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Case PCAP

A 3-year-old male patient was admitted with difficulty breathing, cough, and fever for 2 days. He has a diagnosis of pneumonia. Admitting orders include IV fluids, medications for fever and pneumonia, monitoring vitals every hour, and a chest x-ray. On physical exam, the patient has a fever, fast breathing, crackles in the lungs, and signs of discomfort.

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Nina Anne Paracad
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120 views2 pages

Case PCAP

A 3-year-old male patient was admitted with difficulty breathing, cough, and fever for 2 days. He has a diagnosis of pneumonia. Admitting orders include IV fluids, medications for fever and pneumonia, monitoring vitals every hour, and a chest x-ray. On physical exam, the patient has a fever, fast breathing, crackles in the lungs, and signs of discomfort.

Uploaded by

Nina Anne Paracad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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You are the receiving ward nurse, an ER nurse endorses a newly admitted patient as follows:

Endorsing to you Patient RD, 3 years old, male, under the service of Dr. A. Guzman. Patient is
admitted with chief complains of Difficulty of breathing, cough and fever for 2 days. Patient is admitted
with an initial impression of PCAP.

The following are the admitting orders:

 Please Admit patient to room of choice under my service.


 Secure informed Consent
 VS q 1hour and record
 Monitor I and O every shift
 DAT
 IVF of D50.3 NaCl 500 cc x 6 hrs with strict monitoring and regulation of flow.
 For CBC with platelet
 Schedule chest X-ray AP-L once child is stable.
 Provide O2 support at 2LPM via face mask
 Start the following medications:
o Paracetamol 150 mg IV q4H for fever >38c
o Paracetamol 250 mg/ml give 4L q4h for fever of 37.8 and above
o Start Hydrocortisone 60 mg IV every 6 hours
o Start cetirizine phenylephrine 2.5 ML BID in full stomach
o Cefuroxime 250 mg IV every 8 hours ANST (stock dose 1.5 g, dilution 10ML
sterile water)
 Refer for untoward signs and symptoms

Physical Assessment done with the following findings:


 VS: Temp: 38.6c PR: 98bpm RR- 33cpm bp 90/60 mmhg
 Rales heard in both lungs upon auscultation
 Nasal flaring and used of intercoastal muscles in breathing
 Signs of irritability and discomforts observed
 According to mother, patient had periods of vomiting after eating. No appetite for the
last 3 days.

Tasks:
1. Accomplish the Kardex using the above data.
2. Make a nurses notes using FDAR format.
3. Compute for the flow rate in micro drops of the patient’s IVF. How many ML per
hour should be infused?
4. Make at least 2 NCPs for the patient.
5. Make a drug study for the patient’s medications.

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