This document provides medical information about a 4-day-old male patient admitted to the hospital for bronchiolitis. It includes the patient's medical history, physical assessment, lab results, treatment including antibiotics and acetaminophen, and nursing care plan. The patient presented with shortness of breath, cough, fever and runny nose. Lab results were normal. He is being treated with ampicillin and acetaminophen and is improving with supportive nursing care including respiratory monitoring and oxygen administration.

1. BETHLEHEM UNIVERSITY
FACULTY OF NURSING & HEALTH SCIENCES
Pediatrics of Nursing
NURS 333 / Fall Semester
Data Sheet
Pt. initials: A.R.A Student name: Muna heeh
Age: 4 days Date of admission: 19/9/2014
Sex: male Diagnosis: URTI r/o bronchiolitis
Information:
From patient’s mother ,and from patient's file and from my observation. health team
members(nurses and doctors).my instructorDr (Hanan hasboun).
Chiefcomplaint: Short of breath ,cough ,fever ,running nose.
Pregnancy history: mother 26years old ,G5.P5.A0. she has 3 girls(10,8,3) years
old,and 2 males (5years,4mounths) old. All of them N.V. D,nocomplication during
previous pregnancy.my case, with N.V.D .and birth weight 3.100kg. full term as the
mother said that she complained from viscous vein during her pregnancy and
disappear after delivery .
History of present illness :A 4 month old male was admitted to CaritasHospital as
case of bronchiolitis after c/o S.O.B , cough ,fever ,running nose,sleepness . the
doctor during examination found the pt. complains from otitis media .
Past history: no past operation , pt. was at the same hospital before 10 days as a case
of sepsis and then again readmitted as bronchiolitis . No past Diseases history or
heredity diseases from his family.
Immunizations: (Since birth till now)
Type: Age
BCG vaccine 1 day(take it )
Hepatitis B vaccine 1 day , 1 month (both doses taken)
IPV 1 month , 2 months (both doses taken)
DPT 4 months (didn’t take it yet )
OPV 4 months , 6 months ((didn’t take yet )
Developmental Assessment Identify norms and relate to patient).
1. DDST (<6 yrs) or school performance (>6 yrs). Done (attached to the paper).

2. 2. Psychosocial (Erikson, Freud ,Piaget)
Erikson: trust versus mistrust ,the child seems trusting his mother and feel
comfortable and relax with his mother. Also infant is entirely dependent upon his
mother, trust the people that are caring for him(as it happened with me) and smile to
strangers.
Freud: the oral phase, the child focused on the pleasures that he receive from
sucking and biting with his mouth.
Piaget : The infant knows the world through his movements and sensations. only
aware of what is immediately in front of him. he focus on what he see, what he doing,
and physical interactions with his immediate environment.
Favorite toys, games, hobbies, interests, pets : he likes often to hold his toy (car) he
like to play in hospital playing room (by giving him cards and telling him what the
picture look like) .no favorite pets or interest .
Hobbies and routines and food preference : he used to at hospital routine he wake
up in the morning then take a bath then breast feeding after a while he return to sleep
.no food preference (only milk). No specific habits.
2.Family Assessment
1. Organization (life style, environment, cultural implication).
The family has good live style, live in clean and good environment. They live in
(Beit omer) . the relation between the pt.’s family very good the brothers don’t fight
with each other they like to play with him . the baby live with his parents and
4brothers and sisters in good house. His father is 37 years old and he is (RN),his
mother 29 years old stays at home to take care of her suns .As the mother said that she
live in a quiet area and the place where she live has good ventilation, sanitation, and
hygiene, no financial problems.
2-Relationships, (primary care givers, parent/child relationships, siblings
relationships, recent family crisis or changes).
1. . The baby was taken all his vaccine in health care center with his mother , the
mother and the father give primary care for their children , The patient attached to
his mother since she is the primary caregiver during his Residence in the hospital
, the relationship between family members is strong, they don’t have any problems
or crisis the relation between the pt.’s family very good the brothers don’t fight
with each other they like to play with him. Not very strong relationships with
siplings,

3. PT/Family strengths and weaknesses:
1. .the relationship between husbands and family members is strong, the father work
as a nurse are the mother graduated from college in Elementary Education , the
financial stat is stable.Strong relationship between all family member . and not
very good relationship between the husband’s family end mother`s family so the
sipping relationships not very good.
4. Family tree (Genogram) with pertinent medical history.
85 years
diabetic 94year 69 60
not related
The father 38years the mother 29
years
(RN) house keeper
Healthy healthy
No heredity disease in the family .
Female female 5 years
10 years 8years 3years 4 months
Bronchiolitis
All children born healthy
f
Female female, deceased male
Good relationships

4. Nutritional needs:
Diet: breast feeding every3 hr .
Dietary habits and mealtimes: no special habits, every 3-4 hours .
No IV fluid.Pt. in good growth and development R/to hir age .in good
hygiene.
Physical Assessment/Review of systems:
Finding :
General appearance
he looks active, pale, child’s height 59cm, weight 6.905kg and it’s
appropriate to his age, he breaths well, no abnormalities in his shape
Height: 59cm percentile: 75%
Weight: 6.905 percentile: 50%
Skin:Clean and clear without lesion , the texture of his skin is smooth, no spots
,pink, smooth, unbroken, warm temp. 36.4 ,hydrated not dry . no sweat. Turgor skin
was done and the result is normal (capillary refill less than 3 seconds ).
Head:H.C=41the size of skull is in proportion with the body. smooth texture, normal
distribution, anterior and posterior fontanel are palpable, they are flat and soft, no
tenderness.. Head in midline, the pt. moves her head up to down and from side to side
(full range of motion). Anterior fontanel and posterior fontanel were open. Scalp in
good hygiene, no lesions and trauma. Black color and good distribution of hair.Round
and symmetrical face andcheeks,no lesions or scars ,little pale face.
Neck: normal shape, smooth, short, thick, pink color, surrounded by skin folds, no
masses or tenderness, there is a presence of tonic nick reflex, supports the head in
midline he is able to bend the head forward, backward, and to either side. Equal
bilaterally pulses. There is no bulges or fullness in the neck, no any deviation, masses,
or nodules when palpating neck structures. Thyroid gland not palpated.
Eyes:Both symmetrical, brown color ,sclera is white while conjunctiva is pink,
pupils equal and clearreactive to light (it constrict when put light on , dilate when
shut light), normal tears when he cry and normal eyelashes(the eyelashes are present
along the margins of each eye) and brow hair. clear corneas ,. the eyes are open
normally.

5. Ears:Both symmetrical, normal shape and location without any deformed or lumps
pink external canal, intact . good hygiene, soft. no abnormal opening or discharge,
normal hearing in both ears. Auricle pink in color , no discharge present. Pt has good
hearing acuity and he can respond to sounds. He have acute otitis media at Rt ear .
Nose:symmetricalin midline, with each side, there is no Septal deviation ,nostrils are
patent ,no tenderness ,sinusitis or lesions are present ,dry mucus membranes (mucosal
lining is pink, moist ,intact , and free of obvious drainage or discharge).. Both nostrils
equal in size. Septum in midline.
Mouth & throat:lips pink, smooth ,intact , and no lesions of lips, the gum is pink
and intact,mucous membrane is pink, intact and moist. Tongue in midline, freely
movable, no lesions or masses under the tongue and he has no teeth , no bleedingThe
uvula is in midline. His hard and soft palate are pink, intact , and no lesions. The
sucking reflex is good.no tonsillitis.
Chest & Lungs:The chest is symmetrical,no enlargement ,Patient has symmetrical
lung expansion and normal lungs sound(no wheezes ,no crackles),good air entry to the
lungs, and symmetrical nipples ,normal movement of chest up and down during
breathing ,Respiratory rate is 41 Resp/min, anteroposterior and lateral diameters equal,
normal nipples, symmetrical, no discharge. Clear breath sounds, normal movement of
abdomen during breathing.. Good bilateral air entry.
Heart & circulatory system:Patient has regularheart rate141/min , normal heart
sounds (S1& S2), No heart problems, Normal in size & shape. Blood pressure within
normal. no murmurs evident ,has good peripheral circulation.
Abdomen:Soft, symmetric(cylindrical in shape), abdomen intactno rashes or
masses,no lesionsor organomegaly. Clean umbilical. Normal bowel movements
(frequent, hyperactive, clicks like sounds)., , soft, no bleeding or discharge, femoral
pulses palpated bilateral.normal movement of abdomen during breathing.
RenalSystem: straw color urine, no history of UTI, normal urination with no burning
,no oliguria, and no infections. patient wears diapers, her mother change it for
her 5-7 times per day.
Muscular/ Skeletal system:symmetrical extremities , he can crawl , can control
his head or back to sit alone ,he can hold things put in her both hands, good muscle
toughen .Full (ROM), no fracture, shoulders, scapula, and iliac crests symmetric.
normal shape, no deformities, there is ten fingers and ten toes, good color and
warmth, nails are pink.

6. Neurological system and reflexes: Alert, conscious, active, he can control his
movement, flexion and extension of the extremities, he able to turn his head to the
right and left side, with a good sensory feeling and response( the baby respond to
sound and light and follow them, no tremors, good sucking. normal tone power, equal
muscle tone, no neurological deficit. Pt crying sometimes due to distress or hungry, he
has acceptable and cooperative behavior. Normal reflexes at all sides, good vision &
hearing and good sensory of skin(blinking reflex, papillary, doll’s eyes, and corneal
reflex. Nose reflexes such as Glabellar. Mouth and throat reflex such as sucking, gag,
rooting, and yawn. Extremities reflex grasp, babinski).
Emotional, Intellectual: my patient is quiet child and attract the others by his
smile to them. she is oriented, She alert to other ,can differentiate between stranger
and his caregiver and doctor .very cooperative with other don’t seem afraid or
distressed from hospitalization.
Response to illness: He seems response to treatment very well ,not
distressed, cooperative when given medication, eat well, active , playing
with his play most of the time .
Sleep (nap, bedtime, rituals and pears): he takes(3) naps during the day, and
has good sleeping pattern, usually he sleep from 9pm to 6am , when he gets up in
the morning he take his shower and BF then return to sleep .
Spiritual: relaxant music to relax her (she sing to him sometime to calmdown). he
need to feel safety and love from his mother ,he need to play with and spend more
time with .
Pathophysiology
Bronchiolitis
Bronchiolitis is a common lung infection in young children and infants. It causes
congestion in the small airways (bronchioles) of the lung. Bronchiolitis is almost
always caused by a virus. Typically, the peak time for bronchiolitis is during the
winter months. Bronchiolitis starts out with symptoms similar to those of a common
cold but then progresses to coughing, wheezing and sometimes difficulty breathing.
Symptoms of bronchiolitis can last for several days to weeks, even a month. Most
children get better with supportive care at home. A very small percentage of children
require hospitalization.

7. Diagnosis procedure Laboratory results
Lab investigation
(CBC)
Date
19/9/2014
Pt’s value
Normal value
Comments
leukocytes 19.0 mm*3 5000-10000 Normal
Erythrocyte
4.29 ml/ul 4.2-6.3 10
Normal
HGB
(Hemoglobin)
11.5g/dl 11-16 g/dl
Normal
HCT (Hematocrit).
40% 40-50 Normal
Plt.
410 Higher than
265
Normal
CRB
3.0 mg/L Less than 5 Normal
Lab investigation
Date
20/9/2014
Pt’s value
Normal value
Comments
Glucose 103mg/dl 70-115 normal
Na
134 mmol/l 135-145 normal
K
5.0 mmol/l 3.5-5.5 normal

8. Pharmacology
*Name: Ampicillin
Trade name: Principen, Totacillin, Omnipen, Omnipen-N, Totacillin-N.
Dosage :IV350mg ,Q8hr
Action : stop bacteria from multiplying by preventing bacteria from forming the
walls that surround them. The walls are necessary to protect bacteria from their
environment and to keep the contents of the bacterial cell together. Bacteria cannot
survive without a cell wall. Penicillins are most effective when bacteria are actively
multiplying and forming cell walls.
Rational : for treating bacterial infections (bronchiolitis).
Side effect : nausea, vomiting, loss of appetite, diarrhea, abdominal pain,
rash, itching, headache, confusion and dizziness.
Nursing consideration : Persons who are allergic to the cephalosporin class of
antibiotics, which are related to the penicillins, for example, cefaclor (Ceclor),
cephalexin (Keflex), and cefprozil (Cefzil), may or may not be allergic to penicillins.
Serious but rare reactions include seizures, severe allergic reactions (anaphylaxis), and
low platelet or red blood cell count. Ampicillin can alter the normal bacteria in the
colon and encourage overgrowth of some bacteria such as Clostridium difficile which
causes inflammation of the colon (pseudomembranous colitis). Patients who develop
signs of pseudomembranous colitis after starting ampicillin (diarrhea, fever, abdominal
pain, and possibly shock) should contact their physician immediately.
Evaluation : pt was for 10 days under treatment and from lab test it was
effective.
*Name : Acamol
Trade name : Paracetamol or Tylenol
Dosage : 3.5cc po
Action: Paracetamol is a clinically-proven non-salicylate analgesic and antipyretic
with rapid absorption and action. It produces analgesia by elevation of the pain
threshold, and antipyresis through action on the hypothalamic heat-regulating center.
Rational: antipyretic ,to reduce fever .
Side effect : it could cause serious damage to the liver, or bleeding in the stomach.
Nursing consideration: If a sensitivity reaction occurs, discontinue use.
Paracetamol should be given with care to patients with impaired kidney or liver
function. Risk-benefit ratio should be taken into consideration in the presence of viral
hepatitis and alcoholism, since there is an increased risk of hepatotoxicity.
Evaluation : pt no more complain from fever.

9. Dx1. Ineffective Breathing Pattern related to increased work of breathing and
decreased energy (fatigue).
Goal:
1-The child will return to respiratory baseline. The child will not experience
respiratory failure
2-The child’s oxygenation status will return to baseline
Nursing action :
1-Assess respiratory status a minimum of every 2–4 hours or more often as indicated
for a decreasing respiratory rate and episodes of apnea. Cardio respiratory
monitor and pulse oximeter attached with alarms set.
Record and report changes promptly
to physician.
Rational : Assessment and monitoring baseline reveal rate and quality of air
exchange. Frequent assessment and monitoring provides objective evidence of
changes in the quality of respiratory effort, enabling prompt and effective intervention
2-Administer humidified oxygen via mask, hood, or tent.
Rational :Humidified oxygen loosens secretions and helps maintain oxygenation
status and ease respiratory distress
3-Position head of bed up or place child in position of comfort on parent’s lap, if
crying or struggling in crib or bed.
Rational :Position facilitates improved aeration and promotes decrease in anxiety
Outcomes:
1-The child returns to respiratory baseline within 48–72 hours.
2-The child’s respiratory effort eases. Pulse oximetry reading remains less 94%
oxygen saturation during treatment
3-The child rests quietly in position of comfort.

10. Dx2- imbalanced nutrition, less than body requirements, related to illness.
Goals
after 30min the pt. should be able to breast fed
Nursing Action:
- weigh daily.
- give milk formula.
- monitor daily laboratory data.
- treated the illness.
Rationale:
- to prevent dehydration.
- to prevent losing weight.
- to maintain skin integrity.
Evaluation: The goal is met.

11. DX3. Risk for Fluid Volume Deficit related to inability to meet body requirements
and increased metabolic demand.
Goal:
1-Child’s immediate fluid deficit is corrected.
2-Child will be adequately hydrated,
be able to tolerate oral fluids, and
progress to normal diet (BF)
Nursing action :
1-Evaluate need for intravenous fluids. Maintain IV, if ordered.
Rational: Previous fluid loss may require immediate replacement.
2-Perform daily weight measurement on the same scale at the same time of day.
Evaluate skin turgor.
Rational: Further evidence of improvement of hydration status
3-Assess mucous membranes and presence of tears. Report changes promptly to
physician.
Rational Moist mucous membranes and tears provide observable evidence
of hydration.
Outcomes:
1-Child’s hydration status is maintained
during acute phase of illness.
2-Child’s weight stabilizes after 24–48
hours; skin turgor is supple
3-Child shows evidence of improved hydration

12. DX4. Anxiety (Child and Parent) related to acute illness, hospitalization, uncertain
course of illness and treatment, and home care needs.
Goal:
1-Child and parents will demonstrate behaviors that indicate decrease in anxiety.
2-Parents will verbalize knowledge of symptoms of bronchiolitis and use of home care
methods before the child’s discharge from the hospital.
Nursing action :
1-Encourage parents to express fears and ask questions; provide direct answers and discuss
care, procedures, and condition changes.
Rational: Provides opportunity to vent feelings and receive timely, relevant information.
Helps reduce parents’ anxiety and increase trust in nursing staff.
2-Incorporate parents in the child’s care. Encourage parents to bring familiar objects from
home. Ask about and incorporate in care plan the home routines for feeding and sleeping
Rational: Familiar people, routines, and objects decrease the child’s anxiety and increase
parents’ sense of control over unexpected, uncertain situation
3-Explain symptoms, treatment, and home care of bronchiolitis. Anticipate potential
for recurrence.
Rational: Assist family to be prepared should respiratory symptoms recur after
discharge
4-Provide written instructions for follow-up care arrangements as needed
Rational: written and oral instructions reinforce knowledge. Parents may
not “hear” and remember the particulars of home care if presented only orally
Outcomes:
1-Parents and child show decreasing anxiety and decreasing fear as symptoms
improve and as child and parents feel more secure in hospital environment.
2-Parent freely asks questions and participates in the child’s care The
child cries less and allows staff to hold and/or touch him
3-Parent accurately describes respiratory symptoms and initial home care
actions.

13. STUDENT SELF EVALUATION:-
What I learned?:
I learned from my case about the physical, emotional, and social development of the
child Also I learn and understand that children are not simply small adults They often
present different symptoms from adults. They need different prescriptions or
treatments than adults. And it was an apprutunity to know more about one of upper
respiratory diseases (bronchiolitis) in related to pathophisiology,S&S,complication
and how to take care of a child with this disease .
What I need to work on?:
I need to improve my knowledge about pediatric disease in order to be able to manage
and caring the child and to have the confidence in my knowledge to advice parents
how to take care their children and avoid complication .
What I liked the best?
I was having difficulty in learning reflexes but after I took this case it was very easy to me to
know them, also loved working with children in over all , it was A very useful opportunity to
work with the best in this field .

14. *References
From my observation.
Patient chart.
Health team members (nurses and doctor).
From patient.
Previous data sheets
Internet references :
http://emedicine.medscape.com/article/961963
http://kidshealth.org/parent/system/medical/newborn_screening_test
http://www.peds.arizona.edu/medstudents/Physicalexamination
Book References
Lenin (1995) pharmacology, Philadelphia, Lippincoot Company, fourth edition.
Pillitter, Adel, maternal and child health nursing, fourth edition. Gil Bert and human,
manual of high risk pregnancy and delivery, third edition 2003