CAP Case Study

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CASE PRESENTATIONCOMMUNITY ACQUIRED PNEUMONIA IIIFebruary 19, 2010 GROUP 93 SUBMITTED TO: MR. OLIVER A.SANIDAD R.N.

The Presentors

Introduction The pathogens that cause community-acquired pneumonia (CAP) are predictable; copathogens are involved rarely, if ever. Extrapulmonary clinical features are helpful in distinguishing between typical and atypical causes of CAP. Various clinical findings can also point to specific diagnoses, such as Klebsiella pneumonia or Legionella infection. Severe CAP suggests the presence of underlying problems in the patient, such as cardiopulmonary dysfunction or impaired splenic functioning. Empiric therapy should cover typical and atypical pathogens. Oral antibiotics should be used for as much of the treatment course as is practicable.

Objectives This case study significantly identifies the factors that gave rise for our client to have the diagnosed problem. The ff. are the identified objectives for the case study To develop a comprehensive assessment of the client. To establish a pathophysiology for the disease of the client. To develop a nursing care plan appropriate for the clients diagnosed problem. To be able to teach the mother of the client for proper health maintenance. To lessen the risk of infection and development of complications of the client. To be able to provide an environment conducive for health. To enhance the care that will be given for other clients with the same diagnosis.

BIOGRAPHIC DATAName: CL Address: Age: Marital Status: Room and Bed number: Chief Complaint: Diagnosis: Community Acquired Pneumonia Gender: male Religion: Birthday:

NURSING HEALTH HISTORY

PAST HEALTH HISTORYAYR has Bronchial asthma in acute exacerbation. It was 2004 when he was first diagnosed with the supposed illness. His mother stated that he had complete immunizations. He does not have any allergies. When she was five years old, CL fell-off her bicycle.

PAST HEALTH HISTORYHe had two hospital admissions prior to his recent condition. In 2005, he was first admitted to SCDMMC due to Pneumonia then he was hospitalized again last 2008 due to typhoid fever. He is currently taking Paracetamol for his fever. He does not take any vitamin supplements.

HISTORY OF PRESENT ILLNESSOne day prior to her condition, CL experienced low-grade fever, productive cough with watery nasal discharge. Due to this instance, her mother brought her to SCDMMC and was then admitted with the diagnosis of Community-Acquired Pneumonia.

FAMILY HISTORY

The client has familial history of hypertension and asthma. CLs mother said that her motherin-law has hypertension and her father-in-law has asthma.

GENOGRAMJL (73 y/o) LLLEGEND: HYPERTENSION

(73 y/o)

ASTHMA

EL (50 y/o)

CL (50y/o)

JFL

CL(8 y/o)

NL (19 y/o)

(23 y/o)

Developmental

History

Moral

Emotional

Body concept

Cognitive

Spiritual

Language

Emotional Health The child said that her problems would only include academic activities. She does not want to be sick and absent because she said she would miss school. She is active in school activities. She belongs to a class of excellent students. Her mother said that her teacher does not find any particular problem with her at all. Her greatest fear is the darkness. CL said that she would only cry when her brother teased her or when her parents scold her.

Social Health She has a good relationship with her family. She stated that she is bonded with her family members. She also has good relationship with her teachers, schoolmates and playmates. She allots time for self-enjoyment. Her hobby includes artworks. She loves to draw. She also verbalized that she is active in school. In fact, she joins athletic activities. Her favorite is obstacle race. When her father is available, they would often play badminton. Computer games serve as her bonding activity with her brothers. Walking around the school and eating are her friends past time. She has variety of toys to share with her playmates and cousins. She is always provided with time to play and mingle with them.

Cognitive Patterns The child said that she does well in school. She excels in their academic subjects most especially in Mathematics. She had won in Quiz Bee last schools fest with bronze medal. She belongs to a class of excellent students. She is proud of her achievements in school. She said that her parents are glad about it. She is always present in class. She would only be absent in times of sickness. She loves to do her homework and likes to recite during class discussions.

Language She has good language skills. She speaks Filipino fluently and is able to understand English language. She attentively answered to the questions presented. She would set examples when asked to describe a situation. She had an explorative mind. She too listened carefully and was very eager to answer.

Self-Concept She has no physical defects. She is an active girl, very attentive and smart. The child verbalized, Gusto ko maging doktor at saka teacher paglaki ko.

SPIRITUAL HEALTHReligious Beliefs and Practices The child belongs to ChristianPentecostal religion. Her mother said that CL also does the things that people usually do as Christians. Every Sunday they would go to their church and attend their mass. CL still believes in God Almighty. Her mother stated that they just dont believe in spiritual images and does not worship saints.

Moral DevelopmentThe child at her age has a good understanding about the concept of good and bad. She knows the simple bad deeds that she has to avoid. She said that she is being scolded by her parents when she had done bad things such as being naughty sometimes. She understands that her wrong deeds have corresponding punishments.

Before hospitalization

During hospitalization

Interpretation and analysis

Breakfast: cereal,milk Lunch:Rice with fish and water Dinner:Rice with fish and water

Client has IV fluid attached. Breakfast: pansit, longganisa and water Lunch:

Rice and vegetable(sitaw)

Hospitalization can contribute to decreased food intake in children and adolescents with cancer, making it a challenge to meet their nutritional needs

Before hospitalization

During hospitalization Dinner:Not Applicable Patients mother states that client has decreased appetite.

Interpretation and analysis(A Multidisciplinary Review of Nutrition Considerations in the Pediatric Oncology Population: A Perspective From Children's Oncology Group Nutr Clin Pract, August 1, 2005; 20(4): 377 393)

Before hospitalization

During hospitalization

Interpretation and analysisInterpretation:

The patient intake of food is different when she was hospitalized. Her intake of food is much better when she was not hospitalized. The patients food intake is affected by hospitalization

Before hospitalization

During hospitalization

Interpretation and analysisNormal urine is a straw yellow color and is clear and free of sediment or mucous. The usual amount voided is 200-300 mL five to six times a day; or 1,000 to 1, 500 mL

Usually urinates at least 4 times a day; defecates every morning

Usually urinates at least 5 times a day; defecates a soft stool

every 24 hours;

Before hospitalization

During hospitalization

Interpretation and analysis(http://missouri careeredu cation.org/CDs/ CIHA/CIHA_ ch22.pdf) Interpretation: The patient have a normal elimination.

Before hospitalization

During hospitalization

Interpretation and analysis

Biking

walk in the ward

School age children need daily exercise. Although they go to school all day, they do not automatically receive much exercise because school is basically a sit-down activity. (A. Pillitteri. Maternal and Child Health Nursing Volum 2. P.923)

Before hospitalization

During hospitalization

Interpretation and analysis

Interpretation: The patient doesnt have normal pattern of exercise.

Before hospitalization

During hospitalization

Interpretation and analysisBy age 8, children are generally capable of bathing themselves but may not do it well because they are to busy to take the time or because they do not find bathing as important as their parents do. (Maternal and Child Health Nursing volume II by Adele Pillitteri p. 923)

Takes a bath daily

And brushes her teeth 2x a day

She is being spongedbath by her mother.

Before hospitalization

During hospitalization

Interpretation and analysis

Interpretation:Due to the clients condition he was not able to do bathing.

Before hospitalization

During hospitalization

Interpretation and analysisIt is because of the strange environment and the anxieties associated with illness and hospitalization. Environmental control, such as reduction of noiseand interruptions, and conservative relaxation measures, such as a back rub should be tried before resorting to a hypnotic agent

Sleeps at10 pm and wake up at 5:30am and takes a nap when she reaches home after school (during school days); she actually wakes up at 8am and sleeps at 8:30 pm during weekends

Usually sleeps 5 hours a day

Before hospitalization

During hospitalization

Interpretation and analysis

(http://www.nursingplane t.com/pn/nursing_manag ement_sleep_disorders.ht ml#IV HOSPITALACQUIRED SLEEP DISTUR BANCES) Interpretation: The client was not able to sleep well due to his condition.

Physical AssessmentNORMS (Based on Fundamentals of Nursing 8th Edition, by Kozier, et al., published by Pea