:40 cpm steps in preventing
SpO2: 94% >Know the steps in >Abnormal lung aspiration in the
preventing [Link] for sounds associated instance that it may
aspirations. abnormal respiratory with aspiration will be happen.
Physician’s notes: sounds. that of crackles
>Know the (rales) and wheezing >Understand and
12/1/20 8:25am connection of the (Ausmed, 2017). fully grasp the
disease condition of connection between
RR: 60 cpm the patient and risk >Nausea or vomiting disease and risk of
(+) SC/IC retractions for aspiration. [Link] for places patients at the patient.
presence of nausea great risk for
12/2/20 6:30am or vomiting. aspiration, especially
Long Term: if the level of Long Term:
RR: 50-52 cpm At the end of 3 days, consciousness is At the end of 3 days,
spO2: 97% at 2lpm the patient will be compromised. the patient was able

71
(+) rales able to: Antiemetics may be to:
required to prevent
12/2/20 7:40pm >Maintain a aspiration of >Maintain a
respiratory rate of regurgitated gastric respiratory rate of 34
(+) occasional 30-40 cpm and an contents (Wayne, cpm and an oxygen
wheezing oxygen saturation of 2017). saturation of 97%
(+) rales, bilateral greater than 95% indicating improved
>Maintaining a sitting respiratory function.
12/3/20 9:40am >Show no signs of [Link] the head of position after meals
respiratory distress. bed elevated when may help decrease >Show absence of
(+) wheezing feeding and for at aspiration retractions during
(+) rales, bilateral >Display recovery by least half an hour pneumonia. (Wayne, inhalation and
having no abnormal afterwards. 2017). exhalation.
lung sounds
(wheezing, crackles). >Displayed recovery
Collaborative: >Early intervention by showing no signs
[Link] the protects the patient’s of abnormal lung
physician or other airway and prevents sounds, particularly
health care provider aspiration. Anyone wheezing and
instantly of noted identified as being at crackles, upon
decrease in high risk for auscultation.
cough/gag reflexes or aspiration should be
difficulty in kept NPO (nothing by
swallowing. mouth) until further
evaluation is
completed (Wayne,
2017).

A chest x-ray helps to

[Link] chest x-ray. differentiate the
patient with
aspiration as to

72
 whether they have
acquired pneumonia
or not. Pulmonary
infiltrates on chest
x-ray films indicate
some level of
aspiration has
already occurred
(Wayne, 2017).

>Having smaller and

3. Place on diet for more frequent
age with strict feedings reduces the
aspiration precaution risk of aspiration
as ordered by greatly. The elevation
physician. of the head to greater
than 30 degrees
during feeding
facilitates movement
of food into the GI
(Carrera, 2012).

Nursing Care Plan 5

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

(cite sources)

73
Objective Cues: Interrupted family Short Term: Independent: Short Term:
● Child processes r/t sick At the end of 3 hours, [Link] family >Stable, secure, and At the end of 3 hours,
diagnosed child AEB parental family will be able to:dynamics in handling mutual family family has:
with bronchial stress from current their ill child and to relationships
asthma in situation >Openly facilitate enhance consistent >Openly
acute communicate and communication disease management communicated and
exacerbation discuss their between members. behavior by discussed their
● Emergency thoughts and feelings permitting a sharing thoughts and feelings
hospitalization about disease and of the burdens about disease and
(child hospitalization. associated with hospitalization.
admitted for 3 disease (Berkowitz,
days) >Acknowledge their et al., 2001). >Acknowledged their
emotional and emotional and
personal needs. [Link] information >Patient’s personal needs.
about the child’s hospitalization is not
Long Term: condition. Show a pleasant thing for Long Term:
At the end of 3 days, empathy and any individual in the At the end of 3 days,
family will be able to: support. family, since it can family has:
cause crisis due to
>Cope with the dysfunction and >Coped with the
situation regarding instability. Information situation regarding
the child’s illness. provided by the child’s illness.
healthcare
>Engage in social professionals should >Engaged in social
support and be reliable and support and
educational activities. sincere, it is required educational activities.
at frequent repetition,
so that family can
comprehend the
conditions (Bellou &
Gerogianni, 2014).

[Link] opportunity >Interventions

wherein parents may designed to support

74
discuss their gap in parents in coping
skill and knowledge with the
management of their hospitalization via
child’s disease. communication,
empathy, education,
concrete resources,
or other means are
well positioned to
improve parents’
well-being during and
after the child’s
hospitalization.
(Doupnik, et al.,
2017).

4. Educate parents >Parents value

on effective emotion services to support
and stress their emotional
management skills. well-being as they
cope with a child’s
hospitalization.
(Doupnik, et al.,
2017).

Collaborative:
1. Collaborate with >Coping support
community resources interventions can
for the family after improve parent
discharge. emotional outcomes.
Resources in the These are effective
community may be for improving parents’
from barangay health anxiety and stress
centers and symptoms burden
Department of Health (Doupnik, et al.,

75
programs. 2017).

76
XII. DISCHARGE PLAN
M-E-T-H-O-D-S RATIONALE/NURSING CONSIDERATIONS

Medications

● Salbutamol nebule 1 neb ● Used as a quick-relief agent for acute

every 6 hours bronchospasm and for prevention of
(3am-9am-3pm-9pm) for exercise-induced bronchospasm. Perform chest
for 5 days tapping every after nebulization as ordered by the
physician to help improve lung function and help
breathe better. Instruct parents of patients to
contact a health care professional immediately if
shortness of breath is not relieved by medication or
is accompanied by diaphoresis, dizziness,
palpitations, or chest pain.

● Co-amoxiclav 250mg/62.5 ● Treatment of a variety of infections including: Skin

mcg/5ml suspension 2.5 ml and skin structure infections, otitis media, sinusitis,
3x/day for 5 days resp tract infections, GU tract infections. Instruct
parents of patients that medication should be taken
round the clock and to finish the drug completely as
directed, even if feeling better.

● Prednisone (Pred 20) 20 ● Suppresses the immune system by reducing

mg/5ml suspension 2.5 ml activity and volume of the lymphatic system;
once a day (Give 1st dose suppresses adrenal function at high doses.
today 12-4-2020) for 5
days

● Phenylpropanolamine HCl ● Indicated for allergic and vasomotor or other

+ Brompheniramine hyperactive nasal disorders and acute coryza, relief
maleate (nasatapp) drugs of nasal congestion and hypersecretion. Relief of
1 ml once a day at hours of nasal congestion in infants up to children 12 years
sleep for 3 days of age. Inform parents of patients that drowsiness
may occur. Instruct the parents of the patient to
contact a health care professional if symptoms
persist.

Exercise
Advice parents to teach the
child to breathe out slowly ● Such exercises are aimed at increasing expiratory
through the mouth using function and tightening the abdominal muscles.
pursed lips. This lets
trapped air get out of the
air sacs. Teach him to do it
slowly. A child can be
taught to do this by having
him blow large "play"

Treatment
● Do not stop taking the drug ● To ensure full recovery and alleviation of
without consulting your discomfort.

77
 healthcare provider.

Health Teachings

● Advise the parents to keep ● This will help identify asthma triggers so you can
a diary of their child's keep your child away from them.
asthma symptoms.

● Nicotine and other chemicals in cigarettes and

● Instruct the parents to cigars can make your child's asthma worse. Smoke
distance their child from from e-cigarettes or smokeless tobacco still contain
smoke. nicotine.

● Tell the parents to avoid ● To avoid exacerbation of asthma.

allergens by environmental
control

● Instruct the parents to ● In 2 to 3 days, if your child is not getting better,

observe the child and please make an appointment at your clinic. When
contact physician if their your child feels better, schedule a time to discuss
child has trouble breathing, asthma control with your doctor.
medication doesn’t work,
and the condition gets
worse, appears blue or
pale, won’t drink or can’t
keep down liquids, has
severe pain, goes more
than 8 hours without
urinating/peeing, has dry
mouth or sleepier than
usual.

● Limit exposure to public

areas and people with ● Environmental factors such as dust, pollution, cold
illness temperature, second-hand (even third-hand) smoke
and high humidity are known to trigger asthma.

Out-patient; Follow up Visit

● Instruct the parents to ● Teach parents that the child will need to return to
come back for a follow-up make sure the medicine is working and that his or
visit on 12-14-2020, 12 her symptoms are being controlled. Child may be
noon. referred to an asthma specialist. Bring a diary of
the child's peak flow numbers, symptoms, and

78
 possible triggers to the follow-up appointments.
Instruct to write down questions to remember to
ask them during the child's visit.

Diet

● Place on diet for age with ● Having smaller and more frequent feedings
strict aspiration precaution reduces the risk of aspiration greatly.
as ordered by physician.

● The patient is advised to ● This is done to promote proper nutrition. This can
eat adequate amounts of help support healthy lung function, reduce lung
vegetables and fruits, milk, inflammation, and increase airflow to help make
proteins from whole grain, breathing easier.
omega-3 from fish, and
foods rich in vitamin C, E
and bioflavonoids.
.
● Avoid any processed food, ● This is done to prevent inflammation in the lungs,
sugar, and keep fast food too much sugar which can lead to weight gain, and
meals to a bare minimum. processed foods can result in exacerbated asthma
symptoms.

Spirituality

● Pray daily, read the bible if ● These help in absorbing positivity through beliefs
needed, and go to church and practices that could contribute to a healthy
every Sunday. mind and fast recovery.

XIII. PROGNOSIS

79
Legend:

(5) Excellent — Patient performs excellently; is cooperative, independent and responds

actively to nursing interventions.

(4) Good — The patient is independent in some ways, performs well and responds actively
to nursing interventions.

(3) Fair — Patient performs weakly and is somewhat dependent; responds minimally to
nursing interventions.

(2) Poor — Patient performs poorly and is very dependent; does not respond to some
nursing interventions.

(1) Very Poor — Patient does not perform and is very dependent; does not respond to the
nursing interventions at all.

Criteria 5 4 3 2 1 Justification

A. Physiologic / The physiologic response of the

response of the body is responding to the infection
through an immune reaction
patient to the
however has not sufficiently gotten
disease process rid of the infection in the bronchi
which is mainly the reason for the
asthma. Furthermore the patient
displays bilateral retraction which
indicates inadequate breathing
which has affected the amount of
oxygen available for his body as
indicated by the need for oxygen
therapy. We decided to rate the
patient with fair because his
condition was exacerbated by
natural phenomenon but his
recovery has steady throughout the
following two days, being afebrile
only a few hours after with no
recurrence as well as lowered
retractions and tachypnea by the
next day.

B. Relief of the signs / Upon admission, the patient

and symptoms presented with tachypnea but has
later on improved throughout his

80
 associated with stay. The patient was afebrile
disease condition throughout the admission period. His
appetite improved during his third
of the patient
day. There were negative signs of
wheezing and retractions and health
has greatly improved on the fourth
day thus the patient was permitted
to go home with home medications
given by the physician.

C. Performance of / The patient was able perform daily

daily living of the activities like bathing, eating, change
of clothing and using the restroom
patient during the
with the assistance of the parents.
confinement

D. Compliance of the / Patient was cooperative with the

patient to the drug regimens and was able to take
all medications with the help of the
medication and
nurse. The Patient’s parents were
therapy fully aware of the different
medications, route, and dosage and
fully agreed to the medications
given.

E. Adequacy of rest / Throughout his admission, the

and sleep of the patient was able to maintain
adequate amounts of rest, but sleep
patient receives
was disrupted by the taking of vital
signs and administration of
medications.

F. Consumption of / Patient was cooperative as he was

the medication able to consume all the medications
that were prescribed to him during
and therapeutic
his admission.
regimen of the
patient

Excellent (1) 1x5=5

81
 Very Good (3) 3 x 4 = 12

Good (2) 2x1=2

Fair (0) 0x2=0

Poor (0) 0x1=0

TOTAL 19

Formula:

(The total score / The Highest possible Score) x 100 = Percentage Score (%)

(19 / 30) x 100 = 63.33%

Rating Scale:

81% - 100% - Excellent

61% - 80.99% - Very Good

41% - 60.99% - Good

21% - 40.99% - Fair

20.99% below - Poor

The Prognosis and Rating of the patient: 63.33% - Very Good Prognosis

The patient was admitted to the hospital on December 1, 2020. Upon admission, the

patient had a cough and experienced tachypnea and retractions. Both genetic and

environmental factors may seem to contribute. Positive family history is a risk factor for

asthma but is neither necessary nor sufficient for the development of the disease. Multiple

environmental exposures, either prenatal or during childhood, are associated with the

development of asthma. (Lizzo & Cortes, 2020). The first day, the patient had tachypnea and

it was lessened hours after admission due to the medications that were taken. On the

second day, tachypnea and retractions were still present. The patient experienced

occasional wheezing and food appetite is improving. On the third day, the patient still had

wheezing, rales bilateral, retractions but food appetite was even better. On his last day, the

patient showed no signs of wheezing, rales bilateral, retractions. The patient was afebrile

throughout his admission and vitals were checked from time to time and it was stable and

82
thus permitting the patient to discharge on the fourth day, however, home medications were

still prescribed.

This would indicate that the medications and procedures given to the patient were

effective and these include: Phenylpropanolamine and Brompheniramine maleate drops 1

mL TID, Ceftriaxone 600 mg IV drip x 1hour q12h ANST, Hydrocortisone 45mg IVTT Q6,

Salbutamol nebula q4H, Co-amoxiclav 750mg/62.5mg/5ml 2.5 ml, TB PO, O2 2LPM/Canal.

The overall progress of the patient was very good, with the percentage of 63.33%.

Appropriate nursing care was provided as a result that the patient showed improvements

with the help of the medications and procedures given by the physician. The patient’s

parents interacted with the physician and health care team and as shown by the prognosis

chart, the patient improved well, however, home medications are still needed to be taken.

XIV. CONCLUSION

83
 A 1-year-and-3-month-old male child with a final diagnosis of Bronchial Asthma in

Acute Exacerbation was admitted to the Emergency Room with a chief complaint of cough

and colds.

All necessary information was gathered through thorough studying of the patient’s

chart: admission date (12/01/20 – 11:27PM) until discharge date (12/04/20 – 6:00PM). Client

showed an impression of having PCAP-C (Pediatric Community Acquired Pneumonia) with

asthma and was therefore given nebulization and treatment with medications of Ceftriaxone

(Viatrex), Salbutamol, Phenylpropanolamine HCl + Brompheniramine Maleate (Nasatapp)

Drops, and Paracetamol drops as noted by physician and advised to follow medication

compliance regarding the take-home medications given with no surgical procedures needed.

The client’s condition falls under very good prognosis. Appropriate nursing care

interventions were provided. Client's condition improved as a result of the medications and

procedures prescribed by the doctor.

Upon admission, it was evident that the client had persistence of symptoms

(non-productive cough with clear nasal discharge), associated fast breathing, decreased

appetite, decreased milk formula intake (6 oz from usual intake of 18 oz), positive vomiting

(post tussive), (+) SC/IC (subcostal/intercostal) retractions, and tachypneic. Following

admission, there was evident improvement through decreased tachypnea, decreased

retractions, and afebrile temperature until there are clear breath sounds, no wheezing, no

retractions, good activity, afebrile temperature, and alert state. Health teachings were given

with emphasis on proper nutrition, safety precautions, adequate rest and hydration including

verbalization of any concern, infection control, comfort measures, and precautions regarding

medications (medication compliance).

84
 The proposed nursing actions focused on how to improve the condition affecting the

recovery of the client during their hospitalization. This can be achieved through interactive

discussions and reinforcement of teaching to the parents of the 1-year-old. Furthermore, the

student nurses were able to achieve their objectives. They have gained new knowledge that

raises awareness of personal and professional accountability. With this new knowledge, their

skills will improve to provide the appropriate nursing care to their future clients.

85
VX. RECOMMENDATION

Based on the mentioned conclusions, the student nurses have established the

following recommendations. The following points aim to guide and suggest for improvement

to the following individuals and groups:

Patients with Bronchial Asthma. The patient must know what triggers their signs

and symptoms of asthma. By knowing what activates it, they will be aware of what they

should stay away from as far as possible. They should reduce their contact with pets and

refrain from smoking cigarettes. The best way to prevent an asthma episode, or attack, is to

follow the physician’s treatment plan and to take their medications regularly. On top of

everything else, if the patient experiences adverse effects from the medications, they should

immediately contact the nearest healthcare provider.

Level two, three and four nursing students. For the optimal well-being of the

patient, nursing students should address every sign and symptom by continual monitoring

and ensuring the improvement of the patient’s condition. Pursuing this further, medications

are crucial for the patient’s health and thus, should be checked if the patient is complying

correctly with the doctor’s orders. Also, health teachings should be carefully instructed by

making sure the patient understood the needed information. With this, nursing students

should aspire to improve their knowledge, skills, & character and provide appropriate nursing

interventions. If there is a need to perform a study on a similar case, nursing students must

investigate further into every detail and expand their knowledge on the concept of Bronchial

Asthma.

Physicians, registered nurses, and other members of the healthcare team. As

frontline workers, they need to ensure that quality patient care is observed throughout the

procedure, like measuring effectiveness and tracking improvement. Having an open and

welcoming approach would be appreciated in initiating with the patient. In recognition of the

diagnostic process, healthcare professionals must have the appropriate knowledge, skills,

resources, and support to engage in teamwork. They must also collaborate with patients and

86
their families as healthcare team members and facilitate patient and family engagement

during the whole process.

Future nursing students. The presented data of this study would serve as

information for future purposes such as research studies. Furthermore, case presentations

like this serve not only as a prerequisite for passing the course but also as a learning

opportunity to better understand the conditions of the patients. These are beneficial to future

nurses in understanding the necessary precautions, actions, priorities, and most importantly,

to be free from medical errors.

The community. The data presented in the study encourage families to prioritize

direct protection of health through vaccination. This would give knowledge why vaccinations

are important to people especially in the early stages of life. Also, this would encourage

vaccine recommendations and service programs.

87
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Padula, C. A., Yeaw, E., & Mistry, S. (2009). A home-based nurse-coached inspiratory

muscle training intervention in heart failure. Applied nursing research : ANR, 22(1),

18–25. [Link]

Vallerand, A. H.,; Deglin, J. H. (2009). Davis's Drug Guide for Nurses (11th ed.).

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VanPutte, C., Regan, J., & Russo, A. (2019). Seeley's Essentials of Anatomy and Physiology

(0000)(10th ed.). New York, New York: McGraw-Hill Education.

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exacerbation of asthma. Expert review of respiratory medicine, 4(1), 71–83.

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92
XVII. APPENDICES

A. Doctor’s Orders

PHYSICIANS NOTES (SOAP) ORDERS

12/1/20 ● Please admit

5PM ● TPR q4H
● DA
  ● D50.3 in NaCl 500cc @ 65cc/HR
  ● IVF TF D5LR 1L @ 60cc/Hr
● CXR APL view
● CBC
● U/A
● Salbutamol 1 nebule now then ā4H,
use face mask firmly attached to
patients face.
● Phenylpropanolamine HCI +
○ Brompheniramine maleate
(Nasatapp)drops 1mL TID
P.O.
● Ceftriaxone (Viatrex) 600 mg IV drip x
1 hour q 12h; after negative skin test
(ANST)
● Paracetamol drops (Tempra) 1.2 mL q
4h PRN for temperature ≥ 37.8 C
● Oxygen at 2 L per minute (LPM) via
cannula
● Refer for SPO2 < 95%, cyanosis,
severe respiratory distress
● Inform me once admitted
● Checked informed consent form for
admission

● Give salbutamol 1 nebule now x2 doses

12/1/2020 ● Start hydrocortisone 45 mg IVTT now
5.25 pm then q 6 hrs
● O2 at 2LPM

12/1/2020
Assessment: RR 60, positive SL/IC
retractions
8: 25 PM
● Nebulize salbutamol every 3 hrs
● Please do chest tapping post
nebulizing
● Increase O2 to 3 LPM
● NPO temporarily

93
12/1/2021
Assessment: less tachypnea, afebrile
8:40 PM (absence of fever)

12/1/2020 ● Alternate nebulization using salbutamol 1

nebule and salbutamol + ipratropium 1
10:40 PM nebule q3 hrs
● Start antibiotics now

12/2/2020 Vital signs q 2hrs with strict O2 saturation

1:44 AM ● Refer saturation <95%

12/2/2020 Assessments:
6:30 AM decreased tachypnea,decreased retractions
(chest inwards), RR 50 -52 cpm, O2 sat
at 97% at 2 liters per minute, HR: 150s +
rales(crackles), better at eating
● Decrease O2 to 2 LMP
● Continue meds
●May have diet for age with strict aspiration
precaution
● Follow-up official CXR (chest x-ray) result

12/3/2020 Assessments: afebrile, good appetite, HR

9:40 AM 110s, RR 20s, SPO2 98% - room air
(RA), tolerated well
❏ Positive Rales bilateral o
positive Wheeze
❏ Negative Retraction
❏ Ceftriaxone D1 + 1
● Discontinue O2
● Refer if with desaturation (<95% sat)
● Decrease IVF to 45 cc/hr
● IVF to follow D5IMB @ 50 cc/hr
● Decrease nebulization interval to q4

12/3/2020 ● Assessment: no wheezes, no

11 AM retractions, afebrile, 97% sat at RA
● To consume ceftriaxone 600 mg
● Available stacks then shift to
Co-amoxiclav (Natravox) 250 mg/62.5
mg every 5 mL, 2.5 mL TID PO
● May not reinsert IV line once dislodged
and inform me
● Decrease IVF rate to 30 cc/hr
● Discontinue salbutamol + ipratropium
● Increase salbutamol to 1 nebule q 4h
● Continue hydrocortisone

94
 ● Assessment: 2 HD (hospital day), +
12/3/2020 wheeze (occasional), no retractions,
4:00 PM BP: 90/60, 114 BPM, 30 CPM, 99%
SPO2 at room air

12/4/2020 Assessment: - wheeze, no retraction,

9:00 AM +BM; VS: 90/60, 114 bpm, 28-38
CPM 98% sat
● Advise to do chest tapping every after
nebulization
● Increase oral fluid intake (OFI)
● Refer accordingly

12/4/2020 ● May go home

11:30 AM ● Take home medications
❏ Salbutamol 1 nebule q6h
(3-9-3-9) for 5 days
❏ Co-amoxiclav 250 mg/62.5 mg
(Amoxicillin/clavulanic acid)
❏ Prednisone (Pred 20) 20
mg/5mL (20 mg per 5 mL)
❏ Phenylpropanolamine HCL +
Brompheniramine maleate
(nasatapp) drops 1 mL OD
hour of sleep (HS)
❏ Follow up check up on
12/14/20 at MRXUH clinic
12NN

B. Nurse’s Notes

Date & Focus Data/Action/Response

Time

12/01/20 Pt entered emergency room due to cough and

colds; Ushered safely to bed, side rails raised,

95
3:30 PM ROD informed, admission facilitated, doctor’s
orders carry out

12-2-2020 Admission D: Received patient from emergency room A:

Health teaching given with emphasis on proper
8:00AM nutrition and safety precaution. Emphasized
proper nebulization technique towards watchers.
VS taken and recorded
R: Endorsed to nurse on duty

12-2-2020 Safety D: Pediatric Patient A: Placed on ____ side rails

Precaution raised,______, vital signs taken and
9AM recorded______
R: Safety maintained

12-2-2020 Adequate Rest A: encouraged & reinforced_____ pt’s rest &

& Hydration safety, encouraged verbalization of______
3PM concern, V.S. taken and recorded, needs
attended, kept rested & monitored for any
abnormalities

R : Positive understanding

12-3-2020 Safety A: placed patient safely at the center of the bed,

Precaution  side rails raised, instructed mother not to leave
9AM patients unattended due to medication given,
V.S. taken & recorded,_____ keep watched for
any unusualities/abnormalities

R: Safety Maintained

12-3-2020 Infection Control ________

3PM

12-4-2020 Comfort A: _____

measures R: + well rested
8AM

C. Consent

96
97