CAGAYAN COLLEGES TUGUEGARAOCOLLEGE OF HEALTH

A case Study on Severe Pneumonia

Submitted by: Dennis F. GallardoSubmitted to: Robert Balungaya, RN

GENERAL OBJECTIVE

After this case study, I will be able to know what Pneumonia is, causes of

Pneumonia, how it is acquired and prevented, its treatments and prevention

of the occurrence of Pneumonia

SPECIFIC OBJECTIVES

After the completion of this study, I will be able to:

o Define what is Pneumonia

o Trace the pathophysiology of Pneumonia

o Enumerate the different sign and symptoms of Pneumonia

o Identify and understand different types of medical treatment necessary

for the treatment of Pneumonia

o Formulate and apply nursing care plans utilizing the nursing process

INTRODUCTION

Pneumonia is characterized by inflammation of the alveoli and terminal

airspaces in response to invasion by an infectious agent introduced into the

lungs through hematogenous spread or inhalation. The inflammatory cascade

triggers the leakage of plasma and the loss of surfactant, resulting in air loss

and consolidation. This is in contrast to pneumonitis, which is caused by

noninfectious agents such as radiation or chemicals.

An inhaled infectious organism must bypass the host's normal

nonimmune and immune defense mechanisms in order to cause pneumonia.

The nonimmune mechanisms include aerodynamic filtering of inhaled

particles based on size, shape, and electrostatic charges; the cough reflex;

mucociliary clearance; and several secreted substances (eg, lysozymes,

complement, defensins). Macrophages, neutrophils, lymphocytes, and

eosinophils carry out the immune-mediated host defense.

Conditions that allow pneumonia-causing infectious organisms to circumvent

the upper airway defense mechanisms include the following:

Intubation, tracheostomy, impaired cough reflex, and aspiration: These

conditions provide infectious organisms with easier access to the

alveoli and terminal airspaces.

Ciliary dyskinesia, bronchial obstruction, viral infection, cigarette

smoke, and certain chemical agents: These conditions create

disruption in the mucociliary blanket.

Anatomic abnormalities (eg, sequestrations), gastric fluid aspiration or

other causes of noninfectious inflammation, altered pulmonary blood

flow, and pulmonary edema: These conditions increase the

predisposition for pneumonia.

Immunodeficiency and immunosuppression: These conditions increase

predisposition for pneumonia.

Mortality/Morbidity

The United Nations Children's Fund (UNICEF) estimates that 3 million children

die worldwide from pneumonia each year. Although most fatalities occur in

developing countries, pneumonia remains a significant cause of morbidity in

industrialized nations.

I have chosen this case Pneumonia because it may catch one’s attention,

though the disease is just like an ordinary cough and fever, it can lead to

death especially when no intervention or care is done. Since this case is a

child, an appropriate care has to be done to make the patient’s recovery

faster. Treating patients with pneumonia is necessary to prevent its spread to

others and make them as another victim of this illness.

PATIENT’S PROFILE

Name: J.V.

Address: 181, Ninada Street, Lltex road, Quezon City

Age: 4yrs. and 4 months

Birthday: December 28, 2004

Sex: Male

Nationality: Filipino

Religion: Roman Catholic

Date & Time of Admission: January 18, 2009 (07:00 am)

Mode of Arrival: cuddled by mother

Chief Complaint: abdominal pain, cough and colds

Source of Information: patient, & chart, SO

Admitting Diagnosis: severe Pneumonia

Final Diagnosis: severe Pneumonia

Attending Physician: Dr. Karen Lorenzo MD

NURSING HISTORY

PAST MEDICAL HISTORY

According to the patient SO, he had completed his childhood

immunization. He had no allergy to foods or medications. He experienced

common diseases such as fever, cough and colds she usually took OTC drugs

(Paracetamol syrup, Neosep syrup) to manage his fever cough and colds.

On June 2006 the patient was admitted at Government Hospital due to ilues.

HISTORY OF PRESENT ILLNESS

According to the SO, 3 days prior to admission the patient experienced

sudden onset of squeezing pain at Para gastric area aggravated by activity.

No meds taken or consultation made.

2 days PTA the patient still have the same abdominal pain, this time

was more severe, and associated with DOB and fever of 38°C. His mother

gave him paracetamol. No consultation was made.

Few hours PTA, the patient could not any more tolerate the pain; he

was brought to EAMC hence he admitted.

FAMILY HEALTH HISTORY

According to the patient SO, both his maternal and paternal have a

history of Cancer, PTB, and Bronchial Asthma. PTB is evident on the patient’s

grand father and uncle while cancer and bronchial asthma is evident on the

patient aunt.

Personal/ Social History

The patient is the 4th among 6 siblings. He was lived with 7 other

households’ member. His father work as a garbage collector and his mother

is a house wife they consumed or used tap not boiled water.

PATHOPHYSIOLOGY

Predisposing factor Etiology Precipitating factorAge S. pneumoniae UPTIImmune defenses environment

Immune defenses

Infecting organism enter in the airway

Activation of defense mechanism

Failure to penetrate the pathogen is secreted or dies Pathogen

Pathogen reached the lungs

Pathogen multiplies in the alveoli

Inflammation irritation of airway

Exudates come from Goblet cellBacteria erode the lung mucus Dead space occluded the production happened Air way

Cough cracklesCO2 pagocytosis

Hyperventilation WBC fever chill altered LOC

RR

Impaired O2 and CO2

consolidadtion exchange

Hypoxia

Trigger the kidney

Released of erythropoietin

Long bones RBC

PHYSICAL ASSESSMENT

Date assessed: May 25, 2009Time: 10:30pmInitial vital signs: T=37.9 PR=140bpm RR=25cpmGeneral Appearance: the patient is conscious and coherent with ongoing of D5NM 500ml at 750cc level hook at his left arm, intact and infusing well.

Area Assessed

Technique Normal Findings

Actual Findings Evaluation

skinMoisture

Inspection/Palpation

Skin normally dry Skin is moist d/t hyperthermi

aTemperature Palpation Normally warm 37.9 o C d/t

hyperthermia

Hair Texture

Inspection/ Palpation

Smooth Rough Due t o poor hygiene

Nose and TeethNares

Inspection Oval, symmetric and withoutdischarge

Oval, symmetric but withdischarge

Due to the presence of colds

Teeth Inspection Firmly set, shiny Firmly set, shiny with tooth decay

Due to poor hygiene

Thorax and Lungs

Auscultation Clear breath sounds

Presence of breath sound

Due to congestion

LABORATORY RESULTS

HEMATOLOGY RESULTSMay 18, 2009 Parameter Normal Value Results AnalysisWBC 5-10 x 10 g/L 18.1 Increased due to

infection Hgb M 140-170g/dl 165 Increased due to

infection Hct M 39%-54% .30 DecreasedRBC 4.6- 10 g/l 10.4 Increase due t o

hypoxiaDifferential Count

Lymphocytes 20%-40% .50 Increased due to

infection

PEARSON’S FUNCTIONAL HEALTH PATTERN

Date and Time of Interview: May 25, 2009 (11:00 PM)

Functional Heath Pattern

Before hospitalization

During hospitalization

Psychological The patient is 4yrs and 4 months old

The patient looks pale due to his current condition.

Elimination According to the SO, the patient usually void 5 to 6 times a day. He doesn’t have any problem in voiding.

According to the SO, the patient void 3-4 times a day. Have a 240 ml/ shift yellow amber color urine and dark

brown stool. Rest and Sleep According to the SO, the

patient usually spends his time for playing and sleeping. He sleeps for about 6-8 hours at night.

The patient can’t sleep well because of the hospital routines.

Safety and Security His SO provides all the safety and security that he need

The SO together with his health care providers make him safe and secured.

Oxygenation The patient has difficulty in breathing prior to hospitalization

The patient had difficulty of breathing due to his condition

Nutrition The patient usually eats 2 -3 times a day

The patient in on DAT. He doesn’t have any problem m in swallowing

Spirituality According to SO, The patient was baptized in Roman Catholic. They go to church every Sunday together with his friends, bothers and sisters

The SO prays for the sooner recovery of the patient

GROWTH AND DEVELOPMENT

Age Theorist Stage of Development

Outcome

4 years and 4 month

Erik Erickson;

Psychosocial Theory

Initiative vs. sense of guilt (mimics; more purposeful & active in goal setting)

>Imaginary playmates or companions are common; holds conversations and shares strong emotions with this invisible friend. Boasts, >exaggerates,

and "bends" the truth with made-up stories or claims of boldness; tests the limits with "bathroom" talk. >Cooperates with others; participates in group activities.

Piaget:

Cognitive Theory

Preoperational-preconceptual (egocentric, magical thinking; no cause-effect reasoning; uses symbols)

>Likes stories about how things grow and how things operate. >Delights in wordplay, creating silly Language. >Understands the concepts of "tallest," "biggest," "same," and "more"; selects the picture that has the "most houses" or the "biggest dogs." >Rote counts to 20 or more.

Freud:

Psychosexual Theory

Phallic

(ego develops objective conscious reality; Opedipus complex - love of opposite-sex parent)

According to the SO, The patient begins to fear that his father is suspicious of his longing for his mother, and that the father will punish him for his desires.

Kohlberg:

Moral Reasoning

Preconventional Morality

(based on external control; observe standards of others to avoid

According to the SO, she punished her child if they commit mistakes.

punishment or receive rewards)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Objective: •Use of accessory muscle. •Dyspnea •Fatigue. •V/S taken as follows: T: 37.9 PR: 140 bpm RR: 25cpm

Acute pain r/t localized inflammation and persistent cough.

After 1 hour of nursing interventions, the patient will display patent airway with breath sounds clearing and absence of dyspnea.

>Elevated head of the bed, change position frequently. Assist patient with deep breathing exercises. >Demonstrated or help patient learn to perform activity like splinting chest and effective coughing while in upright position.

>Forced fluids to at least 3000 ml per day and offer warm, rather than cold fluids.

>Provided supplemental fluids.

>Lowers diaphragm, promoting chest expansion and expectoration of secretions.

>Coughing is a natural self cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. >Fluids especially warm liquids aid in mobilization and expectoration of secretions.

>Fluids are required to replace losses and aid in mobilization of secretion.

After 1 hour of nursing interventions, the patient was able to display patent airway with breath sounds clearing and absence of dyspnea.

Assessment Diagnosis Planning Intervention Rationale Evaluation

ObjectiveTemp 37.9ºC Skin warm to touch

Hyperthermia r/t inflammatory response of the body as evidence by increase in core temperature

After 30 minutes of nursing interventions the patient will have lowered temperature from 37.9-37.5 ºC

> monitored V/S

> Performed tepid sponge bath

> demonstrated proper performance of TSB

> instructed the SO to keep the patient rested > administered antipyretics as ordered

> for baseline data > to facilitate heat loss through evaporation and conduction > to provide proper knowledge and to empower the SO in taking care of the –patientTo slow down the patient metabolism > aid in lowering down the temperature> aid in lowering down the temperature

Goal met as evidenced by lowered temperature from 37.9-37.5 ºC

Assessment Diagnosis Planning Intervention Rationale Evaluation Objectives: Ineffective At the end of 15 >auscultated > to ascertain Goal met. The

- ( + ) crackles - tachypnea- ineffective cough

airway clearance r/t increase pulmonary secretion as evidenced by ( + ) crackles, tachypnea, ineffective cough

minutes the patient will be able to demonstrate behaviors to maintain clear airway

breath sound and assessed air movement>elevated the head of the bed / change position

>encouraged deep- breathing and coughing exercise >instructed to increased fluid intake >| kept the environment allergens free

> gave expectorant ( bronchodilator ) as ordered

status and note progress

> to take advantage of gravity decreasing pressure to the diaphragm and enhancing ventilation > to minimize long effort

>to liquefy secretion

> To avoid irritation of airway caused by allergens.>to mobilized secretion

patient was able to demonstrate behavior to maintain clear airway.

Name of the Drug

Dosage Mechanism of action

Indication Contraindication

Adverse effect Nursing responsibility

Generic name: 18 mg IV Ranitidine is Duodenal & Patients known to > Immune System > assess

ranitidinebrand name:ZantacClassification:Antacids, Antireflux Agents & Antiulcerants

q 8 hours a specific, rapidly acting histamine H2-antagonist. It inhibits basal and stimulated secretion of gastric acid, reducing both the volume and the acid and pepsin content of the secretion.

benign gastric ulcer

have hypersensitivity to ranitidine or to any component of Zantac Injection.

Disorders: (urticaria, angioneurotic edema, fever, bronchospasm, and hypotension and chest pain> Nervous System Disorders:Headache (sometimes severe), dizziness >Gastrointestinal Disorders: Acute pancreatitis, diarrhea

patient abdominal pain. Not presence of blood in emesis, stool or gastric pain > drug may be added to total parenteral nutrition

Name of the Drug

Dosage Mechanism of action

Indication Contraindication Adverse effect

Nursing responsibility

CiprofloxacinBRAND NAME:Ciprobay

250-500mg BID

Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria

Infections of the resp. tract, middle ear,paranasal sinuses, eyes, kidneys, urinary trac

Severe and persistent diarrhea during and after treatment

Common:Nausea, diarrhea, vomiting, rashUncommon:Anorexia, headache,dizziness, fever, GI and abdominal pain,

>Assess pt for previous sensitivity reaction>Assess pt for any s/s of infection before & during treatment>Assess for adverse reactions

Name of the Drug

Dosage Mechanism of action

Indication Contraindication

Adverse effect

Nursing responsibility

SalbutamolBRAND NAME:Ventolin vilmax

3-12 yrs4mg tab BID

Facilitates/ potentiates the inhibitory activity of GABA at the limbic system and reticular formation to reduce anxiety, promote calmness and sleep

Reversible airway obstruction including bronchial asthma, chronic bronchiti

Hypersensitivity Fine tremor of skeletal muscle, feeling of tension, a compensory small increase in heart rate, headache, muscle cramps

> drug may be decrese sensitivity of spirometry used for diagnosis of asthma>syrup may be taken as young as age 2>monitor for evidence of allergic rxn

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objectives:>weight loss > lack of interest in food

Altered Nutrition: less than body requirements r/t improper dietary pattern

Within 8 hours of hospital duty, pt. will be able to:1. Verbalize understanding of nutritional needs for his age.2.Identify possible effects of improper eating habits

>Instructed client to eat smaller meals and supplemental snacks, as appropriate.>Established a minimum weight goal and daily nutritional requirements.

>Discussed with client the diet and snacks with substitutions of preferred foods when available.

>Provided health teachings about proper nutrition

>Gastric dilation may occur if re feeding is too rapid following a period of starvation diet.> Malnutrition is mood-altering condition, leading to depression and agitation and affecting cognitive function/decision making. >Helps pt. understand the importance of proper nutrition and the consequences when it is altered.>for adequate information and to promote compliance

Within 8 hours of hospital duty, pt. was :1. Verbalized understanding of nutritional needs for her age.2. Identified possible effects of improper eating habits.

Name of the Drug

Dosage Mechanism of action

Indication Contraindication

Adverse effect Nursing responsibility

Cefuroxime Cefuroxime 750 mg IV q 6h

Cefuroxime, a semisynyhetic, broad-spectrum” second generation” cephalosporin antibiotic, exerts its bactericidal

Indicated in the treatment of the following infections due to cefuroxime-sensitive organisms

Known allergy to the cephalosporin group of antibiotic

CV: phlebitis, thrombophlebitisGI: diarrhea, nausea, vomiting, anorexiaHematologic: hemolytic anemia, eosinophiliaSkin:

>Before giving drug, ask patient if he is allergic to penicillin or cephalosporin.>Obtain specimen for culture and sensitivity

activity by interfering with the synthesis of the bacterial cell wall. It binds to penicillin-binding protein 3 responsible for the synthesis of peptidoglycan, a hetoropolymeric structure that gives the cell wall its mechanical stability.

>Lower respiratory tract infections including pneumonia>Urinary tract infection>Skin and skin structure infections>Septicemia>Meningitis .Gonorrhea

maculopapular and erythomatous rashes, urticaria, pain, indurations, sterile abscesses, temperature elevation

tests before giving first dose. Therapy may begin while waiting the results >Monitor patient for signs and symptoms of super infection

Name of the Drug

Dosage Mechanism of action

Indication Adverse effect Nursing responsibility

Acetaminophen ( Paracetamol )Classification:antipyretics, nonopioid analgesics

1.2 mL q 4 hr PRN

Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS

Mild pain Fever

Hema: hemolytic anemia, neutropenia, leukopenia, pancytopenia.Hepa: jaundiceMetabolic: hypoGGI: HEPATIC FAILURE, HEPATOTOXICITY

EFORE:> Advise parents or caregivers to check concentrations of liquid preparations. Errors have resulted in serious liver damage.~ Assess fever; note presence of associated signs (diaphoresis, tachycardia, and malaise).DURING:>Adults should not take

(overdose). GU: renal failure (high doses/chronic use). Derm: rash, urticaria.

acetaminophen longer than 10 days and children not longer than 5 days unless directed by health care professional.~ Advise mother or caregiver to take medication exactly as directed and not to take more than the recommended amount.AFTER:>Advise patient to consult health care professional if discomfort or fever is not relieved by routine doses of this drug or if fever is greater than 39.5°C (103°F) or lasts longer than 3 days.

LEARNING FEEDBACK DIARY

Name: Dennis Gallardo Date: May 24- 27, 2009

Area: EAMC CI: Mr. Robert Balungaya, RN

General objective:

At the end of the 4 days duty, I will be able enhance my knowledge skills and

attitude regarding the delivery of health in the clinical area.

Specific objectives:

At the end of our 4 days clinical duty, I will be able to:

- Carryout skills I learned from school

- improve my skills regarding patient care

- establish rapport with my patient as well as health team in the EAMC

Insight:

Experience comprises knowledge of or skill in or observation of some thing

or some event gained through involvement in or exposure to that thing or

event.

Experience also is in deed the best teacher. I admit I really did learn a lot of

skills and knowledge inside the school but learning through my experience in

the actual hospital setting is really different. Gaining knowledge and skills in

my actual duty is more different and effective. I have developed a more

organized way of dealing with people that I never had before. Greatly I have

many educational experiences throughout the duration of our duty. One of

this was monitoring the I & O of my 3 patients. I also have been opened to

the different needs of my patients that would sure benefit me in rendering a

more quality care.

For all this learning experience, I appreciated and love more my future

profession. I have been realized that the greatest help we could offer to our

patient is giving them attentions and best quality of health service. I also

thank my CI because of assistance and learning he shared. It’s great under

your supervision…. GOD BLESSES!!!!!!