PRESENTATIO
N
COMMUNITY ACQUIRED
PNEUMONIA III
February 19, 2010
GROUP 93
The Presentors
•
Bumatay, Allan
•
Corpuz, leo
•
Garcia, carla
•
Garcia, krystal
•
GOMEZ, GENELLE
•
Ibañez, Jesus D.C.III
•
ISLES, KRIS EVERT
•
Jereos, Abigail Raejoy A.
•
Lapiña, Danica M.
•
Legaspi, Rochelle Glureen B.
•
Licarte, Charlene Mae M.
•
Introduction
• 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.
Objectives
This case study significantly identifies the factors
that gave rise for our client to have the diagnosed
problem. The ff. are the identified objectives for
the case study
• To develop a comprehensive assessment of the
client.
• To establish a pathophysiology for the disease of
the client.
• To develop a nursing care plan appropriate for
the client’s diagnosed problem.
• To be able to teach the mother of the client for
proper health maintenance.
• To lessen the risk of infection and development of
complications of the client.
• To be able to provide an environment conducive
for health.
• To enhance the care that will be given for other
client’s with the same diagnosis.
BIOGRAPHIC
DATA
Name: CL
Address: Sto. Nino,Meycauayan
Bulacan
Age: 8
Marital Status: NA
Room and Bed number: Room 214-C
Chief Complaint: Fever
Diagnosis: Community Acquired
Pneumonia III
Attending Physician: Dra. Lea Dilag
Gender: Female
Reigion: Pentecostal
NURSING
HEALTH
HISTORY
PAST HEALTH
HISTORY
CL has Bronchial asthma in acute
exacerbation. It was 2004 when she
was first diagnosed with the supposed
illness. Her mother stated that she had
complete immunizations. She does not
have any allergies. When she was five
years old, CL fell-off her bicycle. Her
mother performed first aid treatment
by cleansing the wound with running
water and betadine. That wound left
her a scar on the right ankle. Other
than that, she had not encountered
PAST HEALTH
HISTORY
She had two hospital admissions prior
to her recent condition. In 2005, she
was first admitted to SCDMMC due to
Pneumonia then she was hospitalized
again last 2008 due to typhoid fever.
She is currently taking Paracetamol Jr.
for her fever with Flumuicil and
Duavent for her asthma. She does not
take any vitamin supplements. In April
2005, her family went to Hongkong for
their vacation trip and to witness the
Grand Opening of Hongkong Disney
land.
HISTORY OF
PRESENT ILLNESS
One day prior to her condition, CL
experienced low-grade fever,
productive cough with watery
nasal discharge. Due to this
instance, her mother brought her
to SCDMMC and was then
admitted with the diagnosis of
Community-Acquired Pneumonia
III.
FAMILY HISTORY
The client has familial history of
hypertension and asthma. CL’s mother
said that her mother-in-law has
hypertension and her father-in-law has
asthma.
GENOGRAM
JL LL LEGEND:
ASTHMA
EL CL
(50 y/o) (50y/o)
JFL CL NL
(23 y/o) (8 y/o) (19 y/o)
Developme
ntal
History
Emotional Health
• The child said that her problems would only
include academic activities. She does not
want to be sick and absent because she said
she would miss school. She is active in school
activities. She belongs to a class of excellent
students. Her mother said that her teacher
does not find any particular problem with her
at all. Her greatest fear is the darkness. CL
said that she would only cry when her
brother teased her or when her parents scold
her.
Social Health
• She has a good relationship with her family. She stated
that she is bonded with her family members. She also has good
relationship with her teachers, schoolmates and playmates. She allots time
for self-enjoyment. Her hobby includes artworks. She loves to draw. She
also verbalized that she is active in school. In fact, she joins athletic
activities. Her favorite is obstacle race. When her father is available, they
would often play badminton. Computer games serve as her bonding activity
with her brothers. Walking around the school and eating are her friends’
past time. She has variety of toys to share with her playmates and cousins.
She is always provided with time to play and mingle with them.
Cognitive Patterns
• The child said that she does well in school. She excels in their
academic subjects most especially in Mathematics. She had
won in Quiz Bee last school’s fest with bronze medal. She
belongs to a class of excellent students. She is proud of her
achievements in school. She said that her parents are glad
about it. She is always present in class. She would only be
absent in times of sickness. She loves to do her homework and
likes to recite during class discussions.
Language
• She has good language skills. She speaks
Filipino fluently and is able to understand
English language. She attentively answered to
the questions presented. She would set
examples when asked to describe a situation.
She had an explorative mind. She too listened
carefully and was very eager to answer.
Self-Concept
• She has no physical defects.
• She is an active girl, very
attentive and smart. The
child verbalized, “Gusto ko
maging doktor at saka
teacher paglaki ko.”
SPIRITUAL HEALTH
Religious Beliefs and Practices
• The child belongs to Christian-
Pentecostal religion. Her mother
said that CL also does the things that people
usually do as Christians. Every Sunday they
would go to their church and attend their
mass. CL still believes in God Almighty. Her
mother stated that they just don’t believe in
spiritual images and does not worship
saints.
Moral Development
The child at
her age has a good
understanding about
the concept of good
and bad. She knows the simple bad
deeds that she has to avoid. She said
that she is being scolded by her
parents when she had done bad things
such as being naughty sometimes. She
understands that her wrong deeds
have corresponding punishments.
•Physical Assessment
NORMS ACTUAL FINDINGS INTERPRETATION &
(Based on Fundamentals of ANALYSIS
Nursing 8th Edition, by
Kozier, et al., published by
Pearson Education Inc.,
©2008, pp. 572 – 641)
General Appearance
Posture/gait Relaxed, erect posture; Posture is slightly Physical difficulty can
Coordinated movement slouching affect the posture and
gait of a person. This
may be accompanied by
observable physical
responses. (Medical-
Surgical Nursing 8th
Edition, by Black &
Hawks, published by
Saunders Inc., ©2009, p.
613)
INTEGUMENTARY
A. Skin
d. palpate skin Moisture in skin folds The client’s skin has Normal
moisture moisture in skin
folds.
f. palpate for skin When pinched ,skin When pinched skin Normal
turgor springs back to previous returns back to its
state previous state
•Physical Assessment
B. NAILS
a. inspect Convex curvature; angle Convex curvature; Normal
fingernail plate of nail pate about 160° angle is 160°
shape to
determine its
curvature and
angle
G. IRIS Color brown, flat and round Color brown and round Normal
Shape and color in shape
H. PUPILS Black in color equal in size, Pupils are equal; round Normal
Color, shape, normally 3-7 mm in diameter, and reacts to light
and size round, smooth borders accommodation, color
black, 6 mm
•Physical Assessment
I. VISUAL Able to identify Able to identify Normal
ACUITY Near pictures; pictures
vision
Distance vision
B. External Ear Distal third contains hair The client’s external Normal
Canals follicles and glands, and ear canal has no
Cerumen, skin tha external ear canals haslesions, pus, and
Lesions, pus cerumen. blood and has
And blood presence of
cerumen.
Nasal cavities: Mucosa is pink and no Discharges are seen. Discharges from the
>Redness, watery discharge and nasal cavity are often
swelling, lesions influenced by the
Growths, and increased secretion of
discharge mucus, and/or brought
about by allergic
reaction. (Fundamentals
of Nursing 8th Edition, by
Kozier, et al., published
by Pearson Education
Inc., ©2008, p. 613)
•Physical Assessment
Nasal septum Nasal septum is in the Intact and in the Normal
midline midline
Nasal cavity Air moves freely as the client The air moves freely Air movement is
patency breathes through the nares on the left side, and restricted in one nares
obstructed on the right since the client has
side. increased mucus
production.
(Fundamentals of
Nursing 8th Edition, by
Kozier, et al., published
by Pearson Education
Inc., ©2008, p. 613)
D. Gums Gums should be pink and smooth Pale gums, dry when mouth breathing, the
Color, Pink gums; firm texture; moist brain thinks carbon dioxide is
condition being lost too quickly and
sensing this, will stimulate the
goblet cells to produce
mucous, slow the breathing
and cause constriction of
blood vessels.
(http://www.breathing.com/art
icles/nose-breathing.htm)
•Physical Assessment
E. Tongue/ Floor of The tongue relaxed on the Pink color of the Dry/furry tongue may
the Mouth floor of the mouth tongue. indicate or be associated
Surface of the Smooth tongue base; Slightly rough. Semi with fluid deficiency.
tongue prominent veins. moist, move freely, (Fundamentals of Nursing
For position ,color, Smooth moves freely; no central position, 8th Edition, by Kozier, et
texture and tongue tenderness. smooth with no al., published by Pearson
movement palpable nodules. Education Inc., ©2008, p.
Nodules, lumps or Functions normally. No 603)
enlarged lymph tenderness.
F. Palates & Uvula Light pink hard palate, more Light pink, smooth (soft Normal
>Palate color, irregular texture palate)
shape, texture and The uvula is normally Lighter pink, more
body prominence centered and freely movable. irregular texture (hard
>Position of uvula palate)
and mobility The uvula is at the
center and freely
movable.
G. Oropharynx & Pink and smooth posterior Tonsils are pink and Normal
Tonsils wall symmetric in size,
Color, texture Tonsils are small, pink and Grade 1 tonsils
Tonsils color symmetric in size.
Discharge
H. Gag Reflex Present Present Normal
•Physical Assessment
NECK AND LYMPH NODES
A. LYMPH NODES Not palpable Lightly enlarged Enlarged, palpable, possibly
Locate/palpate/ submandibular lymph tender lymph nodes are
identify lymph nodes node often associated with
and note for infection and tumors
tenderness (Fundamentals of Nursing
8th Edition, by Kozier, et al.,
published by Pearson
Education Inc., ©2008, p.
607)
Percussion each of Tympany over the stomach Tympany and gas Normal
the four quadrants and gas-filled bowels; filled bowels; dull
dullness, especially over the abdomen
liver and spleen, or a full
bladder
•Physical Assessment
MUSCULOSKELETAL
Muscles: Equal size on both sides of Equal size on both Normal
>Size the body; no contractures; no sides of the body; no
>Tendons for fasciculation or tremors; contractures or
contractures normally firm; smooth shortenings; no
>Fasciculation and coordinated movements; fasciculation or
tremors equal strength on each body tremors; normally firm;
>Palpate muscle side equal leg strength,
tonicity
>Muscle Strength
1. 300 Mucolytic Treatment of respiratory infection MAO inhibitor therapy within Bronchospasm, 1. Monitor
ACETYLCYSTEINE MG(NEB) OD Agent characterized by thick and 14 days initiating therapy; angioedema, pruritus, effectiveness of
(Fluimucil) viscous hyper secretions: Acute severe HPN; severe CAD; nausea and vomiting, therapy and advent of
Bronchitis, Chronic Bronchitis and hypersensitivity to syncope, sweating, fever,allergic/adverse effect.
its exacerbation, Pulmonary Pseudoedephrine, acrivastine arthralgia, blurred vision, 2. Instruct client in
emphysema and bronchiectasis or any component; renal disturbances of liver appropriate use and
impairment function adverse effect to
report.
2. IPRATROPIUM (Neb) TID Antiasthmatic prevent wheezing, difficulty Hypersensitivity to so lecithin Headache, dizziness, Teach the client about
SALBUTAMOL and COPD breathing, chest tightness, and and other related products like cough, sinusitis, dry the medication;
(Duavent) preparation coughing in people with chronic soybean and peanuts, and to cough, dyspnea, Assess for allergy
obstructive pulmonary disease any component of Duavent, bronchitis, dry mouth, before administration
(COPD atropine and its derivatives, rash, pain, and at the peak of
Hypertophic obstructive hypersensitivity reaction administration; Check
cardiomyopathy or or evaluate the client
tachyarrhythmia after giving the
medication.
3. Paracetamol 325 mg Tab Non-opiod Acute pain treatment There are no absolute Occasional GI side effect Monitor SBS of
q4 analgesic contraindications but in patient may occur but these are hepatomegaly esp. in
with gastric ulceration relative almost invariably mild. individuals with poor
caution should be observed. nutrition; Don’t take
other medications
containing
acetaminophen
without medical
advice; Patient and
family education
• Upper Respiratory Tract
• Nose Inspiration and expiration usually
occurs through the nose. The nose has main
two functions: The cilia and hairs which line
the nasal cavities trap dust and other foreign
particles and the rich supply of blood
surrounding the cavities warms the air
before it enters the lungs.
Pharynx Allows for separation of food and
air. The epiglottis closes the trachea when
we eat and opens when we breathe.
• Lower Respiratory Tract
Larynx This structure sits on top of the trachea. Air rushing across
two ligaments causes sounds that we shape into speech. Also
called the voice box.
Trachea Also called the windpipe
• Bronchi The trachea branches into two forks each called a bronchi