A.
CLIENT PROFILE
I. GENERAL INFORMATION
Name: Patient L. B. N
Age: 3 years old
Sex: Female
Source of Information: Chart
(If client is child) Relationship to client:
Date of Admission: June 6, 2028
Hospital/Institution: Tanza Doctors Hospital Inc.
Ward/Area and Bed number: 2401
FOR PEDIATRIC CLIENTS:
Number of Siblings: 2
Ordinal position in the Family: Youngest
Home Address: Blk 3 Lot 23 L Lynvville Halayhay, Tanza, Cavite
Occupation: N/A
Civil Status: N/A
II. MEDICAL DIAGNOSIS: Acute Bronchitis,
III. CHIEF COMPLAINT: Fever
IV. BRIEF HISTORY OF HOSPITALIZATION: On June 27, 2024, patient had a
fever (Tmax 38.2°C). She has refused food intake and had an episode of
vomiting and no medication was taken. 5 hours later, she had a fever (Tmax
of 40°C) associated with 3 episodes of vomiting. Hence, consulted to ER.
On her admission, Patient L. B. N was hooked with IV Fluids
(D50.3Nacl 500 ml to run for 5hrs) and managed with medications
including IV Paracetamol as PRN and Zinc Syrup,. Laboratories and
Diagnostic (CBC, Urinalysis, CXR) procedures were also initiated.
During her 1st day of being admitted. Her vital signs were stable.
However, she was noted to have bilateral crackles and fever for
which IV ceftriaxone and IV Omeprazole were commenced. In
addition, D5 LR 1000ml to run for 24 hours was hooked.
Two days later, Her crackles decreased but with coughing episodes
for which dynatussin oral was given. She was managed and
monitored until her 4th and 5th day with improving overall health. On
her 6th day where she was discharged and her overall health was
improved.
What is acute bronchitis in children?
Bronchitis is an inflammation of the large breathing tubes (bronchi)
in the lungs. The illness can be short-term (acute) or long-term
(chronic). Acute bronchitis means that the symptoms often develop
quickly and don’t last long. Most cases are mild.
What causes acute bronchitis in a child?
Acute bronchitis is most often caused by a viral infection. It may also
be caused by bacteria or things such as dust, allergens, strong
fumes, or tobacco smoke.
In children, the most common cause of acute bronchitis is a virus.
The illness may develop after a cold or other viral infection in the
nose, mouth, or throat (upper respiratory tract). Such illnesses can
spread easily from direct contact with a person who is sick.
Gastroenteritis is inflammation of the digestive tract that results in vomiting,
diarrhea, or both and is sometimes accompanied by fever or abdominal cramps.
Gastroenteritis is usually caused by a viral, bacterial, or parasitic infection.
The infection causes a combination of vomiting, diarrhea, abdominal cramps,
fever, and poor appetite, which can lead to dehydration.
Incidence in the Philippines
Respiratory tract infections and gastroenteritis remain in the
top five causes of mortality in the under 5 age group in the
Philippines in 2019.
Anatomy and Physiology
The respiratory system consists of all the organs involved in breathing. These include the nose,
pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important
things: it brings oxygen into our bodies, which we need for our cells to live and function
properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function.
The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which
the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is
brought into the bloodstream and carbon dioxide is pushed from the blood out into the air.
When something goes wrong with part of the respiratory system, such as an infection like
pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste
product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and
chest pain.
The Upper Airway and Trachea
When you breathe in, air enters your body through your nose or mouth. From there, it travels
down your throat through the larynx (or voice box) and into the trachea (or windpipe) before
entering your lungs. All these structures act to funnel fresh air down from the outside world
into your body. The upper airway is important because it must always stay open for you to be
able to breathe. It also helps to moisten and warm the air before it reaches your lungs.
The Lungs Structure
The lungs are paired, cone-shaped organs which take up most of the space in our chests, along
with the heart. Their role is to take oxygen into the body, which we need for our cells to live
and function properly, and to help us get rid of carbon dioxide, which is a waste product. We
each have two lungs, a left lung and a right lung. These are divided up into 'lobes, or big
sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left
lung has only two, because the heart takes up some of the space in the left side of our chest.
The lungs can also be divided up into even smaller portions, called 'bronchopulmonary
segments'. These are pyramidal-shaped areas which are also separated from each other by
membranes. There are about 10 of them in each lung. Each segment receives its own blood
supply and air supply.
How they work Air enters your lungs through a system of pipes called the bronchi. These pipes
start from the bottom of the trachea as the left and right bronchi and branch many times
throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as
the alveoli. The alveoli are where the important work of gas exchange takes place between the
air and your blood. Covering each alveolus is a whole network of little blood vessel called
capillaries, which are very small branches of the pulmonary arteries. It is important that the air
in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon
dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the
trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some
of this oxygen will travel across the walls of the alveoli into your bloodstream. Traveling in the
opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air
in the alveoli.
Blood Supply
The lungs are very vascular organs, meaning they receive a very large blood supply. This is
because the pulmonary arteries, which supply the lungs, come directly from the right side of
your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs
so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the
bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary
veins into the left side of your heart. From there, it is pumped all around your body to supply
oxygen to cells and organs.
The Work of Breathing
The Pleurae
The lungs are covered by smooth membranes that we call pleurae. The pleurae have two
layers, a 'visceral' layer which sticks closely to the outside surface of your lungs, and a 'parietal'
layer which lines the inside of your chest wall (ribcage). The pleurae are important because they
help you breathe in and out smoothly, without any friction. They also make sure that when
your ribcage expands on breathing in, your lungs expand as well to fill the extra space.
The Diaphragm and Intercostal Muscles
When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The
diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does
much of this work. At rest, it is shaped like a dome curving up into your chest. When you
breathe in, the diaphragm contracts and flattens out, expanding the space in your chest and
drawing air into your lungs. Other muscles, including the muscles between your ribs (the
intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration)
does not normally require your muscles to work. This is because your lungs are very elastic, and
when your muscles relax at the end of inspiration your lungs simply recoil back into their resting
position, pushing the air out as they go.
The Respiratory System Through the Ages
Breathing for the Premature Baby
When a baby is born, it must convert from getting all of its oxygen through the placenta to
absorbing oxygen through its lungs. This is a complicated process, involving many changes in
both air and blood pressures in the baby's lungs. For a baby born preterm (before 37 weeks
gestation), the change is even harder. This is because the baby's lungs may not yet be mature
enough to cope with the transition. The major problem with a preterm baby's lungs is a lack of
something called 'surfactant'. This is a substance produced by cells in the lungs which helps
keep the air sacs, or alveoli, open. Without surfactant, the pressures in the lungs change and
the smaller alveoli collapse.
This reduces the area across which oxygen and carbon dioxide can be exchanged, and not
enough oxygen will be taken in. Normally, a fetus will begin producing surfactant from around
28-32 weeks gestation. When a baby is born before or around this age, it may not have enough
surfactant to keep its lungs open. The baby may develop something called 'Neonatal
Respiratory Distress Syndrome', or NRDS. Signs of NRDS include tachypnoea (very fast
breathing), grunting, and cyanosis (blueness of the lips and tongue). Sometimes NRDS can be
treated by giving the baby artificially made surfactant by a tube down into the baby's lungs.
The Respiratory System and Ageing
The normal process of ageing is associated with a number of changes in both the structure and
function of the respiratory system. These include:
• Enlargement of the alveoli. The air spaces get bigger and lose their elasticity, meaning that
there is less area for gases to be exchanged across. This change is sometimes referred to as
'senile emphysema'.
• The compliance (or springiness) of the chest wall decreases, so that it takes more effort to
breathe in and out.
• The strength of the respiratory muscles (the diaphragm and intercostal muscles) decreases.
This change is closely connected to the general health of the person. All of these changes mean
that an older person might have more difficulty coping with increased stress on their
respiratory system, such as with an infection like pneumonia, than a younger person would.
Pathophysiology
Laboratory Studies
Laboratory Studies
Hematology
Hemoglobin 12.25
Hematocrit 35.1
Red blood cells 3.89
MCV 90.3
MCH 31.5
MCHC 34.9
RDW – CV 14
White blood Cells 6.91
Neutropil 60
Lympocyte 35
Monocyte 4
Eosinophils 1
Basophils
LABORATORY INDICATION FINDINGS RESULT
STUDIES
Hematology
CBC
→RBC 3.89 NORMAL
→WBC 6.91 NORMAL
→Hgb 12.25 NORMAL
→Hematocrit
35.1 LOW- Hematocrit
levels that are too
high or too low can
be a sign of a blood
disorder, dehydration
, or other medical
conditions that affect
→Platelet your blood.
216 LOW - high or low
platelet levels can
indicate the presence
of an underlying
health condition,
infection, or injury.
High or low platelet
levels can increase
→Lymphocytes the risk of clotting or
excessive bleeding.
35
LOW- Lymphocytes
are white blood cells
that help the body
fight infection and
→Monocytes disease.
CXR
Urinalysis
Drug Study
Name of Drug Desired Mechanism General Contraindic General Nursing
Dosage, of Actions Indications ations Side Effects Responsibility
Route, and and
Frequency Adverse
Effects
Generic 140mg, IV, Q4 Exhibits - Fever - Side Effects 1. Do not take
Name: analgesic Contraindica - skin rashes, other
Paracetamol action by - Mild to ted for hypersensitiv medications
peripheral moderate patients with ity reactions, containing
blockage of pain hypersensitiv nephrotoxicit acetaminophen
l pain impulse ity to y, and as it may lead
generation. paracetamol. abdominal to drug
It produces pain overdose.
antipyresis - Patients
by inhibiting with severe Adverse 2. Inspect the
the hepatic Effects injection site
hypothalami impairment - frequently and
c heat- or active Thrombocyto check for any
regulating liver disease. penia, signs of
centre. Its leucopenia, phlebitis
weak anti- neutropenia,
inflammatory pancytopenia 3. Check for
activity is , history of
related to metahemogl hypersensitivity
inhibition of obinemia, and allergies to
prostaglandi agranulocyto acetaminophen
n synthesis sis, or phenacetin
in the CNS. angioedema,
pain and 4. Take history
burning of use of
sensation at alcohol
the injection
site, 5. Monitor for
hypotension, signs and
tachycardia, symptoms of
N/V, hepatotoxicity,
constipation, even with
headache, moderate
insomnia, acetaminophen
erythema, doses,
flushing, and especially in
pruritus. individuals with
poor nutrition
or who have
used alcohol
for prolonged
periods.
Name of Drug Desired Mechanism General Contraindic General Nursing
Dosage, of Actions Indications ations Side Effects Responsibility
Route, and and
Frequency Adverse
Effects
Generic 20 mg / IV OD It works by It is used to headache, take 30-60
Name: lowering the treat Hypersensi abdominal minutes prior
Omeprazole amount of conditions tivity to pain, to eating
acid caused by constipation, capsules
produced by too much omeprazole diarrhoea, should be
your acid , flatulence swallowed
stomach. It production substituted and whole
accomplishe in the nausea/vomit instruct patient
benzimidaz
s this by stomach, ing. to report black
inhibiting the such as: oles or to tarry stool
proton (GERD) any of the
pump, a -erosive excipients.
mechanism esophagitis Adverse
found in the -gastric Omeprazol Vitamin B-12
cells of your (stomach) e like other deficiency,
stomach. In ulcers or proton low
the final duodenal pump magnesium
stage of acid ulcers levels
development -Zollinger- inhibitors Diarrhea,
, the proton Ellison (PPIs) severe
pump is syndrometo should not Inflammation
used. Your mach of the lining
be used
stomach infections of the
produces caused by concomitan intestine,
less acid Helicobacte tly with Fractures of
while the r nelfinavi the bones,
proton pump pyloribacteri Damage to
is blocked. a. the kidneys
This may aid -It may also Fundic gland
in the be used as polyps,
reduction of part of a Cutaneous
your combination lupus
symptoms. therapy. erythematos
This means us, and
By binding you may Systemic
to gastric need to lupus
parietal take it with erythematos
cells, it other us
inhibits H medications
ions from .
entering the Specific:
gastric used to treat
lumen, conditions
reducing caused by
gastric acid too much
content. acid
production in
the stomach
Generic 750 mg / PO / Bacterial cell This general: With prolonged
Name:
Q8h
wall antibiotic is Allergy to Jarisch/ therapy,
Cefuroxime replication is used to cefuroxime Herxheimer monitor renal,
inhibited. cure reaction, hepatic, and
Brand Name: Cefuroxime respiratory -like drugs, which is a hematologic
is active infections. Clostridium short-term function on a
against difficile- reaction regular basis.
certain seen during During
related
Gram- antibiotic cephalosporin
negative and diarrhea, therapy with therapy,
Gram- and some monitor
positive phenylketo infections, prothrombin
bacteria's causes time in patients
beta- nuria. diarrhea, who are at risk
lactamases, nausea, and of prolongation
including vomiting. (nutritionally-
penicillinase Fever, chills, deficient,
s and and body prolonged
cephalospori pain are also treatment,
nases. possible renal or
symptoms. hepatic
It prevents disease).
the bacteria adverse: During the first
from Allergic injection, keep
growing. reactions. an eye out for
Symptoms signs and
can include effects of
hives, trouble anaphylaxis.
breathing,
swelling of
your face,
lips, tongue,
or throat.
FDAR
Date & Focus D: Data A: Action R: Response
time
Elevated Body D: Skin warm to touch, tachycardic, flushed
Temperature face, irritability with axillary temperature of 38.1
A: Continuous TSB rendered, encouraged to
increase fluid intake, Monitored patient’s heart
rate and temperature, Applied cold compress to
forehead, Observed IV site for infiltration,
regulated IV fluids as ordered, anti pyretic
medication given.
R: Decreased patient body temperature to 37.1
Ineffective Breathing D: Tachypneic, Presence of bilateral crackles,
Pattern Xray revealed Pneumonitis, Coughing episode,
poor oral intake
A: Placed on semi-fowler position at all times,
encouraged increase fluid intake, Referred to
ROD, Dynatussin syrup given as prescribed,
Continuous Antibiotic given.
R: Stable V/S, seen relaxed at ease, still with
occasional cough
Discharge Teaching D: with May Go home ordered by AP, Stable
VS
A: Assesed patient’s condition, Informed about
discharge process, heath teaching provided,
instructed home medications and care,
encouraged to come back for follow up check
up
R: Patient went home accompanied and carried
by mother in good condition
Infiltration D: Swollen IV site, not flowing, cold to touch,
tenderness, pain at the site
A: Observed for signs of infiltration or phlebitis,
Explain the importance of reinsertion to
relatives, Reinserted IV device aseptically,
Placed patient on comfortable position
R: Seen patient comfortable, IV site free from
infiltration and infusing well
