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I. INTRODUCTION
A distinguishing feature of lower airway and pulmonary vessel disorders is the
presence of dyspnea. Dyspnea (shortness of breath) is a subjective experience that
results when air flow, oxygen exchange, or both are impaired. The sensation of
uncomfortable breathing can be as distressing as pain and can lead to severe functional
disability. The intensity and frequency of dyspnea as well as its association with
specific activities must be assessed to develop realistic expectations of treatment
outcomes. Because the experience of dyspnea is associated with much anxiety, nursing
interventions to relieve this manifestations are essential to the care of clients with
conditions of the lower airways and pulmonary vessels.
Pneumonia (pneumonitis) is an inflammatory process in lung parenchyma usually
associated with a marked increase in interstitial and alveolar fluid. Advances in
antibiotic therapy have led to the perception that pneumonia is no longer a major health
problem in the United States. Among all nosocomial infections (hospital acquired),
pneumonia is the second most common, but has the highest mortality. Pneumonia can
be divided into three groups, which guide management: community acquired, hospital
or nursing home acquired (nosocomial), and pneumonia in an immunocompromised
person.
Complications of pneumonia include pleural effusion, septic shock, pericarditis,
bacteremia, meningitis, delirium, atelectasis, and delayed resolution.
1
II. GENERAL DATA:
Name: Ms. M.A.C
Address: Ilihan, Toledo City
Gender: Female
Status: Infant
Date of Birth: August 28, 2009
Age: 5 months old
Nationality: Filipino
Religion: Roman Catholic
Father’s Name: Mr. H.C
Father’s Occupation: Laborer
Mother’s Name: Mrs. M.C
Mother’s Occupation: Housewife
Chief Compliant: Cough and LBM
Date of Admission: February 24, 2010
Time Admitted: 12:50 AM
2
Room Number: BB
Admitting Diagnosis: Pneumonia, AGE with no Dehydration
Physician: Dr. Egbert Ian Echavez
III. HISTORY OF PRESENT CONDITION / ILLNESS
The patient’s mother claims that her baby experienced cough for three days.
According to the patient’s mother her child also experienced four episodes of LBM
for one day and two episodes of vomiting prior to admission. The patient’s mother
also claims that the night prior to admission, her child cries after every cough and felt
that her child is hot to touch, which she concluded that her child has fever. With this
situation, she was alarmed and decided to go to the hospital for her child to be
checked upon.
IV. PAST HEALTH HISTORY
The patient’s mother claims that this is the first time her child was admitted in
the hospital due to a serious condition. She also mentioned that whenever her child
experiences mild fever and colds, she buys over the counter medications and uses
herbal plants to alleviate the patient’s condition. According to her, her child doesn’t
have any known allergy to any kind of food or drug.
V. NURSING REVIEW OF SYSTEMS
Nutrition – Metabolic Pattern
3
Before Admission:
As stated by the patient’s mother, the patient has good appetite. She drinks
breast milk as often as possible. The patient’s mother also claims that before
admission, the patient is a healthy child.
During Admission:
The patient’s mother claims that her child became thin due to her present
condition. The patient is still able to drink breast milk from her mother despite her
condition.
Elimination Pattern
Before Admission:
According to patient’s mother, her child defecates everyday. Stool is solid and
cylindrical in form. The color of patient’s stool is brownish or yellowish. According
to patient’s mother she changes her child’s diaper 2-3 times a day.
During Admission:
The patient’s mother claims that her child defecates watery ,yellowish to
brownish color of stool. She changes her child’s diaper 3-4 times a day.
Activity – Exercise Pattern
Before Admission:
4
According to patient’s mother, her child shows activeness while playing with
her toys and as well as playing with her.
During Admission:
The patient’s mother claims that her child seemed weak and cries upon
coughing.
Sleep – Rest Pattern
Before Admission:
According to patient’s mother, her child most of the time sleeps at home and
wakes up or cries whenever she wants to drink milk.
During Admission:
The patient cries and is not able to sleep properly because of present condition.
Role Relationship Pattern
Before Admission:
The patient’s mother claims that her child is able to interact and play with
people she is familiar with but cries whenever she sees someone unfamiliar to her.
During Admission:
5
The patient’s mother claims that her child is still able to interact and play with
people she is familiar with and still cries whenever she sees someone unfamiliar to
her.
VI. FAMILY, PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY
A. MEMBERS OF IMMEDIATE FAMILY
NAME AGE
POSITION
IN THE
FAMILY
EDUCATIONAL
ATTAINMENT
OCCUPATION
GENERAL
HEALTH
STATUS
Mr. H.C 29 Father Highschool
Graduate
Laborer Healthy
Mrs.
M.C
28 Mother Highschool
Graduate
Housewife Healthy
B. PERSONAL AND SOCIAL HISTORY
The patient is the only child of Mr. and Mrs. Castillano. Because she is the only
child, is well loved by her parents as well as her grandparents. The patient also cries upon
seeing an unfamiliar face approaching towards her.
C. ENVIRONMENTAL HISTORY
The patient’s mother said that their house is near the road where most vehicles
pass by. She also said that their house is made of cement and wood which is enough for
6
her family to live in. According to her, cockroaches and flies are present at their house.
They also own some appliances like television, radio and electric fan. They have an
electric and water connection. They live in a place where houses are near each other.
D. HEREDO – FAMILIAL HISTORY
The patient’s mother claimed that they have a family history of being
hypertensive but does not have any allergy to any kind of food or drug. They do not have
a family history of being asthmatic. On the patient’s father side, there is no known
serious condition. Aside from that, they have no other history of having serious illnesses.
VII. Physical Assessment:
GENERAL APPEARANCE
The patient was seen lying on bed, conscious, febrile, with her mother beside
her, with ongoing IVF # 2 D5.3% Nacl infusing well @ 22- 24 micro gtts/min on
right arm. With the following vital signs of:
Temperature – 38.4 ºC
Pulse rate – 168 bpm
Respiratory rate – 64 cpm
Skin
7
The patient has brown skin. Skin is smooth and soft to touch when being palpated.
No ecchymoses noted. There are no lesions and masses palpated. Skin is also warm to
touch with good turgor.
Hair
Patient’s hair is fine, proportionately distributed on the head with no greasy scales
on scalp noted. No presence of infestations noted. No tenderness upon palpation of scalp
noted.
Head
The shape of the patient’s head is symmetrical without depressions or bulging of
fontanel. The head is round in shape. No tenderness upon palpation noted.
Face
Able to smile and frown, face is symmetrical in contour, no masses palpated.
Eyes
Patient’s eyes are positioned symmetrically. Patient can see clearly and reacts on
moving objects. Patient’s eyes are not sunken, sclera is clear and moist.
Ears
Top of the ear is in lined with the imaginary line drawn from the outer cantus.
Both ears are symmetrical to each other. No presence of any drainage and tenderness
noted upon assessment.
8
Nose and Sinuses
Nose is symmetrical to both sides. Nasal flaring noted. No tenderness of sinuses
upon palpation. Nostrils are patent.
Mouth and Throat
Patient’s lips are intact and moist. Oral mucosa is moist and reddish in color.
Absence of lesions noted.
Neck
Able to hold her neck erect and at midline. Able to move neck from side to side
without difficulty. No swelling or masses noted. Trachea is symmetrical and in midline
position. Pulsation is felt in carotid artery. Lymph nodes are non- palpable.
Anterior Chest
Patient experiences tachypnea with respiratory rate of 64 cpm. Chest rises upon
inspiration and falls upon expiration. No tenderness lumps and nodules felt during
palpation. Crackles heard upon auscultation.
Posterior Chest
Posterior chest is symmetrical. No nodules and tenderness felt upon palpation.
Heart
No pulsations, heave or retractions. No murmurs heard upon auscultation.
9
Breast
No tenderness, masses or nodules noted upon palpation.
Abdomen
Abdomen is round and slightly protuberant. No swelling and tenderness noted.
Veins are not visible upon inspection. No abnormal sounds heard on abdomen upon
auscultation.
Female External Genitalia and Anus
No lesions noted. No tenderness noted upon palpation. Anus is patent.
Upper Extremities
Fingers, hands and wrist are straight. Elbows are at the same height and
symmetrical in appearance. Able to move arms and hands without pain. Capillary refill of
2 seconds. Able to grasp objects firmly.
Lower Extremities
Legs and thighs are slightly curved No lesions or edema noted. Able to move
legs and feet without any pain.
VIII. DEVELOPMENTAL DATA
Traditionally, infancy is designated as the period of time from 1 month to 1
year of age. In these important months, an infant undergoes such rapid development that
10
parents sometimes believe looks different and demonstrates new abilities each day.
During this time, an infant triples birth weight and increases length by 50%. A baby’s
senses sharpen and, with the process of attachment to caregivers, she forms a first social
relationship. Because of the growth and learning potential that occurs, this first year is a
crucial one. Without proper nutrition, a baby will not grow and physically thrive, and
without proper stimulation and nurturing care by consistent caregivers, an infant may not
develop a healthy interest in life or a feeling of security essential for future development.
Summary of Infant Growth and Development
Month Motor
Development
Fine Motor
Development
Socialization and
Language
Play
0-1 Largely reflex Keeps hands fisted;
able to follow object
to midline
Enjoys watching
face of primary
caregiver,
listening to
soothing sounds.
2 Holds head up when
prone
Has social smile Makes cooing
sounds;
differentiates cry
Enjoys bright-
colored mobiles
3 Holds head and
chest up when
prone
Follows objects past
midline
Laughs out loud Spends time
looking at hands
or uses them as
toy during the
month(hand
regard)
4 Grasp, stepping,
tonic neck reflexes
are fading
Needs space to
turn
11
5 Turns front to back;
no longer has head
lag when pulled
upright; bears
partial weight on
feet when held
upright
Handles rattles
well
IX. A. ANATOMY AND PHYSIOLOGY OF THE SYSTEMS INVOLVED
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The Respiratory system consists of the external nose, the nasal cavity, the
pharynx, the larynx, the trachea, the bronchi and the lungs. Although air frequently
passes through the oral cavity, it is considered to be part of the digestive system instead
of the respiratory system. The upper respiratory tract refers to the external nose, nasal
cavity, pharynx, and associated structures; and the lower respiratory tract includes the
larynx, trachea, bronchi, and lungs.
Nose
The nose consists of the external nose and the nasal cavity. The external nose is
the visible structure that forms a prominent feature of the face. Most of the external nose
is composed of hyaline cartilage, although the bridge of the external nose consists of
bone. The bone and cartilage are covered by connective tissue and skin.
13
The nasal cavity extends from the nares to the choane. The nares or nostrils, are
the external openings of the nose and the choane are the openings into the pharynx. The
nasal septum is a partition dividing the nasal cavity into left and right parts. A deviated
nasal septum occurs when the septum bulges to one side or the other. The hard palate
forms the floor of the nasal cavity, separating the nasal cavity from the oral cavity. Air
can flow through the nasal cavity when the mouth is closed or when the oral cavity is full
of food. Three prominent bony ridges called conchae are present on the lateral walls on
each side of the nasal cavity. The conchae increase the surface of the nasal cavity.
Paranasal sinuses are air-filled spaces within bone. The maxillary, frontal,
ethmoidal and sphenoidal sinuses are named after the bones in which they are located.
The paranasal sinuses open into the nasal cavity and are lined with a mucous membrane.
They reduce the weight of the skull, produce mucus, and influence the quality of the
voice by acting as resonating chambers. The nasolacrimal ducts, which carry tears from
the eyes, also open into the nasal cavity. Sensory receptors for the sense of smell are
found in the superior part of the nasal cavity. Air enters the nasal cavity through the
nares. Just inside the nares the epithelial lining is composed of stratified squamous
epithelium containing coarse hairs. The hairs trap some of the large particles of dust
suspended in the air. The rest of the nasal cavity is lined with pseudostratified columnar
epithelial cells containing cilia and many mucus-producing goblet cells. Mucus produced
by the goblet cells also traps debris in the air. The cilia sweep the mucus posteriorly to
the pharynx, where it is swallowed. As air flows through the nasal cavities, it is
humidified by moisture from the mucous epithelium and is warmed by blood flowing
through the superficial capillary networks underlying the mucous epithelium.
14
Pharynx
The pharynx is the common passageway of both respiratory and digestive
systems. It receives air from the nasal cavity and air, food, and water from the mouth.
Inferiorly, the pharynx leads to the rest of the respiratory system through the opening into
the larynx and to the digestive system through the opening into the larynx and to the
digestive system through the esophagus. The pharynx can be divided into three regions:
the nasopharynx, the oropharynx, and the laryngopharynx.
The nasopharynx is the superior part of the pharynx. It is located posterior to the
choaneae and superior to the soft palate, which is an incomplete muscle and connective
tissue partition separating the nasopharynx from the oropharynx. The uvula is the
posterior extension of the soft palate. The soft palate forms the floor of the nasopharynx.
The nasopharynx is lined with pseudostratified ciliated columnar epithelium that is
continuous with the nasal cavity. The auditory tubes extend form the middle ears open
into the nasopharynx. The posterior part of the nasopharynx contains the pharyngeal
tonsil, which aids in defending the body against infection. The soft palate is elevated
during swallowing, this movement results in the closure of the nasopharynx, which
prevents food from passing from the oral cavity into the nasopharynx.
The oropharynx extends from the uvula to the epiglottis, and the oral cavity opens
into the oropharynx. Food and drink all passes in the oropharynx. The laryngopharynx
passes posterior to the larynx and extends from the tip of the epiglottis to the
esophagus.The larynx (plural larynges), colloquially known as the voicebox, is an organ
in the neck of mammals involved in protection of the trachea and sound production. The
15
larynx houses the vocal folds, and is situated just below where the tract of the pharynx
splits into the trachea and the esophagus. Sound is generated in the larynx, and that is
where pitch and volume are manipulated. The strength of expiration from the lungs also
contributes to loudness.The trachea, or windpipe, is the bony tube that connects the nose
and mouth to the lungs, and is an important part of the vertebrate respiratory system.
When an individual breathes in, air flows into the lungs for respiration through the
windpipe. Because of its primary function, any damage incurred to the trachea is
potentially life-threatening.The bony skeletal trachea is comprised of cartilage and
ligaments, and is located at the front of the neck. The trachea begins at the lower part of
the larynx and continues to the lungs, where it branches into the right and left bronchi. It
measures 3.9 to 4.7 inches (10-12 cm) in length, and .62 to .7 inches (16-18 mm) in
diameter. The trachea is composed of 16 to 20 “c” shaped rings of cartilage connected by
ligaments, with a ciliated-lined mucus membrane. It is this structure that helps push
objects out of the airway should something become lodged.
Larynx
The larynx is the portion of the breathing, or respiratory, tract containing the
vocal cords which produce vocal sound. It is located between the pharynx and the
trachea. The larynx, also called the voice box, is a 2-inch-long, tube-shaped organ in the
neck.
We use the larynx when we breathe, talk, or swallow. Its outer wall of cartilage
forms the area of the front of the neck referred to as the "Adams apple". The vocal cords,
two bands of muscle, form a "V" inside the larynx.
16
Each time we inhale (breathe in), air goes into our nose or mouth, then through
the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air
goes the other way. When we breathe, the vocal cords are relaxed, and air moves through
the space between them without making any sound.
When we talk, the vocal cords tighten up and move closer together. Air from the
lungs is forced between them and makes them vibrate, producing the sound of our voice.
The tongue, lips, and teeth form this sound into words.
The esophagus, a tube that carries food from the mouth to the stomach, is just
behind the trachea and the larynx. The openings of the esophagus and the larynx are very
close together in the throat. When we swallow, a flap called the epiglottis moves down
over the larynx to keep food out of the windpipe.
Trachea
A tube-like portion of the breathing or "respiratory" tract that connects the "voice
box" (larynx) with the bronchial parts of the lungs.
Each time we inhale (breathe in), air goes into our nose or mouth, then through
the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air
goes out the other way.
The esophagus, the tube that carries food from the mouth to the stomach, is just
behind the trachea and the larynx. The openings of the esophagus and the larynx are very
17
close together in the throat. When we swallow, a flap called the epiglottis moves down
over the larynx to keep food out of the windpipe.
The trachea is also called the windpipe, weasand (sometimes written wesand or
wezand) or wesil. "Cut his weasand with thy knife." The Tempest, Shakespeare.
Bronchi
The trachea divides into left and right main (primary) bronchi. Each of which
connects to a lung. The left main bronchus is more horizontal than the right main
bronchus because of it is displaced by the heart. Foreign objects that enter the trachea
usually lodge in the right main bronchus, because it is more vertical than the left main
bronchus and threfore more in direct line with the trachea. The main bronchi extend from
the trachea to the lungs. Like the trachea, the main bronchi are lined with pseudostratified
ciliated columnar epithelium and are supported by C- shaped pieces of cartilage.
The large air tubes leading from the trachea to the lungs that convey air to and
from the lungs. The bronchi have cartilage as part of their supporting wall structure. The
trachea divides to form the right and left main bronchi which, in turn, divide to form the
lobar, segmental, and finally the subsegmental bronchi.
Bronchi is the plural of bronchus from the Greek word bronchos, a conduit to the lungs.
Lungs
The lungs are the principal organs of respiration. Each lung is cone-shaped, with
its base resting on the diaphragm and its apex extending superiorly to a point about 2.5
18
cm above the clavicle. The right lung has three lobes called the superior, middle and
inferior lobes. The left lung has two lobes called the superior and inferior lobes. The
lobes of the lungs are separated by deep, prominent fissures on the surface of the lung.
Each lobe is divided into bronchopulmonary segments separated from one another by
connective tissue septa, but these separations are not visible as surface fissures. There are
9 bronchopulmonary segments in the left lung and 10 in the right lung. The main bronchi
branch many times to form the tracheobronchial tree. Each main bronchus divides into
lobar bronchi as they enter their respectibe lungs. The lobar (secondary) bronchi, two in
the left and three in the right lung, conduct air to each lobe. The lobar bronchi in turn give
rise to segmental (tertiary) bronchi, which extends to the bronchopulmonary segments of
the lungs. The bronchi continue to branch many times, finally giving rise to bronchioles.
The bronchioles also subdivide numerous times to give rise to terminal bronchioles,
which then subdivide into respiratory bronchioles. Each respiratory bronchiole subdivides
to form alveolar ducts, which are like long, branching hallways with many open
doorways. The doorways open into alveoli which are small air sacs become so numerous
that the alveolar duct wall is little more than a succession of alveoli. The alveolar ducts
end as two or three alveolar sacs, which are chambers connected to two or more alveoli.
There are about 300 million alveoli in the lungs. As the air passageways of the lungs
becomes smaller, the structure of their walls changes. The amount of cartilage decreases
and the amount of smooth muscle increases, until at the terminal bronchioles, the walls
have a prominent smooth muscle layer, but no cartilage. Relaxation and contraction of
the smooth muscle within the bronchi and bronchioles can change the diameter of the air
passageways. For example, during exercise the diameter can increase, thus increasing the
19
volume of air moved. During an asthma attack, however, contraction of the smooth
muscle in the terminal bronchioles can result in greatly reduced air flow. In severe cases,
air movement can be so restricted that death results. As the air passageways of the lungs
become smaller, the lining of their walls also changes. The trachea and bronchi have
pseudostratified ciliated columnar epithelium, the bronchioles have ciliated simple
cuboidal epithelium. The ciliated epithelium of the air passageways functions as mucus-
cilia escalator, which traps debris in the air and removes it from the respiratory system.
The respiratory membrane of the lungs is where gas exchange between the air and blood
takes place. It is mainly of the alveoli and surrounding capillaries but there’s some
contribution by the alveolar ducts and respiratory bronchioles it is very thin to facilitate
the diffusion of gases.
Pleural cavity
In human anatomy, the pleural cavity is the body cavity that surrounds the lungs.
The pleura are a serous membrane which folds back upon itself to form a two-layered,
membrane structure. The thin space between the two pleural layers is known as the
pleural cavity; it normally contains a small amount of pleural fluid. The outer pleura
(parietal pleura) is attached to the chest wall. The inner pleura (visceral pleura) covers the
lungs and adjoining structures, viz. blood vessels, bronchi and nerves.
The pleural cavity, with its associated pleurae, aids optimal functioning of the
lungs during respiration. The pleural cavity also contains pleural fluid, which allows the
pleurae to slide effortlessly against each other during ventilation. Surface tension of the
20
pleural fluid also leads to close apposition of the lung surfaces with the chest wall. This
physical relationship allows for optimal inflation of the alveoli during respiration. The
pleural cavity transmits movements of the chest wall to the lungs, particularly during
heavy breathing. This occurs because the closely opposed chest wall transmits pressures
to the visceral pleural surface and hence to the lung itself.
IX. B. CONCEPTUAL FRAMEWORK ON THE CONDITION /
PATHOPHYSIOLOGY
PneumoniaEtiologic/ risk factors
Non infectious causes
Aspirati-on of food and water
Inflammation
Organisms penetrate airway mucosa
WBC migrate
Causes exudates collect in/ around alveoli
Organisms
Immune system unable to fight
From environ- ment and other people
Such as fungi, viruses & bacteria
Signs and symptoms
FatigueChillsFeverCough
21
Alveolar walls thicken
Hypoxemia Reduced gas exchange
Chest pain Sputum Production Dyspnea Tachypnea Crackles in lungs
IX. C. DISCUSSION ON THE CONDITION / PATHOPHYSIOLOGY
Upper airway characteristics normally prevent potentially infectious particles
from reaching the sterile lower respiratory tract. Pneumonia arises from normal flora
present in patients whose resistance has been altered or from aspiration of flora present in
the oropharynx; patients often have an acute or chronic underlying disease that impairs
host defenses. Pneumonia may also result from blood borne organisms that enter the
pulmonary circulation and are trapped in the pulmonary capillary bed. Pneumonia affects
both ventilation and diffusion. An inflammatory reaction can occur in the alveoli,
producing an exudate that interferes with the diffusion of oxygen and carbon dioxide.
White blood cells, mostly neutrophils, also migrate into the alveoli and fill the normally
air-containing spaces. Areas of the lung are not adequately ventilated because of
secretions and mucosal edema that cause partial occlusion of the bronchi or alveoli, with
a resultant decrease in alveolar oxygen tension. Bronchospasm may also occur in patients
with reactive airway disease. Because of hypoventilation, a ventilation-perfusion
mismatch occurs in affected area of the lung. Venous blood entering the pulmonary
circulation passes through the underventilated area and travels to the left side of the heart
poorly oxygenated. The mixing of oxygenated and unoxygenated or poorly oxygenated
blood eventually results in arterial hypoxemia. If a substantial portion of one or more
lobes is involved, the disease is refers to as “lobar pneumonia”. The term
“bronchopneumonia” is used to describe pneumonia that is distributed in patchy fashion,
having originated in one or more localized areas within the bronchi and extending to the
adjacent surrounding lung parenchyma. Bronchopneumonia is more common than lobar
pneumonia.
22
D. SYMPTOMATOLOGY
fever
chills
cough
tachypnea
breathing with grunting or wheezing sounds
labored breathing that makes a child's rib muscles retract (when muscles under the
rib cage or between ribs draw inward with each breath)
vomiting
chest pain
abdominal pain
decreased activity
poor feeding (in infants)
X. MEDICAL MANAGEMENT
A. TREATMENT AND PROCEDURES
Chest X-Ray –PA -A chest X-ray is a test that uses a small amount of radiation to
create an image of the structures within the chest, including the heart, lungs, blood
vessels and bones. A chest X-ray may be used to help diagnose and plan treatment
for various conditions, including lung disorders such as pneumonia.
Nebulization - To deliver medication by a fine mist that is inhaled directly into the lungs.
Medication used is Salbutamol which dilates bronchioles of patients having bronchospasm.
23
B. MEDICATIONS
Cefuroxime (Zinacef) – 180 g IVTT every 8 hrs.
Salbutamol (Ventolin)- 6 mc ½ nebule every 6 hrs.
Paracetamol (Calpol)- .8 ml every 4 hrs. for temperature >38ºC
Zinc Sulfate- 2ml OD
Protexin Balance- 1 cap BID mixed with 5ml H20
C. DIAGNOSTIC PROCEDURES
Complete Blood Count- An individual's white blood cell count can often give a hint
as to the severity of the pneumonia and whether it is caused by bacteria or a virus.
An increased number of neutrophils, one type of WBC, are seen in bacterial
infections, whereas an increase in lymphocytes, another type of WBC, is seen in
viral infections.
Urinalysis - The urinalysis is used as a screening and/or diagnostic tool because it
can help detect substances or cellular material in the urine associated with different
metabolic and kidney disorders. It is ordered widely and routinely to detect any
abnormalities that require follow up.
Stool exam- To determine whether you have pathogenic bacteria in your
gastrointestinal tract.
24
Diagnostic exam Result Normal valuesFecalysis Macroscopic
Cellular finding
color yellow soft in consistency Fat globules- moderate Bacteria – abundant
Hematology Hgb Hematocrit WBCWBC Differential Count Stab - Segmenter -
Lymphocyte Monocyte Eosinophil Basophil
Platelete
123g/L - .3720.30 x 10 /L
.14
.23
.63
000_1.0307 x 10 /L
120-160g/L0.37-0.495-10x 10 /L
150-400 x 10 /L
D. DIET
The patient is breastfed by mother which is her only source of nutrition. The
patient is breastfed as often as necessary.
XI. NURSING MANAGEMENT
A. ACTUAL CARE GIVEN
Care given to patient includes nebulization. Performed tepid sponge bath. Also
instructed SO to give paracetamol to patient when pt’s temperature is above normal
limits. Provided a clean environment for the patient to prevent exacerbation of patient
25
condition. . Frequent breastfeeding and promoting fluid intake was very much
encouraged because labored breathing may lead to insensible fluid loss that would lead
to dehydration if not monitored. Vital signs taking was also monitored every 4 hours. I
and O taken every shift.
B. PROBLEMS ENCOUNTERED DURING THE IMPLEMENTATION OF
NURSING CARE
I haven’t encountered any problem in implementing nursing care to the patient
because the patient’s mother was very cooperative. Even though the patient cries
whenever I get her vital signs, her mother was always there to help me that is why I
was able to manage taking care of the patient.
C. RESTORATIVE MEASURES USED
I was able to perform tepid sponge bath whenever the patient’s temperature is
above normal limits. I also assisted in nebulization of patient which promotes
bronchodilation. Thus, facilitates proper breathing. I also provided a clean and safe
environment for the patient.
D. EVALUATION
I think, what I have done is partially effective because patient’s condition was
slightly reduced to normal. Patient also has a certain time to rest to conserve energy.
Activities were limited and asked to adhere on a complete bed rest all the time with the
help of the significant others. Hydration is good as evidenced by an adequate fluid intake
and urine output and with a normal skin turgor. Patient’s complies with all management
26
strategies and also complies with treatment protocol and prevention strategies for her
sake.
E. PATIENT TEACHING
Patient education is crucial regardless of the setting and the proper administration
of antibiotics is important. In this case in which the patient is still 5 months old, she is
still dependent on her parents especially her mother to care for her.
In these instances, the patient is initially treated with intravenous antibiotics in
the hospital or may be in home setting. It is important that a seamless system of care be
maintained for the patient from hospital to home, this induces communication between
the nurses caring for this patient in both settings. In addition, oral antibiotics are
prescribed, the importance to teach the patient’s mother about proper administration and
potential side effects was greatly taught. Patient’s mother was also advised to avoid
exposing the patient to sudden changes in temperature that will further lower her immune
system. Adequate nutrition was greatly emphasized to patient’s mother to boost the
immune system.
XII.A. CONCLUSION
At first I was hesitant to approach the patient, but when I came to know her
significant others, especially her mother, my anxiety decreased and was able to mingle
with them accordingly. I never thought that family members of the patient would be that
warm and cooperative to me. With this study I have, I learned a lot of things in life.
Confidence in dealing with difficult situations, although encountered many times, will
still bother you. Because of the fact that different situation have different results, you tend
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to be anxious of the outcome. As a student nurse, we should be flexible in dealing with
situations so as to have a positive result. We should be responsible enough in any actions
that we do. We can be successful by our own little way with guidance from God. A
patient should always be treated well whatever the patient’s status might be. Perseverance
and determination will help us to succeed. Serving the needs of the ill is the primary role
of a nurse and that shall be enhanced as we go along our journey in life.
B. RECOMMENDATION
This case study promotes the growth and wellness of the patient and her parents,
as well as the nurse. Current trends and issues should be examined and undergo specific
observations to enlighten the minds of students in understanding an infant with
pneumonia. This case study is focused more especially as to with health care providers,
that would serve as a guideline on how to render effective nursing care to patients having
pneumonia. This would be of great help on how to manage those infant patients with
pneumonia who are physically not in a healthy state.
XIII. IMPLICATIONS OF THE STUDY TO:
A. NURSING EDUCATION
Aspiration is a common problem that can lead to Severe Pulmonary
complications, potential complications of aspiration include obstruction, inflammation
and infection. Nursing assessment and knowledge of risk factors are key in evaluating
patient at risk for potential aspiration problems and preventing this complication. The
focus of this study is in the optimal health of the patient and to know the complications it
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may lead. As a student nurse, it is very important in our field that we both have
knowledge and competent skills that we may apply in the near future.
B. NURSING PRACTICE
Nursing is the diagnosis and treatment of human responses to health and illness
and therefore, focuses on a broad array of any phenomena. Knowledge, skills and ability
should always come together. Knowledge alone is not enough neither skills nor ability is
not enough. It is an important factor that we perform nursing actions considering its
rationale and principles for it guides us in the care that we give to our patients. Skill
needs to be mastered as we go through the journey of the field we choose to have.
C. NURSING RESEARCH
Nursing research is designed to help solve particular, existing problems so there
is a much larger audience eager to support research that is likely to be profitable or solve
problems of immediate concern. Much medical research on pneumonia with considerable
impact is a good example. Some sort of research is required to support normal decision-
making. Just as nursing is dynamically changing, so is with the nursing research. We
should be updated in laboratory test and procedures that are constantly changing over
time.
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