WESTERN MINDANAO STATE UNIVERSITY

COLLEGE OF NURSING
ZAMBOANGA CITY

Related Learning Experience

Zamboanga City Medical Center
Rotation 13 – Pediatric Intensive Care Unit

Submitted by:

Aquino, Ruthelle T.
BSN 4B

Submitted to:

Alfaida Tiblani-Akmadul, RN, MN

Clinical Instructor
 PATIENT’S PROFILE

Name: Mohammad Japira B.

Age: 1 month old

Sex: Female

Birthday: February 06, 2023

Address: Near Mosque, Urban Poo, Sta. Barbara, Zambonaga City

Mother: Nursaima Mohammad

Occupation: Housewife

Religion: Tausug

Admission Diagnosis: PCAP-D; Sepsis

Birth Weight: 1.6kg

Chief Complaint: Fast breathing

Medical History:

 Admitted at NICU for 8 days

 Small to gestational age
 Prior to admission fast breathing was noted
 (+) Respiratory distress at deep retraction and noted Bird Fancier's Lung (BFL)
 (+) Fever
 (+) Cough
 (+) Vomiting
Name: Aquino, Ruthelle T. Rotation & Date: Rotation 13 – April 3-5, 2023
Year & Section: BSN 4B Clinical Instructor: Alfaida T. Akmadul, RN, MAN

NURSING CARE PLAN

Nursing Diagnosis:
1. Ineffective airway clearance related to increased sputum production
2. Impaired gas exchange related to fluid and mucus in the alveoli
PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Subjective cues: At the end of 8 hours The nursing intervention At the end of 8
“Tumataas yung dibdib of nursing Independent happened April 03-04, hours of nursing
 Assess vital signs.  To provide
nya pag humihinga at interventions, the 2023 interventions, goals
baseline data.
may konting plema din patient is expected were met as
sya ngayon” as to:  Assess respiratory  Use of accessory evidenced by:
Ineffective airway April 03, 2023
verbalized by the movements and use muscle indicates
clearance related  Demonstrate  Assessed vital signs  Demonstrated
patient’s mother. of accessory an abnormal
to increased behaviors to with normal readings behaviors to
Objective cues: sputum muscles. increase in work of:
achieve achieve airway
 White mucus in production of breathing. RR: 47 bpm
airway clearance.
the endotracheal clearance.  Assess sputum and HR: 136 bpm
 A sign of infection Temp.: 36.5C Vital Signs:
tube  Display amount and report to is discolored
 Barrel chest effective the clinical O2 sat: 98%  RR: 26 bpm
sputum.
 Abnormal breath airway instructor.  HR: 120 bpm
 Assessed respiratory  Temp.:36.3C
sounds clearance and
 Assist the patient's  Patients with movements and used
(crackles) no sputum  O2 sat: 100%
mother about pneumonia of accessory
 Medical history: productions
hydration by using typically have muscles.
- (+) fever as evidenced GOAL
- (+) cough by clear lung Orogastric Tube poor appetites, but PARTIALLY MET
 Assisted Orogastric
- (+) vomiting sounds. feeding. need appropriate Tube feeding using 3
- (+) fast nutrition and  Displayed
mL milk every 3hrs
breathing hydration to heal. effective airway
as ordered.
 Assist with suction clearance and
 Stimulates cough no sputum
of secretions.  Suctioned the
or mechanically
 clears airway in a secretions in the productions as
patient who cannot endotracheal tube as evidenced by
do so because of needed. clear lung
ineffective cough. sounds.
Note: Suctioning  Assisted to X-ray
can cause room for chest X-ray GOAL NOT MET
increased as ordered.
hypoxemia; hyper
 Educate the patient’s oxygenate before, April 04, 2023
during, and after  Assessed vital signs
mother about the with normal readings
causes and risk suctioning.
of:
factors of the RR: 26 bpm
 Help care provider
disease. HR: 120 bpm
understand the
care setting most Temp.:36.3C
Dependent appropriate for the O2 sat: 100%
 Administer condition  Assessed respiratory
medication as movements and used
ordered such as of accessory
 To promote
Piperacillin + muscles.
pharmacological
tazobactam, and  Suctioned the
regimen.
Amikacin. secretions in the
endotracheal tube as
Collaboration
needed.
 Refer to radiologist
 Discussed with the
for chest X-ray as
 This helps the patient’s mother
ordered.
doctor diagnose about the causes and
pneumonia and risk factors of the
determine the condition such as
extent and location second-hand smoke,
of the infection. air pollution, age,
immunocompromise,
and underlying lung
disease.
 Taught the patient
the importance of
breastfeeding and
immunizations that
 can help protect
babies against short-
and long-term
illnesses and
diseases.

REFERENCES:
Wagner, M. (2023, February 24). Pneumonia Nursing Diagnosis & Care Plan. NurseTogether. Retrieved from https://www.nursetogether.com/pneumonia-nursing-diagnosis-care-
plan/
Vera, M. (2023, March 1). 11 Pneumonia Nursing Care Plans. Nurseslabs. Retrieved from https://nurseslabs.com/pneumonia-nursing-care-plans/
GENERIC NAME: MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE REACTION NURSING RESPONSIBILITY

PIPERACILLIN Piperacillin: Binds to bacterial cell wall membrane,  Diarrhea 14 Rights of Drug Administration
SODIUM/TAZOBACTAM SODIUM causing cell death. Spectrum is extended compared with  Constipation  Right Drug/Medication
other penicillin.  Nausea  Right Client/Patient
Tazobactam: Inhibits beta-lactamase, an enzyme that  Vomiting  Right Route
can destroy penicillin.  Heartburn  Right Dose
Therapeutic Effects: Death of susceptible bacteria.  Right Frequency/Time
 Stomach pain
 Right Assessment
 Fever
BRAND NAME: INDICATION:  Right Approach
 Headache
 Right Education
 Mouth sores
Tazocin, Vigocid Treatment of moderate to severe appendicitis,  Right Evaluation
uncomplicated and complicated skin and skin structure  Difficulty falling asleep or staying  Right Documentation
infections, endometritis, pelvic inflammatory disease, or asleep  Right to Refuse
DRUG ILLUSTRATION: nosocomial or community-acquired pneumonia caused by  Rash  Right Principle of Care
piperacillin-resistant, piperacillin/tazobactam susceptible,  Itching  Right Prescription
beta-lactamase-producing bacteria.  Hives  Right Nurse Clinician
 Difficulty breathing or swallowing
 Wheezing Assessment & Drug Effects
 Severe diarrhea (watery or bloody
stools) that may occur with or  Obtain history of
without fever and stomach cramps hypersensitivity to
penicillin, cephalosporins,
or other drugs prior to
administration.
 Lab tests: C&S prior to first
dose of the drug; start drug
CLASSIFICATION CONTRAINDICATION: pending results. Monitor
hematologic status with
Anti-infective; Beta-Lactam Hypersensitivity to piperacillin/tazobactam, any prolonged therapy (Hct and
Antibiotic; Antipseudomonal Penicillin penicillin. Hgb, CBC with differential
Cautions: History of allergies (esp. cephalosporins, beta-
and platelet count).
 Monitor patient carefully
lactamase inhibitors), renal impairment, preexisting
during the first 30 min after
DOSAGE/FREQUENCY/ROUTE: seizure disorder.
initiation of the infusion for
signs of hypersensitivity
200mg + 10cc D5W
 Expect to obtain blood,
sputum, or other samples
 for culture and sensitivity
testing before giving
piperacillin and to start
therapy before results are
available.
 Be aware that sunlight may
darken piperacillin powder
for dilution but won’t alter
drug potency.

Patient & Family Education

GENERIC NAME: MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE REACTION NURSING RESPONSIBILITY

AMIKACIN SULFATE  Appears to inhibit protein synthesis in bacterial  Impaired renal function 14 Rights of Drug Administration
cell and is usually bactericidal by binding to  Eighth cranial (auditory) nerve  Right Drug/Medication
ribosomal subunits. impairment  Right Client/Patient
 Preexisting vertigo or dizziness  Right Route
 Tinnitus, or dehydration  Right Dose
BRAND NAME: INDICATION:  Fever  Right Frequency/Time
 Hypocalcemia.  Right Assessment
Amikin
 Right Approach
 Primarily for short-term treatment of serious
 Right Education
infections of respiratory tract, bones, joints, skin,
DRUG ILLUSTRATION: and soft tissue, CNS (including meningitis),  Right Evaluation
peritonitis burns, recurrent urinary tract  Right Documentation
infections (UTIs).  Right to Refuse
 Suspected or proven late-onset neonatal sepsis.  Right Principle of Care
 Right Prescription
 Right Nurse Clinician

Assessment & Drug Effects

 Lab tests: Periodic serum

creatinine and BUN,
complete urinalysis. With
treatment over 10 d, daily
CLASSIFICATION CONTRAINDICATION: tests of renal function,
weekly audiograms, and
Antiinfective; Aminoglycoside Antibiotic History of hypersensitivity or toxic reaction with an vestibular tests are strongly
aminoglycoside antibiotic. advised.
 Monitor serum creatinine or
DOSAGE/FREQUENCY/ROUTE: creatinine clearance
(generally preferred) more
15mg IVT q8h often, in the presence of
impaired renal function, in
neonates, and in the older
adult; note that prolonged
high trough (>8 mcg/mL)
 or peak (>30–35 mcg/mL)
levels are associated with
toxicity.
 Monitor S&S of ototoxicity
[primarily involves the
cochlear (auditory) branch;
high-frequency deafness
usually appears first and
can be detected only by
audiometer]; indicators of
declining renal function;
respiratory tract infections
and other symptoms
indicative of
superinfections and notify
physician should they
occur.
 Monitor & report any
REFERENCES:
Vallerand, A.H., & Sanoski, C. (2019). Davis’s drug guide for nurses (16th ed.). F.A. Davis Company.
Skidmore-Roth, L. (2014). Mosby’s 2014 nursing drug reference (27th ed.). Elsevier Mosby.
 PATHOGENESIS OF PCAP-D; SEPSIS

Second-hand Air Pollution Neonates Immunocompromise Underlying lung

Smoke < 11 especially bottle fed disease (Cystic
months fibrosis, Cilliary
dysfunction,
bronchiectasis)

Susceptible
host/virulent pathogen

Streptococcus pneumoniae, influenza A,

Mycoplasma pneumoniae and Chlamydophila
pneumoniae

Infection and proliferation of pathogen in lower

respiratory system/parenchyma

Inflammatory response to proliferation of

SEPSIS
microbial pathogens at the alveolar level

SIGNS and SYMPTOMS

1. Acute abdominal pain
2. Crackles; decreased breath sounds
3. Hypoxemia
4. Respiratory failure: Supraclavicular;
Intercostal; Subcostal
5. Tachypnea
 2-12 months: >70 bpm
 1-5 years old: >50 bpm
 > 5 years old: > 35 bpm
6. Fever
7. Chills
8. Severe dehydration
9. Lethargic
10. Stuporous

REFERENCES:
Yu, Y. (2020, October 4). Pediatric Pneumonia: Pathogenesis and clinical findings | Calgary Guide. The
Calgary Guide to Understanding Disease. Retrieved from https://calgaryguide.ucalgary.ca/pediatric-
pneumonia-pathogenesis-and-clinical-findings/
Pediatric Community Acquired Pneumonia (2015, August 11). Retrieved from
https://www.slideshare.net/crisbertc/pediatric-community-acquired-pneumonia