ILOILO DOCTORS’

COLLEGE
COLLEGE OF NURSING West
Avenue, Molo, Iloilo City

NCM 109 (RLE):

Care of the Mother, Child at Risk or with Problems
(Acute or Chronic PEDIATRIC NURSING

Case Scenario No.2

Pediatric-Community ACQUIRED Pneumonia PCAP-C

Members:

Calunsod, Alija Joy L.

Capindit, Kyle Angelo C.
Castor, Chona S.
Del Mundo, Krisamae R.
Erodias, Zyra Mia H.
Espeniel, Renalyn L.
Failanza. Christine Joy G.
Fernandez, Julie Rose B.
Garbanzos, Reyanne Chloe A.

Presented to:

Ma’am Brenda Colendres

Clinical Instructors

Presented on:

March 2023
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I. Introduction (Failanza)

Community Acquired Pneumonia (CAP) affects children frequently. It is an infection

of the lower respiratory tract in a youngster who has not spent time in a hospital or
other healthcare facility in the previous 14 days. The majority of CAP cases in the
first two years of life are caused by viruses. Following this time, Chlamydia
pneumoniae, Mycoplasma pneumoniae, and Streptococcus pneumoniae become
increasingly prevalent. Younger infants experience non-specific CAP symptoms,
whereas older children typically experience cough and tachypnea. An x-ray of the
chest can help to confirm the diagnosis. The majority of youngsters can be treated
empirically as outpatients with oral antibiotics without particular laboratory tests.
Those with serious infections or symptoms that are chronic or getting worse require
more thorough testing and may need to be admitted to the hospital.

II. Objectives (Fernandez)

GENERAL OBJECTIVE: This study aims to determine what is Pediatric-Community

Acquired Pneumonia or PCAP-C, its assessment, cause, and therapeutic management

KNOWLEDGE:
1. To learn more skills about how to treat and to approach this type of situation
2. To comprehend the patient's condition's etiology, typical clinical presentations, and
dangers, as well as its anatomy and physiology

SKILLS
1. To be able to assist the patient in recovering, a practical nursing care plan must be developed
based on the subjective and objective clues obtained during nurse-patient interaction.

ATTITUDE
1. To build a nurse-patient relationship while dealing with PCAP-C diagnosed patient.
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III. Nursing Health History ( Castor & Espeniel )

a. Chief Complaint

Harry was presented with a four-day history of fever (greater than or equal) 40°C (despite
receiving regular antipyretics), feeling generally unwell and with abdominal pain.

b. Present history of illness

Prior to the admission, the patient experienced a four a day history of fever ≥40°C (despite
receiving regular antipyretics), feeling generally unwell and with abdominal pain. Initial
observation showed a temperature of 38.4°C, pulse rate 138bpm, respiratory rate of 40 breaths
per minute. Oxygen saturation at 97% in air and a central capillary refill time of two seconds.
He was restless during the examination and had chest wall recessions and suspected bronchial
breathing on the right side. Air entry was reported to be good bilaterally. Two days after,
findings revealed that there were decreased breath sounds and rales on the right upper lobe. He
was observed to have occasional productive cough and with difficulty of breathing. He appears
to be weak, pale, irritable and always crying.

c. Past Health History

Harry had completed his immunizations and his past medical history show no significant health
deficiencies.

d. Lifestyle

They lived in a swampy, crowded area in a resettlement village in Arevalo. Harry is an only
child, his mother, a housewife and his father a construction worker.

e. Psychological data

Harry is irritable and always crying.

f. Physical Examination

For vital signs, initial observations showed a temperature of 38.4 °C, pulse rate 138 bpm,
respiratory rate of 40 breaths per minute, oxygen saturation at 97% in air and central capillary
refill time of 2 seconds. For anthropometric data, weighed is at 12.5 kg. And body system
assessments: skin is pale, neck has inflamed throat, and chest has chest wall recessions and
suspected bronchial breathing on the right side. For lungs, air entry was reported to be good
bilaterally, decreased breath sounds and rales on the right upper lobe, occasional productive
cough and with difficulty of breathing. Abdomen had abdominal pain. And neurological system
is weak, irritable and always crying.
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IV. Anatomy and Pathophysiology (Capindit)

a) Target organ: Lungs

The respiratory system is composed of the lungs, which are responsible for facilitating gas
exchange from the environment into the bloodstream. The alveoli are the main organs of the respiratory
system, transferring oxygen into the capillary network and eventually perfuse tissue. The lungs are further
subdivided into lobes and astral areas, with the diaphragm being the major respiratory muscle and the C3,
C4, and C5 nerve roots providing inspiratory muscles during exercise and in times of respiratory crisis.
b) Organ System Involved
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B. Predisposing and Precipitating Factors

a) Predisposing Factors— age, sex, previous illnesses may create a state of susceptibility.
1. Sex— Male
2. Extremes of age (very young)— 3 years old
3. Certain populations (various racial or ethnic groups)— Filipino
o There is additionally limited evidence that male patients as well as those
of certain racial or ethnic groups may be at increased risk of pneumonia.
b) Precipitating Factors— exposure to a particular disease agent or toxic agent may be
linked with onset of the disease.
1. Lifestyle factors (unhealthy weight according to the patient’s sex and age)—
12.5kg
2. Environment— swampy, crowded area in a resettlement village in Arevalo.
3. Climate
4.
C. Etiology

a) Viral pathogen — Streptococcus pneumonia

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Pneumococcus is a human-specific pathogen that colonizes the nasopharynx and spreads between
hosts by aerosol and, potentially, contamination of objects with mucosal secretions if the bacteria is
growing in a biofilm.

Within the initial few months of life, S. pneumoniae colonizes the human nasopharynx. Several
mechanisms defend the human airway from colonization and invasive pneumococcal infection. The
cough reflex, the mucociliary escalator, and a variety of pattern recognition receptors are examples of
innate immune defenses.
Despite the fact that these mechanisms protect the airways from S. pneumoniae, antibody-
mediated mechanisms, and cell-mediated immunity are crucial in removing this pathogen from the lower
airways.
In healthy people, pneumococcus carriage occurs in the nasopharynx and is normally
asymptomatic. The bacteria is disseminated by aerosol from the nasopharynx of carriers. Pneumococcus
can spread from the nasopharynx to a wide range of tissues. Otitis media is most usually caused by
bacteria in children. Invasive diseases typically begin in the lungs and extend to the bloodstream, with
meningitis being the most dangerous outcome. In healthy people, the transition from asymptomatic
colonization to invasive illness usually occurs when the innate immune systems are compromised.
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V. Diagnostic and Laboratory (Del Mundo)

Diagnosis: Pediatric-Community Acquired Pneumonia PCAP-C

The initial diagnosis was of an Upper respiratory tract infection URTI and the need to rule out pneumonia
was documented. Laboratory tests were ordered and were advised to return with results for further
evaluation.

Clinical Manifestation:
 Fever
 Abdominal pain
 Restlessness
 Chest wall recessions
 Bronchial breathing
 Decreased breath sound
 Occasional productive cough

Laboratory Result Normal Values Significant

Urinalysis Normal Color: amber/straw

Urinalysis showed
Odor: aromatic
Turbidity/Opacity: normal results
clear
Specificgravity: 1.015-
1.030
ph: slightly acidic 4.6-
8( average of 6)
WBC- 3-4
RBC- 1-2
Protein- 2.8 mg/dl

CBC Harry’s blood Hemoglobin (Fe), Hemoglobin decreased

inflammatory markers Massc: 110 g/L because If a disease or
were raised. Leukocytes, numc.: condition affects the
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15x109/L body’s ability to
BandNeutrophils: 0.10 produce red blood cells,
Segmented your hemoglobin levels
Neutrophils: 0.8 may drop.
- Eosinophils: 0.06
Monocytes: 0.09
Haemoglobin (Fe), Leukocytes increased
Massc: F=120-160 g/L because the body makes
Leukocytes, numc.: more white blood cells
4,5-11,0x109/L to fight the bacteria,
viruses, or other foreign
(Differential Count) substances causing your
Band Neutrophils: illness.
0,02-0,05
Segmented Band and segmented
Neutrophils: 0,5-0,7 neutrophils increased
Eosinophils:0,1-0,4 because Neutrophils
Monocytes: 0.03-0.08 migrate directly to the
site of infection, where
they accumulate in
significant numbers and
unleash a torrent of
antimicrobial factors
aimed at controlling and
clearing infection.

Eosinophils increased
because it helps
promote inflammation,
which plays a beneficial
role in isolating and
controlling a disease
site.

Monocytes increased
because it was noted
that in the cases of
pneumonia, the
monocytes in the
circulating blood
increased in the early
stages of the disease to a
point definitely above
normal, and that later
the number1 again
became normal.
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Chest X-ray PA view Pneumonia upper lobe Severity: A further chest
of the right lung. Normal: 371 (58.3%) ultrasound scan showed
Mild: 195 (30.7%) that the pleural effusion
. Moderate: 65 (10.2%) was resolving.
The X-ray showed a Severe: 5 (0.8%)
right-sided
consolidation with a Type of infiltrate: Most pneumonia occurs
moderately large right consolidation: 34 when a breakdown in
pleural effusion (5.3%) your body's natural
defenses allows germs
Location: lower to invade and multiply
(215[33.8%]), within your lungs.
upper(128 [20.1%]),
diffuse (6[0.9%]) There is a consolidation
because the air-filled
Other: effusions: 2 alveoli are replaced by
(0.3%) fluid, blood, pus,
mucus, edema or
another substance.

There is effusion
because there is an
accumulation of the
fluid in the lungs.

Sputum culture and Positive for N: 135-145 meqs.L He had serum sodium of
sensitivity Streptococcus 129mmol/L, indicating
Pneumoniae. low antidiuretic
hormone secretion
He had serum sodium of which is a recognized
129meqsl/L complication of
pneumonia

Other test to be used to evaluate Pediatric-Community Acquired Pneumonia PCAP-C

• CT scan. If the pneumonia isn't clearing as quickly as expected, doctor may recommend a chest CT
scan to obtain a more detailed image of your lungs.
• Pleural fluid culture. A fluid sample is taken by putting a needle between the ribs from the pleural area
and analyzed to help determine the type of infection.
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VI. Nursing Care Plan (ERODIAS)

Defining Nursing Outcome Nursing Rationale Evaluation

Characteristics Diagnosis Identification Intervention

Long term: Independent: Long Term:

Subjective cues: Ineffective After 6th day of Goal met as
“My son has poor airway nursing ● Assess rate When evidence by
appetite, consumed clearance intervention, the and depth of pneumonia is the patient has
approximately 100ml related to patient will be respirations severe, the a normal
of decreased able to maintain and chest client may depth of
“lugaw” and 4 oz of breath clear, open movement. require respiration,
milk formula two times sounds and airways as endotracheal unproductive
per day.” As verbalized rales, have evidence by intubation and cough and has
by the mother. an normal breath mechanical a clear, open
occasional sounds, ventilation to airways.
productive unproductive keep airways
cough and cough and clear.
Objective cues: with normal depth of ● Auscultate
 Temp. 38.4oC difficulty of respiration. lung fields. Decreased
 Decreased breathing, airflow occurs
breath sounds appears to be Short term: in areas
 Productive weak, pale . After 4h of consolidated Short Term:
cough and irritable. nursing with fluid. Goal partially
intervention, the met as
Lab result client will be evidence by
 Chest X-ray able to maintain ● Elevate clear breath
Impression: airway patency, head of bed; Maintain an sounds and
Pneumonia clear breath change elevated head the client
upper lobe of sounds. position of bed as maintain
the right lung. frequently tolerated to help airway
 Sputum prevent patency.
Culture and secretions from
Sensitivity accumulating.
(Positive for Sliding down in
Streptococcus the bed or a
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Pneumoniae) slumped
 Serum sodium posture
of 129meqsl/L prevents proper
● Suction. lung expansion.

Dependent Stimulates
● Assist with cough or
and monitor mechanically
effects of clears airway.
nebulizer
treatments
and other Facilitates
respiratory liquefaction and
physiothera removal of
py. secretions.

● Administer
medications
, as
indicated.
Aids in
reduction of
bronchospasm
and
● Provide mobilization of
supplementa secretions.
l fluids such
as IV,
humidified
oxygen, and Fluids are
room required to
humidificati replace losses,
on including
insensible
losses, and aid
Monitor in mobilization
serial chest of secretions.
x-rays, and
(respiratory
rate) pulse
oximetry Follows
readings. progress and
effects of
disease process
and therapeutic
regimen and
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facilitates
necessary
alterations in
therapy..

Nursing Care Plan 2

Defining Nursing Outcome Nursing Rationale Evaluation
Characteristics Diagnosis Identification Intervention

Subjective cues: Risk for Long Term: Independent 1.During this Long Term:
“my son has poor Infection After 10th day of period, potentially Goal met as
appetite, consumed related to nursing 1.Monitor vital fatal evidence by
approximately 100ml of community interventions, lab signs closely, complications, lab results are
“lugaw” and 4 oz of acquired result will reach especially during such as all normal.
milk formula two times pneumonia the normal limits. initiation of hypotension or
per day.” As verbalized (spread) therapy. shock, may
by the mother. develop.

2. Demonstate 2.Effective means

Short Term: and encourage the of reducing spread
Objective cues: After 8h of mother good or acquisition of Short Term:
 Temp. 38.4oC nursing hand-washing infection. Goal met as
 productive interventions, the technique. evidence by
cough patient have normal vital
 Inflamed throat absence of signs signs
and symptoms of 3.Limit visitors as 3.Reduces especially
Lab result infection, vital indicated. likelihood of temperature
 Chest X-ray signs are normal exposure to other and absence of
Impression: from T. 38.4oC to infectious signs and
Pneumonia 37.5oC. pathogens. symptoms of
upper lobe of infection.
the right lung.
 Sputum Culture
and Sensitivity 4.Encourage 4.Facilitates
(Positive for adequate rest healing process
Streptococcus balanced with and enhances
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Pneumoniae) moderate activity. natural resistance.
 Serum sodium
129mEq/L

5.Monitor 5.Signs of
effectiveness of improvement in
antimicrobial condition should
therapy. occur within 24 to
48 hours.

6.Investigate 6.Delayed
sudden changes or recovery or
deterioration in increase in
condition severity of
symptoms
suggests resistance
to antibiotics or
secondary
infection.

Dependent

1.Administer 1.These drugs are

antimicrobials, as used to combat
indicated, by most of the
results of sputum microbial
and blood pneumonias.
cultures, for Combinations of
example, drugs can be used
macrolides such when the
as azithromycin pneumonia is a
(Zithromax). result of mixed
organisms.

2.Prepare for and 2.Fiberoptic

assist with bronchoscopy may
additional be done for clients
diagnostic studies, who do not
as indicated. respond in a
reasonable amount
of time to
antimicrobial
therapy to clarify
diagnosis and
therapeutic needs
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VII. DRUG STUDY

Prescribe Classification Indication and Side Effects Special Nursing

drug dosage, and Contraindicatio or Adverse Precautions Responsibilities
route, Mechanism ns Reactions
frequency, of action
timing
Paracetamol Thought to Acetaminophen CNS: Contraindicated Check for doctor’s
120 mg/5ml produce temporarily agitation (I. in patients order before drug
syrup, oral, 5 analgesia by relieves minor V.), anxiety, hypersensitive administration.
fatigue,
ml q4H PRN inhibiting aches and pains to drug. I.V.
headache,
prostaglandin due to headache, insomnia, form is Observe 10 rights
and other backache, the pyrexia. contraindicated in drug
substances common cold, in patients with administration.
that sensitize and reduces CV: HTN, severe hepatic
pain receptors. fever. hypotension, impairment or Advise parents
peripheral severe active that drug is only
edema,
Drug may Drug can cause liver disease. for short- term use;
periorbital
relieve fever acute liver edema, urge them to
through failure, which tachycardia Warn the consult prescriber
central action may require a (I. V.). mother that high if giving to
in the liver transplant doses or un- children for longer
hypothalamic or cause death. GI: nausea, supervised long- than 5 days or
heat- vomiting, term use can adults for longer
abdominal
regulating Most cases of cause liver than 10 days.
pain, diar-
center. liver injury are rhea, damage.
associated with constipation Caution patient Take patient’s
Inhibiting the drug doses (I.V.) to contact health temperature before
effects of exceeding 4,000 care provider if drug
pyrogens on mg/day and GU: signs and administration.
the often involve oliguria(I.V. symptoms of
).
hypothalamic more than one liver damage if Monitor for
Hematologi
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heat regulating acetaminophen- c: hemolytic the following possible adverse
centers and by containing anemia, signs occur: reactions:CNS:dro
a product. leukope- illogical wsiness, dizziness
nia,
hypothalamic thinking, severe GI: nausea,
neutropenia,
action leading May cause pancytopeni dyspepsia,
to sweating. serious, a, anemia. jaundice,
potentially fatal inability to eat,
skin reactions, Hepatic: weakness.
including jaundice
Stevens-Johnson Metabolic:
hypoalbumi
syndrome, toxic
nemia (I.
epidermal V.), hypo-
necrolysis, and glycemia,
acute hypokalemia
generalized hypervolemi
exanthematous a, hy-
pustulo- sis. pomagnese
mia,
hypophosph
Reaction may atemia (I.
occur with first V.).
or subsequent
use when Musculoske
acetaminophen leta: muscle
is used as spasms,
extremity
monotherapy or
pain (I.V.).
when it is one
component of Respiratory
combination : abnormal
drug therapy. breath
sounds,
Monitor for dysp- nea,
hypoxia,
reddening of the
atelectasis,
skin, rash, pleural
blisters, and effusion,
detachment of pulmonary
the upper edema,
surface of the stridor,
skin. Stop drug wheezing (I.
V.).
immediately if
skin reaction is Skin: rash,
suspected. urticaria;
infusion-site
pain (I.V.),
pruntus.
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Cefuroxime A bactericidal Cefuroxime is CV: Use cautiously Check for doctor’s
400 mg, agent that acts used in the phlebitis, in patients order before drug
IV ,q8H by inhibition treatment of thrombophle hypersensitive administration.
ANST for 10 of bacterial infections bitis. GI: to penicillin
days. cell wall caused by diarrhea, because of Observe 10 rights
8- 4- 12 synthesis. Has bacteria. It pseudomem possibility of in drug
activity in the inhibits cell wall branous cross sensitivity administration.
presence of synthesis colitis, with other beta-
some beta- preventing their nausea, lactam Monitor patient for
lactamases, growth. anorexia, antibiotics. signs and
both Contraindicated vomiting. Before symptoms of
penicillinases in patients Hematologi administering superinfection and
and hypersensitive c: hemolytic the drug consult diarrhea and treat
cephalosporin to drug or other anemia, the physician. appropriately.
ases, of Gram- cephalosporins. throm-
negative and bocytopenia, Diarrhea Drug may increase
Gram-positive transient medicines may INR and risk of
bacteria. neutropenia, make the bleeding. Monitor
eosinophilia. diarrhea worse patient.
or make it last
Skin: longer. Instruct patient to
maculopapul notify prescriber
ar and about rash, loose
erythematou stool, diarrhea, o
s rashes, evidence of
urticaria, superinfection.
pain,
induration, Advice patient
sterile receiving drug I.V.
abscesses, to report
temperature discomfort at I.V.
elevation, site.
tissue
sloughingg
at I.M.
injection
site.

Other:
anaphylaxis,
hypersensiti
vity reac-
tions, serum
sickness
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Azithromycin Azithromycin Background CNS: Long-term Check for doctor’s
suspension of belongs to the Low-dose oral fatigue, exposure may order before drug
200mg/5ml class of drugs azithromycin headache, increase the risk administration.
with an initial known as therapy is somnolence, of hematological
dose of 3 ml macrolide recommended as dizzi- ness. malignancy Observe 10 rights
and 5mg/kg of antibiotics. It a preventive relapse and in drug
bodyweight. works by treatment for CV: chest death. administration.
1.6 ml for day killing acute pain,
2-5 days. bacteria or exacerbations of palpitations. Drug may cause Advise patient to
preventing COPD. CDAD ranging avoid excessive
their growth. Contraindicated ENT: eye in severity from sunlight exposure.
However, this in patients irritation mild diarrhea to May cause
medicine will hypersensitive (ophthalmic) fatal colitis, photosensitivity
not work for to azithromycin, . which may reactions.
colds, flu, or erythromycin, or Gl: occur over 2
other virus other macrolide abdominal months after Let patient have
infections. or ketolide pain, administration. food before
antibiotics and anorexia, If CDAD is administering the
in those with diarrhea, suspected or drug to avoid GI
history of nau- sea, confirmed, drug irritation.
cholestatic vomiting, may need to be
jaundice or pseudomem discontinued Monitor patient for
hepatic branous and appropriate superinfection.
dysfunction colitis, treatment begun. Drug may cause
from prior use dyspepsia, overgrowth of
of azithromycin. flatulence, nonsusceptible
melena. bacteria or fungi.

GU: Monitor patient for

candidiasis, allergic and skin
nephritis, reactions.
vaginitis.
Discontinue drug
Hepatic: if reactions occur.
cholestatic Be aware that
jaundice. allergic symptoms
Skin: may recur when
photosensiti symptomatic
vity therapy is
reactions, discontinued;
rash, pain at patient may
injection require prolonged
site, monitoring and
pruritus. treatment.
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Other:
angioedema. Monitor patient
for jaundice,
hepatotoxicity, and
hepatitis.

Discontinue drug
immediately if
signs and
symptoms
(yellowing of skin
or sclera,
abdominal pain,
nausea, vomiting,
dark urine) occur.
Tell patient to
report adverse
reactions
promptly.
Salbutamol Albuterol Salbutamol is CNS: Patiens with Check for doctor’s
Nebule (also known used to relieve tremor, hypersensitivy order before drug
PAI with as salbutamol) symptoms of nervousness, to the drug may administration.
Salbutamol is used to treat asthma and headache, develop a skin
Nebule 2.5 ml wheezing and chronic hyperactivit rash, hives, Observe 10 rights
plus PNSS shortness of obstructive y, insomnia, itching, trouble in drug
1ml q6H chest breath caused pulmonary dizziness, breathing or
physiotherapy by breathing disease (COPD) weakness, swallowing, or administration.
after PAI. problems such such as CNS any swelling of Shake the aerosol
10-4-10-4 as asthma. It is coughing, stimulation, hands, face, or inhaler well before
a quick-relief wheezing and malaise. mouth while use and prime
medication. feeling using this using inhaler according
Albuterol breathless. It CV: the medication. to manufacturer's
belongs to a works by tachycardia, Hypokalemia instructions before
class of drugs relaxing the palpitations, may occur while first use, when it
known muscles of the HTN, chest using this drug. has been dropped,
as bronchodila airways into the pain, or when it hasn't
tor lungs, which lymphadeno been used for more
makes it easier pathy, than 2 weeks.
to breathe. edema.
Do the chest
Drug may cause EENT: physiotherapy
paradoxical cojuctivitis, after PAI.
bronchospasm. otitis media,
Monitor patient dry and Keep cap on
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closely; irritated inhaler closed
discontinue drug nosse and during storage.
immediately and throat (with
use alternative inhaled Monitor patient for
therapy if form), effectiveness.
paradoxical pharyngitis,
bronchospasm rhinitis. Using drug alone
occurs. may not be
Bronchospasm GI: nausea, adequate to control
with inhaled vomiting, asthma in some
formulations heartburn, patients. Long-
frequently anorexia, term control
occurs with first altered test, medications may
use of new increasd be needed.
canister or vial. appetite.
Teach patient to
GU: UTI perform oral
Metabolic: inhalation
hypokalia correctly.

Musculoske If prescriber orders

letal: more than 1
muscle, inhalation, tell
back pain. patient to wait at
least 2 minutes
Respiratory before repeating
:bronchospa procedure.
sm, cough,
wheexing,
dyspnea,
bronchitis,
increased
sputum.
cramps

Other:
hypertensivi
ty reactions,
flulike
syndrome,
cold
symptoms.

Carbocistein Reduces the Carbocisteine is There have Patients taking Check for doctor’s
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(Loviscol) viscosity of a mucolytic been reports concomitant order before drug
Oral, 5 mL bronchial agent for the of medicines administration.
TID secretions and adjunctive anaphylactic known to cause
8-1-6 facilitate therapy of reactions, gastrointestinal Observe 10 rights
prostaglandin respiratory tract allergic skin bleeding. in drug
synthesis at disorders eruption and administration.
the CNS but characterised by fixed drug Not
does not have excessive, eruption. recommended to Obtain patient’s
antiinflammat viscous mucus, There have be history of cough
ory action including been reports concomitantly before therapy and
because of its chronic of diarrhea, used with reassess after
minimal effect obstructive nausea, antitussives giving the drug.
on peripheral airways disease. epigastric and/or
prostaglandin It is a mucolytic discomfort, medicines that Assess cough:
synthesis that helps to nausea and dry up bronchial type, frequency,
cough up vomiting, secretions. character,
phlegm or headache, including sputum:
sputum. It works stomach provide adequate
by making the upset, hydration to
phlegm less weight gain, 2L/day to decrease
thick and sticky. alsopain in viscosity of
the muscles secretions
This can helps and the
with condition joints, sore Monitor for
that affects the throat, and possible adverse
lungs, including: gastrointesti reactions: CNS:
chronic nal bleeding drowsiness,
obstructive occurring dizziness GI:
pulmonary during nausea, vomiting,
disease (COPD). treatment abdominal pain
with
Carbocistein is carbocistein Discuss on detail
not suitable for e. all information
some people that regarding the drug.
have ever had an
allergic reaction
to the drug and
to patients that
have a stomach
ulcer.
 ILOILO DOCTORS’
COLLEGE
COLLEGE OF NURSING West
Avenue, Molo, Iloilo City

VIII. DISCHARGE PLANNING

GOING HOME INSTRUCTION AND FOLLOW UP SHEET

Name of Patient: Harry Age/Sex: 3y.o, Male Date: 03/08/2023 Doctor: N/A Room/Ward No.: N/A
Diagnosis: Pneumonia
Operation/Procedure Done: N/A To Come Back On: N/A
Others: Fever, feeling generally unwell, abdominal pain, difficulty of breathing, weak and pale
Diet: N/A
Others: Instruct the mother to increase the patient’s fluid intake to help decrease fever.
 ILOILO DOCTORS’
COLLEGE
COLLEGE OF NURSING West
Avenue, Molo, Iloilo City

VIII. EVALUATION

Harry, aged three years and a previously healthy baby boy, presented with a four-day history of
fever ≥40°C (despite receiving regular antipyretics), feeling generally unwell and with abdominal pain.
Upon thorough medication and requires fluid input to be restricted. Also, the patient was ordered to take a
Chest X-ray PA view, CBC, Sputum culture and sensitivity, and urinalysis resulting in Pedia Community
Acquired Pneumonia-C (PCAP-C). He was also given the doctor's prescribed medication. The goal of the
nursing care plan has been met, as evidence of repeat chest X-ray showed complete resolution of the
pneumonic change.