URDANETA CITY, PANGASINAN COLLEGE OF NURSING

A CASE STUDY ON PNEUMONIA

SUBMITTED BY: Pangan, Jeusu O. Bsn-3

SUBMITTED TO: Lendl Deo Osias

I.

PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Patients Name: B.C Address: Villasis, Pangansinan Age: 32 Sex: Female Birth Date: January 26, 1981 Rank in the Family: Mother Nationality: Filipino Civil Status: Married Date of Admission: July 22,2013 Order of Admission: Please admin to Medical Ward, secure consent inserted IVF with D5LRS 1L to regulate @ 20-21 gtts/min. Admitting Diagnosis: PNEUMONIA Attending Physician: Dr. BUENCONCEJO

B. CHIEF COMPLAINT
According to the patient is experiencing cough fever and dizziness

C. HISTORY OF PRESENT ILLNESS:

Present condition started 2days prior to admission

D.

PAST HEALTH HISTORY: 1. 2. 3. 4. 5. Childhood Illness: She experienced chicken pox, colds, cough and cold Immunization: Complete Major Illness: None Current Medications: Paracetamol, Mefenamic Acid Allergies: Allergy to Tahong

E. FAMILY ASSESSMENT: Name B.C B.T B.O . Relation Pt/Mother Father Son Age 32 37 1/8 Months old Sex Female Male Male Occupation None None N/A Educational Attainment College Undergraduate College Undergraduate N/A

F. SYSTEM REVIEW : 1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN Clients perception of health: The client perceives health as if we take care of our self, we will be healthy Clients perception about illness : The client perceives illness as it was really hard t o get sick if you dont have money Health maintenance and habits: In maintaining his health as well as his family, they have their check up and sometimes just have selfmedicated of the illness is not severe. Compliance with prescribed medications and treatment: according to the client they always follow the medication and treatment being prescribed. 2. NUTRITIONAL METABOLIC PATTERN: Appetite : The smell and taste can trigger the clients appetite. According to the client, the usual diet is high in fiber an d carbohydrates and eats 3 times a day with 2-3 cups of rice and 1 bowl of dish. Usual Daily Menu: - Food : vegetables, fish and meet - Water : pt BC drinks 6-8 glasses of water per day - Beverage : she drinks coke and coffee 3. ELIMINATION PATTER Bowel Habits : According to the client, he usually defecates once a day - Color : Brown - Odor : Aromatic - Consistency : Soft 4. ACTIVITY EXERCISE PATTERN 0 Feeding 1- Dressing 0- Grooming 0 Bathing 0- Toileting 0- Cooking 1 Bed Mobility 1- Home Maintenance Legend: 0 Full Care I Requires use of assistance II Requires assistance and supervision by others III Requires assistance and supervision from another and equipments and devices IV Dependent, Doest participate 5. COGNITIVE PERCEPTUAL PATTERN Hearing : Upon interviewing, Mrs. B.C can perceive sounds and hears all the questions that were being asked Vision: My client can read books and newspapers clearly.

Sensory: Upon applying slight pressure with both arms of Mrs. B.C can differentiate the scent of alcohol from the smell of food. Learning Styles: The client can supervice his learning abilities and level of understanding through watching television and listening in the radio. In tems of decision making, Mrs. B.C approaches her husband they make their decisions together.

6. SLEEP REST PATTERN Sleep habits: Mrs. B.C stated that before she goes to sleep she watches a television program Hours of sleep: She sleeps at 10pm up to 4am Sleeping alteration: Mrs. B.C had alterations in sleeping because he usually work at night. Sleeping aids: her sleeping aids is only watching television 7. SELF PERCEPTION AND SELF CONCEPT PATTERN Felling about current state : Regardless of his situation Mrs. B.C still believed that God will help him in any situation. Description of self: She described herself as kind, loving mother and wife Known capabilities and weakness: As verbalized by the client my weaknesses are my family Self worth: The client sees herself as kind, loving mother and wife

8. ROLE RELATIONSHIP PATTERN According to Mrs. B.C she is doing her responsibility to her son as well as to his husband 9. SEXUALTY REPRODUCTIVE PATTERN Physical and psychological effect of the clients current health status on sexual expression: Mrs. B.C stated that she can still performed sexual activity together with her husband but thers a limitation. 10. COPING STRESS TOLERANCE PATTERN Perception of stress and problems : Mrs. B.C perceives stress as a problem as we can easily solve our problems if we think for the solution Coping method and support system according to Mrs. B.C she prays all the time. 11. VALUE BELIEF PATTERN Values, goals and philosophical belief: According to the client she believes that GOD is always there for us Religious and spiritual beliefs: the client is Roman Catholic and believes that be contented f what GOD gave to you

G.

HEREDO- FAMILIAL ILLNESS 1. Paternal no known illness 2. Maternal no known illness

H.

DEVELOPMENTAL HISTORY Patients Description INTIMACY vs. ISOLATION - It is involves parenting care and offers support and praise for decision making

Theorist

Age

Sex

Erik Erickson

32

Female

Jean Piaget

32

Female

Formal operation thought - First it relates how she really thinks nd - 2 , how she solved/ handled problems in a mature though and reasoning and lastly - On how she accept opinions of significant others Post conventional, Level 3 stages 6 It involves on how an individuals internalized the standards of conduct and how he apply/ put the standards conduct into her life

Lawrence Kohlberg

32

Male

I.

PHYSICAL ASSESSMENT A. General Survey 1. Overall appearance and grooming: The client is conscious and coherent 2. Actual height and weight vs. ideal body weight: Height: 5ft and weight 65 kg. 3. Symptoms of distress: none 4. Posture and gait: The client has a good posture 5. Affect and mood: According to the client he still shows great happiness

6. Relevance and organization of thoughts: She can understand and answer all questions appropriately 7. Vital signs of the day of physical examination Temperature: 37.3 degrees Celsius Pulse rate: 86 beats per minute Respiratory rate: 60 cycle per minute Blood pressure : 100/70

B. Regional exam- utilize IPPA technique 1. Hair: Upon inspection, Hair are evenly distributed, short and no presence of infection Head : Head is round. 2. Eyes: Upon inspection of the clients eyes, eyebrows are evenly distributed, 3. Nose: Not performed 4. Ears: Not performed 5. Mouth and throat: Upon inspection, outer lips are uniform in color, soft and dry. Oral mucosa is also dry. 6. Neck and lymph nodes: The clients neck muscles are equal in size, no visible nodules or masses upon palpation 7. Skin: Brown in color, warm to touch 8. Nails: Fingernail plate shape convex, smooth texture 9. Thorax and lungs: With RR of 60 cpm, fast rhythm breath and has crackles upon inhalation. 10. Cardiovascular: With CR of : 86 beats per minute, lub/dub can be heard upon auscultation. 11. Abdomen: Not performed 12. Extremities: He was able to flex and extend his extremities actively but with weakness noted. 15. Neurological/Cranial nerves: Not performed

II. PERSONAL/SOCIAL HISTORY A. Habits: a. b. c. d. e. Caffeine: She drinks 2 cups every day Smoking: no Alcohol: She drinks alcohol occasionally Tea: Sometimes Drugs: The drug regimen prescribed to her by the doctor.

B. Lifestyle: According to the patient she does the Activities of Daily Living C. Social Affiliation: The patient is obeying the rules and regulation in their barangay D. Rank in the family: Mother E. Travel (within 6 months): The patient dint travel to far F. Educational Attainment: College Undergraduate III. ENVIRONMENTAL HISTORY According to his mother, they are living with her husbands family. Their house is located at the rice field. Its made of raw m aterials like cement and hollow blocks; their using tricycle as their transportation going to market/town which about 5 km away from their house.

IV.

INTRODUCTION

Pneumonia is an inflammatory condition of the lungaffecting primarily the microscopic air sacs known as alveoli. It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other foreign substances. In all cases, the lungs , air sacs fill with pus, mucous and other liquids and cannot function properly. The most common cause of bacterial pneumonia in adult is a bacteria called streptococcus pneumonia or pneumococcal. Most viral pneumonias are patchy and the body usually fights them off without help from medication or other treatments. Pneumococcus can affect more than the lungs. The bacteria can also cause serious infection of the covering of the brain (meningitis ), the bloodstream, and other parts of the body.

V.

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 uo to 20 times per minute taking in and disposing of those gases. Air that is breath 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 pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body.

VI. Pathophysiology Virulent Microorganism Streptococcus Pneumoniae Microorganism enters the nose (nasal passages )

Passes through the larynx, pharynx, tracheas

Microorganism enters and affects both airway and lung parenchyma Airway damage Infiltration of bronchi Infectious organism lodges Stimulation in bronchioles Alveolar collapse Increase pyrogen in the body Fever DIFFICULTY OF BREATHING (Productive/ non-productive) Necrosis of bronchial tissues Narrowing of air passage Lung invasion Flattening of epithelial Macrophages and leukocytes Mucus and phlegm production Coughing

VII. Laboratory Test

HEMATOLOGY Test Hemoglobin Result 95 Normal values 130.00 180.00 g/L 0.42 0.52 g/L Significance Decreased hemoglobin levels imply decrease oxygen carrying capacity of the blood A low hematocrit referred to as being anemic caused by loss of blood or dietary deficiency Within normal range Within normal range Within normal values Within normal values

Hematocrit

0.31

Segmenters Lymphocyte Monocyte Platelet

0.59 0.39 0.02 177

0.50-0.70 0.20-0.40 0.00-0.07 150-400 x 10 g/L

IX. DRUG STUDY Generic Name: Ampicillin Brand Name: Ampicillin Trihydrate

Drug Classification: Anti-infective, bactericidal Dosage: 150mg IVP every 6 ANST (-) Indication: respiratory tract or skin and skin-structure infection. Mechanism of Action Inhibit cell-wall synthesis during bacterial multiplication Side Effect Nausea and vomiting, diarrhea, abdominal pain, fatigue, headache, dysuria, urinary retention Contraindication Contraindicated in patients hypersensitive to drug or other penicillin and cephalosporins Adverse Effect CNS: dizziness, fatigue, agitation, confusion Nursing Consideration Prior to administration, skin test is to be done to determine signs and symptoms of hypersensitivity; Monitor seizures when giving high doses. Do not miss a dose unless ordered by physician. Instruct mother to report signs and symptoms of super infection

Generic Name: Gentamycin sulfate Brand Name: Garamycin Drug Classification: Anti-bacterial o Dosage: 25 mg SIVP q 6 ANST Indication: to prevent enodocarditis before GI ir GU procedure Mechanism of Action Side Effect Contraindication Adverse Reaction Nursing consideration

Inhibits protein synthesis by binding directly to the 5 oS ribosomal subunit; bactericidal.

CNS: fever, headache, lethargy, confusion, dizziness, vertigo GI: Nausea, vomiting Skin: rash, urticaria, pruritus, injection site pain.

Contraindicated in patients hypersensitivity to drug or tother aminoglycosides Use cautiously in neonates, infants, elderly patients, and patient with impaired renal function or neuromascular disorder.

CNS: encephalopathy, seizures GU: nephrotoxicity Hematologic: leucopenia, thrombocytopenia, agranulocytosis. Respiratory: apnea Other: anaphylaxis

Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin while awaiting results.(Skin test is commonly done for hypersensitivity to drug) Evaluate patients hearing during therapy because of ototoxicity Weigh patient and review renal function studies before therapy begins. Instruct patient to promptly report adverse reactions, such as dizziness, vertigo, hearing loss, numbness or muscle twitching Encourage patient to drink plenty of fluid Warm patient to avoid hazardous activities if adverse CNS reactions occur. Check auditory function before therapy then recheck again every 3 to 4 weeks after the drug is discontinue.

Generic Name: Metoclopramide Brand Name: Reglan Drug Classification: Anti-emetic Dosage: O.3 ml SIVP every 6 hours Indication: Prevention of nausea and vomiting associated with emetogenic cancer chemotherapy Mechanism of Action Dopamine antagonist that acts increasing sensitivity to acetylcholine; results in increased motility of the upper GI tract and relaxation of the pyloric sphincter and duodenal bulb Side Effect Nausea, restlessness and diarrhea Contraindication Contraindicated with allergy to metoclopramide, GI hemorrhage, perforation Adverse Reaction Insomnia, dystonia and akathesia Nursing consideration Give this drug exactly as prescribed Inject slowly to prevent transient feeling of anxiety and restlessness Maintain fluid and electrolyte balance

Generic Name: Paracetamol Brand Name: Medamol Drug Classification: analgesic, antipyretic Dosage: 90ml IV every 6 hours Indication: treatment for mild fever Mechanism of Action May produce analgesic effect by blocking pain impulses, by inhibiting prostaglandin, or pain receptor sensitizers. May relieve fever by acting on hypothalamic heat-regulating center. Relieves fever Side Effect Anemia Contraindication Contraindicated in patients hypersensitive to drug or its components. Adverse Effect Chest pain Headache Dyspnea Nursing Consideration Monitor for S&S of hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition. Patient & Family Education Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects. Do not self-medicate children for pain without consulting a physician Do not give children more than 5 doses in 24 hours unless prescribed by physician Monitor for

Jaundice

Rash

urticaria

temperature changes

X. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY a. Fluid Volume Deficit related to fluid lose b. Hyperthermia related to infection c. Imbalanced nutrition less than body requirements related to inability to ingest food

X. Nursing Care Plan ASSESSMENT Subjective: Walang ganang dumede ang anak ko as verbalized DIAGNOSIS Imbalanced Nutrition less than body requirements related to decrease ability to ingest foods 2 hours to vomiting and LBM SCIENTIFIC BACKGROUND PLANNING After 1-2 days of nursing intervention, the mother will be able to demonstrate behavior that maintain appropriate amount. NURSING INTERVENTION > Monitor Vital Signs > Assess weight, age, body built, strength, and activity > Determine the ability to swallow and taste > Provide SFF with SAS >Administer pharmacological agents as prescribed for example: -medications -vitamin / mineral supplements >Promote adequate fluid intake RATIONALE > To serve as baseline data > To provide comparative baseline EVALUATION Goal met after 1-2 days of nursing intervention the mother was able to demonstrate behavior that maintain appropriate amount.

Objective: > Weak and pale in appearance > Pallor > Loss of weight from 11 kg to 9 kg >>Vital signs as Follows: PR: 124 bpm RR: 37 cpm o T: 38.8 C

>To assess contributing factors.

> To provide pharmacological treatment

>To replace fluids

> Encourage the mother of the patient to eat foods that is necessary to patient age such as cereals, mashed apples and bananas.

>To provide nourishment

ASSESSMENT

DIAGNOSIS

SCIENTIFIC BACKGROUND

PLANNING

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective: mainit ang aking anak as verbalized by the mother of our patient Objective: >slightly irritable >flushed skin >warm to touch >dry skin with poor turgor >dry oral mucosa >Vital signs as follows: RR: 37 cpm PR: 124 bpm T: 38.8

Hyperthermia r/t infection process or dehydration

Infectious agents stimulate monocytes and release pyrogenic cytokines and may stimulate anterior hypothalamus results in elevated thermoregulatory set point and leads to increased heat conservation then result in fever

After 30 60 minutes of rendering nursing interventions, the patient s temperature will decrease from 38.8C to 37.6C

Monitor Vital signs Provide proper ventilation.

Serve as baseline data Proper ventilation may reduce the temperature of the patient. Dysrhythmias are common due to electrolyte imbalance, dehydration, and direct effects of hyperthermia on blood and cardiac tissue. Heat loss by convention.

Monitor heart rate and rhythm.

After 30 60 minutes of rendering nursing interventions, the patients temperature decreased from 38.8C to 37.6C.

Promote surface cooling by means of cool environment and/or fans. Instruct client/SO to increase fluid intake.

Adequate fluid intake prevents dehydration.

Review signs and symptoms of hyperthermia. Remove excess clothing and blanket

These may indicate prompt interventions.

Administer antipyretic drugs as prescribed by the doctor

To relieve fever

ASSESSMENT Subjective: ilang araw ng ngtatae at nagsusuka ang anak ko as verbalized by the mother Objective: >dry mucous membrane >slightly irritable >seen vomiting the milk >dry skin with poor turgor >depressed fontanelles >Vital Signs as follows: RR: 37cpm PR: 124bpm T: 38.8

DIAGNOSIS Fluid volume deficit related to fluid loss

SCIENTIFIC BACKGROUND A state in which an individual is experiencing vascular, cellular, or intracellular dehydration due to active or regulatory losses of body water in excess of needs or replacement capability.

PLANNING After 12 hours of rendering nursing intervention, the patient will be able to replace lost fluid gradually or evidence by: a. drinking milk without vomiting b. patients IVF is adequately regulated as ordered c. increase intake of water for 2ml per day

NURSING INTERVENTION Monitor vital signs Monitor input and output

RATIONALE Serve as baseline data Fluid replacement needs are based on correction of current deficits and ongoing losses Measurement provides useful data for comparison Regulation of fluid is critical in maintaining adequate circulating fluids to recover for amount of water loss through vomiting Skin and mucous membranes are dry with decreased elasticity because of vasoconstriction and reduced intracellular water To maintain fluid and electrolyte balance

EVALUATION After 12 hours of rendering nursing intervention, the patient replaced fluid loss.

Weigh daily and compare with 24 hours fluid balance Regulated IVF according to specified flow rate basing on the doctors order

Provide skin and mouth care

Advise mother or significant others to increased fluid intake of he patient Instruct mother to practice proper milk preparation of food handling Encourage mother to offer baby with mashed banana or apple

XII. ONGOING APPRAISAL The patient shows progressive recovery and is responding well to both medical and nursing interventions.

XIII. DISCHARGE PLAN (HEALTH TEACHINGS) Medication: Instruct mother of our patient to continue to give the medications and take medications on time. Treatment: Instruct the mother of our patient to continue to give the medications of her baby Clinical Follow-up: Instruct mother of the patient to have his follow-up check- up after one week. Diet: Encourage mother to feed the baby which is rich in iron, vitamin C to avoid any problems to the baby. Health Teachings: Advised the mother to clean properly the bottle to use in feeding her baby. Instruct mother to feed the baby through breastfeeding rather than bottle feeding. Advised mother to maintain cleanliness of the objects around her baby to avoid ingestion of contaminated objects.