I.

DEMOGRAPHIC DATA

• FULL NAME:
• ADDRESS:
• CIVIL STATUS: Child
• BIRTHDAY: April 16, 2010
• BIRTHPLACE: Benguet General Hospital
• NATIONALITY: Filipino
• RELIGION: Roman Catholic
• EDUCATIONAL ATTAINMENT: n/a
• AGE: 2/12 mo
• GENDER: female
• FATHER:
• OCCUPATION: conductor
• AGE: 25
• MOTHER:
• OCCUPATION: housewife
• AGE: 22
• SIBLINGS:

ADMISSION DETAILS

• DATE ADMITTED: June 19, 2010

• TIME ADMITTED: 9:45 am
• WARD: Pediatric Ward, PO1
• CHIEF COMPLAINT: cough and colds for 1 week
• ADMITTING DIAGNOSIS: Pneumonia, Congenital Heart Disease, Cyanotic
• PEDIATRICIAN:

ROTATION DETAILS

• CLINICAL INSTRUCTOR:
• WARD: Pediatric Ward, BeGH
• DATE: June 20, 2010

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 II. HEALTH HISTORY

A. History of Present Illness

Client’s condition started 2 weeks prior to admission. The client’s mother
noticed that her daughter had been having bouts of productive cough. The child
was given a concoction from boiled oregano leaves for 2 days before her mother
decided to consult doctors from Epiphany, a private clinic at Km.6 La Trinidad,
Benguet. The client was seen and the doctor prescribed a mucolytic and
antibiotic which was to be taken for 5 days and 7 days respectively. The mother
only gave the medicines for 4 days because she did not notice any effects.

1 day PTA, the client was brought back to Epiphany for a follow-up check-up.
Because of the child’s worsened condition, the patient was refered to BeGH for
admission.

B. Past Medical History

The client’s mother claimed that the child was healthy up until 2 weeks ago,
when the cough and colds started. The client’s mother also stated that the child
was healthy when she was born and that doctors did not inform her of possible
defects. Although, the client was born almost a month before her mother’s
expected date of confinement (May 1, 2010).

C. Socio-Cultural History
Although the client is still quite young for this to be assessed, she would be
raised under the influence of her parents’ cultures and as a Roman Catholic.
Client also lives in a home shared with her sibling and parents. The client’s
mother stated that only their family live in their home.

D. Heredofamilial History
The client’s mother stated that she and her husband had no hereditary
diseases that the child may have acquired. However, the child’s grandmother –
from the mother’s side – was diagnosed with hypertension. Her grandfather –
also from the mother side – had a history of kidney disease, although her mother
did not specify what. No diseases from the father’s side were made mention.

E. Pediatric History
The client was born on April 16, 2010 despite her mother’s EDC being on May
1, 2010 based on her ultrasound results. At birth, the client weighed 2.57 kg and
anthropometric measurements were unrecalled. The mother said the baby had a
good cry. At present, the child weighs 4 kg. Her anthropometric measurements
are: HC = 38 cm; CC = 37.5 cm; AC = 11 cm. The client’s mother stated that the
child had been healthy up until 2 weeks PTA.

The client’s mother stated that she did not have any history of smoking and
drinking of alcoholic substances both before and during her pregnancy. She
recalls having cough and colds during her pregnancy but did not take any
medications. She also does not recall being exposed to any teratogenic materials
that may have caused the congenital heart disease of the patient.

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 III. 13 AREAS OF ASSESSMENT

I.PSYCHOSOCIAL STATUS
The client is the 2nd child of Mr. and Mrs. Ernest Tiongco of Bayabas, Pico, La
Trinidad, Benguet. She was born on April 16, 2010 at BeGH. She is still
unbaptized but her parents are both Roman Catholics. Her father works as a
conductor while her mother stays at home and watches over the children. Her
sibling, Jesse, is 2 years old.
At this age, the child is believed to belong at the “trust versus mistrust” stage
of Erik Erikson’s Social Development theory. Hence infantile needs must be met
at once upon demand. This means that the client is completely dependent on
her parents, specially her mother, for her survival. It is her mother who spends
the most time with her. Her activities are mostly limited to basic survival
instincts such as eating, eliminating body wastes and sleeping. The child’s fears
may be evident as well when she exhibits a reflexive startle response to loud
noises and sudden movement sin the environment (Muscari, 2005).
Although the client is already the 2nd child of the family, the mother stated
that she was not a planned baby. However, the client’s parents are still
supportive of the well being of their daughter.

II. MENTAL AND EMOTIONAL STATUS

During this age, the client is believed to belong to the sensorimotor stage of
development. It is where she uses the senses, particularly through sucking and
grasping, that the child gains knowledge of the environment. This is also the
reason why a positive grasping reflex was seen upon assessment of the patient.
The client’s current means of communication is through crying, which is said
to be successfully differentiated by the patient’s parents. This is true to the
patient upon assessment. Client is also already able to coo.

III. ENVIRONMENTAL STATUS

Before hospitalization, the client lives with her parents and sibling in their
home in La Trinidad. Her mother stated that despite their humble abode, they
still try to provide a safe environment for the patient. During hospitalization, the
child stays in the pediatric ward where beds are at least 3 feet apart from one
another. The beds have no side rails hence making the child prone to falls. Still,
the client’s mother attempts to keep her baby warm by covering her in the
appropriate clothes and blankets.
The client’s bed is near a window hence ventilation and lighting are not a
problem. However, upon interview, the outside rain creates a cold atmosphere
that may not be comfortable to the baby.
Although the client is not isolated from other patients, there are no other
patients with infectious diseases within the proximity. Also, the client’s mother
stated that at home, the family members were all healthy; hence she could not
have acquired the infection from their home.

IV. SENSORY STATUS

Although this part can not be assessed well because of the patient’s inability
to respond, the client is seen with various evidences of sensory intactness. The
patient is able to respond to voices which show the ability to hear. Client may
also focus her stare on something of interest to her. Lastly, the patient may cry
when painful stimuli is introduced, hence showing intact tactile ability.
Client’s physical features were normal. Her ears were symmetrical and so
were her upper and lower extremities. Her sclera however appeared to be
jaundiced despite her skin being of normal color.

V. MOTOR STATUS
The client is able to turn her head from side to side when in a prone position.
This is basic to infants of her age. The client is also already able to have a good
grasp when an object is placed on her palm. Those are the gross motor and fine
motor skills that she can perform respectively.

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VI. NUTRITIONAL STATUS
The client’s mother stated that she was purely breast fed since birth. The
only exception was when they tried to give her the concoction of boiled oregano
leaves to help alleviate her cough and colds. Her mother stated that the client
was breastfed around 5 times per day, depending on the baby’s demand.
During hospitalization, the client’s diet was not changed. However,
medications are already given to the client. Amikacin 60 mg is given once a day
orally. Ceftazidine 200 mg and Furosemide 4mg are given via IV push every 12
hours. Paracetamol 100/500 ml 0.6 ml is also given to the child every 4 hours if
the child has fever.

VII. ELIMINATION STATUS

The client’s mother stated that the client uses an average of 3 diapers per
day. Often, these diapers would contain both urine and fecal matter. Client’s
urine is described to be yellow in color and not foul smelling. The client’s feces is
described to be yellowish to greenish with a soft consistency. Erikson states that
even at the second week of life, elimination patterns are already developed. He
also states that the color and amount of stool depend on what the child eats and
that urine output averages to 350 – 550 ml/day.

VIII. FLUID AND ELECTROLYTE STATUS

Client’s main source of hydration is her breastfeeding. However, to aid her,
an IVF of DsIMB 90cc via soluset is administered to the child via her right
metacarpal, in a span of 8 hours. No diagnostic tests were ordered to see her
electrolyte levels.

IX. CIRCULATORY STATUS

Client’s cardiac rate upon assessment was at 144 beats per minute. Muscari
states that an infants normal resting and awake pulses should be at 80 – 130
bpm. This elevated cardiac rate may be attributed to the patient’s congenital
heart disease. The client had no cyanosis and no nail clubbing. The client had
pinkish nail bed s with a capillary refill of 1-2 seconds. Client also has heart
murmurs upon auscultation.

X. TEMPERATURE STATUS
The client’s temperature upon assessment was at 37.8°C and his skin was
febrile to touch. Client is often kept warm by the mother through the use of
appropriate clothing such as bonnets, mittens and socks and the use of blankets
to cover the child.

XI. INTEGUMENTARY STATUS

The client’s skin was uniformly brown in color. No lesions were seen upon
inspection. Client had a skin turgor of 1-2 seconds. No ointments or creams were
said to be applied to the baby’s skin.

XII. REPRODUCTIVE STATUS

The client is female with in tact genitalia. Freud stated that the child is at the
oral stage of psychosexual development where in the infant sucks for enjoyment
as well as nourishment and also gains gratification by swallowing, chewing and
biting.

XIII. SLEEP-REST PATTERN

The client’s mother stated that the child only gets 8 hours of sleep at night
before and during hospitalization. She attributes this to the child’s desire to feed
every so often. However, the child also sleeps in the mornings and afternoons, in
between feedings. The mother did not state any bed time rituals that are
initiated, although the mother may sway the child whenever she wants the baby
to sleep.

XIV. RESPIRATORY STATUS

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 The client’s respiratory rate was counted at 60 breaths per minute upon
assessment. Client breathing was rapid and shallow. Client had symmetrical
breath sound but crackles were heard upon auscultation of both lung fields. No
wheezes were heard. Client was also on low flow oxygen therapy which was set
at 1LPM via nasal cannula. Client had no cyanosis but she had subcostal
retractions.

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IV. PATHOPHYSIOLOGY

6
 V. NURSING DIAGNOSIS AND PRIORITIZATION

Nursing Diagnosis Classification Justification

This is of initial priority
because this is crucial to
the survival of the patient.
When in comes to ABCs,
Airway is of first priority.
Maslow’s supports this
because he states that
oxygen is a physiologic
1. Ineffective Airway
need, and hence must be
Clearance Related to
addressed immediately.
Accumulation of
Secretions in the
Actual, Overt Abdellah places this as her
Tracheobronchial Tree
5th priority: To facilitate
secondary to
the maintenance of a
Pneumonia
supply of oxygen to all
body cells where as in
Henderson’s theory, it is of
first priority.

Also, this is the chief

complaint of the patient,
hence it must be
considered as first.
In ABCs this is 3rd priority
under circulation hence it
comes after airway
clearance. This is also
2. Decreased Cardiac
under the physiologic
Output related to
needs of Maslow’s
ineffective pumping of
Actual, Covert hierarchy.
the heart secondary to
Congenital Heart
This problem, if not
Disease
addressed on the earlier
stages may lead to future
problems with the
development of the child.
This problem also referecs
to circulation under ABCs.
3. Impaired tissue However, it is possible to
integrity related to address this
altered circulation simultaneously with
Actual, Covert
secondary to decreased cardiac output.
Congenital Heart Hence, it is not placed on
Disease higher priority. Still, it is
part of Maslow’s
physiologic needs
4. Hyperthermia Actual, Overt This actual problem is only
related to 4th priority because
inflammatory process nursing interventions have
secondary to already been done in the
pneumonia clinical area. Also, the
increase in temperature is
most likely brought about
by the inflammatory
process due to the
patient’s pneumonia.
Hence, one the pneumonia
is addressed, the problem

7
 also may cease to exist.
This is the 6th priority in
Henderson’s theory.
This is both 3rd priority
under Maslow’s and
Hendersons’ theories
hence this is prioritized
5. Risk for falls related
above the others.
to child’s age less than Potential, Overt
1 year old
Also, this is of initial
priority because it may be
prevented within the 8
hour shift.
This belongs under safety
and security of Maslow’s
6. Risk for activity
Hierarchy of needs. Also,
intolerance related to
this may be prevented if
presence of Potential, Covert
the cardiac output and
cardiopulmonary
airway clearance problems
disorders
are resolved, hence it is
not of initial piority.
This is last priority
because this is a wellness
7. Effective diagnoses. Maslow places
breastfeeding related this under physiologic
to infant gestational Wellness, Overt needs and Abdellah places
age greater than 34 this under 6th priority: To
weeks facilitate the maintenance
of nutrition of all body
cells.

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 VI. NCP PROPER

Nursing Diagnosis: Ineffective Airway Clearance Related to Accumulation of Secretions in the Tracheobronchial Tree secondary to
Pneumonia

Goal: Client will be able to achieve and maintain a patent airway

Long Term Objectives:

After the entire duration of the client’s stay in the hospital, the client will be able to maintain a patent airway as evidenced by:
• Independence from oxygen
• Absence of crackles auscultated over both lung fields
• Absence of bronchial secretions

Short Term Objectives:

After 8 hours of nursing intervention, the client will be able to maintain a respiratory rate within the normal limits of 30-50 breaths per minute
After 8 hours of nursing interventions, the client will display a decreasing amount of secretions (less than 30 cc)

Cues Explanation of the

Interventions Rationale Criteria for Evaluation
Problem
S > “isang linggo siyang Normally, the lungs Dx: Long Term Objectives:
sinisipon at inuubo” stated are free from secretions, > Assess respiratory rate > Provides a basis for Goal will be fully met if:
the mother but with pneumonia evaluating the adequacy > After the entire duration
bacteria are invading the of ventilation of the client’s stay in the
O> client appears calm lung parenchyma thus >Note chest movements: hospital, the client will be
and conscious producing inflammatory use of accessory muscles > Use of accessory able to maintain a patent
> with good cry noted process. And this response during respiration muscles of respiration may airway as evidenced by all
> with pinkish nailbeds leads to filling of the occur in response to of the following:
noted alveolar sacs with ineffective ventilation •
> with crackles heard exudates leading to >Auscultate breath Independence from
upon auscultation of both consolidation. Due to sounds; noted areas with > Crackles indicate oxygen
lung fields consolidation, the airway presence of adventitious accumulation of secretions •
> on O2 inhalation of 1 lpm is narrowed thus sounds and inability to clear Absence of crackles
per nasal cannula increasing the need for airways auscultated over
> with subcostal oxygen, which increases >Document respiratory both lung fields
retractions noted the respiratory rate. secretions: character and > Expectorations may be •

9
> no cyanosis noted
> vital signs are as Also, the problem
follows: may be explained by the
T˚: 37.8 ˚C accumulation of fluids in
RR: 60 cpm lungs. Ineffective pumping
CR: 144 bpm of the heart means that
fluid may flow back
towards the lungs. This in
turn fills the lungs with
fluids; hence crackles may
be heard upon inspiration.
This is true in the case of
the client because she has
congenital heard disease.
amount of sputum different when secretions Absence of
are very thick bronchial secretions
Tx:
>Acknowledge reality of Goal will be partially met
situation > To establish therapeutic if:
relationship and support > After the entire duration
hopeful emotions of the client’s stay in the
hospital, the client will be
> Provide a safe > Safety may be ensured able to maintain a patent
environment by staying at airway as evidenced by 1
bedside or 2 of the following:
> Amikacin is an •
>Administer medications aminoglycoside antibiotic Independence from
as indicated: amikacin that stops the growth of oxygen
bacteria that causes •
pneumonia Absence of crackles
auscultated over
> Maintain patient on low > This aids in providing both lung fields
flow oxygen therapy as adequate oxygenation to •
ordered be patient. Absence of
bronchial secretions
Edx:
> Provide information > Helps to facilitate the Goal will be not met if:
regarding the child’s participation of the > After the entire duration
condition significant others with the of the client’s stay in the
patient’s plan of care hospital, the client is
unable to maintain a
> Frequent contact helps patent airway because
> Encourage active reduce feelings of isolation neither of the following are
participation of patient’s and helplessness achieved:
significant others by •
maintaining contact > To assist client to Independence from
establish optimal oxygen
> Encourage significant sleep/rest pattern •
others to maintain a Absence of crackles
relaxed, calm, non- auscultated over
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stimulating environment both lung fields
•
Absence of
bronchial secretions
.

Short Term Objectives:

Goal will be fully met if:
> After 8 hours of nursing
intervention, the client will
be able to maintain a
respiratory rate within the
normal limits of 30-50
breaths per minute

> After 8 hours of nursing

interventions, the client
will display a decreasing
amount of secretions (less
than 30 cc)

Goal will be partially met

if:
> After 16 hours of
nursing intervention, the
client will be able to
maintain a respiratory rate
within the normal limits of
30-50 breaths per minute

> After 16 hours of

nursing interventions, the
client will display a
decreasing amount of
secretions (less than 30
cc)

11
Goals will be not met if:
> After 16 hours of
nursing intervention, the
client is still unable to
maintain a respiratory rate
within the normal limits of
30-50 breaths per minute

> After 16 hours of

nursing interventions, the
client is unable to display
a decreasing amount of
secretions (less than 30
cc)

12
Nursing Diagnosis: Decreased Cardiac Output related to ineffective pumping of the heart secondary to Congenital Heart Disease

Goal: Patient maintains warm, dry skin; regular cardiac rhythm; clear lung sounds; and strong bilateral, equal peripheral pulses.

Long Term Objectives:

After the entire duration of the client’s stay in the hospital, the client will be able to demonstrate adequate cardiac output as evidenced by:
• Pulse rate and rhythm within normal parameters for client
• Strong peripheral pulses
• An ability to tolerate activity without symptoms of dyspnea, syncope, or
chest pain

Short Term Objectives:

After 8 hours of nursing intervention, the client will be able to maintain a pulse rate within the normal limits of 80-130 beats per minute
After 8 hours of nursing interventions, the client will have strong peripheral pulses

Cues Explanation of the

Interventions Rationale Criteria for Evaluation
Problem
S > “isang linggo siyang Inadequate blood Dx: Long Term Objectives:
sinisipon at inuubo” stated pumped by the heart to > Assess heart rate and > Sinus tachycardia and Goal will be fully met if:
the mother meet the metabolic blood pressure. increased arterial blood> After the entire duration
demands of the body. pressure are seen in theof the client’s stay in the
O> client appears calm Note that in a early stages; Pulsus
hospital, the client will be
and conscious hypermatabolic state, alternans (alternating
able to demonstrate
> no nail clubbinfgnoted although cardiac output strong-then-weak pulse) is
adequate cardiac output
> with capillary refill of 1-2 may be within normal often seen in heart failure
as evidenced by:
seconds range, it may still be > Assess skin color and patients. •
> with pinkish nailbeds inadequate to meet the temperature. Pulse rate and
noted needs of the body’s > Cold, clammy skin is rhythm within
> with crackles heard tissues. Cardiac output secondary to normal parameters
upon auscultation of both and tissue perfusion are compensatory increase in for client
lung fields interrelated, although sympathetic nervous •
> on O2 inhalation of 1 lpm there are differences. > Assess peripheral system stimulation and Strong peripheral
per nasal cannula When cardiac output is pulses. low cardiac output and pulses
> with subcostal decreased, tissue desaturation. •
retractions noted perfusion problems will An ability to tolerate
> no cyanosis noted develop; however, tissue > Assess lung sounds. > Pulses are weak with activity without

13
> vital signs are as perfusion problems can Determine any occurrence reduced cardiac output. symptoms of
follows: exist without decreased of paroxysmal nocturnal dyspnea, syncope,
T˚: 37.8 ˚C cardiac output. dyspnea (PND) or > Crackles reflect or chest pain
RR: 60 cpm orthopnea. accumulation of fluid
CR: 144 bpm secondary to impaired left Goal will be partially met
ventricular emptying. They if:
are more evident in the > After the entire duration
dependent areas of the of the client’s stay in the
lung. Orthopnea is hospital, the client will be
Tx: difficulty breathing when able to demonstrate
>Acknowledge reality of supine. PND is difficulty adequate cardiac output
situation breathing that occurs at as evidenced by only 1 or
night. 2 of the following:
•
Pulse rate and
> Provide a safe > To establish therapeutic rhythm within
environment by staying at relationship and support normal parameters
bedside hopeful emotions for client
•
> Administer medication > Safety may be ensured Strong peripheral
as prescribed, noting pulses
response and watching for •
side effects and toxicity. > Depending on An ability to tolerate
Clarify with physician etiological factors, activity without
parameters forcommon medications symptoms of
withholding medications. include digitalis therapy, dyspnea, syncope,
diuretics, vasodilator or chest pain
> Organize nursing and therapy, antidysrhythmics,
medical care. ACE inhibitors, and Goal will be not met if:
inotropic agents. > After the entire duration
> Provide quiet, relaxed of the client’s stay in the
environment. > This allows rest periods. hospital, the client is still
unable to demonstrate
Edx: adequate cardiac output
> Provide information > Emotional stress because of failure to meet
regarding the child’s increases cardiac any of the following:

14
condition demands. •
Pulse rate and
rhythm within
> Helps to facilitate the normal parameters
> Encourage active participation of the for client
participation of patient’s significant others with the •
significant others by patient’s plan of care Strong peripheral
maintaining contact pulses
> Frequent contact helps •
>Encourage significant reduce feelings of isolation An ability to tolerate
others to maintain a and helplessness activity without
relaxed, calm, non- symptoms of
stimulating environment > To assist client to dyspnea, syncope,
establish optimal or chest pain
sleep/rest pattern .

Short Term Objectives:

Goal will be fully met if:
> After 8 hours of nursing
intervention, the client will
be able to maintain a
pulse rate within the
normal limits of 80-130
beats per minute

>After 8 hours of nursing

interventions, the client
will have strong peripheral
pulses

Goal will be partially met

if:
> After 16 hours of
nursing intervention, the
client will be able to

15
maintain a pulse rate
within the normal limits of
80-130 beats per minute

>After 16 hours of nursing

interventions, the client
will have strong peripheral
pulses

Goals will be not met if:

> After 16 hours of
nursing intervention, the
client is still unable to
maintain a pulse rate
within the normal limits of
80-130 beats per minute

>After 16 hours of nursing

interventions, the client
still does not have strong
peripheral pulses

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 VII. REFERENCES

ONLINE REFERENCES
http://nursing-concept.blogspot.com/2009/02/nursing-care-plans-for-decreased.html
http://wiki.answers.com/Q/Discuss_21_nursing_problem_by_faye_g._abdellah
http://wiki.answers.com/Q/What_are_the_14_basic_needs_according_to_Henderson
http://www.annals.in/article.asp?issn=0971-
9784;year=2007;volume=10;issue=1;spage=19;epage=26;aulast=Chowdhury
http://www.scribd.com/doc/1868979/Nursing-Care-Plan-for-Ineffective-Airway-
Clearance
http://www.scribd.com/doc/12446291/NCP-Ineffective-Airway-clearance-rt-retained-
secretions-2-BPN-
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?
plan=09
http://www.reference.com/browse/atrial+septal+defect
http://www.pterrywave.com/Nursing/Care%20Plans/27.aspx

BOOK REFERENCES
2009 Lippincott’s Nursing Drug Guide by Amy M. Karch
Medical - Surgical Nursing 7th Ed. By Brunner and Suddarth
Pediatric Nursing 4th Ed. By Mary e. Muscari, RN, PhD, CRNP, CS
Nurses’ Pocket Guide 11th Ed. By Marilynn E. Doenges, et al.

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