PANPACIFIC UNIVERSITY NORTH PHILIPPINES
Urdaneta City, Pangasinan
A
CASE STUDY
ON
PNEUMONIA
Submitted by:
GARCIA, Neil A.
BSN-3E
Group 6
Submitted to:
Ms. Joann Guzman, RN
Clinical Instructor
September, 2009
I. PATIENT ASSESSMENT DATA BASE A. GENERAL DATA
1. Patient’s Name: K. I. 2. Address: Sison, Pangasinan 3. Age: 1 y/o & 1 mo.
4. Sex: Female
5. Birth Date: July 18, 2008 6. Rank in the Family: 1st child
7. Nationality: Filipino
8. Civil Status: Single (child)
9. Date of Admission: August 30, 2009 10. 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 Educational Attainment 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, asthma Paternal – hypertension, asthma
H. DEVELOPMENTAL HISTORY
Theorist Age Sex Patient Description
Erik Erikson’s Psychosocial Theory (Trust vs. Mistrust Stage) Birth to 12-18 months for both male and female
I observed that she depends primarily to her mother to feed her. Yet there were times she would respond when her
Jean Piaget’s Cognitive Development (Sensorimotor Stage) Lawrence Kohlberg’s Moral Development (Pre-Conventional Level) Birth to age 2 for children for both male and female for both male and female
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 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 °C RR: 56 bpm CR: 140 bpm
C. Regional Exams
Area Assessed Techniques Used Findings Skin > color > texture > temperature > moisture inspection palpation palpation palpation fair-skinned, no discoloration and hyperpigmentations smooth, soft warm to touch
moist due to perspiration
Nails > color of nailbed > texture > shape > nail base inspection palpation inspection inspection
pink and clean smooth convex curvature firm Hair > color > distribution > moisture > texture inspection inspection inspection inspection black evenly distributed
not excessively dry or oily fine, silky, resilient
Eyes > eyebrows > eyelashes > eyelids inspection inspection inspection symmetrically aligned, equal movement
slightly curved upward smooth, pink, close symmetrically
> ability to blink > ocular movement > size > texture > conjunctiva > cornea > pupils inspection inspection inspection palpation inspection inspection inspection
blinks voluntarily and bilaterally
eyes move freely medium
mobile, firm, not tender transparent with light color, shiny and smooth, no lesions
clear, shiny, smooth, transparent
equal size, round and
constricts briskly, equally reactive light,
Nose
> symmetry, shape, size and color > mucosa color > nasal septum > nasal discharge > sinuses inspection inspection inspection inspection palpation
symmetrical, smooth and fair
pinkish
oval and symmetrical nares with clear discharges not tender Mouth > lips > gums > buccal mucosa > tongue > uvula > teeth inspection inspection inspection inspection inspection inspection
pinkish, symmetrical, soft and moist
pinkish and moist pinkish, soft, moist
pinkish, small, symmetrical at the midline 6 milk teeh Heart > heart rate > heart sounds auscultation auscultation 140 bpm clear
Thorax and Lungs
> symmetry > respiratory rate > breathing pattern > lung/breath sounds inspection inspection inspection auscultation symmetrical 56 bpm
irregular, with effort wheezes
Abdomen > contour > texture > frequency and character inspection palpation auscultation flat smooth
soft gurgling sound
Upper Extremities > skin color > size > symmetry inspection inspection inspection fair
equal and appropriate for her body symmetrical Lower Extrremities > skin color > size > symmetry inspection inspection inspection fair
equal and appropriate for her body symmetrical Neurologic > level of consciousness > behavior and appearance > mood > mannerisms and actions interview interview interview interview
responds quickly when name was being called
makes eye contact, normal behavior of a toddler irritable
likes to cuddle to her mother
II. PERSONAL/ SOCIAL HISTORY
K.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 History
Date of birth: July 18, 2008
Birth weight: 6 lbs. (as recalled by the mother) Type of delivery: normal delivery
Condition after birth: normal, no complications after birth
Hospital: mother gave birth at their house by a “hilot”
B. Mother
Complications of delivery: there were no complications as recalled by the mother
Anesthesia: no anesthesia Exposure 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 s severe, 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
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.
I. 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.
II. 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 airway
and lung parenchyma
Airway Damage Lung Invasion
Infiltration of Bronchi Flattening of
Epithelial Cells Infectious organism lodges
stimulation in bronchioles macrophages and
Leukocytes Alveolar wall collapse
mucus and phlegm
Increase pyrogen in production
the body
COUGHING FEVER necrosis of bronchial
tissue
narrowing of air passage
DIFFICULTY OF BREATHING
necrosis of pulmonary tissue
overwhelming sepsis
DEATH
III. LABORATORY AND DIAGNOSTIC PROCEDURES Hematology Report
Examination Requested: CBC
Parameter Actual Result Normal Values SI Units
Hemoglobin (Hgb) Hematocrit (Hct) 128 0.39 M=140-170g/L; F=120-150g/L M=0.40-0.50; F=0.37-0.42
White Cell Count Differential Count Segmenters Lymphocytes 5.9 0.64 0.36 5-10 X 109/L 0.55-0.65 0.25-0.35 Chest X-ray
Streaky densities are seen on both lung fields Heart is not enlarged with undilated aorta Lung vascularity is within normal
Bone, 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 organisms D. Discomfort related to respiratory distress
E. High risk for altered nutrition (less than body requirements) related to lack of appetite
XII. ONGOING APPRAISAL
September 1, 2009
It 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.
