2. 01 02
04 05 06
ANATOMY &
PHYSIOLOGY
REVIEW OF SYSTEM PHYSICAL
ASSESSMENT
INTRODUCTION
TABLE OF CONTENTS
03
PATHOPHYSIOLOGY
PATIENTS PROFILE
3. 07 08
10 11 12
THEORETICAL
FRAMEWORK
PHARMACOLOGY NURSING CARE
PLAN
HEALTH
TEACHING/DISCHARGE
PLANNING
GENOGRAM
TABLE OF CONTENTS
09
LABORATORY
4. INTRODUCTION
Community-acquired pneumonia is one of the most common serious
infections in children. When diagnosing community-acquired pneumonia,
physicians should rely mainly on the patient’s history and physical
examination, supplemented by judicious use of chest radiographs and
laboratory tests as needed. The child’s age is important in making the
diagnosis. Pneumonia in neonates younger than three weeks of age
most often is caused by an infection obtained from the mother at birth.
Streptococcus pneumoniae and viruses are the most common causes
in infants three weeks to three months of age. Viruses are the most
frequent cause of pneumonia in preschool-aged children; Streptococcus
pneumoniae is the most common bacterial pathogen.
5. INTRODUCTION
Mycoplasma pneumoniae and Chlamydia pneumoniae often are the
etiologic agents in children older than five years and in adolescents. In
very young children who appear toxic, hospitalization and intravenous
antibiotics are needed. The symptoms in outpatients who present with
community-acquired pneumonia can help determine the treatment.
Knowing the age-specific causes of bacterial pneumonia will help guide
antibiotic therapy. Childhood immunization has helped decrease the
incidence of invasive Haemophilus influenzae type B infection, and
the newly introduced heptavalent pneumococcal vaccine may do the
same for Streptococcus pneumoniae infections.
6. ANATOMY & PHYSIOLOGY
The respiratory system is the set of organs that allows
a person to breathe and exchange oxygen and carbon
dioxide throughout the body.
The respiratory system performs two major tasks:
1. External respiration
2. Internal respiration
Nose or Nasal Cavity
It allows air to enter your body, then filters debris and
warms and moistens the air. As air passes through the
nasal cavities, it is warmed and humidified, so that air
that reaches the lungs is warmed and moist. The nasal
airway is lined with cilia and kept moist by mucous
secretions.
7. ANATOMY & PHYSIOLOGY
Pharynx
The pharynx, or throat, is a versatile muscular tube,
shaped like a funnel, that delivers air from the mouth
and nose to the trachea, or windpipe. It also connects
the nasal and oral cavities with the larynx and
esophagus. The pharynx is key to the respiratory and
digestive systems. It allows inhaled air to pass from the
nasal cavity to the larynx, trachea, and lungs.
Larynx
Commonly known as the voicebox, it is located in the
anterior throat and extends from the base of the tongue
to the trachea.
Trachea
The trachea or windpipe, serves as the passageway for
air to move in and out of the lungs. It is a membranous
tube attached to the larynx. It consists of connective
tissue and smooth muscle, reinforced with 16-20 C-
shaped pieces of hyaline cartilage. The adult trachea is
about 1.4-1.6 centimeters (cm) in diameter and about
10-11 cm long.
Bronchi
A large airway that leads from the trachea
(windpipe) to a lung. The bronchi enables and
ensures the passage of air from the trachea to the
bronchioles and the alveoli. Similar to trachea with
ciliated mucous membrane and hyaline cartilage
There are two main bronchi within the human
body: right bronchus and left bronchus.. The left
main bronchus is more horizontal than the right
main bronchus because it is displaced by the
heart.
Bronchioles
The bronchioles carry oxygen rich air into the
lungs and carry carbon dioxide rich air out of the
lungs, thereby aiding in the processes of
breathing and respiration. The smooth muscle that
surrounds the bronchioles can constrict or dilate
the airway, which can aid in getting the proper
amount of oxygen into the blood.
8. ANATOMY & PHYSIOLOGY
ALVEOLI
The alveoli are where the lungs and the blood
exchange oxygen and carbon dioxide during the
process of breathing in and breathing out.
Oxygen breathed in from the air passes through
the alveoli and into the blood and travels to the
tissues throughout the body.
DIAPHRAGM
The diaphragm, located below the lungs, is the
major muscle of respiration. It is a large, dome-
shaped muscle that contracts rhythmically and
continually, and most of the time, involuntarily. Upon
inhalation, the diaphragm contracts and flattens and
the chest cavity enlarges. This contraction creates a
vacuum, which pulls air into the lungs. Upon
exhalation, the diaphragm relaxes and returns to its
domelike shape, and air is forced out of the lungs.
Lungs
The lungs are spongy structure where the
exchange of gases takes place. Each lung is
surrounded by a pair of pleural membranes.
Between the membranes is pleural fluid,
which reduces friction while breathing. The
bronchi are divided into about a million
bronchioles. The end of the bronchioles are
hollow air sacs called alveoli. There are 700
million alveoli in the lungs. This greatly
increase the surface area through which gas
exchange occurs. Surrounding the alveoli are
capillaries. The lungs give up their oxygen to
the capillaries through the alveoli. Likewise,
carbon dioxide is taken from the capillaries
and into the alveoli.
9. PATHOPHYSIOLOGY
RISK FACTORS
MODIFIABLE
• Secondhand Smoke exposure
• Exposure to sick people
NON-MODIFIABLE
• AGE (<2 years old)
Weak immune System
DISEASE PROCESS
Entry of the
pathogens to the
lungs reaching the
alveoli.
The pathogen
thrives and
multiply causing
infection.
The macrophages inside
the alveoli are triggered and
overwhelmed activating
inflammatory mediators.
•Cytokines
•Histamine
•Leukotrienes
These inflammatory
mediators cause the
blood vessels to dilate
and increase its
permeability.
The fluids from
the blood vessel
starts leaking
(capillary leaking)
filling the alveoli
sac.
Exudative congestion
of the alveoli sac
(fluids, WBC, RBC,
Debris, Pathogen)
Community
Acquired
Pneumonia
10. PATIENT’S PROFILE
Name: L. K C.
Age: 3 Months old
Date of Birth: June 28, 2022
Sex: Male
Address: Zone II, Pinamalayan, Oriental Mindoro
Civil Status: N/A
Religion: Catholic
Nationality: Filipino
Occupation: N/A
Admitting Diagnosis: PCAP D
Other Diagnosis:
Date of Admission: Oct. 1, 2022
Hospital Number: 00018344
Chief Complain: Colds, Cough with Difficulty of Breathing
11. PATIENT’S PROFILE
Present Health History
On August 31, 2022, the mother of the infant brought
her child to the center for having a fever, cough, and
cold, and the center gave them a drug prescription. But
her child's condition does not improve depending on
the given drugs, instead, it got worse. On September
30, 2022, she observed that her child was having a
difficulty in breathing. It got worse and became more
severe, that's why on October 1, 2022, they brought her
child to the Community Hospital in Pinamalayan, where
they give her child immediate action by giving
intravenous fluid and oxygenation, and the center refer
them for admission in the Hospital and later after they
brought her child to the Provincial Hospital where her
child stayed until October 9, 2022.
Past Health History
The child doesn't have a previous
hospitalization, and it's the first
time that the child was hospitalized
in a hospital. The child doesn't
have any complications upon birth.
And the mother stated that she
doesn't have any complications
during her pregnancy. And she
delivered the baby through normal
spontaneous delivery without any
complications.
12. PATIENT’S PROFILE
Family History
The father of the patient has
a history of asthma when he
was 7 years old.
While the mother and other
family members has no
other health issues.
Lifestyle and Health Practices Profile
The patient's lifestyle solely depends on the
mother and other family members. The
patient's feeding is through the means of
breast feeding (from the mother) and does not
used any commercial or other source of milk.
And they didn't do hand washing before
handling the baby.
His other family members such as the
father and grandfather has a hobby of
smoking which we have interviewed that
before the baby's condition is diagnosed,
they have been smoking inside their
house or near the baby.
13. REVIEW OF SYSTEM
Respiratory – patient is having difficulty of breathing, wheezing and rales sound
and coughing
Cardiovascular – patient doesn’t have irregular heartbeat
Gastrointestinal – patient doesn’t have vomiting and doesn’t have change in
bowel movement
Integumentary – the patient doesn’t have rashes and other skin problem
Urinary System- Normal
Musculoskeletal- Normal
Neurologic - Normal
14. PHYSICAL ASSESSMENT
VITAL SIGNS
Temperature: 37.6
RR: 54
Oxygen Saturation:92
Pulse Rate: 144bpm
Weight: 5.5 kg
Height: 67cm
GENERAL SURVEY OF PATIENT
1. Appears stated age: Pt seems appropriate for stated age.
2. Level of consciousness: Alert, awake and oriented.
3. Skin: Brown in color, no presence of edema, warm to touch
and smooth.
4. Nutritional Status: Breastmilk feeding
5. Obvious physical deformities: No physical deformities found.
6. Facial expression: Irritated
7. Speech: Pt not yet able to speak
8. Hearing: Pt can response to any noises.
9. Personal hygiene: Poorly groomed
The patient has IV line. Upon observation the pt
experience nasal flaring, retraction, chest indrawing
and his mouth is open.
15. MENTAL STATUS
He is conscious . The pt respond to any noises.
INTEGUMENTARY SYSTEM
Skin: Brown in color, no presence of edema, warm to
touch and smooth, the skin turgor return slowly in
usual form.
Hair: Black in color,No thickness and oiliness with
normal hair distribution.
Nails: The patient has a pink nails and it's flat, no
clubbing. In capillary refill the nails return to usual color
in less than 4 seconds , has dirt.
HEAD
Skull and Face: His head is symmetrical in shape,
no presence of edema upon palpation.
EYE AND VISION: PERRLA is full visual field .
Sclera is white in color, Pupils black in color.
EARS AND HEARING : Symmetrical in size,
any masses and tenderness is not palpable,
can hear any noises.
NOSE AND SINUSES: Nasal Flaring is
observed.
Mouth: Lips are pale, no lesions and scars.
Neck
Neck Muscle: The patient has smooth
head movement with no discomfort.
Lymp Nodes: No enlargement of lymph
nodes.
Trachea and Thyroid glands: Trachea is
placed on the midline of the neck.
Thorax and Lungs : Upon auscultation
wheezes sound are heared in all quadrant.
Chest: The patient experience chest
indrawing and upon auscultation rales
sounds are heared in all quadrant.
16. PHYSICAL ASSESSMENT
PERIPHERALS
Shoulder: Symmetrical posture, without any discomfort found when he moved.
Elbows: No presence of abnormal bony prominence, swelling, and lesion with warm
temperature.
Hands and fingers: no abnormalities of hand posture, has IV line
Abdomen: Any tenderness and masses is not palpable.
Lower Extremities: Has firm muscles. Lymph nodes or other masses is not palpable.
Genitalia: This part was not assessed
18. THEORETICAL FRAMEWORK
Katharine Kolcaba’s Theory
Kolcaba's theory of comfort defines comfort as a fundamental need
of all human beings for relief, ease, or transcendence in stressful
health care situations. Comfort can encourage patients, family
members, and nurses to seek medical attention. The comfort is the
central concept in Katharine Kolcaba's theory. Caring, comfort
measures, holistic care, health seeking behaviors, institutional
integrity, and intervening variables are all related concepts.
Metaparadigm of Comfort Theory:
Nursing: There is an assessment of comfort needs, followed by
comfort-promoting actions and a reassessment of comfort levels.
Patient: It could be an individual or a family.
Environment: is any aspect of the patient's environment that the
nurse can manipulate to improve the patient's comfort.
Health: is the patient's optimal functioning (Tomey & Alligood,
2002)
The comfort theory
was used in the
development of a
nursing process for the
clinical case of an
infant with pneumonia
who was being treated
at home under hospital
conditions. It was
discovered that the
theory is simple to
apply in the domiciliary
context and allows for
the implementation of
a comprehensive care
plan.
19. THEORETICAL FRAMEWORK
Dorothea Orem’s Theory
Dorothea Orem developed the Self-Care
Deficit Nursing Theory, also known as the
Orem Model of Nursing, between 1959 and
2001. It is regarded as a grand nursing
theory, which means that it covers a broad
range of topics and contains general
concepts that can be applied to all
instances of nursing. The Self-Care
Deficit Nursing Theory's central
philosophy is that all patients want to care
for themselves, and they can recover more
quickly and holistically by performing as
much self-care as they are able. This
theory is most commonly applied in
rehabilitation, primary care, and other
settings where patients are encouraged to
be self-sufficient.
The purpose of this study was to assess the self-care needs
of pediatric patients with pneumonia using Orem's Self-care
Theory and to refer them to nursing care. Establishing a
scientific foundation is one of the primary goals of a
professional discipline and a prerequisite for
professionalization.
Nursing is an applied medical discipline founded on a
professional philosophy, theory, practice, and research.
Orem, a leading theorist of nursing practice, emphasizes the
interaction between humans and their surroundings. Orem
also contends that humans are unique and unitary beings
who cannot be separated from their environment, and thus
divides the components of his nursing theory into humans,
health, environment, and nursing practice. As a result, this
paper discusses Orem's theory of self-care deficiency in
relation to pneumonia.
24. PHARMACOLOGY
Name Classification Indication Contraindication Adverse effect
Ceftriaxone IV cephalosporin Ceftriaxone is used to
treat bacterial
infections in many
different parts of the
body. This medicine is
also given before
certain types of surgery
to prevent infections.
Hypersensitivity
to ceftriaxone or
other
cephalosporins
Use cautiously in
breast feeding
women and in
patients with
penicillin energy.
Diarrhea, upset
stomach, or
throwing up.
Change in taste.
Irritation where
this drug is given.
Dizziness or
headache.
Flushing.
Amikacin IV aminoglycoside Indicated in the short-
term treatment of
serious bacterial
infections due to
susceptible strains of
gram-negative bacteria,
including Pseudomonas
species, Escherichia
coli, etc.
A history of
hypersensitivity
to amikacin
diarrhea,
hearing loss,
spinning
sensation
(vertigo),
numbness,
skin tingling,
muscle twitching
and convulsions,
dizziness,
25. PHARMACOLOGY
Name Classification Indication Contraindication Adverse effect
Salbutamol neb bronchodilators treatment and
prevention of
bronchospasm (acute
or severe) in patients
with reversible
obstructive airway
disease, including
exercise-induced
bronchospasm.
Contraindicated in
patients with high
blood pressure during
pregnancy, uterine
infection, miscarriage,
heart disease, and
hypersensitivity.
•trembling, particularly
in the hands.
•nervous tension.
•headaches.
•suddenly noticeable
heartbeats
(palpitations)
•muscle cramps.
Budesonide neb corticosteroids used to prevent
difficulty breathing,
chest tightness,
wheezing, and coughing
caused by asthma.
contraindicated in any
patients with a history
of hypersensitivity to
budesonide or any of
the ingredients of the
budesonide
formulation.
• headache.
• dizziness.
• runny nose,
sneezing, coughing.
• nausea.
• indigestion.
• abdominal pain.
• dry, itchy skin.
26. PHARMACOLOGY
Name Classification Indication Contraindication Adverse effect
Hydrocortisone IV corticosteroids indicated to treat
inflammation, status
asthmaticus, acute and
chronic adrenal
insufficiency, and as a
physiologic replacement
in pediatric use.
Hypersensitivity to
hydrocortisone or any
component of the
formulation
blurred vision; dizziness
or fainting; a fast,
irregular, or pounding
heartbeat; increased
thirst or urination;
irritability; or unusual
tiredness or weakness
Combivent neb bronchodilator to treat and prevent
symptoms (wheezing
and shortness of breath)
caused by ongoing lung
disease (chronic
obstructive pulmonary
disease-COPD, which
includes bronchitis and
emphysema).
contraindicated in
patients with
hypertrophic
obstructive cardio-
myopathy or
tachyarrhythmia.
• headache,
• dizziness,
• nausea,
• dry mouth,
• shaking (tremors),
• nervousness, or
• cold symptoms such
as stuffy nose,
sneezing, cough, or
sore throat
27. PHARMACOLOGY
Name Classification Indication Contraindication Adverse effect
Zinc Sulfate Sulfate, Inorganic
compound
used to treat zinc
deficiency and to
prevent the condition
in those at high risk.
Avoid taking this
medication with foods
that are high in calcium
or phosphorus, which
can make it harder for
your body to absorb
zinc sulfate.
an irritate the
respiratory tract, cause
nausea, vomiting,
stomach ache,
dizziness, depression,
metallic taste in the
mouth, and death.
Co-Amoxiclav penicillin to treat: middle ear and
sinus infections. throat
or lung respiratory tract
infections. urinary tract
infections.
Do not take Co-
amoxiclav: if you are
allergic to amoxicillin,
clavulanic acid,
penicillin or any of the
other ingredients of this
medicine
skin rash or itching, is
short of breath,
wheezing, or their face,
lips or tongue start to
swell
28. ASSESSMENT NURSING
DIAGNOSIS
PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective
“Nakita ko nalang na
nahihirapang huminga
ang baby ko, tapos
nakabuka yung bibig nya
at napansin ko na
lumulubog ang tiyan at
parting dibdib nya” - as
verbalize by the mother
of the patient
Objective Data:
Vital Sign
O2sat: 92
RR: 64 bpm
PR: 144 bpm
Auscultation
Abnormal breath sound:
(+) wheezing
Observation:
(+) Nasal Flaring
(+) Retraction
Ineffective breathing
pattern related to airway
obstruction secondary to
community-acquired
pneumonia as evidenced by
decreased O2sat, increased
respiratory rate, presence of
abnormal breath sound,
nasal flaring, and chest
retraction
After 30 minutes of nursing
intervention the patient will
maintain and effective
breathing pattern
Objectives:
1. Immediately administer
oxygen inhalation via nasal
cannula as ordered by the
physician.
2. Every 30 minutes the
patient will be repositioned
to promote the breathing
pattern
3. After 15 minutes of
applying the intervention
the patient’s oxygenation
will be monitored through a
pulse oximeter
1. Administer oxygen
inhalation via nasal cannula a
order by the physician.
2. Reposition the infant every
30 minutes to promote the
breathing pattern
3. Monitor the oxygenation
through a pulse oximeter
after applying the
intervention
1. To provide supplement
oxygenation support to the
infant.
2. Charging position can
promote breathing patterns,
especially in the infant.
3. Monitoring is essential to
determine if the
intervention applied is
working.
Was the patient able to
maintain an effective breathing
pattern 30 minutes after
applying the nursing
intervention
Met: /
Pmet:____
Unmet:____
1. Was the patient breathing
pattern stabilized after
administering oxygen inhalation
via nasal cannula
Met:
Pmet:
Unmet:/
2. Was repositioning the infant,
stabilizing his breathing pattern.
Met: /
Pmet:
Unmet:
3. Was the infant oxygenation
monitored properly through the
use of a pulse oximeter
Met: /
Pmet:
Unmet:
29. ASSESSMENT NURSING
DIAGNOSIS
PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective:
"Willing akong matuto
at magkipagtulungan
para mas maging
mabuting ina kay baby"
as verbalized by the
patient
Objective:
•The parents of the
infant appear to be
attentive and
cooperative throughout
our assessment.
•The mother is asking
questions on how to
improve her ways of
caring her baby.
•The parents and other
family members were
willing to give time for
us to perform our health
teaching.
Readiness for
enhanced parenting as
evidenced by parents’
eagerness and desire
to improve their
parenting
Goal:
After 1 hour of nursing
intervention the parents
will be able to improve
their parenting to provide
efficient care to their
baby.
Objectives:
Immediately establish
rapport to the parents to
create a safe and free
environment to express
thoughts and feelings.
After 10 minutes of
physical assessment in
front of the parents, the
parents will be able to
learn the normal physical
characteristics and
behavior of an infant
1.) Establish rapport to the
parents of the infant to
create a safe and free
environment to express
thoughts and feelings.
2.) Perform physical
assessment with the
parents involved and
educate the parents about
the normal physical
characteristics and
behavior of an infant.
It will help in establishing
trust, where the parents
will be able to express
their thoughts and
feelings, optimizing their
needs for parenting
improvement.
Educating the parents
about the differences
between the normal and
unusual physical
characteristics and
behaviors of an infant will
help them determine the
infants’ wellness.
Was the parents able to
improve their parenting to
provide efficient care to
their baby 1 hour after
nursing intervention?
Met: /
P.Met____
Unmet____
Was the parents able to
freely express their
thoughts and feelings and
optimize their needs?
Met:/
P.Met____
Unmet____
Was the parents able to
learn and distinguish the
normal and unusual
physical characteristics and
behavior of the infant?
Met:/
P.Met____
Unmet_____
30. ASSESSMENT NURSING
DIAGNOSIS
PLANNING IMPLEMENTATION RATIONALE EVALUATION
After 15 minutes of health
teaching, the parents will
able to learn different
information that will help
them improve their
parenting.
3.) Provide information
about;
a.) Proper Hand washing
before handling the infant
b.) Proper Hygiene of the
caregivers and the infant
c.) Keeping the
environment clean and
safe for the infant
d.) the proper way of
breastfeeding and burping.
e.) Avoiding the infant from
exposure to smoke, and
educate the parents and
other family members
about how dangerous for
the infant to be exposed to
secondhand smoke.
Was the parents able to
learn the information
needed to improve their
parenting?
Met:/
P.Met_____
Unmet_____
31. ASSESSMENT NURSING
DIAGNOSIS
PLANNING IMPLEMENTATION RATIONALE EVALUATION
After 10 minutes of
nursing intervention, the
parents will be able to
express their thoughts
and concerns about
being a teenage parent
4.) Encourage the parents
to express their thoughts
and concerns about being
a teenage parent.
Verbalizing their thoughts
and concerns as a
teenage parents will help
us determine their needs
and provide opportunity
for long term plans for
enhancing their parenting
skills. Was the parents able to
express their thought
and concerns about
being a teenage
parent?
Met:/
P.Met_____
Unmet_____
32. Health Teaching/ Discharge Planning
DISCHARGE PLAN
Medications:
1. Advised to give the medications as
prescribed by the physician at right dose, right
route and right time.
Environment
1. Encourage the guardian of the patient to
maintain cleanliness of their house and
surroundings.
2. Encourage the guardian of the patient to
avoid smoking near the baby instead place the
baby in a non smoke area or well ventilated
area.
3. Encourage the mother to secure and
maintain cleanliness to the patient's bed and
things to be used.
Teaching:
1. Encourage the mother to secure the patient's good sleeping
time and it's adequate nutrition.
2. Teach the guardian the signs and symptoms of the patient's
condition as well as how to determine the situation. Advised them
to go to the health center or hospital in case the following signs
and symptoms reoccur or observed:
* Fever
*Cough
*Chills
*Usually rapid breathing
*Abnormal breath sounds e.g. grunting and wheezing sounds
* Breathing that makes the child rib muscle retract
*Poor feeding
*Vomiting
*Bluish or gray color of nails or lips.
3. Inform the parents especially the mother to have follow up
check up as per doctors order.
4. Teach or reminded the guardian on how to apply family
planning and what to know about it.
33. Health Teaching/ Discharge Planning
Diet Reminder for the Mother:
1. Advised to eat fruits rich with vitamin C
(e.g. citrus fruit) and green leafy vegetables
(e.g. malunggay, kangkong,petchay etc.)
2. Encouraged oral fluids at least 8 glasses
per day.
34. MEMBERS
Catly, Clarisse
Caudor, Kaye Katherine
Comendador, Suzanne
Michelle
Cordero, Krystel Joy
Cruz, Hanna Suzenne
Caytilles, Jeanette
Dacoycoy, Margie
Daquis, Jean Mariel
De Torres Kliana Nicole
Decenan, Irish
Del Mundo, Kayce
Dela Cruz, Arfela Joy
