PANPACIFIC UNIVERSITY NORTH PHILIPPINESUrdaneta City, Pangasinan

A

CASE STUDY

ON

PNEUMONIA

Submitted by:GARCIA, Neil A.

BSN-3EGroup 6

Submitted to:Ms. Joann Guzman, RNClinical Instructor

September, 2009

I. PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA1. Patient’s Name: K. I.2. Address: Sison, Pangasinan3. Age: 1 y/o & 1 mo.4. Sex: Female5. Birth Date: July 18, 20086. Rank in the Family: 1st child7. Nationality: Filipino8. Civil Status: Single (child)9. Date of Admission: August 30, 200910. Order of Admission:

> Please admit order re service of Dr. Callanta> secure consent> I & O every shift & record> Monitor VS q 4° & record> DAT with SAP> Dx with CBC, CXR> IVF D5 0.3 NaCl 500cc X 37-38 ugtts/min> Cefuroxime 250mg IVP q 8° ANST (-)> Pediatapp drops 1ml TID> Salbutamol + Ipratopium ½ neb q 6°> Paracetamol drops 100mg/ml 1ml q 4° prn for fever> E-zinc drops 1ml OD> refer accordingly

11. Attending Physician: Dr. Callanta, MD

B. CHIEF COMPLAINT

Cough and difficulty of breathing for one week, fever for three days prior to admission

C. HISTORY OF PRESENT ILLNESS

One week prior to admission, K. O. had positive signs and symptoms of cough and yellowish phlegm followed with fever, three days before admission. Her mother knowing that these signs and symptoms were just the usual cough that her daughter had, she gave her carbocisteine drops for her cough and paracetamol drops for her fever. However, she noticed no changes so she decided to bring her to Pozorrubio Municipal Hospital. She was diagnosed of Pneumonia and because of the severity of the condition, she was admitted. She was given initial medications and has had her for further observations and laboratory exams.

D. PAST HEALTH HISTORY/STATUS

K. O. had measles when she was around 10-month old. According to her mother, she frequently had colds which were almost every month. She said that her daughter only had BCG vaccine. She never brought her daughter back for other immunization. The mother told me that her daughter never had operations or injuries. Everytime her daughter got sick, she would ask medicines from their Barangay Health Center. These would include medicines like Ambroxol drops, Cotrimoxazole drops, and Paracetamol drops. She recalled buying Zeditapp (Phenylpropanolamine HCl) drops for her daughter’s colds. Sometimes they would result using boiled oregano leaves for her cough.

E. FAMILY ASSESSMENT

Name Relation Age Sex Occupation EducationalAttainment

Reynaldo Oligo

Marilyn Oligo

Father

Mother

25

23

Male

Female

none

none

1st Year Highschool

4th Year Highschool

F. SYSTEMS REVIEW (applicable only for patients that are 3 years old and above)

G. HEREDO-FAMILIAL ILLNESS

Maternal – kidney diseases, asthmaPaternal – hypertension, asthma

H. DEVELOPMENTAL HISTORY

Theorist Age Sex Patient DescriptionErik Erikson’sPsychosocial Theory (Trust vs. Mistrust Stage)

Jean Piaget’s

Birth to 12-18 months

Birth to

for both male and female

for both

I observed that she depends primarily to her mother to feed her. Yet there were times she would respond when her grandmother and aunt gives her food. I have seen that she is most calm when breastfeeding. I sometimes tried to make funny faces and she smiled once in a while.I noticed that she always play

Cognitive Development(Sensorimotor Stage)

Lawrence Kohlberg’sMoral Development (Pre-Conventional Level)

age 2

for children

male and female

for both male and female

with her favorite toy. She pushes and pulls the toy car and knows what button to press so she can hear the sound. She could immediately recognize a syringe and cries. She always tried to reach out for my thermometer everytime I finished taking her temperature.

I observed that the mother could not immediately make her daughter stop crying even if she would mention scary things that might show up if she did not stop.

I. PHYSICAL ASSESSMENT

A. General Survey

The patient is awake and sitting on bed. She appeared to be clean with her unsoiled clothes on, well- trimmed nails and with baby cologne. There is no noticeable physical deformities or abnormalities. Her size is appropriate to her age. There is observable difficulty of breathing and coughing. She seemed to be irritable and exhausted from crying.

The patient’s weight is 9.3 kgs and her height is 71.12 cms. At one year and 1 month, the ideal body weight is 7.5 -12 kgs and the optimal weight is 9 kgs, therefore she is within the range and very near the optimal weight. The ideal height at her age is within the range of 67 - 80 cms with the optimal height of 74 cms wherein the patient’s height is still within the range.

B. Vital Signs

T: 37.2 °CRR: 56 bpmCR: 140 bpm

C. Regional Exams

Area Assessed Techniques Used FindingsSkin> color

> texture> temperature> moisture

inspection

palpationpalpationpalpation

fair-skinned, no discoloration and hyperpigmentationssmooth, softwarm to touchmoist due to perspiration

Nails> color of nailbed> texture> shape> nail base

inspectionpalpationinspectioninspection

pink and cleansmoothconvex curvaturefirm

Hair> color> distribution> moisture> texture

inspectioninspectioninspectioninspection

blackevenly distributednot excessively dry or oilyfine, silky, resilient

Eyes> eyebrows

> eyelashes> eyelids

> ability to blink

> ocular movement> size> texture> conjunctiva

> cornea

> pupils

inspection

inspectioninspection

inspection

inspectioninspectionpalpationinspection

inspection

inspection

symmetrically aligned, equal movementslightly curved upwardsmooth, pink, close symmetricallyblinks voluntarily and bilaterallyeyes move freelymediummobile, firm, not tendertransparent with light color, shiny and smooth, no lesionsclear, shiny, smooth, transparentequal size, round and constricts briskly, equally reactive light,

Nose> symmetry, shape, size and color> mucosa color> nasal septum> nasal discharge> sinuses

inspection

inspectioninspectioninspectionpalpation

symmetrical, smooth and fairpinkishoval and symmetrical nareswith clear dischargesnot tender

Mouth> lips inspection pinkish, symmetrical, soft

and moist

> gums> buccal mucosa> tongue> uvula> teeth

inspectioninspectioninspectioninspectioninspection

pinkish and moist pinkish, soft, moistpinkish, small, symmetricalat the midline6 milk teeh

Heart> heart rate> heart sounds

auscultationauscultation

140 bpmclear

Thorax and Lungs> symmetry> respiratory rate> breathing pattern> lung/breath sounds

inspectioninspectioninspection

auscultation

symmetrical56 bpmirregular, with effort

wheezes

Abdomen> contour> texture> frequency and character

inspectionpalpationauscultation

flatsmoothsoft gurgling sound

Upper Extremities> skin color> size

> symmetry

inspectioninspection

inspection

fairequal and appropriate for her bodysymmetrical

Lower Extrremities> skin color> size

> symmetry

inspectioninspection

inspection

fairequal and appropriate for her bodysymmetrical

Neurologic> level of consciousness> behavior and appearance> mood> mannerisms and actions

interview

interview

interviewinterview

responds quickly when name was being calledmakes eye contact, normal behavior of a toddlerirritablelikes to cuddle to her mother

II. PERSONAL/ SOCIAL HISTORYK.O. is only 1 y/o and 1 month. Any data pertaining to this section cannot be established at her age.

III. ENVIRONMENTAL HISTORY (LIVING/NEIGHBORHOOD/CIRCUMSTANCES)The family belongs to the poverty line. They live in an area near mountainside. They need to walk far to be able to reach roads where they are vehicles going to the nearest town. That only means they have no immediate access to health centers and hospitals when they need to. They were not able to meet some of their basic needs simply because of their living condition.

IV. PEDIATRIC HISTORY

A. Maternal and Birth HistoryDate of birth: July 18, 2008Birth weight: 6 lbs. (as recalled by the mother)Type of delivery: normal deliveryCondition after birth: normal, no complications after

birthHospital: mother gave birth at their house by a “hilot”

B. MotherComplications of delivery: there were no complications as

recalled by the motherAnesthesia: no anesthesiaExposure to teratogens: none

V. INTRODUCTION

Pneumonia is an inflammation of the lungs caused by an infection. Many different organisms can cause it, including bacteria, viruses, and fungi. It can range from mild to ssevere, even fatal. The severity depends on the type of organism causing pneumonia, as well as our age and underlying health.

Causes of Pneumonia

Pneumonia is not a single disease. It can have over 30 different causes. There are five main causes of Pneumonia.

Bacteria Viruses Mycoplsmas Other infectious agents such as fungi – including

pneumocystis Various chemicals

Symptoms

The main symptoms of pneumonia are:

Cough with greenish or yellow mucus; bloody sputum happens on occasion

Fever with shaking chills Sharp or stabbing chest pain worsened by deep breathing

or coughing Rapid, shallow brething Shortness of breath

Additional symptoms include:

Headache Excessive sweating and clammy skin Loss of appetite Excessive fatigue Confusion in older people

Signs and Tests

Chest x-ray Gram’s stain and culture of the sputum for the organism

causing the symptoms CBC to check white blood cel count; if high, this

suggests bacterial infection CAT scan on the chest Pleural fluid culture if there is fluid in the space

surrounding the lungs

Treatment

If the cause is bacterial, the goal is to cure the infection with antibiotics. If the cause is viral, antibiotics

will not be effective. In some cases, it is difficult to distinguish between viral and bacterial pneumonia, so antibiotics may be prescribed.

Many people treated at home with antibiotics. If there is an underlying chronic disease, severe symptoms, or low oxygen levels, it will likely require hospitalization for intravenous antibiotics and oxygen therapy. Infants and the elderly are more commonly admitted for treatment of pneumonia.

If at home:

Drink plenty of fluids to help loosen secretions and bring up phlegm

Get lots of rest. Have someone else do household chores Control your fever with aspirin or acetaminophen. Do not

give aspirin to children.

When in the hospital, respiratory treatments to remove secretions mat be necessary. Occasionally, steroid medications may be used to reduce wheezing if there is an underlying lung disease.

Complications

Empyema or lung abscesses are infrequent, but serious, complications of pneumonia. They occur when pockets or pus around or inside the lung. These may sometimes require surgical drainage.

Prevention

Wash hands frequently, especially after blowing the nose, going to the bathroom, diapering, and before eating or preparing foods.

Don’t smoke. Tobacco damages the lung’s ability to ward off infection.

Wear a mask when cleaning dusty or moldy areas

Vaccines can help prevent pneumonia in children, the elderly, and people with diabetes, asthma, emphysema, HIV, cancer, or other chronic conditions

Pneumococcal vaccine (Pneumovax, Prevnar) prevents Streptococcus pneumonia

Flu vaccine prevents pneumonia and other infections caused by Influenza viruses. It must be given yerly to protect against new viral strains

Hib vaccine prevents pneumonia in children from Haemophilus influenza type b.

VI. ANATOMY AND PHYSIOLOGY

The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in and disposing of those gases.Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body.Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.

VII. PATHOPHYSIOLOGY

Predisposing Etiology Precipitating Factors Factors

Age Virulent Microorganisms Lifestyle Sex Streptococcus Pneumoniae Environment

Microorganism enters the nose (nasal passages)

Passes to the Pharynx, Larynx, Trachea

Microorganism enters and affects both airwayand lung parenchyma

Airway Damage Lung Invasion

Infiltration of Bronchi Flattening of Epithelial Cells

Infectious organism lodgesstimulation in bronchioles macrophages and

LeukocytesAlveolar wall collapse

mucus and phlegmIncrease pyrogen in production

the body COUGHING

FEVER necrosis of bronchialtissue

narrowing of air passage

DIFFICULTY OF BREATHING

necrosis of pulmonarytissue

overwhelming sepsis

DEATH

VIII. LABORATORY AND DIAGNOSTIC PROCEDURES

Hematology Report

Examination Requested: CBC

Parameter Actual Result Normal Values SI UnitsHemoglobin (Hgb)

Hematocrit (Hct)

White Cell Count

Differential Count Segmenters Lymphocytes

128

0.39

5.9

0.640.36

M=140-170g/L; F=120-150g/L

M=0.40-0.50; F=0.37-0.42

5-10 X 109/L

0.55-0.650.25-0.35

Chest X-ray

Streaky densities are seen on both lung fieldsHeart is not enlarged with undilated aortaLung vascularity is within normalBone, soft tissue of the chest wall are unremarkable

Impression : Pneumonia

IX. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY (P + E)

A. Ineffective airway clearance related to increased sputum production in response to respiratory infection

B. Impaired gas exchange related to collection of mucus in airways

C. Infection related to invading bacterial organismsD. Discomfort related to respiratory distressE. High risk for altered nutrition (less than body

requirements) related to lack of appetite

XII. ONGOING APPRAISAL

September 1, 2009It was being recommended by the attending physician that

the patient needs to stay at the hospital for further observations since it was seen that the disease at this point of the treatment process still cannot be managed at home by medications only.

XIII. DISCHARGE PLAN (HEALTH TEACHINGS)

Take the entire course of any prescribed medications. After a patient’s temperature returns to normal, medication must be continued according to the doctor’s instructions, otherwise the pneumonia may recur. Relapses can be far more serious than the first attack.

Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse.

Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs.

Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected. It’s important to have the doctor monitor his progress.

Encourage the guardians to wash patient’s hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter one’s body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk.

Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.

Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed.

Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isn’t possible, a person can help protect others by wearing a face mask and always coughing into a tissue.