pneumonia

1. PNEUMONIA

2. INTRODUCTION
Pneumonia is a disease process involving inflammation of lung tissue. Pulmonary inflammation caused
by bacteria, viruses, fungus, or parasites is classified as infectious pneumonia. Infectious pneumonia
typically results when microorganisms enter the normally sterile lungs from the na-sopharynx and
produce inflammation of the lung parenchyma. Because of the inflammation, the alveoli fill with fluid or
mucous, and gas exchange cannot take place at the alveolar-capillary-cellular membrane level.
Microorganisms can also enter the lungs from the bloodstream in sep-ticemia, from infected lymph, or
from infected pleural fluid. Pulmonary inflammation caused by aspiration of gastric contents, inhalation
of toxic gases, or radiation therapy is classified as non-infectious pneumonia. Noninfectious pneumonia
commonly evolves into infectious pneumonia as bacteria colonize the inflamed pulmonary tissue.

3. INTRODUCTION
The most common cause of bacterial pneumonia in worldwide is Streptococcus pneumoniae. This type of pneumonia
can occur on its own or after you've had a cold or the flu. It may affect one part (lobe) of the lung, a condition called
lobar pneumonia. Bacteria-like organisms. Mycoplasma pneumoniae also can cause pneumonia. It typically produces
milder symptoms than do other types of pneumonia. Walking pneumonia is an informal name given to this type of
pneumonia, which typically isn't severe enough to require bed rest. Fungi This type of pneumonia is most common in
people with chronic health problems or weakened immune systems, and in people who have inhaled large doses of the
organisms. The fungi that cause it can be found in soil or bird droppings and vary depending upon geographic location.
Viruses, including COVID-19. Some of the viruses that cause colds and the flu can cause pneumonia. Viruses are the
most common cause of pneumonia in children younger than 5 years. Viral pneumonia is usually mild. But in some cases
it can become very serious. Coronavirus 2019 (COVID-19) may cause pneumonia, which can become severe.Hospital-
acquired pneumonia Some people catch pneumonia during a hospital stay for another illness. Hospital-acquired
pneumonia can be serious because the bacteria causing it may be more resistant to antibiotics and because the people
who get it are already sick. People who are on breathing machines (ventilators), often used in intensive care units, are at
higher risk of this type of pneumonia. Health care-acquired pneumonia is a bacterial infection that occurs in people who
live in long-term care facilities or who receive care in outpatient clinics, including kidney dialysis centers. Like hospital-
acquired pneumonia, health care-acquired pneumonia can be caused by bacteria that are more resistant to antibiotics.
Aspiration pneumonia occurs when you inhale food, drink, vomit or saliva into your lungs. Aspiration is more likely if
something disturbs your normal gag reflex, such as a brain injury or swallowing problem, or excessive use of alcohol or
drugs. vaccination status with your doctor even if you recall previously receiving a pneumonia vaccine.

4. WORLDWIDE STATISTIC
• • The fight to reduce deaths from the single, biggest infectious
killer of adults and children has never been more urgent. In 2021,
pneumonia claimed the lives of 3.5 million, including 2.5 million
children killed, according to the "Global Burden of Disease".
Together, they caused more deaths than any other cause,
including heart disease. With climate change continuing to
increase the burden of respiratory conditions and the risk of
another pandemic of respiratory infection high, there is a
pneumonia crisis across the life course placing millions at risk of
infection and death.
• • Tragically, it is the very young and the very old who are at
greatest risk. Children living in areas with low vaccination rates
and rising malnutrition, and in homes that use polluting fuels for
cooking and heating, are particularly vulnerable. Older adults
exposed to outdoor air pollution – most significantly from burning
fossil fuels – and smoking are also at risk. Almost half of the
estimated 3.5 million pneumonia deaths among adults aged over
70+yrs old are attributable to air pollution and smoking.
(www.gavi.org)

5. LOCAL STATISTIC

6. LOCAL STATISTIC
Pneumonia remains a significant health concern in the Philippines, contributing to a substantial number of
deaths each year. In 2021, pneumonia caused approximately 76,006 deaths both male and female in the
Philippines, highlighting the significant impact of this respiratory infection on mortality rates in the country.
While recent statistics show a decline in cases and deaths, particularly in 2020, pneumonia continues to be a
major contributor to mortality, especially among vulnerable populations like infants, young children, the
elderly, and those with weakened immune systems. The contagious nature of pneumonia, spread through
droplets expelled during coughing or sneezing, and the presence of risk factors like age, smoking, recent viral
infections, and pre-existing health conditions, make it a persistent threat. Prevention strategies, including
vaccination against influenza and pneumonia, practicing good hygiene, and maintaining a healthy lifestyle,
are crucial for reducing the risk of infection. Early detection and appropriate treatment, including antibiotics
for bacterial pneumonia and oxygen therapy for breathing difficulties, are essential for managing the disease
and preventing complications. Despite the recent decline in cases and deaths, continued efforts to improve
access to healthcare and effective treatments are critical for reducing the impact of pneumonia in the
Philippines.

7. Research into new medicines for pneumonia is rapidly evolving, driven by the increasing threat of
antibiotic-resistant bacteria and the need for more effective treatments. A major focus of research is on
developing new antibiotics that can overcome the challenge of multidrug-resistant Gram-negative bacteria
and Gram-positive bacteria (MDR-GNB & GPB), which are increasingly common and difficult to treat.
Several new antibiotics with activity against MDR-GNB & GPB have recently become available, offering
hope for treating infections that were previously difficult to manage. Researchers are also exploring
alternative therapies, such as immunotherapies to boost the body's immune system, anti-inflammatory
agents to reduce lung inflammation, and nanotechnology to deliver antibiotics directly to the site of
infection. Personalized medicine approaches are being developed to tailor therapies to individual patients
based on their specific genetic makeup and the bacteria causing their infection. New vaccines are also
being developed to protect against pneumonia, particularly those caused by Streptococcus pneumoniae.
However, research into new pneumonia medicines faces challenges in securing adequate funding and
conducting lengthy and expensive clinical trials. The ongoing evolution of antibiotic resistance is a constant
challenge, requiring ongoing research and development of new drugs. Despite these challenges, research
into new medicines for pneumonia is a dynamic field with significant potential to improve patient
outcomes. Continued research and investment are crucial to address the challenges posed by pneumonia
and ensure effective treatment options for patients.
CURRENT TRENDS

8. REASON FOR CHOOSING SUCH CASE
Student nurses often choose pneumonia case studies because they offer a valuable learning opportunity
related to a common and serious condition. Pneumonia is a prevalent respiratory illness, making it a
high-priority condition for nurses to understand and likely to be encountered in their clinical practice.
Case studies allow students to explore a range of nursing concepts and skills, including assessment,
medication administration, patient education, collaboration, and ethical considerations. They can delve
into the intricacies of lung function and respiratory distress while developing critical thinking skills and
applying their theoretical knowledge to practical situations. Pneumonia case studies often highlight the
importance of providing holistic patient-centered care, considering the patient's physical, emotional, and
social needs. These studies are readily available and engaging, making pneumonia a popular and
relevant choice for student learning.

9. OBJECTIVES OF THE STUDY
Student Nurse-centered:
At the end of the rotation, the student nurses shall be able to:
• Understand and gain knowledge about the condition of the patient
• Gain knowledge about the causes or signs and symptoms of Pneumonia.
• Provide relevant information on the health condition of the patient
Psychomotor
• Establish rapport or effective communication skills to the patient.
• Assess the patient's condition.
• Provide appropriate nursing interventions and treatment plan for patient with Pneumonia
Affective
• Improve their confidence in handling a patient with a same condition

10. OBJECTIVES OF THE STUDY
Client Centered:
At the end of the rotation the patient shall be able to:
• Gain knowledge about her son’s condition.
• Understand the sign and symptoms.
• Follow the nursing intervention given by the student.
• Affective
• Develop a good working relationship to the student nurses to meet the goal of improving health.

11. NURSING ASSESSMENT
PERSONAL DATA:
NAME: LABI, JUWI ASKALANI
AGE: 2 YEARS OLD
SEX: MALE
RELIGION: ISLAM
NAME OF PARENTS:
MOTHER: KARINA LUKAYA ASKALANI
FATHER: JUWALTI LUKAYA LABI
ADDRESS: PUROK-V TAMPLAN,MALAMAWI,ISABELA
DATE OF BIRTH: DECEMBER 12, 2022
PLACE OF BIRTH: ISABELA CITY BASILAN
NATIONALITY: FILIPINO
CHIEF COMPLAINT: COUGH AND LBM
ADMISSION DIAGNOSIS:

12. GORDON’S ELEVEN FUNCTIONAL HEALTH PATTERN
1.HEALTH PERCEPTION:
•As stated by the patient mother her son is incomplate immunization and has been experiencing fever cough and diarrhea for the 2 days
2.NUTRITIONAL METABOLIC PATTERN:
•Acoording to the mother of the patient her child eating three times a day. and he loves eating biscuit and porridge. then when they are in the
hospital her child eating pattern is change he lost appetite he just eat two times a day.
3. ELIMININATION PATTERN:
•The mother of the patient reported that’s her son has normal urination and defecation before. but when they are in the hospital her son is
currently having defecating five times a day
4. ACITIVITY AND EXERCISE PATTERN :
•Accrding to the mother her son was previously active and playful but when they are in the hospital her son become weak due to illnes

13. GORDON’S ELEVEN FUNCTIONAL HEAL TH PATTERN
5 COGNITION AND PERCEPTION PATTERN:
• The patient mother reported that her reported her son has active memory
6. SLEEP AND REST PATTERN:
•Acoording to the mother her son sleep two times a day before. and when they are in the hspital her son has been experiencing difficulty
sleeping due to illness and discomport
7.SELF- PERCEPTION AND SELF CONCEPT PATTERN:
•Accordingly to the mother her son is hysterical type of person
8.ROLE AND RELATIONSHIP PATTERN:
• As stated by patient mother her child is the younges among their siblings and her husband is a fisherman and the dicision maker in their family
is the mother
9.SEXUALITY AND REPRODUCTIONG PATTERN:
• Is not aplicable for our patient

14. GORDON’S ELEVEN FUNCTIONAL HEALTH PATTERN
10. COPING AND STRESS TOLERANCE PATTERN:
•As stated by the patient mother when her son is crying she give her phone to her son
11. VALUE AND BELIEFS:
• The patient is religious preference islam

15. FAMILY HISTORY
GENOGRAM
FATHER SIDE MOTHERSIDE
LEGEND: GRANDPARENTS GRANDPARENTS
MALE -
FEMALE -
DECEASED: BLUE
ALIVE: GREEN FATHER MOTHER
THE PATIENT: RED
SMOKER: GRAY

16. FAMILY HISTORY
INTERPRETATION
According to the child’s mother MRS. Karina she stated that her parent’s is still alive with no noted
disease however, her father is a heavy smoker and they live together in the same house. MR. Duwalti is
the husband of MRS. Karina a 24 years old the father of two childs, he stated that he is an orphan living
with no parents his father died from dynamite while fishing and his mother died from sudden
unexplained death.

17. HISTORY OF PAST ILLNESS
According to the patient’s mother she stated that her son Juwi was hospitalized three times during this
year 2024-2025 at Infante Hospital Isabela City and was diagnosed as Gastroenteritis patient.

18. HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS
March 10, 2025 at 10:15 pm Juwi was immediately rushed to the hospital due to unpleasant sensory feeling, before
he was admitted they try to manage with Paracetamol medication however it didn’t provide a total relief. After Two
days prior to admission,onset of cough associated with fast breathing and watery stool. Persistence of condition
associated with body weak prompted consult and admission.

19. PHYSICAL EXAMINATION
INITIAL ASSESSMENT UPON ADMITTION: March 10, 2025 (Lifted from chart)
CHIEF COMPLAINT: Loss of Appetite.
Vital Signs:
Temperature: 36.1℃
Pulse: 131 bpm
Respiration: 34 bpm
O2 sat: 97
GENERAL SURVEY: Active, Conscious
Skin/Integument: Skin is colored browned,moist, signs of cyanosis or pallor
HEENT: head; symmetric, with presence of merkel cell carcinoma, Ears; no discoloration, with small hairand yellowish browned ear wax or cerumen, Eyes: isoconic
and icteric
Respiratory:upon auscultation: ronchi
Cardiovascular: negative mur-mur
Genitourinary: essentially normal, no discharges
Neurologic: essentially normal
Extremities: essentially normal

20. DATE PERFORMED: March 12 2025 (Nurse-Patient Enteraction)
(Performed by the student Nurse)
CHIEF COMPLAINT: Watery stool with particles 2× episodes
GENERAL SURVEY: awake, conscious
HEAD:
Inspection:
EARS;
Inspection:
Palpation:
EYES;
Inspection:
FACE;
Inspection:
NECK:
Inspection: head; symmetry, face; is symmetry, Neck; with skin tags.
MOUTH AND THROAT;
Inspection: Lips are symmetric, moist, smooth, no discoloration.
VITAL SIGNS 4:00PM 8:00PM
TEMPERATURE 36°C 37°C
PULSE RATE 104 bpm 110 bpm
RESPIRATION RATE 26 bpm 30 bpm
O2 SAT 99 97

21. PHYSICAL EXAMINATION
NAILS: He has concave nail on his hands and feet, healthy pinkish nail bed.
EYES & EARS:The eyeballs are symmetrycal in size and position, eye move smoothly and in coordination. Pupils are isoconic.
NECK: presence of skin tags
Skin/Integument: Skin with scar marks, brown color moist no signs of cyanosis, orpallor (paleness)
Respiratory: Harsh breath sound
Cardiovascular: negative mur-mur
Genitourinary: essentially normal
Neurologic: essentially normal

22. ANATOMY AND PHYSIOLOGY
The respiratory system is responsible for gas exchange,
taking in oxygen and expelling carbon dioxide, and includes
organs like the nose, mouth, throat, windpipe, and lungs,
with the diaphragm and other muscles aiding in breathing.
TYPES OF GASES:
OXYGEN 21%
CARBON DIOXIDE 0.04%
NITROGEN 78%
OTHER GASES 0.96%

23. PATIENT AND HIS ILLNESS

24. PATIENT AND HIS ILLNESS
RISK FACTORS SIGNS AND SYMPTOMS: RELEVANT TO OUR PATIENT
• MODIFIABLE: • Cough
- Smoking • Fever
- Poor Nutrition • Chills
- Lack of vaccination • Shortness of breath
- Exposure to air pollution • Chest pain
- Crowded living condition • Fatigue
- Weakened Immune system • Nausea or Vomiting
• NON-MODIFIABLE: • Bluish lips or Finger
- Age • Confusion
- Premature Birth • Tachypnea
- Chronic lung disease
RISK FACTORS SIGNS & SYMPTOMS
MODIFIABLE:
- Smoking
- Lack of
vaccination
NON-MODIFIABLE:
- Age
- Cough
- Slightly tachypnic
- Fever

25. MEDICAL MANAGEMENT
a. DIAGNOSTIC
DIAGNOTIC
LABORATORY
PROCEDURES
`DATE ORDERED
DATE RESULTS IN
GENERAL
DESCRIPTION
INDICATION OF
PURPOSE
RESULT NORMAL VALUES ANALYSIS AND
INTERPREATATION
CHEST -AP date ordered:
March 10, 2025
date released:
March 10, 2025
A chest x-ray is a
type of medical
imaging that
uses small
amount of
radiation to take
pictures of the
inside chest.
- To determine the
presence of pneunomia
or fungal infection
- It can help to
determine if the heart is
an unusual shape or if it
is larger than it should
be.
- It can also help confirm
the presence of a valve
disorder and provide
important detailed
information about your
condition and its
seriousness.
Streaky densities in
the perihilar region
Heart is not enlarged
Bony thorax,
diaphragms and
costophrenic sulci
are intact.
Lung field clear.
The heart is not
enlarged. The
aorta sclerotic
Diaphragm, sulci
and chest bones
are intact.
‘’Pneumonia’’

26. MEDICAL MANAGEMENT
NORMAL LUNGS ABNORMAL LUNGS

27. MEDICAL MANAGEMENT
HEMATOLOGY
WBC
date ordered:
March 10 2025 /
10 28pm
date released:
March 10 2025/
10 37pm
White blood
count (CBC) are a
vital part of the
immune system
defending the
body against
infection by
attacking
bacteria viruses,
and foreign
substance.
A WBC count is
often included in a
complete blood
count (CBC), a
routine blood test
used for general
health screening. It
used to determine
if the total number
of WBCs is within
a healthy range.
1)WBC: 16-86
2)NEUTROPHIL:
55.3
3)LYMPHOCYTE:3
5.8
4)MONOCYTE:5.6
5)EOSINOPHIS:1.
9
6)BASOPHIS:1.4
3.50 -1O.0O.10^3/UL
40.00-73.00
15.00-45.00%
4.00-12.00%
5.00-7.00%
0.00-2.00%
Elevated white
blood cells clearly
indicate the
presence of
foreign bodies and
quite possibly the
presence of
disease.

28. MEDICAL MANAGEMENT
HEMATOLOGY
RBC
Date ordered:
March 10,
2025 /10 28pm
Date released:
March 10, 2025/
10 37pm
Red blood cell
count are
responsible for
carrying oxygen
throughout the
body they are
produced in the
bone marrow
and contain
haemoglobin, a
protein that
binds to oxygen.
a test that
measures the
number of red
blood cell in your
blood.
•to help diagnose
conditions that
effect red blood
cell, such as
anemia or other
blood related
condition.
1)RBC 4.85
2)HEMOGLOBIN
11,7
3) Hematocrit
35.6
4)MCV 73.3
5)MCH 24.1
6)MCHC 34.8
7)RDY 17.1
3.80-6.00 10^6/UL`
11.50-17.00g/dl
35.00-52.00%
76.00-100.00%
27.00-34.00pg
32.00-35.00g/dl
11.00-17.00%
NORMAL
NORMAL
NORMAL
LOW
LOW
NORMAL
HIGH

29. MEDICAL MANAGEMENT
b. IVF, 02 THERAPY, NEBULIZATION,NGT, ETC
MEDICAL
MANAGEMENT
DATE ORDERED DATE
STARTED DATE
CHANGED
GENERAL DESCRIPTION
INDICATION
INDICATION /PURPOSE CLIENTS RESPONSE
D5LRip
G 24
4Ougtts/min
D5LRip
G 24
40ugtts/min
Date started:
MARCH 10 2025
12:20am
Date changed :
March 11 2025
8am
Date started:
March 11 2025 8am
Date changed:
March 11 2025 4pm
Hypertonic nature: D5LRip is
a hypertonic solution,
meaning it has a higher
osmolarity than body fluids.
This causes fluid to move
from the intracellular and
interstitial compartments in
to the vascular volume.
-increased osmatic
pressure :D5LR raises
intravascular osmatic
pressure, helping to maintain
fluid balance and provide
essential electrolyte and
calories for energy
Treatment for those needing
extra calories:D5LR is
indicated for patients who
require additional calories but
cannot tolerate fluid
overload.
-Treatment of shock :D5LR
can be used to treat shock by
volume and providing
electrolyte and calories.
Replacement therapy D5LR is
particularly useful in replacing
extracellular fluid deficits
accompanied by acidosis.
My patient show improvement
in his hydration status,
electrolyte balance, and
overall well-being. He
experience increases energy
levels due to the calories
provision.

30. MEDICAL MANAGEMENT
MEDICAL
MANAGEMENT
DATE ORDERED DATE
STARTED DATE
CHANGE
DISCONTINUED
GENERAL DESCRIPTION INDICATION/PURPOSE CLIENT’S RESPONSE
D5IMBip
G 24 LH
45ugtts/min
D5IMBip
G 24 LH
45ugtta/min
Date started:
March 11 2025 4pm
Date changed:
March 11 2025 12mn
Date started:
March 11 2025 12mn
Date changed :
March 12 2025 12mn
-hypertonic nature:D5IMB is a hypertonic
solution meaning it has higher osmolarity than
body fluid. This causes fluid to move from the
intracellularand interstitial compartment inti the
vascular compartment expanding vascular
volume
-electrolyte replenishment :D5IMB provides
essential electrolyte. Incloding sodium, chloride,
and potassium. Which are crucial for maintaining
fluid balance and various bodily functions.
-calories provision: the dextrose in D5IMB
provides calories for energy especially important
for patients who are unable to eat or drink.
-Dehydration :D5IMB Indicated for patients
experiencing dehydration due to condition
like vomiting diarrhea. Fever. Or excessive
sweating
-electrolyte imbalance this solution is used
to correct electrolyte imbalance. Particularly
hypokalemia (low potassium level)and
hyponatremia (low sodium level),
-maintenance therapy D5IMB can be used
for maintenance therapy in patients who are
unable to consume fluids orally or who have
ongoing fluid and electrolyte losses
-post operative fluid replacement to
replacement to replenish fluid and
electrolyte lost during surgery
Patients may experience improvement in their
hydration status electrolyte balance and overall
well being ,they may feel less tred and
experience increased energy level.
-negative some patients may experience side
effects such as
-fluid overload rapid or excessive
administration can lead to fluid overload
especially in patients with heart or kidney
problems
-electrolyte imbalance inappropriate
administration can worsen exiting electrolyte
imbalance
-hypornatremia high potassium levels can be a
concern, especially in patients with renal
impairment
-hypernatremia :high sodium levels occur, can
occur particularly in patient with pre-existing
sodium retention –phlebitis :inflammation of
the vein at the injection site can occur.

31. MEDICAL MANAGEMENT
c. DRUGS
NAME THE DRUG GENERIC
NAME BRAND NAME
CLASSIFICATION
DATE ORDERED
DATE STARTED
ROUTE OF
AMINISTRATION
DOSAGE AND
FREQUENCY OF
ADMINISTRATION
GENERAL ACTION INDICATION CLIENTS RESPONSE WITH
ACTUAL ADVERSE
REACTIONS
GENERIC
NAME:AMPICILLIN
BRAND NAME:OMNIPEN
CLASSIFICATION:
ANTIBIOTIC
PENICILLIN
March 10 2025
/10:45pm
ROUTE: IV
(intravenous)
DOSAGE: 25Omg
FREQUENCY: Q°6
every 6 hours
Bactericidal action
against sensitive
organisms; inhibit
synthesis of bacterial
cell wall. Causing cell
death.
Ampicillin is used to
treat certain infections
that are caused by
bacteria such as
meningitis (infection
of the membranes
that surround the
brain and spinal cord )
and infections of the
throat, sinuses, lungs,
reproductive organs,
urinary tract,and
gastrointestinal tract.

32. MEDICAL MANAGEMENT
GENERIC NAME:
Lactobacillus
BRAND NAME: Reuteri
CLASSIFICATION:
Antidiarrheal
March 10 2025
12am
ROUTE :P.O
Dosage:
Frequency : OD
-contribute to the
recovery of the
intestinal microbial
flora altered during
the course of
microbial disorders of
diverse origin
- diarrhea Frequency of watery
stool decrease from 4
episodes to 2 episodes.

33. MEDICAL MANAGEMENT
GENERIC NAME:
SALBUTAMOL
BRAND NAME: VINTOLIN
CLASSIFICATION:
PHARMACOLOGIC
BRONCHODILATOR
March 10 2025
10:50PM
ROUTE:
INHALATION
DOSAGE:1 nebule
FREQUENCY:Q6
every 6 hours
Salbutamol is a beta-
adrenergic agonist
that acts on beta- 2
adrenergic receptors
in the smooth
muscles , of the
bronchial
muscles ,leading to
bronchodilator and
improved airflow in
conditions such as
asthma and copd.
-Rlief
Bronchospasm
condition such as
asthma, chronic
obstructive
pulmonary disease
(COPD) AND other
lung condition.
-prevention of
exercise- induced
bronchospasm
Patient gradually relived
from slight tachypnic

34. MEDICAL MANAGEMENT
GENERIC NAME:
Budesonide
BRAND NAME: pulmicort
flexhaler
CLASSIFICTION :
antiasthmatic steroidal
anti-inflammatory
March 10 2025
10:59pm
ROUTE:
DOSAGE: 1 nebule
FREQUENCY: every
12 hours
Decrease
inflammations by
inhibiting activity of
specific inflammation
mediator such as
prostaglandins
leukotrienes, and
kinins.
Asthma
management and
prophylactic
treatment cronic
obstructive
pulmonary disease
(copd)
-allergic rhinitis -
nasal polyps -
inflammatory bowel
disease colitis,
microscopic colitis
Monitor patient for signs
of adrenal insufficiency
-Educate patients on
proper inhaler use and
nasal spray
administration
-monitor for systemic
side effect , such as
increased risk of
infection and loss of
bone strength.

35. MEDICAL MANAGEMENT
GENERIC NAME:
Acetylcysteine BRAND
NAME: acetadote
CLASSIFICATION:
March 10 2025
11:20pm
ROUTE:
Intravenous(IV)
DOSAGE: 100mg
FREQUENCY: every
4 hours
Acetylcysteine
replenishes
glutathione level to
detoxify the liver and
protect against
oxidative stress.
Acetycysteine is
used to treat
acetaminophen
overdose and
prevent liver
damage.
Anaphylaxix, rash
urticaria, angioedema,
nausea, vomiting, and
headache.

36. MEDICAL MANAGEMENT
GENERIC NAME:
Gentamicin sulfate
BRAND NAME: cidomycin
CLASSIFICATION :
antibiotic
March 10 2025
11pm
ROUTE: VI
DOSAGE: 30mg
FREQUENCY: q12
every 12 hours
Bactericidal: inhibits
protein synthesis in
susceptible trains of
gram-negative
bacteria, appears to
disrupt functional
integrity of bacterial
cell membrane,
causing death.
-serious infections
caused by
susceptible strains
of pseudomonas
aeruginosa proleus
species, citobacter
staphylococcus
species.
-serious infections
when causative
organism are not
know (often in
conjunction with a
penicillin or
cephalasphin)
- instruct the patients to
rest and provide
therapeutic environment
-place place cold cloth
on the forehead to help
relieve the ache.-instruct
to move slowly and to
have assistance in
rendering activities
-provide ice chips
-place basin beside the
bedside
-increase protein intake
to gain energy and avoid
losing weight once
allowed to eat.

37. MEDICAL MANAGEMENT
GENERIC NAME:
Montelukast
BRAND NAME: Singulair
CLASSIFICATION:
Leukotriene receptor
antagounts, anti-
asthmatic
March 10 2025
11:25pm
ROUTE:4mg
DOSAGE:
FEQUENCY : once
daily
Montelukast blocks
the action of
leukotriene, which
are chemical
messenger s involved
in inflammatory
processes thereby,
reducing
inflammation and
bronchoconstriction.
-Prophylaxis and
chronic treatment
of asthma
-Relief of
symptoms of
seasonal allergic
rhinitis
-relief of symptoms
of perennial
allergic
-assess the patients
medical history,
including allergies and
liver function.
-administer montelukast
orally, once daily in the
evening
-monitor the patients for
sign of adverse effect
such as headache
-educate the patients
caregiver on the
importance of taking
montelukast regularly as
directed.
- Document the patients
response to
montelukast, including
any adverse effect or
concers.

38. NURSING CARE PLAN
ASSESSMENT OBJECTIVES INTERVENTION RATIONALI IMPLEMENTATI
ON
EVALUATION
SUBJECTIVES DATA:
iyubo ma’am in anak
ko mahulak sya mag
u
OBJECTIVE DATA:
• CYNOSIS
RESTLESSNESSS
IRRITABILITY
NURSING
DIANGNOSIS:
IMPAIRED GAS
EXCHANGE RELATED
TO VENTILATION
PERFUSION
IMBALANCE
At the end of 8
hours of nursing
intervention
patient well be
able to:
•Relief from
difficulty of
breating.
•Return to normal
respiration rate.
Encourage frequent
position change
and deep breathing
and coughing
exercise use
incentive
spirometer chest
physiotheraphy
intermittint
positeve pressure
breathing as
indicated
•Administer
brochodillitors
through
nubullization as
ordered.
This promotes
optimal chest
expansion
mobillization of
secreation and
oxygen diffusion
•Loosen mucos
plugs thus
increasing area
available for gas
exchange
•Dilates airway
enchancing the
abillity to exchange
gases and facillitate
mucos.
•Encouraged
adequate fluid
intake.
•Administered
brochodillitors
through and
nubullization as
ordered .
•.
At the end of 8
hours of nursing
intervention
patient was able to.
•Relief from
difficulty of
breating.
•Return normal
respiration rate.

39. NURSING CARE PLAN
ON
SUBJECTIVE DATA :
Mataas po lagnat ng
anak ko po ma’am
“ as verbalize by the
mother of the patient
OBJECTIVES:
Flush skin
skin warm to touch
38℃
NURSING DIAGNOSIS:
HYPERTHERMIA
RELATED TO
DECREASE
SWEAT RESPONSE
DEHYDRATION
SHORTH TERM:
•The client
lowered body
temperature and
maintain hearth
rate within normal
limits
LONG TERM:
At the end of
hospitalization
patient well able to
maintain body
temperature
within normal
range will
experience no
associated
complication at the
time of discharge.
• Discuss the
importance of
adequate fluid
intake
•Cool sponge baths
or immersion
•Administer anti
pyretics as
prescribed
•
•To prevent
dehydration
•Heat loss by
evaporation and
conduction
• use to reduce
fever by its central
action on
hypothalamus
Discussed the
importance of
adequate intake
cooled sponge bath
or immerssion
administered anti
pyritics as
prescribed
At the of 8 hours of
nursing
interventions
patient well able to
show signs the
fever is relieve
and will rapport no
asssociated
complications

40. FDAR
DATE/TIME/ SHIFT FUCOS DAR
03-10-25/4:02PM
4:04PM
4:06PM
4:08PM
4:13PM
8:00PM
. Patient recieve lying on bed awake oreinted with ongoing IVF
# 4 D5LRIP 40 UGTTS /MIN at 100 fluid level infusing via right
hand
D- 32 BPM
A- Increase fluid intake
A-Administer brochodillitors through nebullization as ordered
A- Perform chestphysiotheraphy
R- Patient mother stated her son relief from difficulty of breating

41. FDAR
DATE/TIME/SHIFT FOCUS DAR
03-12-2025 4:00PM
4:02PM
4:05PM
4:06PM
4:09PM
4:12PM
4:14PM
4:20PM
8:00PM
Fluid volume deficit
related to Diarrhea
Received patient lying on bed awake, oriented with ongoing IVF# 4
D5IMip × 45 ugtts/min at 150 fluid level infusing via right hand.
D. 4 episodes of watery stool.
D. Poor skin turgor.
D. Sunken eye balls
D. Dry lips
A. Increase fluid intake.
A. Encourage frequent small amount of food.
A. Administer antidiarrheal as prescribed.
R. patient’s mother stated that her son reduced the frequency of
watery stool.

42. DAILY PATIENT’S RECORD/EVALUATION
DAYS ADMISSION DAY 1 DAY 2 DAY 3 DISCHARGE
NSG. PROBLEMS UPON ADMISSION
CHIEF COMPLAINT:
COUGH, LBM
STILL WITH LOSS
BOWEL
MOVEMENT STILL
WITH RALES
SLIGHTLY
TACHYPNIC
AFEBRILE STILL
WITH WATERY
STOOL WITH
PARTICLES
CONTINUE IVF
AND MEDS
AFEBRILE NO LOSS
BOWEL
MOVEMENTS
HARSH BREATH
SOUND CONTINUE
IVF AND MEDS
VITAL SIGNS TEMP: 36.2
RR: 34 bpm
PR: 131 bpm
O2: 97
TEMP: 36.5
RR: 24 bpm
PR: 118 bpm
O2: 97
TEMP: 36.7
RR: 35 bpm
PR: 112 bpm
O2: 97
TEMP: 37.1
RR: 33 bpm
PR: 103 bpm
O2: 98
LABORATORY
PROCEDURES
- CHEST AP
- HEMATOLOGY
- LIPID PROFILE
TEST
- PARASITOLOGY
- CLINICAL
MICROSCOPY

43. DAILY PATIENT’S RECORD/EVALUATION
IVF, O2, NGT,
NEBULIZATION
IVF: D5LRip 45
ugtts/min
IVF: D5LRip 45
ugtts/min
D5IMBip 45
ugtts/min
IVF: 2 BOTTLES
OF D5IMBip 45
ugtts/min
IVF: 2 BOTTLES
OF D5LRip
DRUGS •AMPICILLIN
•LACTOBACILLUS
•SALBUTAMOL
•BUDESONIDE
•ACETYLCYSTEINE
•GENTAMAMICIN
SULFATE
•MONTELUKAS

44. DAILY PATIENT’S RECORD/EVALUATION
DIET AS TOLERABLE AS TOLERABLE AS TOLERABLE AS TOLERABLE
ACTIVITY NO RESTRICTION NO RESTRICTION NO RESTRICTION NO RESTRICTION

45. DISCHARGE PLANNING
MEDICATION
- Medication should be taken regularly as prescribed, on exact dosage, time and frequency.
EXERCISE
- Encourage the child to engage in gentle activites, such as playing quitely or taking short walks, as tolerated. Avoid strenuous
activities that could worsen respiratory symptoms.
TREATMENT
- Continue oral rehydration therapy to prevent dehydration, offering small amount of fluids frequently. Encourage the child to rest
and sleep as much as possible to promote healing.
HEALTH TEACHING
- Handwashing: Emphasize the importance of frequent handwashing with soap and water for atleast 20 seconds.
- Respiratory hygiene: Teach the child to cover his mouth and nose with a tissue when coughing or sneezing.
- Infaction Prevention: Avoid contact with sick individuals and practice good hygiene to prevent yhe spread of infections.

46. DISCHARGE PLANNING
OUTPATIENT DEPARTMENT (OPD)
- Follow up: Schedule a follow up appointment with the pediatrician to monitor the child’s recovery and ensure complete
resolution of symptoms.
DIET
- Offer bland, easily digestible food, such as:
• Bananas
• Rice
• Applesauce
• Toast
- Encourage plenty of fluids, Including:
• Water
• Diluted juice
• Broth
• Breast Milk or Formula.

47. SUMMARY OF FINDINGS
• Patient Presentation and Chief Complaint: •Briefly description the patient's initial symptoms or reason for seeking medical
attention.
• -The patient a 2-years-old male presented with a 2-days history of cough with fast breathing and LBM. The patient's
condition worsened, prompting the parents to seek immediate medical attention.
• -Vital Signs:
• T: 36.2 PR: 131 bpm RR: 34 bpm O2: 97
• Relevant History
• •Highlight key aspects of the patient's past medical, social, and family history that are relevant to the current case.
• -The patient has history of previous episode of gastroenteritis, exposure to smoke or pollutants or with no known allergies.
• Diagnostic Findings:
• • Summarize the result of relevant investigation such as lab test, imaging studies , or other diagnostic procedures.
• -Chest X-ray revealed streaky densities in the perihilar region consistent with pneumonia.

48. SUMMARY OF FINDINGS
• Proposed Management Plan:
• Outlined the proposed treatment or management strategy based on the findings:
• -The patient was started on Intravenous Fluid Solution (D5LRip) rehydrate the patient, maintain fluid balance , and
provide electrolytes. Ampicillin for antibiotics treats bacterial infections , Lactobacillus for antidiarrheal helps maintain gut
flora, Salbutamol for Bronchodilator relaxes airway muscle, Budesonide for Anti-asthmatic Steroidal Anti-inflammatory
reduces inflammation in the airways, Acetylcysteine for Mucolytic Agent or Anti-dot helps reduces respiratory secretion,
and Montelukast for Leukotriene receptor antagounts Blocks Leukotrienes which contribute to inflammation and asthma
symptoms.
• Conclusion:
• Provide a concise summary of the case emphasizing the key findings and the proposed management plan.
• -In conclusion, this patient present with a case of pneumonia , and is being managed with antibiotics and supportive
care.
• " A 2-years old male patient presented with a 2-day history of cough with fast breathing and LBM. He has a history of
GASTROENTERITIS. Chest X-ray revealed streaky densities in the perihilar region consistent with pneumonia. The
patient was started Intravenous Fluid Solution and other Medications therapy and is expected to be discharged in 3-
days. "

49. RECOMMENDATION/s and CONCLUSION
For: Clients and Family, General Public, Nursing Practice, Health Care Professionals
Pneumonia is known as chronic disease and people suffering from acute pain in the lungs changes in lifestyle and health
status. Since pneumonia is may rsult to complications involving multiple body systems, patients with pneumonia oftentimes
feel unconscious due to sufocation . Therefore, family and support from other members of society would play a role in
assisting the clients. Health promoting activities is very important in preventing complications. This is only achievable with the
help of the family, society and the healthcare team.
Though pneumonia is a common disease, every individual still needs unique care. The student nurses encourage people with
pneumonia and their families to learn as much as possible about the disease itself as well as healthy lifestyle choices. If
pneumonia is left untreated or poorly managed, it can lad to more progressive and severe disease that can damage other
organs. can be acquire through toxic gass, so there is an increased chance that children from unhealthy environment may
acquire this disease so proper care for the body should be practiced even before symptoms of the disease is seen.

50. LEARNING DERIVED
This case study has augmented the knowledge, skills, and attitude of the students. Since the case of Baby Juwi is very
relevant, the students were able to venture in different medical conditions and complications as they relate to the main
cause which is pneumonia. They were able to synthesize the manifestations seen on the client and correlate these with
the conditions, complications with the laboratory findings, tests and medications. This is the real deal where the
information stated in books are felt and seen firsthand as the case is studied, broken down into its and pieces and then
re-assembled to see the connections to the primary illness. Though there was difficulty as time was limited, it was
nevertheless fulfilling as the lessons learned in this case will definitely be handy in the future endeavors of the student
nurses.
Moreover, this case study has helped the students to know how pneumonia progresses and affects the respiratory organ,
if left untreated and poorly managed. Furthermore, they were able to properly assess the patient and note abnormal
findings. As future nurses the student nurses employs to render appropriate nursing intervention, promote health
teaching and help the patient and the family to understand the details of the illness. The student nurses did not fail to
see that knowledge and skill should always be paired with a compassionate and loving care to the client without
discrimination.

51. REFERENCES/BIBLIOGRAPHY
• www.Global Burden of Disease.org
• www.mim.philippines.com
• www.gavi.org
• www.worldhealth.org
• www.pacehospital.com
• www.unicef.com
• McGraw-Hill NURSE’S DRUG Handbook 7th Edition
•