Nursing Case Study

PATIENT’S DATA
Name : John Lester P. Aguilar
Address: : Bucot, Aliaga, Nueva Ecija
Gender : Male
Age : 9 months old
Date of Birth : September 17, 2008
Place of Birth : Cabanatuan City
Religion : Roman Catholic
Nationality: : Filipino
Weight : 7 kilos
Father’s Name: Norman Aguilar
Mother’s Name: Leonora Aguilar

Admission Data:

Chief Complaint : DOB (Difficulty of Breathing)
History of Present Illness: Two weeks prior to admission, the patient experienced on and off fever accompanied by fever , No consult done.
One day prior to admission patient had + LBM 10x and also vomiting.
Date of Admission : June 23, 2009
Time of Admission : 08:25 pm
Mode of Arrival : Cuddled by her mother
Clinical Diagnosis : Bronchopneumonia with Dehydration

Latest Vital Signs

Temp : 38.1
PR : 154 bpm
RR : 59 cpm

PATHOPHYSIOLOGY

Etiologic Agent: Predisposing Factors:
* Bacteria * Elderly
* Virus * Hospitalization
* Immobilization
* Immune Deficiency
* Long Term Illness
* Smoking
Microorganism enter alveolar
Spaces by droplet inhalation

?
Inflammation occurs

?
Alveolar fluid increase

?
Ventilation decreases as secretion thicken

?
Bronchopneumonia

Empyema Pleurisy
(collection of pus & liquid (Inflammation of membrane)
From infected tissue)
Lung Abscess
(collection of pus, inflammation
& destruction of tissue)

?
Cancer of the lung

?
Death
DRUG STUDY
DRUG USES SIDE EFFECTS CONSIDERATION
Generic Name:
Hydrocortisone sodium succinate

Dosage:
70 mg – IVP
Then 30 mg IVP after 6 hours
Classification:
Corticosteroids
Prophylaxis and treatment of chronic bronchial asthma, perennial rhinitis, symptomatic sarcoidosis
Anorexia
N&V
Lethargy
Headache
Fever
Joint pain
Desquamation
Myalgia
Weight loss
Hypotension
* Assess for any allergic reaction
* Monitor v/s, I&O, and weight
* Avoid alcohol and caffeine
DRUG NAME USES SIDE EFFECTS CONSIDERATION Generic Name:
Paracetamol
Drops

Route:
Oral

Dosage:
0.7 mL – Q6h

Available forms:
Tablet and Syrup

Classification:
Non-opioid analgesic Analgesics and antipyretic commonly used for relief of fever, head aches and other minor pains and aches. Rare side effects:

Hives; rash;
Shortness of breath.

Prolonged & habitual use may lead to liver damage or failure. Check the time and dosage before administering.

Assess for possible drug reactions.
DRUG NAME USES SIDE EFFECTS CONSIDERATION Generic Name:
Cefuroxime

Brand Name:
Plerozef

Route:
IV

Dosage:
120 mg/q8

Classification:
Cephalosporin, Second Generation
For lower respiratory tract infection due to S. pneumoniae, UTI’s due to e. coli & skin and skin structure due to s. aureus
Most common:
Diarrhea/loose stools, abdominal pain & N/V
Asses for possible S&S of drug reaction.

Asses for anemia & renal dysfunction.

DRUG NAME USES SIDE EFFECTS CONSIDERATION Generic Name:
Metronidazole

Route:
IV

Dosage:
120 mg/q8

Classification:

-Metronidazole is an antibiotic especially effective against anaerobic infections (infections that grow without the presence of oxygen.)
-it has anti-inflammatory properties in the large intestine and is a very effective anti-diarrhea medication.
Side effects are not commonly seen with this medication unless the patient is taking especially high doses or moderate doses for a long time period (months). Side effects seen can relate to nausea or appetite loss or side effects can be neurologic (staggering, head tilt to one side)
Metronidazole is best given with food.

Metronidazole can cause birth defects if given to a pregnant patient. It should never be administered during pregnancy.

DRUG NAME USES SIDE EFFECTS CONSIDERATION Generic Name:
Metoclopramide

Route:
IV

Dosage:
1.5 mg PRN for vomiting

Classification:

Blocks dopamine receptors in chemoreceptor trigger zone of the CNS.
Drowsiness, weakness