St. Anthony College of Roxas City, Inc.

Case Study for Pediatric

Nursing Clinical Rotation

Case:
Patient H, 4-year-old female, Filipino, born on Feb 15, 2017 in Brgy. Libas, Roxas City was
admitted on Oct. 25, 2021 @ 10AM due to cough, fever, accompanied by nausea and vomiting
under the service of Dr. V. Arancillo. Initial diagnosis: PCAP-C

Situation: You are on duty at 7-3 shift and you receive the following data during endorsement;

• Admitted at Big Pedia Ward (WPW) bed 1 with 02 @ 2LPM via NC

• With PNSS 500mL to run for 8hrs @ 300mL level
• Diet for age
• Meds: Paracetamol 5mL every 4hrs for Temp >37.8 and above; Pen-G 200,000U IV q
6hrs; Salbutamol neb 1respoule q 6hrs; Erceflora 1 sachet TID PO, Zinc sulfate 2mL
OD PO
• Latest temp: 37.9 C

History:
Born full-term via CS in SACRI (Hospital), 2 out of 3 children of a Jeepney driver (35 y/o) and
nd

a housewife (33 y/o). Both parents are hypertensive and father is smoking 2 packs/day for 8
years. Cough started 2 days prior to admission, followed by an on & off fever thereafter. Nausea
and vomiting followed after giving Paracetamol as home remedy. 3 hrs. prior to admission,
temperature went up to 38.8 C. AM shift’s nursing diagnosis is Hyperthermia. Lab/Radiological
test done Oct. 26: XR result reveals pneumonia, WBC at 14,000, RBC & platelets normal. Stool
and urine analysis is also normal.

Focus assessment includes: RR 44cpm, irregular, shallow, breathes through mouth, uses
accessory muscle for breathing, unable to breathe in supine position, audible breathe sounds
within few feet. Auscultation reveals bilateral coarse crackles on lower lobes with decreased
breath sounds at posterior area. T 38.2C, PR 125bpm, SPO2 92% with 02. Assessment findings
of all other areas must be filled-up using fictional data BUT should be within the scope of the
case scenario given.

Learning Activities: Print the worksheet to answer or answer directly on the worksheet

A. Application of the Nursing Process

1. Fill-up the needed data based on the given scenario/case

2. Document the assessment data using BLUE pen for normal findings and RED for abnormal
findings under Review of Systems (ROS)
3. Create a concept map using Lucid chart integrating all the concepts (Possible risk factors,
disease process/patho, signs and symptoms, diagnostic tests, medical diagnosis,
pharmacology, at least 3 nursing diagnoses, expected outcomes, nursing interventions).
Please use the object-color- coded legend for better understanding and easier traceability.
Fill up also the additional learning worksheet tables/charting.

Reference site for Lucidchart sample:

https://www.lucidchart.com/pages/templates/mind-map/lucidchart-nursing-concept-map-example
 4. Present your drug study and IVF data
5. Prepare your nursing care plan
6. Make a D-A-R charting
7. Clinical Reasoning Questions

What possible COMPLICATIONS do you

anticipate?

What ASSESSMENT do you need to identify &

respond to if this complication develops?

What EDUCATIONAL OPPORTUNITIES

have you identified for your client?

B. Communication: Using ISBAR as a model for structured clinical communication and ensure
accurate handover of information between shifts, write down your end of the shift report for the
incoming nurse/student nurse guided by the following questions:

Identify: Identify yourself, who you are talking to and who you are talking about
Situation: What is the current situation, concerns, observations,etc
Background: What is the relevant background information? This helps you set the scenario to
interpret the situation accurately
Assessment: What do you think the problem is? This requires the interpretation of the situation and
background information to make an educated conclusion about what is going on
Recommendation: What do you need them to do? What do you recommend should be done to
correct the current situation?
Recommendation: What do you need them to do? What do you recommend should be done to
correct the current situation?

Reference: http://www.inmo.ie/tempDocs/ISBAR

B. Collaboration: You noticed that the antibiotics are given at same time with probiotics. You are
asked by your clinical instructor to refer the matter to the staff nurse. Using C-U-S as an assertive
technique, what would you tell the staff nurse?

C. Ethico-Moral-Legal: The Doctor advised the mother for her child to be immunized with
pneumococcal vaccine. The mother refused saying that she has read somewhere that it can cause
autism. What would be your nursing action? What ethical principle is applicable in this scenario?
Justify?
 St. Anthony College of Roxas City, Inc.

LEARNER’S WORKSHEET

Name of STUDENT: Rose-Ann Estores

Section/Group: BSN 2B
Date: December 06, 2021 Institution:
Area:
A. Application of the Nursing Process

FILL-UP data completely (Put N/A if not applicable) while receiving endorsement from
staff.
In compliance with the Data Privacy Act, Personal Data are NOT ALLOWED in this worksheet
Patient’s Case: _ Hyperthermia ___ ____ Age 4 y.o Sex Female Room/Bed# BPW/ bed 1
Doctor/s: Dr. V. Arancillo
Diagnosis: PCAP-C Activity restrictions:
Chief complaint/s: cough, fever, accompanied by nausea and vomiting Diet: _for age_____

Brief History (Part of #2: Assessment)

Present Illness : Pediatric Community Acquired Pneumonia (PCAP-C)
Past Med/Sur : N/A
Family : 2nd out of 3 children of a Jeepney driver (35 y/o) and a housewife (33 y/o).
OB-Gyne : N/A

Personal/Social: Both parents are hypertensive and father is smoking 2 packs/day for 8 years.
Previous Nursing Diagnoses: N/A

ASSESS THE PATIENT (Initial/Focus/General): Use BLUE for normal findings and RED for
ABNORMAL
General
Skin Skin is intact and there are no reddened areas or other discoloration.

Head, Eyes, Ears, Head is symmetrical, Eyes non sunken eyeballs the pupil Is symmetrical and
Nose, Throat coordinate,

Nose difficult to breath, Throat difficult to coordinate

Neck Symmetrical
Breast No rashes, Symmetrical
Respiratory RR 44 cpm, irregular, shallow, breathes through mouth.

Cardiovascular Auscultation reveals bilateral coarse crackles on lower lobes with decreased
breath sounds at posterior area. PR 125 bpm
PR 125 bpm, 100/70 mmHg
 Gastrointestinal Vomiting, Bowel movements I normal
Urinary No dysuria, No hematuria
Genital Normal
Upper extremities are symmetrically align, Capillary refill: <2 secs, lower
Peripheral / extremities are bilaterally symmetrical and equal, right foot has complete
Vascular fingers, skin color is as same as the other parts of the body, T 38.2 C

Musculoskeletal Normal
Neurologic Active, alert, recognizes familiar faces and objects
Hematologic WBC at 14,000, RBC and platelets normal
Endocrine Normal release of hormones
Psychiatric Patient is cooperative

Concept Map

Risk Factors
Pathophysiology Signs/Symptoms Diagnostic Test/Results Medical Diagnosis

Pharmacology 3 Nursing Diagnosis Expected Outcomes Nursing Interventions

Concept Map
Drug Study
Dose Classification Mechanism Nursing
Frequen of action responsibilities
cy Time
of
Drug adminis
tration

Dosage: 5ml Analgesic and An antipyretic • Observe the

Antipyretic right dose.
Frequency: q 4 hrs
Advise the
Reference: parents to
Paracetamol increase fluid
mechanisms and intake
updates • Do the tepid
sponge bath to
lower the
temperature of
the patient
• Discontinue drug
if
hypersensitivity
reactions occur.
• Make sure
patients are
aware they must
not exceed the
recommended
dose.
• Evaluate
therapeutic
response.

Penicillin-G Dosage: 200,000U beta-lactam Penicillin • Observe right

antibiotic component of drug
Frequency: q 6 hrs
procaine • Obtain an exact
penicillin history of
is a beta-lactam, patient's
exerting it’s previous
bactericidal exposure and
effects via the sensitivity
inhibition of cell • Observe
wall patients closely
for at least 30
synthesis.
min following
administration of
parenteral
penicillin. The
rapid appearance
of a red flare or
wheal at the IM
or IV injection
site is a possible
sign of
sensitivity. Also
suspect an
allergic reaction
 if patient
becomes
irritable, has
nausea and
vomiting,
breathing
difficulty, or
sudden fever.
Report any of
the foregoing to
physician
immediately.

Salbutamol neb Dosage: 1 respoule Bronchodilators Salbutamol is a  Observe rights in

selective medication
Frequency: q 6 hrs
beta2adrenoceptor administration
agonist. At such as giving the
therapeutic doses it right drug to the
acts on the right patient using
beta2adrenoceptor the right route and
s of bronchial at the right time.
muscle to provide

bronchodilation. Monitor ECG,
With its fast onset serum
of action (within 5
electrolytes and
minutes) it is
thyroid function
particularly
test results.
suitable for the
management and
prevention of
attacks in asthma.

 Assess lung
sounds, PR
and BP before
drug
administration
and during peak
of medication.

 Auscultate lungs
for presence of
adventitious
breath sounds that
may signal
pulmonary
edema, airway
resistance or
bronchospasm.

Erceflora Dosage: 1 sachet Antidiarrheal  Shake drug well

Frequency: TID before
Contributes to the
PO administration
recovery of the
Allows equal
intestinal
distribution of
microbial flora
the drug in the
altered during the
 course of fluid it is in.
microbial
disorders of
diverse origin. It
produces various
vitamins,
particularly group
B vitamins thus
contributing to
correction of
vitamin disorders
caused by
antibiotics &
chemotherapeutic
agents. Promotes
normalization of
intestinal flora.

 Administer
drug within 30
minutes after
opening
container. To
avoid
contamination
of the drug.

 Dilute drug
with sweetened
milk, orange
juice or tea. To
allow easy
administration
of the drug.

 Administer
drug orally.
Proper
administration
allows better
effects of the
drug and
prevent possible
complications

Zinc sulfate Dosage: 2 mL Copper absorption Zinc facilitates  Monitor

inhibitor, nutritional wound healing, progression
Frequency: OD of zinc
supplement helps maintain
PO deficiency
normal growth
rates, normal skin symptoms

hydration and the during therapy.
senses of taste Encourage
and smell. Zinc patient to
inhibits cAMP-  comply with the
induced, chloride- diet
dependent fluid recommendation.
secretion by Ask the patient
inhibiting to notify any of
basolateral the healthcare
 potassium (K) team if the he
channels, in feels nausea,
invitro studies vomiting,
with rat ileum. abdominal pain
or tarry stools
occur.

IV Line
IV Line hooked PNSS 500mL to run for 8 hrs
IV Level received 300mL
IV rate per hour 30 cc per/hr
IV level to endorse 60cc

Nursing Care Plan

FOCUS /Nursing Expected Outcome/s PLAN: Nursing Interventions Rational

(Of e
Diagnosis
PRIORITY
diagnosis)
Hyperthermia related to Short term: INDEPENDENT: - These methods provide
infection for a more gradual
After 4 hours of nursing -Regulate the environment
warming of the body.
As evidenced by body intervention the patient’s temperature or relocate the Rapid warming can
temperature of 38.2 body temperature will patient to a warmer setting. induce ventricular
C decrease Keep the patient and linens fibrillation. Moisture
dry. promotes evaporative
Long term:
- Give extra covering heat loss.
After 2 days of nursing (passive warming), such as - Warm blankets provide
intervention patient clothing and blankets; cover a passive method for
maintain body postoperative patients with rewarming. Acidosis
temperature within heat-retaining blankets. - may emerge from
normal range. - Check for electrolytes, hypoventilation and
arterial blood gases, and hypoxia.
oxygen saturation by pulse - To effectively reduce
oximetry. body temperature and
COLLABORATIVE: treat underlying cause
of infection.
- Administer antipyretics as
ordered and prescribed
medications such as
antibiotics.
Risk for infection related Short term: INDEPENDENT  To provide baseline
to altered oxygenation data to monitor
After 8 hours of nursing • Monitor vital sign
secondary to PCAP-C  effectiveness of
intervention the patient • Assess sputum
treatment
will have no further • Teach patient’s mother to to facilitate better
signs of infection and chest physiotherapy  excretion of sputum to
will remain afebrile.
treat existing disease
COLLABORATIVE

Long term: • Administer medicine as

After 4 days of nursing ordered by the doctor
intervention the patient
will remain afebrile and
displays no further signs
of infection.

Ineffective Airway Short Term: INDEPENDENT  Altered breathing

Clearance related to pattern may occur
increased sputum After 8 hours of nursing • Assess the rate, rhythm, and
together with use
production intervention the patient depth of respiration, chest
of accessory
will maintains a patent movement, and use of
muscles to
As evidenced by airway with breath accessory muscles.
increase chest
Abnormal breath sounds sounds clearing; absence
excursion to
(rhonchi, bronchial lung of dyspnea, cyanosis, as • Auscultate lung fields,
sounds) facilitate effective
evidenced by keeping a noting areas of decreased or
patent airway and breathing.
absent airflow and  Decreased airflow
effectively clearing adventitious breath sounds:
secretions. occurs in areas
crackles, wheezes. with consolidated
fluid. Bronchial
• Assess the patient’s breath sounds can
Long Term: hydration status. also occur in these
consolidated areas.
After 5 days of Crackles, rhonchi,
nursing intervention COLLABORATIVE
and wheezes are
the patient will • Administered oxygen as heard on
demonstrate behaviors ordered by the doctor inspiration and/or
to achieve airway expiration in
clearance. Administer medications as response to fluid
indicated: accumulation,
thick secretions,
• mucolytic and airway spasms
• expectorants and obstruction.
 Airway clearance
• bronchodilators is hindered with
• analgesics inadequate
hydration and
thickening of
secretions.
 Mucolytic
increase or liquefy
respiratory
secretions.
 Expectorants
increase
productive cough
to clear the
airways. They
liquefy lower
respiratory tract
secretions by
reducing its
viscosity.
 Bronchodilators
 are medications
used to facilitate
respiration by
dilating the
airways.
 Analgesics are
given to improve
cough effort by
reducing
discomfort, but
should be used
cautiously because
they can decrease
cough effort and
depress
respirations.
F-D-A-R Charting

FOCUS DAT ACTIO RESPONSE

/Nursing A N
Diagnosis
10/26/2021 The client body temperature Administered Paracetamol 10/26/2021
is 38.2 C of 5 mL via oral route
8:00AM 12:00 Noon

Fever The patient has a body

temperature of 37 C.

Clinical Reasoning Questions

What possible COMPLICATIONS do you A pleural effusion wherein there is an unusual amount of
anticipate? fluid around the lung.

What ASSESSMENT do you need to identify & Assess the airway and breathing sounds of the client.
respond to if this complication develops?

What EDUCATIONAL OPPORTUNITIES have • Encourage the patient to get plenty of rest. Getting
you identified for your client? enough sleep will help her body to get strength.
• Inform the folks of the patient to not smoke
around the patient to lessen the complication.
• Drink enough glasses of water.

Communication
 Identify Hello. Good morning. How are you? I am nurse Ann and this is Nurse Kim she
will be taking care of you for the next 8 hrs. If you have questions or needs, just
call her. Patient name: Z, 4 years old, female
Situation Client was admitted at room BPW bed 1 with 02 @ 2 LPM via NC. With PNSS
500mL to run for 8hrs @ 300mL level. Diet for age. Meds: Paracetamol 5mL every
4hrs for Temp >37.8 and above; Pen-G 200,000U IV q 6hrs; Salbutamol neb
1respoule q 6hrs; Erceflora 1 sachet TID PO, Zinc sulfate 2mL OD PO. Her latest
temp is 37.9 C
Background The client is from Brgy. Libas, Roxas City and was admitted on Oct. 25, 2021 @
10AM due to cough, fever, accompanied by nausea and vomiting under the service
of Dr. V. Arancillo has an initial diagnosis of PCAP-C. She was born full-term via
CS in SACRI (Hospital. Both parents are hypertensive and father is smoking 2
packs/day for 8 years. Cough started 2 days prior to admission, followed by an on &
off fever thereafter. Nausea and vomiting followed after giving Paracetamol as home
remedy. 3 hrs prior to admission, temperature went up to 38.8 C. AM shift’s nursing
diagnosis is Hyperthermia.
Lab/Radiological test done Oct. 26: XR result reveals pneumonia, WBC at 14,000,
RBC & platelets normal. Stool and urine analysis is also normal.

Assessment The client has a RR of 44cpm, irregular, shallow, breathes through mouth, uses
accessory muscle for breathing, unable to breathe in supine position, audible breathe
sounds within few feet. Auscultation reveals bilateral coarse crackles on lower lobes
with decreased breath sounds at posterior area. T 38.2C, PR 125bpm, SPO2 92% with
02.
Recommendation Q 1hr monitor the clients vital sign especially her body temperature for any changes.
Elevate the head of the patient and encourage the patient to do pursed lip breathing
exercise. Monitor through auscultation the breath sounds and breathing pattern of the
patient.

Collaboration:

C I’m concerned about the condition of patient Z.

U I’m uncomfortable that patient Z has difficulty in this condition.

S I believe that patient Z is not safe; maybe there is something more serious than this.

Ethico-Moral-Legal Considerations

Nursing Action
It is the right of the mother of the patient to refuse the Pneumococcal vaccine
for her child but as a nurse we have the responsibility to explain the side effect
of not having her child vaccinate and educate the mother about the false
information that he read about the autism but instead tell the mother about the
benefits of the vaccine to her child if ever she will let her child to be
vaccinated if not we should set aside and respect the decision of the mother.

Ethical Principle Upheld AUTONOMY

Learning Insights/ Reflective Journaling:

 As a student nurse I truly speak that its very challenging doing this activity especially
we are learning through virtual class all the knowledge and insight that we gain
through this class is not enough for us to be a proficient nurse someday. But as I fill
up this worksheet, I realize that it will help me someday. Being a student nurse in this
pandemic give me a realization that as a nurse you must be productive, wide
understanding and not a TAN.G. A, and especially on how to develop a care plan for
my patient, how to administer right IV and medication, the thing that should and not
follow, those things give me a challenging life. Also, on how to communicate as we
know dealing with the parents, guardians or family members of the pediatric patient
is difficult but as a student within the nursing curriculum we are taught the
importance of developing a trusting relationship with our patient or to the patient’s
family by having a positive relationship with them can give as accurate data. All in
all, I learn in this kind of activity that no matter the situation is you should put your
mind in this scenario that even though it is only measure with our fictional mind and
virtual classroom we can still use the knowledge that we gain from this when
everything is back to normal and if we are in an actual setting of the health care
facilities.