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PANPACIFIC UNIVERSITY NORTH PHILIPPINES

Urdaneta City, Pangasinan

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 Father 25 Male none 1st Year


Highschool

4th Year
Highschool
Marilyn Oligo Mother 23 Female none

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 Birth to for both I observed that she depends


Psychosocial male and primarily to her mother to feed
Theory (Trust 12-18 female her. Yet there were times she
vs. Mistrust months would respond when her
Stage) 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.
Jean Piaget’s for both I noticed that she always play
Cognitive male and with her favorite toy. She
Development female pushes and pulls the toy car
(Sensorimotor and knows what button to press
Stage) so she can hear the sound. She
could immediately recognize a
syringe and cries. She always
Birth to tried to reach out for my
age 2 thermometer everytime I
finished taking her
temperature.

Lawrence for both I observed that the mother


Kohlberg’s male and could not immediately make her
Moral female daughter stop crying even if
Development she would mention scary things
(Pre- that might show up if she did
Conventional not stop.
Level)

for
children

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 inspection fair-skinned, no
discoloration and
hyperpigmentations
> texture palpation smooth, soft
> temperature palpation warm to touch
> moisture palpation moist due to perspiration

Nails
> color of nailbed inspection pink and clean
> texture palpation smooth
> shape inspection convex curvature
> nail base inspection firm

Hair
> color inspection black
> distribution inspection evenly distributed
> moisture inspection not excessively dry or oily
> texture inspection fine, silky, resilient

Eyes
> eyebrows inspection symmetrically aligned,
equal movement
> eyelashes inspection slightly curved upward
> eyelids inspection smooth, pink, close
symmetrically
> ability to blink inspection blinks voluntarily and
bilaterally
> ocular movement inspection eyes move freely
> size inspection medium
> texture palpation mobile, firm, not tender
> conjunctiva inspection transparent with light
color, shiny and smooth, no
lesions
> cornea inspection clear, shiny, smooth,
transparent
> pupils inspection equal size, round and
constricts briskly, equally
reactive light,

Nose
> symmetry, shape, inspection
size and color symmetrical, smooth and
> mucosa color inspection fair
> nasal septum inspection pinkish
> nasal discharge inspection oval and symmetrical nares
> sinuses palpation with clear discharges
not tender

Mouth
> lips inspection pinkish, symmetrical, soft
and moist
> gums inspection pinkish and moist
> buccal mucosa inspection pinkish, soft, moist
> tongue inspection pinkish, small, symmetrical
> uvula inspection at the midline
> teeth inspection 6 milk teeh

Heart
> heart rate auscultation 140 bpm
> heart sounds auscultation clear

Thorax and Lungs


> symmetry inspection symmetrical
> respiratory rate inspection 56 bpm
> breathing inspection irregular, with effort
pattern
> lung/breath auscultation wheezes
sounds
Abdomen
> contour inspection flat
> texture palpation smooth
> frequency and auscultation soft gurgling sound
character

Upper Extremities
> skin color inspection fair
> size inspection equal and appropriate for
her body
> symmetry inspection symmetrical

Lower Extrremities
> skin color inspection fair
> size inspection equal and appropriate for
her body
> symmetry inspection symmetrical

Neurologic
> level of interview responds quickly when name
consciousness was being called
> behavior and interview makes eye contact, normal
appearance behavior of a toddler
> mood interview irritable
> mannerisms and interview likes to cuddle to her
actions 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
• 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.

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

Hematocrit (Hct) 0.39 M=0.40-0.50; F=0.37-0.42


White Cell Count 5.9 5-10 X 109/L

Differential Count

Segmenters 0.64 0.55-0.65

Lymphocytes 0.36 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.