In Partial Fulfillment of the Requirements In Related Learning Experience 106 A CASE STUDY OF A PATIENT WITH

PNEUMONIA
Submitted by:

CRUZ ADRIAN B. BSN IV AO4

I.

CASE ABSTRACT

Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake. Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.1 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide. Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa. Children can be protected from pneumonia, it can be prevented with simple interventions, and treated with low-cost, low-tech medication and care. Typical symptoms include a cough, chest pain, fever, and difficulty breathing. Diagnostic tools include x-rays and culture of the sputum. Vaccines to prevent certain types of pneumonia are available. Treatment depends on the underlying cause. Pneumonia presumed to be bacterial is treated with antibiotics. If the pneumonia is severe, the affected person is, in general, admitted to hospital. The presenting features of viral and bacterial pneumonia are similar. However, the symptoms of viral pneumonia may be more numerous than the symptoms of bacterial pneumonia. In children under five years of age, who have cough and/or difficult breathing, with or without fever, pneumonia is diagnosed by the presence of either fast breathing or lower chest wall in drawing where their chest moves in or retracts during inhalation (in a healthy person, the chest expands during inhalation). Wheezing is more common in viral infections. Very severely ill infants may be unable to feed or drink and may also experience unconsciousness, hypothermia and convulsions. The case was taken from Justice Jose Abad Santos General Hospital last February 17 2014. Patient DM. is a 1 month old male patient confined at Pedia (Respiratory) ward because of cough for 2 weeks. According to the patients mother, patient DM was experiencing cough for 2 weeks, she did not seek consult and did not medicate the patient, she continued not to treat patient DM for 2 weeks and the cough worsen. A day before confinement (February 14 2014) patient DM experienced episodes of cyanosis and difficulty of breathing when coughing and was rushed to the hospital. As nurses, it is our responsibility to give care to our patients. Nurses should always provide holistic care to their patients taking into consideration not only their physical and physiological needs but also their emotional, social, intellectual, and spiritual needs. On the case of patient DM. Nursing care focuses on maintaining and improving respiratory function, support for recuperative process, preventing further complications and providing information about disease process.

II.

Nursing Health History

a. Biographic Data Patients Initials: D.M Educational Attainment N/A Gender male Occupation: N/A Age 1 month 12 days old Date of Birth January 6 2014 Place of Birth Manila

Date of Admission February 14 2014

No. of Days in hospital: 5 days

Order of admission Ambulatory

Source(s) of Information Patient mother Patients chart

b. Chief Complaint Dalawang lingo nainuubo yang baby ko, ginamot ko naman sya pero hindi pa in nawawala yung ubo, nung gabi nab ago kami sumugod ditto nangitim na lang sya tapos parang hirap na hirap na huminga kaya sinugod ko na sya kaagad dito c. History of Present Illness 2 weeks prior to admission, patient experienced cough. The patients mother verbalized akala ko simpleng ubo lang kaya hindi ko muna binigyan ng kahit anong gamot si baby. A week before admission the patient started to have episodes of difficulty in breathing. Few days prior to admission the patient experiences cyanosis of the extremities when crying and coughing. On the day of admission, the patient had cough and cyanotic extremities. He was admitted at Justice Jose Abad Santos General Hospital vital signs were taken and are as follows: PR: 170 bpm, RR: 60 cpm, T: 36.8 and wt: 5.4lbs d. History of Past Illness/es none BCG, Hep B none none none

Childhood illness(es) Childhood immunization(s) Accidents and injuries: Previous hospitalization/surgery: Medication prior to confinement:

e.
Name

Family History
Relation Age Gender Educational Attainment Occupation Diseases/D isorder None

M.D

Mother

37

H.S Graduate

Selfemployed Technician Construction worker N/A N/A N/A N/A

N.D R.D

Father Sibling

42 21

M M

Vocational Course H.S Graduate

Asthma None

F.D C.D R.D B.D

Sibling Sibling Sibling Sibling

20 17 14 10

F F F M

H.S Undergraduate H.S Undergraduate H.S Undergraduate Elementary Undergraduate

None Asthma None None

Genogram:

FATHER MOTHER ASTHMA

F.D

C.D ASTHMA

R.D R.D B.D

PT.DM Pneumonia

LEGEND: = Female = Male = Patient

f.

Developmental History Theory Age Developmental task ORAL Stage Client description Interpretation Its normal for the clients age to manifest this kind of behaviour.

Sigmund Freud (Psychosexual Development Theory)

Erik Erickson (Psychosocial Development Theory)

The first stage of personality development 58 years where libido is centered in a baby's mouth. It gets old much satisfaction from putting all sorts of things in its mouth to satisfy libido, and thus its id demands. Which at this stage in life are oral, or mouth orientated, such as sucking, biting, and breast-feeding. (trust vs. mistrust) During this stage the 58 infant is uncertain about years the world in which they old live. To resolve these feelings of uncertainty the infant looks towards their primary caregiver for stability and consistency of care. If the care the infant receives is consistent, predictable and reliable they will develop a sense of trust which will carry with them to other relationships, and they will be able to feel secure even when threatened. Sensorimotor stage During this first stage, 58 children learn entirely years through the movements old they make and the sensations that result

The client engages in both breast feeding and other form of liquid feeding

The client is fed on time and needs are attended on time.

The patient achieved the stage of trust as evidenced by his needs is given consistently.

Jean Piaget Cognitive Development Theory

During the interview with the mother, patient was able to grab things which is handed to him. The patient was able to breastfeed when stimulated to feed.

The patient learns to follow motor and sensation.

g.

Environmental History The client lives in a Barangay compound in Sta. mesa. Their house is near the road,

basketball court, and school. There are a lot of stray dogs. Their house as the mother described it as a two floor made from wooden walls, wooden doors. It consists of 1 bedroom, a kitchen and a bathroom. The quality of ventilation in the house is poor because they dont have enough windows to facilitate in the circulation of air. The water supply is piped with water meter to monitor their consumption. The bathroom has a faucet and toilet with a pail to flush down waste. The sewage system is closed drainage and is cleaned everyday in the gutters to prevent blockage most especially this rainy season. The safety and security of the barangay is headed by the Barangay Tanod which they patrol the streets and there is minimal crime/violence incidence in the area. The neighbors around his home are smokers and there are men who drink near the sari-sari stores. Trash collection in the area is every Saturday with no designated areas of collection. There is presence of many vectors include flies, mosquitoes and cockroaches. They only cover up their food to protect against flies and cockroaches contaminating it. Their sleeping quarters are clean but they sometimes have bed bugs in the banig that they sleep on. They hang the mat outside in the sun to get rid of the bugs.

III.

PHYSICAL ASSESSMENT:

IV. Physical Assessment (February 17 2014) A. General Survey Body Built: Grooming Hygiene: Endomorph Well Groomed.

Posture & Gait: N/A

Body Odor & Breath Odor: None

Signs of Distress: cyanotic extremities Orientation: N/A

Obvious Signs of Illness(es): Appears weak Level of Affect: Consciousness: N/A N/A Organization of Thoughts: N/A Mood: N/A

Quantity & Quality of Speech: N/A

B. Vital Signs Temperature: 36.8C

Pulse rate: 170 beats per minute

Respiratory rate: 60 breaths per minute

Blood Pressure: N/A

C. Physical Examination

Body Part Skin

Normal Findings Uniform skin color with slightly darker exposure areas. No jaundice, cyanosis, pallor, erythema, or hyper/hypopigmentation.

Actual Findings Fair Complexion and Uniform skin color with moles around the back area. Warm to touch, skin turgor is normal. With HEplock insertion on Left pedal vein (-)jaundice, (+)cyanosis when crying ,

Analysis & Interpretation The skin is well hydrated with no dry skin present. Presence of moles are normal and are flat, noncancerous.

Hair

Evenly distributed hair, Silky, resilient hair Eye brows evenly distributed & aligned

Hair is shiny and resilient. Eyebrows and eyelashes evenly distributed. (-) infestations

Nails

Clean. Pink tones should be seen. Some longitudinal ridging is Normal. There is normally a 160-degree angle between the nail base and the skin. Nails are hard and basically immobile. Smooth and rm; nail plate should be rmly attached to nail bed. Pink tone returns immediately to blanched nail beds when pressure is released.

Nails are long with no chipping or nail polish. Pinkish in color. (+) Diamond shape when fingers are place together. No irregular ridges on nails. Nails are smooth convex and attached to nail bed firmly Blanching: Pink tones returned after 2 second after pressure was released.

Proper hygiene and grooming are observed with the patient. Hair on the head is trimmed. Body hair fine and is evenly distributed Good peripheral circulation on hands and feet noted when nail is pressed and pinkish color returned after 2 second.

Head & Face

The parts of the head and face is proportion to each other and symmetric Shape is gently curved with prominences at the frontal and parietal

Facial expressions symmetrical when instructed to smile, frown and to protrude tongue. Face is smooth and

Good muscle tone of the facial features No signs of lipid dystrophy noted.

bones Symmetrical facial movements

Eyes

Ears

Nose

Mouth & Pharynx

rounded with no acne marks Eyes, nose, mouth, and ears proportional to the face Positioned symmetrical Eyes are symmetrical in to each other size There are no (-) Cloudiness, pigmentations, pigmentations or any cloudiness or any abnormal discharge presence of abnormal (+)Corneal reflex discharges in the eyes Pupils constrict to light Pupils equally rounded and dilate to darkness and appear normal in size Light accommodation: Pupillary activity appears Patient is farsighted. normal Pink conjuctiva The ear lobes are bean Ears are symmetrical shaped, parallel, and and parallel. Upper symmetrical. The upper connection of the ear connection of the ear lobe parallel to outer lobe is parallel with the cantus of both eyes. outer cantus of the eye. No lesions noted on Skin is same in color as in inspection. the complexion. No (-) cerumen in ears lesion noted on Pinna recoils when inspection. The auricles folded have firm cartilage on palpation. The pinna recoils when folded. No pain or tenderness when palpation of the auricles. Same color as the face Nostrils patent with no (-) nasal flaring and noise during breathing patent nostrils (-) nasal flaring, lesions Pink nasal mucosa Septum in midline and pink nasal mucosa No nasal obstruction or mucus. Non tender sinuses Pink lips, symmetrical, Mucosa uniform pink in moist color Pink gums Soft moist, smooth in With complete set of texture teen, (-) dental caries (-) blisters, lesions, Tongue is in midline sores Pink, Moist, Intact Oral (+) Gag reflex mucosa without lesions Lips pink and Tonsils without bleeding symmetrical not inflamed (-) breath odor Uvula is in midline Smooth uniform consistency; absence of nodules or masses

Needs further assessment patient is new born and cannot be assessed at the moment.

The patient cannot be assessed with some test due to age.

Air moves freely as the client breathes through the nares

The patient cannot be assessed completely with some test due to age.

Neck

There is no significant or palpable mass at the thyroid area Jugular vein is not distended The lymph nodes are not distended Trachea is palpable at the midline of the neck The neck is straight. No visible mass or lumps. Symmetrical. No jugular venous distension. Can move freely and coordinated. Lymph nodes are not palpable.

The neck is straight. No visible mass or lumps. Symmetrical. No jugular venous distension. Can move freely and coordinated. Lymph nodes are not palpable.

Thorax/Lungs

Chest is symmetric and skin is intact Quiet, rhythmic, and effortless respirations Clear breath sounds

Cardiovascular/Heart No visible lifts or heaves Peripheral veins in dependent position, distention and nodular bulges at claves are present B. Laboratory Results Laboratory and Date Normal Values Result

Neck is in proportion to gross body structure Has coordinated head movement and able to perform full range of motion Chest is symmetric and Lungs are clear skin is intact and has no Shallow respirations adventious Clear breath sounds breath sounds or (-) wheezing, crackles or infiltrates any adventious breath Increased sounds Respiratory Rate Respiratory Rate: 25 due postbreaths per minute operative pain Use of accessory and decreased muscles when lung expansion breathing secondary to spinal anesthesia Apical pulse visible. Normal.

Analysis and Interpretation

HEMATOLOGY Jan. 20, 2014 White Blood cell 3.9810.04

18.7

White blood cells help the body fight bacterial & viral infections. An elevated white blood cell count can arise due to infection. When the body detects infection the bone marrow is stimulated to produce more WBC to destroy bacteria. The client WBC is within normal range indicating that there is no infection.

Hemoglobin

112.00157.00

121

Hemoglobin is a protein found in the red blood cells whose job is to carry oxygen from your lungs to all parts of the body. If the hemoglobin is low, it may mean that the body is not getting enough oxygen to produce the energy required, and the patient may feel very tired. The client hemoglobin is within the normal range indicating that there is sufficient oxygen supply. The Hct is an indirect measurement of red blood cell number and volume. It is used as a rapid measurement of RBC count. It is repeated serially in patients with ongoing bleeding or as a routine part of the complete blood cell count. It is also an integral part of the evaluation of anemic patients together with Hgb. The client hematocrit is within the normal range.

Hematocrit

0.34-0.45 0.35

Platelet count

150.00450.00

631

Platelets (thrombocytes) are the smallest type of blood cell. They are important in blood clotting. When bleeding occurs, the platelets swell, clump together, and form a sticky plug that helps stop the bleeding. If there are too few platelets, uncontrolled bleeding may be a problem. If there are too many platelets, there is a chance of a blood clot forming in a blood vessel. The client platelet is within the normal range.

Differential count Feb 17, 2014 Neutrophils

34.0071.00

47

The primary function of the neutrophil is. Acute bacterial infection and trauma stimulate neutrophil production, resulting in an increase in the WBC count. The client neutrophils is within normal range indicating that there is no infection. Lymphocytes are small white blood cells that play a role in the bodys immune response (that is, in the bodys fight against germs and diseases). The clients lymphocytes is within the normal range. Monocytes are white blood cells that help other white blood cells to remove dead or damaged tissues, destroy cancer cells, and regulate immunity against foreign substances An increased number of monocytes in the blood (monocytosis) occurs in response to chronic infections, in autoimmune disorders, in blood disorders, and in cancers. The clients monocyte is within the normal range.

Lymphocytes

19.0052.00

51

Monocyte

5.0012.00

6.90

Nursing Care Plan Assessment Nursing Diagnosis O> tachypnea RR = bpm > (+) DOB > productive cough >(+) wheezing >(+) cyanosis Ineffective airway clearance r/t accumulation of tracheobronchial secretions ST> After 3-4 hours of nursing interventions, client will be able to demonstrate improve airway clearance as evidence by improve in RR, clear breath sounds and absence of dyspnea and cyanosis. Auscultate lung fields, noting area of decreased or absent airflow LT> After 2-3 days of nursing interventions, client will be able to establish and maintain patent airway. Elevate head of bed and change position frequently. Keeping the head elevated lowers diaphragm promoting chest expansion, mobilization and expectoration of secretions to keep airway clear. and adventitious breath sounds. To ascertain status and note progress. Assess rate and depth of respirations and chest movement. Tachypnea, shallow respirations and asymmetric chest movement are present because of discomfort of moving chest wall or fluid in lungs. Goal MET patient was able to demonstrate improved airway clearance as evidence by improve in RR, clear breath sounds and absence of dyspnea and cyanosis. Planning Interventions Rationale Evaluation

Give expectorants and bronchodilators as prescribed.

Aids in reduction of bronchospasm and mobilization of secretions.

O> (+) rales >(+) cyanosis > DOB

Impaired gas exchange r/t inflammation of

ST> Within the shift, patient will be able to

Assess respiratory rate and depth.

Manifestations of respiratory distress are

GOAL MET The patient was able to

airways and accumulation of sputum affecting O2 and CO2 transport.

demonstrate improvement in gas exchange as evidence by decrease in respiratory rate within normal limits. Observe color LT> After 1-2 days of nursing interventions, patient will be able to demonstrate improve in ventilation and adequate oxygenation of tissues as evidence by absence of symptoms of respiratory distress. Monitor heart rate and rhythm. of skin, mucous membranes and nail beds, note presence of peripheral cyanosis or central cyanosis.

dependent on and indicative of the degree of lung involvement and underlying general health status.

demonstrate improvement in gas exchange as evidence by decrease in respiratory rate within normal limits.

Cyanosis of nail beds may represent vasoconstriction or bodys response to fever or chills. Cyanosis of mucous membranes and skin are indicative of systemic hypoxemia.

Tachycardia is usually present as a result of fever and dehydration but may represent a response to hypoxemia.

Elevate head of bed and frequent change in position.

To promote maximal inspiration and enhance expectoration of secretions to improve ventilation. To liquefy secretions.

Increase OFI

Administer O2 therapy as ordered. To increase oxygen saturation.

S> O>

Deficient knowledge regarding condition,

ST> After nursing interventions, patients

Emphasize necessity for continuing antibiotic

Early discontinuation of antibiotics may result in

GOAL MET The patients relatives will verbalize

treatment and discharge needs r/t

relatives will verbalize understanding of condition, disease process, prognosis and therapeutic regimen and initiate necessary lifestyle changes.

therapy for prescribed period.

failure to completely resolve infectious process.

understanding of condition, disease process, prognosis and therapeutic

Review importance of cessation of smoking.

Smoking destroys tracheobronchial ciliary action, irritates bronchial mucosa and inhibits alveolar macrophages.

regimen and initiate necessary lifestyle changes.

Identify signs and symptoms requiring notification of health care provider such as increasing dyspnea, prolonged fatigue, weight loss, fever and persistence of productive cough.

Prompt evaluation and timely intervention may prevent or minimize complications.

Drug Study: