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I. INTRODUCTION

A. Overview of the study

Community-acquired pneumonia (CAP) is an infection of the alveoli,

distal airways, and interstitium of the lungs that occurs outside the hospital

setting. Characterized clinically by, Fever, chills, cough, pleuritic chest pain,

sputum production and at least one opacity on chest radiography. Manifests

as four general patterns : Lobar pneumonia: involvement of an entire lung

lobe, Bronchopneumonia: patchy consolidation in one or several lobes,

usually in dependent lower or posterior portions centered around bronchi and

bronchioles, Interstitial pneumonia: inflammation of the interstitium, including

the alveolar walls and connective tissue around the bronchovascular tree and

Miliary pneumonia: numerous discrete lesions due to hematogenous spread

Epidemiology of Community acquired pneumonia incidence: U.S, 800–

1500 cases per 100,000 persons annually, Affects 4 million adults per year,

~20% require hospitalization and annual cost: $9.7 billion : Incidence highest

at extremes of age, rate higher among men than among women, more

common among African Americans than among whites and more common

during the winter months.

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.

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B. Objectives and Purpose of the Study

This study generally aims to investigate the condition of a client and

further understand the extent of the case. Specifically the student nurse

sought

to:

Perform Physical Assessment, Data Base and History Taking that

solidifies the present diagnosis of the client.

Identify Signs and Symptoms associated with the disorder.

Identify priority nursing problems which will be the basis of the care

plan.

Develop Plan of Care and Implement nursing interventions relevant

and suitable to the case.

· Evaluate the effectiveness of the interventions and detect any

progress or regression of the client’s disease condition.

The purpose of the study is to gather significant data to broaden our

knowledge of the disease process and to improve my abilities as future

healthcare provider. This is done to be able to aid in the recovery process of

the client. Moreover this case study will enable me to apply the acquired skills

we have obtained in the classroom set-up.

C. Scope and Limitation of the Study

The scope of the study consists of one pedia ward client of the Talakag-

Bukidnon Provincial Hospital. Significant others was interviewed specially her

mother to know more about the client and her condition. The time period for

which the study was conducted and completed, was constrained and limited

to a span of 1 week. The first assessment done was last December 9, 2010,

at around 8:00 am. Then continuous assessment was done in the span of my

duty in the said ward from December 9 and 10 2011.The said assessment

dates were maximized to gather of information including profile, data base,

history of present illness, chart data and many others.

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D. SPOT MAP

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II. HEALTH HISTORY

A. Patients Profile

Name of Patient: XX

Sex: female

Age: 1 year and 5 months

Birthday: July 15, 2009

Birthplace: Talakag, Bukidnon

Religion: Roman Catholic

Civil Status: Child

Educational Attainment: Not applicable (our pt. is still an infant)

Mother: MG

Father: AG

Number of Siblings: 1( she is the only child)

Nationality: Filipino

Date Admitted: December 9, 2010

Time Admitted: 12:15 am

Informant: Mother

Temperature: 36.0̊ C

Pulse Rate: 138 bpm

Respiration: 40 cpm

Attending Physician: Dr. Joseph J. Borong, M.D.

B. Family & Past Health History

My patient XX was born through a normal vaginal delivery. she had completed

all her immunization. She has not received any blood from the past. It was his

first time to be admitted in the hospital. She has no known food and medicine

allergies. The patient had no previous history of surgery.She had experienced

cough, colds, and fever that don’t necessitate the patient to be admitted at the

hospital. Although she had an asthma her mother manage it well at home.

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C. Chief Complains and History of Present Illness

Patient XX, a 1 year and 5 month old child from Talakag, Bukidnon was

admitted for the first time due to fever and productive cough , with the initial

vital signs of: temperature- 36.0 ˚C, respiratory rate- 44 cpm, and a pulse rate

of 138 bpm. 2 days prior to her condition, XX experienced low-grade fever,

productive cough with watery nasal discharge. Due to this instance, her

mother brought her to BPH - Talakag and was then admitted with the

diagnosis of Pedia Community-Acquired Pneumonia .

III. DEVELOPMENT DATA

Sigmund Freud’s Theory (Psychosexual Theory)

The 0-2 years of age is under the oral stage of Freud’s psychosexual

theory. Early in your development, all of your desires were oriented towards

your lips and your mouth, which accepted food, milk, and anything else you,

could get your hands on (the oral phase). The first object of this stage was, of

course, the mother's breast, which could be transferred to auto-erotic objects

(thumbsucking). The mother thus logically became your first "love-object,"

already a displacement from the earlier object of desire (the breast). When

you first recognized the fact of your father, you dealt with him by identifying

yourself with him; however, as the sexual wishes directed to your father grew

in intensity, you became possessive of your father and secretly wished your

mother out of the picture (the Electra complex). This electra complex plays out

throughout the next two phases of development. Feeding, crying, teething,

biting, thumbsucking, weaning - the mouth and the breast are the centre of all

experience. The infant's actual experiences and attachments to mum (or

maternal equivalent) through this stage have a fundamental effect on the

unconscious mind and thereby on deeply rooted feelings, which along with the

next two stages affect all sorts of behaviours and (sexually powered) drives

and aims - Freud's 'libido' - and preferences in later life. XX is under the oral

stage of Freud’s psychosocial theory in which she find more pleasure in

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sucking his thumb every time she is going to bed. I had also observed that XX

is a papa’s girl because she won’t go to sleep unless her mother would carry

her.

Erik Erikson’s Theory

The infant will develop a healthy balance between trust and mistrust if fed

and cared for and not over-indulged or over-protected. Abuse or neglect or

cruelty will destroy trust and foster mistrust. Mistrust increases a person's

resistance to risk-exposure and exploration. "Once bitten twice shy" is an apt

analogy. On the other hand, if the infant is insulated from all and any feelings

of surprise and normality, or unfailingly indulged, this will create a false sense

of trust amounting to sensory distortion, in other words a failure to appreciate

reality. Infants who grow up to trust are more able to hope and have faith that

'things will generally be okay'. This crisis stage incorporates Freud's

psychosexual Oral stage, in which the infant's crucial relationships and

experiences are defined by oral matters, notably feeding and relationship with

mum. Erikson later shortened 'Basic Trust v Basic Mistrust' to simply Trust v

Mistrust, especially in tables and headings. Hope & Drive (faith, inner calm,

grounding, basic feeling that everything will be okay - enabling exposure to

risk, a trust in life and self and others, inner resolve and strength in the face of

uncertainty and risk). My patient is irritable and crying when she cannot see

her mom or when her mom is not around. But when her mother came and he

recognized the voice, the touch, XX will stop from crying.

Jean Piaget’s Theory (Cognitive Theory)

Sensorimotor stage. In this period, intelligence is demonstrated through

motor activity without the use of symbols. Knowledge of the world is limited

(but developing) because it’s based on physical interactions / experiences.

Children acquire object permanence at about 7 months of age (memory).

Physical development (mobility) allows the child to begin developing new

intellectual abilities. Some symbolic (language) abilities are developed at the

end of this stage. My patient learns many things by what she saw. At this

moment she is still developing his motor skills. she is aware only of their

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sensations, fascinated by all the strange new experiences his bodies is

having. She like little scientists exploring the world by shouting at, listening to,

banging and tasting everything.

Robert Havinghurst’s Theory (Developmental Task)

Havinghurst believes that learning is basic to life and people continue to learn

throughout life. He describes growth and development as occurring in six

stages, each associated from task to be learned. Havinghursts promoted the

Developmental task in 1950’s which arises at a certain period in the life of an

individual. Successful achievement of the task leads to happiness and to

succeed in the next task. Failure to achieve a task leads to sadness of an

individual, disapproval in the society and difficulty with later task.

Kohlberg’s Theory (Moral Development Theory)

The conventional level of moral reasoning is typical of adolescents and

adults. Those who reason in a conventional way judge the morality of actions

by comparing them to society's views and expectations. The conventional

level consists of the third and fourth stages of moral development.

Conventional morality is characterized by an acceptance of society's

conventions concerning right and wrong. At this level an individual obeys rules

and follows society's norms even when there are no consequences for

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obedience or disobedience. Adherence to rules and conventions is somewhat

rigid, however, and a rule's appropriateness or fairness is seldom questioned.

 

In Stage three (interpersonal accord and conformity driven), the self

enters society by filling social roles. Individuals are receptive to approval or

disapproval from others as it reflects society's accordance with the perceived

role. They try to be a "good boy" or "good girl" to live up to these

expectations, having learned that there is inherent value in doing so. Stage

three reasoning may judge the morality of an action by evaluating its

consequences in terms of a person's relationships, which now begin to

include things like respect, gratitude and the "golden rule". "I want to be liked

and thought well of; apparently, not being naughty makes people like me."

Desire to maintain rules and authority exists only to further support these

social roles. The intentions of actions play a more significant role in reasoning

at this stage; "they mean well ...”

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IV. MEDICAL MANAGEMENT

A. DOCTORS ORDER

IDEAL DOCTOR’S ORDER

Therapeutics:

1.Antibiotic regimen as listed above for 7-14 days

2.Berodual nebulization (10 gtts in 3ml NSS) q 6 hours and prn 3.Switch therapy: Intravenous antibiotic treatment may be shifted to oral antibiotics after 48-72 hours if the following parameters are fulfilled(a)there is less cough and resolution of respiratory distress (normalization of respiratory rate),(b) the temperature is normalizing,(c) the etiology is not a high risk(virulent/resistant) pathogen, (d) there is no unstable co-morbid conditions or life-threatening complications, and (e) oral medications are tolerated.

4.Fo abundant secretions,may give Acetylcysteine (Fluimucil) 100mg or 200 mg sachet dissolved in ½ glass H2O TID . Discontinue if patient has wheezing.

MEDICAL PROCEDURES

INTRAVENOUS THERAPY

Intravenous therapy or IV therapy is the giving of liquid substances

directly into a vein. It can be intermittent or continuous; continuous

administration is called an intravenous drip. The word intravenous simply

means "within a vein", but is most commonly used to refer to IV therapy.

Therapies administered

intravenously are often called specialty pharmaceuticals.

Compared with other routes of administration, the intravenous route is the

fastest way to deliver fluids and medications throughout the body. Some

medications, as well as blood transfusions and lethal injections, can only be

given intravenously.

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NEBULIZATION

It is the process of using a nebulizer that changes liquid medicine into

fine droplets (in aerosol or mist form) that are inhaled through a mouthpiece or

mask Nebulizers is used to deliver bronchodilator (airway-opening) medicines

such as albuterol or ipratropium bromide. Nebulizers are hand-held machines

with an airflow meter that measures oxygen flow. These machines administer

a variety of medications. Nebulizers vaporize this mixture and deliver it as a

fine mist or steam. Nebulizers are usually used in the hospital or nursing

home setting.Disposable nebulizers are often sent home with a patient and

are cleaned and reused for a limited time.

TEPIDS SPONGE BATH

Tepid sponging is a time honored and well known method of reducing

the elevated temperature. Tepid sponging is useful as an immediate but

transient measure in bringing down the temperature and it should always be

supplemented with drugs like paracetamol for a longer antipyretic effect. A

tepid sponge bath relieves fever without cooling the body too fast. Eighty

degrees Fahrenheit is still 20oF below body temperature and yet warm

enough not to drive blood from the skin, thereby preventing the cooling from

getting to the body's core. Limbs are bathed first and then the chest,

abdomen, back, and buttocks. Tepid baths should be 80-93oF (26.7-34oC).

B. LABORATORY TEST

(-Not assessed due to the unavailability of the results.)

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V. PATHOPHYSIOLOGY & ANATOMY AND PHYSIOLOGY

A. PATHOPHYSIOLOGY PEDIA COMMUNITY ACQUIRED

PNEUMONIA

B. ANATOMY AND PHYSIOLOGY

In humans, the trachea divides into the two main bronchi that enter the roots

of the lungs. The bronchi continue to divide within the lung, and after multiple

divisions, give rise to bronchioles. The bronchial tree continues branching until

it reaches the level of terminal bronchioles, which lead to alveolar sacs.

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Alveolar sacs are made up of clusters of alveoli, like individual grapes within a

bunch. The individual alveoli are tightly wrapped in blood vessels and it is

here that gas exchange actually occurs. Deoxygenated blood from the heart is

pumped through the pulmonary artery to the lungs, where oxygen diffuses into

blood and is exchanged for carbon dioxide in the hemoglobin of the

erythrocytes. The oxygen-rich blood returns to the heart via the pulmonary

veins to be pumped back into systemic circulation.

Human lungs are located in two cavities on either side of the heart. Though

similar in appearance, the two are not identical. Both are separated into lobes

by fissures, with three lobes on the right and two on the left. The lobes are

further divided into segments and then into lobules, hexagonal divisions of the

lungs that are the smallest subdivision visible to the naked eye. The

connective tissue that divides lobules is often blackened in smokers. The

medial border of the right lung is nearly vertical, while the left lung contains a

cardiac notch. The cardiac notch is a concave impression molded to

accommodate the shape of the heart. Lungs are to a certain extent 'overbuilt'

and have a tremendous reserve volume as compared to the oxygen exchange

requirements when at rest. Such excess capacity is one of the reasons that

individuals can smoke for years without having a noticeable decrease in lung

function while still or moving slowly; in situations like these only a small

portion of the lungs are actually perfused with blood for gas exchange. As

oxygen requirements increase due to exercise, a greater volume of the lungs

is perfused, allowing the body to match its CO2/O2 exchange requirements.

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Additionally, due to the excess capacity, it is possible for humans to live with

only one lung, with the other compensating for its loss.

The environment of the lung is very moist, which makes it hospitable for

bacteria. Many respiratory illnesses are the result of bacterial or viral infection

of the lungs. Inflammation of the lungs is known as pneumonia; inflammation

of the pleura surrounding the lungs is known as pleurisy.

Vital capacity is the maximum volume of air that a person can exhale after

maximum inhalation; it can be measured with a spirometer. In combination

with other physiological measurements, the vital capacity can help make a

diagnosis of underlying lung disease.

The lung parenchyma is strictly used to refer solely to alveolar tissue with

respiratory bronchioles, alveolar ducts and terminal bronchioles.[4] However, it

often includes any form of lung tissue, also including bronchioles, bronchi,

blood vessels and lung interstitium.[4]

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VI. NURSING REVIEW CHART

IV. PHYSICAL ASSESSMENT

NURSING SYSTEM REVIEW CHART

Name: XXDate: December 9, 2010Vital Signs:Pulse:138 bpm BP: N/a Temp: 36.0 Respi: 40 cpm

EENT [] impaired vision [] blind[] pain reddened [] drainage [] gums [] hard of hearing [] deaf [] burning [] edema [] lesion teeth[] asses eyes, ears, nose[] throat for abnormality [X] no problemRESPIRATION [] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [X] cough [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [x] wheezing[] pain [] cyanotic[] assess resp rate, rhythm, depth, pattern[] breath sounds, comfort []no problem GASTRO INTESTINAL TRACT[] obese [] distention [] mass [] dysphagia [] rigidly [] pain [] asses abdomen, bowel habits, swallowing [] bowel sounds, comfort [X]no problemGENITO-URINARY and GYNE[] pain [] urine color [] vaginal bleeding[] hematuria [] discharge [] nocturia[] assess urine freq., control, color, odor, comfort[] grip, gait, coordination, speech, [X]no problemNEURO[] paralysis [] stuporous [] unsteady [] seizure[] lethargic [] comatose [] vertigo [] tremors[] confused [] vision [] grip[] assess motor function, sensation, LOC, strength[] grip, gait, coordination, speech, [X]no problem2MUSCULOSKELETAL and SKIN[] appliance [] stiffness [] itching [] petechiae[] hot [] drainage [] prosthesis [] swelling[] lesion [] poor turgor [] cool [] deformity[] atrophy [] pain [] ecchymosis [] diaphoretic[] assess mobility, motion, gait, alignment, joint function

[] skin color, texture, turgor, integrity [x] no problem

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Expelled white sputum

Wheezing sound heard upon auscultation

Productive cough observed

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VII. NURSING MANAGEMENT

A. IDEAL NURSING MANAGEMENT

PATIENT XX

CUES NURSING DX OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S:

“ arang2x na gani ni

yang ubo karon”

As verbalized by the

mother

O:

cough

restlessness

expelled white

sputum

Ineffective

airway

clearance

related to

increased

amount of

secretion

At the end of 30

mins the patient

will be able to

expectorate

secretions &

improve /

maintain airway

clearance.

> facilitate maintainace of

patient upper airway by proper

positioning

> assist w/ coughing/ deep

breathing exercises position

changes

> increase fluid intake

>administer Salbutamol per

doctors order 1 neb q 6o

> altered level of

consciousness, sedation

are some condition that

alters pt. to project

airways

> for easy expectoration

of secretions

>oral fluid intake may

liquefy secretion/

enhance expectorant

>to improve ventilation &

facilitate removal of

secretions

Goal partially m

pt. was able to

expectorate

secretion which

is the white

sputum &

improve airway

clearance

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Patient: XX

CUES NURSING DX OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S:

“ sige sya ug hilak,

gipangita niya iya

papa”

As verbalized by the

mother

O:

crying

restlessness

Anxiety related to

separation from

support system

in potential

stressful situation

like

hospitalization

At the end of 30

mins the patient

will be able to

demonstrate

relief from

somatic

manifestation of

anxiety

> maintain home routines

whenever possible. Encourage

bring child’s toys or pillows.

> help family support child

emotionally by being available,

active and listening

> provide child w/ choices

when possible

> promote family interactions

> use of age appropriate

object enhance sense of

security when child is

being hospitalized

> conveys acceptance of

the child & confidence in

ability to cope w/

situation

>promotes sense of

control, demonstrate

regard for individual

> family involvement in

activities promotes

continuity of family unity

> goal partially

met, patient

demonstrate

from

manifestation on

anxiety

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B. ACTUAL NURSING MANAGEMENT

S “”

O cough

restlessness

expelled white sputum

A Ineffective airway clearance related to

increased amount of secretion

P At the end of 30 mins the patient will be

able to expectorate secretions & improve /

maintain airway clearance.

I> facilitate maintainace of patient upper airway

by proper positioning

- altered level of consciousness, sedation are some

condition that alters pt. to project airways

> assist w/ coughing/ deep breathing exercises

position changes

- for easy expectoration of secretions

> increase fluid intake

- oral fluid intake may liquefy secretion/ enhance

expectorant

>administer Salbutamol per doctors order 1 neb

q 6o

- to improve ventilation & facilitate removal of

secretions

EDemonstrate improved ventilation and oxygenation

of tissues by ABG within clients acceptable range.

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S “”

O crying

restlessness

A Anxiety related to separation from support

system in potential stressful situation like

hospitalization

P At the end of 30 mins the patient will be

able to expectorate secretions & improve /

maintain airway clearance.

I> maintain home routines whenever possible.

Encourage bring child’s toys or pillows.

- use of age appropriate object enhance sense of

security when child is being hospitalized

> help family support child emotionally by being

available, active and listening

- conveys acceptance of the child & confidence in

ability to cope w/ situation

> provide child w/ choices when possible

-promotes sense of control, demonstrate regard for

individual

> promote family interactions

- family involvement in activities promotes continuity

of family unity

E > goal partially met, patient demonstrate

from manifestation on anxiety

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C. DRUG STUDY

NAME OF

DRUG

DATE

ORDERED

CLASSIFICATION DOSE/

FREQUENCY/

ROUTE

MECHANISM

OF ACTION

SPECIFIC

INDICATION

CONTRAINDICATION SIDE EFFECTS NURSING

PRECAUTION

SALBUTAMOL December

9, 2010

Brochodilator 1 neb q 6 beta2-adrenergicbronchodilator

InhalationSolution is indicated for the relief ofbronchospasm. This drug relaxesthe smooth muscle in the lungsand dilates airways to improvebreathing.

Contraindicated

w/

hypersensitivity to

salbutamol;

tachyarrytmias,

tachycardia

causes by

digitalis

Cases of urticaria,angioedema, rash,bronchospasm,hoarseness,oropharyngeal edema,and arrhythmias(including atrialfibrillation,supraventriculartachycardia,extrasystoles) have beenreported after the use ofsalbutamol

- Do not take any of thesemedications without consultingyour doctor (even if you never hada problem taking them before).- Do not allow anyone else to takethis

medication.

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NAME OF

DRUG

DATE

ORDERED

CLASSIFICATION DOSE/

FREQUENCY/

ROUTE

MECHANISM

OF ACTION

SPECIFIC

INDICATION

CONTRAINDICATION SIDE EFFECTS NURSING

PRECAUTION

Ampicillin

Gentamicin

December 9,

2010

December 9,

2010

Antibiotic

Aminoglycoside

250 mg q8

IVTT

15 mg q 8

IVTT

Bactericidal;

inhibits

synthesis of

bacteria on

the cell wall

causing cell

death

Inhibits

protein

synthesis in

susceptible

gram neg.

bacteria

appears to

disrupt

functional

integrity of

bacterial cell

membrane

Treatment of

infection caus

strains of

shigella

salmonella,

E.Coli,

haemophillus

influenzae

Serious

infection

caused by

pseumodomas,

E.coli, serios

infection when

causative

agent is not

known

Allergy to

penicillins

With allergy to

drug

aminoglycoside

CNS: Lethargy

CV: heartfailure

GI: gastritis

Hypersensitivity:

Rashes, fever

CNS:Otoxicity

CV: Palpitaion

GI: Hepatic

toxicity

>check IV site

for signs of

thrombosis

>cultureinfected

area

>check for

reaction of

allegy to

aminoglycoside

> check the site

of infection.

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VIII. REFERRAL AND FOLLOW – UP

Once the client will be discharged, we had instructed her mother encouraged

my client to drink her home medications religiously to prevent further infection.

We have also instructed her mother to let her daughter have a daily exercise

like deep breathing pattern and teach the mother some of the range of motion

exercises in order to promote proper blood circulation and attain proper

oxygenation. And We have also reminded her mother to stick with her diet

and to have adequate amount of it to meet nutritional needs and attain full

wellness.

IX. EVALUATION AND IMPLICATION

At the end of my hospital duty, We were able to render care to my patient to

help him resolve his health condition. Through observing the patient’s status,

we able to identify priority problems related to his health. The patient’s mother

was willing to pursue the medical therapy just to promote health and wellness

for the betterment of her son’s condition. We have also made the patient’s

mother realize the importance of completing the course of therapy by taking

the medicines prescribed or ordered for her daughter by his physician. In

addition, eating healthy or nutritious foods that were prescribed to her by the

health providers was further been explained to her mother especially the

benefits she will gain in eating those foods. Moreover, this several

interventions given to the patient made her body conditioning normal and We

can say that our patient has somehow recovered from her illness.

X. DOCUMENTATION

(None, we have no written consent that will allow us to take a picture/

photo of the said client.)

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