Patients Data

Name of Patient: Peach Twinkle T. Abundo Age: 1 Sex: Female Address: Calatagan Virac, Catanduanes Religion: Roman Catholic

Medical Data:
Date of Admission: September 17. 2011 Time of Admission: 12:25 PM Hospital Number: 557 Attending Physician: Dr. Louie Panti Chief Complaint: Vomiting Diagnosis: Pneumonia, Intestinal Parasitism

Health History
Present Health History
Peach Twinkle T. Abundo, 1 years old, female from Calatagan Virac, Catanduanes was admitted at EBMC on September 17, 2011 at 12:25 PM with a chief complaint of vomiting.

Upon admission baby Peach Twinkle T. Abundo is conscious and coherent. Her CR is 101 bpm, RR is 25 bpm and T of 37.1 C. She weighs 8 kg. Upon auscultation fine crackles is noted. Cough and colds are present. She also vomits and her mother claimed that there is a change in her bowel habit. Dr. Panti, as an Attending Physician, requested for laboratory examinations such as CBC and Stool Examination. The result of the Hematology revealed an increased in WBC counts therefore the patient have an infection.

Past Health History

The patient is born through CS. Her feeding is composed of breastmilk and also formula milk. Her immunization is complete. The patient dont have any past confinement after she was born.

Developmental Task
Autonomy vs. Shame & Doubt is Eriksons second developmental stage, as the child gains control over eliminative functions and motor abilities, they begin to explore their surroundings. The parents still provide a strong base of security from which the child can venture out to assert their will. The parents' patience and encouragement helps foster autonomy in the child. Children at this age like to explore the world around them and they are constantly learning about their environment. Caution must be taken at this age while children may explore things that are dangerous to their health and safety. At this age, children develop their first interests. For example, a child that enjoys music may like to play with the radio. Children that enjoy the outdoors may be interested in animals and plants. Highly restrictive parents, however, are more likely to instill the child with a sense of doubt and reluctance to attempt new challenges. As they gain increased muscular coordination and mobility, toddlers become capable of satisfying some of their own needs. They begin to feed themselves, wash and dress themselves, and use the bathroom. If caregivers encourage self-sufficient behavior, toddlers develop a sense of autonomy- a sense of being able to handle many problems on their own. But if caregivers demand too much too soon, refuse to let children perform tasks of which they are capable, or ridicule early attempts at selfsufficiency; children may instead develop shame and doubt about their ability to handle problems.

Anatomy and Physiology of the Affected

Organ

The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply. Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

Phatophysiology

Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells cant work properly. Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs. Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most common. Other pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella) catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gram-negative bacilli. Major pulmonary pathogens in infants and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever).

The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions from the upper airways. Other means include hematogenous or lymphatic dissemination and direct spread from contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility, immunocompromise (as in diabetes mellitus and chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissible agents. Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. This
syndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.

Laboratory Results and Diagnostic Exams

CBC Result
Diagnostics Done SI Values Significance

Hematocrit

0.40 0.54

Increased in: polycythemia, dehydration, Addisons disease, acute thermal injury, Extreme physical exertion, COPD

Decreased in: hemorrhage, anemia, hemolytic anemia, fluid overload, fluid retention, cirrhosis, leukemia, lymphoma

Increase d in: polycythemia, dehydration, acute thermal injury, COPD Hemoglobin 120 140 g/L Decreased in: hemorrhage, bleeading, anemia, hemolytic anemia, fluid overload, fluid retention, pregnancy, cirrhosis of the liver , hyperthyroidism

Increase indicates presence of systemic infections.

WBC Count

5.0 10 x 10/L

Increase indicates presence of bacterial infections. Segmenters 0.58 0.66 Increased in: infectious mononucleosis, infectious hepatitis, cytomegalo virus infection, pertussis, brucellosis, tuberculosis, syphilis, lymphocytic leukemia, Decreased in: thoracic duct drainage, right-sided heart failure Hodgkins disease,SLE,aplastic anemia, HIV infection, military TB,renal failure,Terminal cancer

Lymphocytes

0.21 0.3

Increased in: skin diseases, trichinosis, scar let fever, CML, MPD, Hodgkins disease, malignancy, rheumatoid arthritis, sarcoidosis, allergic reaction to drugs, allergies Eosonophil 0.02 0.04 Decreased in: pyrogenic infection, shock, postsurgical response

Stool Examination
Color: Yellow

Consistency: soft Red Cells: 0.2 Pus Cells: 0.2 Ascaris Ova: 2/smear Bacteria: Few Other: flat globules

Nursing and Medical Management

Pharmacological Treatment:
IVF: D5 0.3% NaCl L

Medications:

Cefuroxime 270 mg IV q8 ANST ( ) Metronidazole 140 mg IV q8 ANST ( ) Combivent Nebulization Neb q4 Metoclopramide Amp 1ml IV now then 0.8 ml q8 @ PRN for vomiting Paracetamol 125/5ml 3-4 ml q4 for fever Efamd plus 3ml q6

Non-pharmacological Treatment:
Health Teachings Imparted Routine Nursing Care

Drug Study
Name of Drug: Cefuroxime Dosage: 270 mg Indications: Listed in Dosage. Administration: Should be taken with food. Contraindications: Hypersensitivity to cephalosporins. Special Precautions: Severe renal impairment; pregnancy, lactation; hypersensitivity to penicillins. Adverse Drug Reactions: Large doses can cause cerebral irritation and convulsions; nausea, vomiting, diarrhoea, GI disturbances; erythema multiforme, Stevens-Johnson syndrome, epidermal necrolysis. Potentially Fatal: Anaphylaxis, nephrotoxicity, pseudomembranous colitis. MIMS Class: Cephalosporins

Name of Drug: Metronidazole Dosage: 140mg Indications: Listed in Dosage. Administration: Tab: Should be taken with food. Susp: Should be taken on an empty stomach. (Take at least 1 hr before meals.)

Contraindications: History of hypersensitivity to metronidazole or other nitroimidazole derivatives. Pregnancy (1st trimester) and lactation. Special Precautions: Patients with CNS diseases; discontinue IV therapy if abnormal neurologic symptoms occur. History of seizure disorder. Evidence or a history of blood dyscrasias; perform total and differential leukocyte counts before and after treatment. Severe hepatic impairment; monitor plasma levels. Predisposition to oedema (inj contains sodium). Prolonged use may result in fungal or bacterial superinfection. Adverse Drug Reactions: GI disturbances e.g. nausea, unpleasant metallic taste, vomiting, diarrhoea or constipation. Furred tongue, glossitis, and stomatitis due to overgrowth of Candida. Rarely, antibiotic-associated colitis. Weakness, dizziness, ataxia, headache, drowsiness, insomnia, changes in mood or mental state. Numbness or tingling in the extremities, epileptiform seizures (high doses or prolonged treatment). Transient leucopenia and thrombocytopenia. Hypersensitivity reactions. Urethral discomfort and darkening of urine. Raised liver enzyme values, cholestatic hepatitis, and jaundice. Thrombophlebitis (IV). Potentially Fatal: Anaphylaxis. MIMS Class: Other Antibiotics / Antiamoebics / Preparations for Vaginal Conditions / Topical Antibiotics

Name of Drug: Combivent Nebule Dosage: Neb Indications: COMBIVENT (ipratropium bromide and albuterol sulfate) Inhalation Aerosol is indicated for use in patients with chronic obstructive pulmonary disease (COPD) on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and who require a second bronchodilator. Administration: It is recommended to test-spray three times before using for the first time and in cases where the aerosol has not been used for more than 24 hours. Avoid spraying into eyes. Contraindications: Combivent Inhalation Aerosol is contraindicated in patients with a history of hypersensitivity to soya lecithin or related food products such as soybean and peanut. Combivent Inhalation Aerosol is also contraindicated in patients hypersensitive to any other components of the drug product or to atropine or its derivatives Special Precaution: Effects Seen with Anticholinergic Drugs: Combivent Inhalation Aerosol contains ipratropium bromide and, therefore, should be used with caution in patients with narrow-angle glaucoma, prostatic hyperplasia, or bladder-neck obstruction. Adverse Drug Effects: Additional adverse reactions, reported in less than two percent of the patients in the Combivent Inhalation Aerosol treatment group include edema, fatigue, hypertension, dizziness, nervousness, paresthesia, tremor, dysphonia, insomnia, diarrhea, dry

mouth, dyspepsia, vomiting, arrhythmia, palpitation, tachycardia, arthralgia, angina, increased sputum, taste perversion, and urinary tract infection/dysuria.

Name of Drug: Metoclopramide Dosage: 1 ml Indications: Disturbances of GI motility Relief of symptoms of acute andrecurrentdiabeticgastroparesis Nausea and vomiting Metabolic diseases Short-term therapy for adults with symptomatic gastroesophageal reflux who fail to respond to conventional therapy. Prophylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable. Contraindications: Contraindicated with allergy to metoclopramide GI hemorrhage Mechanical obstruction or perforation Epilepsy Use cautiously with previously detected breast cancer, lactation, pregnancy, fluid overload, renal impairment Side Effects: CNS: restlessness, drowsiness, fatigue, Insomnia, dizziness, anxiety CV: transient hypertension GI: nausea and diarrhea

Name of Drug: Paracetamol Dosage: 4ml Indications: Mild to moderate pain and fever. Administration: May be taken with or without food Special Precautions: Renal or hepatic impairment; alcohol-dependent patients; G6PD deficiency. Adverse Drug Reactions: Nausea, allergic reactions, skin rashes, acute renal tubular necrosis. Potentially Fatal: Very rare, blood dyscrasias (e.g. thrombocytopenia, leucopenia, neutropenia, agranulocytosis); liver damage. MIMS Class: Analgesics (Non-Opioid) & Antipyretics

Name of Drug: Efamed Plus

Dosage: 3ml Indications: Resp disorders complicated by bronchospasm & excessive secretion of tenacious mucus, bronchial asthma, chronic bronchitis & emphysema. Administrations: Should be taken on an empty stomach (Take on an empty stomach 1 hr before or 2 hr after meals.). Contraindications: -blocker therapy, thyrotoxicosis. Pregnancy Adverse Drug Reactions: Efamed syr Fine tremor, tension, angioedema, urticaria, bronchospasm, hypertension, collapse. Efamed Plus tab & syr Confusion, irritability, tremor, insomnia & restlessness; loss of appetite, nausea & vomiting, feeling of tension, peripheral vasodilation, slight increase in heart rate, headache, transient muscle cramps, hypersensitivity reactions, hyperactivity in childn, risk of dental caries. MIMS Class: Cough & Cold Preparations

Nursing Care Plan

ASSESSMENT Subjective: Nasakitan pa siya makahangos as claimed by mother
Ineffecti

DIAGNOSIS

INFERENCE

PLANNING
Short term goal:

INTERVENTIO N
Independent: Establish rapport to patient and watcher

RATIONALE
Independent:

EVALUATION Short term goal:

ve breathi ng pattern

Excess of fluid in the lungs

After 3-4 hours of nursing interventions, the patients respiration will improve and difficulty of breathing

To gain the trust and After 3-4 hours of cooperation nursing interventions, the patients respiration was

Objective:
-

(+) DOB Crackles noted (+) Wheezing V/S taken: T: 37.2 P: 100 R: 39

related to pulmon ary infectio n

will be relieved. Assess patients condition

Resulting from an inflammatory process

To know and determine patients needs

able to improve and difficulty of breathing was relieved.

Monitor and record V/S

Inflammation is triggered by many infectious organisms and inhalation of irritating agents

Auscultate lung fields, noting areas of decreased/ absent airflow and adventitiou s breath sounds

To establish base line data

Alveolar walls thickened and become irritated

To identify areas of consolidatio n and determine possible bronchospa sm or obstruction

Assist patient to change position

every 30 minutes To mobilize secretions

Accumulation of mucus and inflammatory cells

Encourage to increase fluid intake.

To liquefy secretions

Leads to Pneumonia

Short term goal: Impaired gas exchang e r/t collectio n of secretio ns affecting After 2-4 hours of nursing interventions, the patient will achieve timely resolution of current infection without complications.

Independent: Assess respiratory rate, depth and ease.

Independent: Manifestatio n of respiratory distress is dependent on indicative of the degree of lung

Short term goal: After 2-4 hours of nursing interventions, the patient was able to achieve timely resolution of current

oxygen exchang e across alveolar membra ne. Monitor body temperatur e

involvement and underlying general status.

infection without complications.

High fever greatly increases metabolic demands and oxygen consumptio n and alters cellular oxygenation .

Dependent: These drugs are used to combat most of the microbial pneumonias .

Dependent: Administer antimicrobi als as prescribed

 Administer nebulizer treatment as prescribed Ineffecti ve airway clearanc e related to excessiv e, thickene d mucus secretio ns Short term goal: After 4 hours of nursing interventions the patient will : Independent: Assess respiratory rate, depth. Note use of accessory muscles, pursed lip breathing.

Facilitates liquefaction and removal of secretions.

Independent: Useful in evaluating the degree or respiratory distress and chronicity of the disease process.

Demonstrate improved ventilation and adequate oxygenation. Arterial blood gases (ABGs) within normal range. No signs of respiratory

Routinely monitor skin and mucus membrane color.

Cyanosis may be peripheral in nail beds or central in lips or

distress.

earlobes. Duskiness and central cyanosis indicate advance hypoxemia. Evaluate sleep patterns, note report of difficulties and whether patient feels well rested.

Long term:

After months nursing interventions, patient:

of the

Multiple external stimuli and presence of dyspnea may prevent relaxation and inhibit sleep.

Collaborative: Ventilation or oxygenation is adequate to meet self care needs. Administer supplemen tal oxygen as indicated by ABG results and patients May correct or prevent worsening of hypoxia.

tolerance.

Nursing Implications
Nursing Practice
It is essential to be able to understand contemporary nursing practice, which looks at the overall aspects of the nursing profession. This study enhances the quality and effectiveness of nursing care that will rendered to the clients with similar condition. Nursing practice itself could also be evaluated in this case This case study will be beneficial to nursing practices. This implies that the health care providers must become more dedicated in rendering nursing care but there must be no exceptions upon rendering services regardless of the case handled by the caregiver. The greatest impact of the implication is the equality in treatment upon rendering nursing care, that all patients must be entitled to a quality and effective care regardless of who they are and what their health problem is.

Nursing Research
This case study is equipped with useful information, ample opportunities and responsibilities to the nurses, not exempting the affiliating student nurses in order for them to be well-informed and competitive in this field. Research findings will provide them a broader knowledge of the said case and will enhance their skills for them to be globally competitive in the profession.

Nursing Education
Education is one of the important processes of learning because it is continuous and it can help achieve the optimum level of knowledge to every individual in all aspects of life not just in the field of nursing. This case study is accomplish through the thorough research and studies made intentionally for other proponents who will handle same case for them to be encouraged and aim for the best to further go through series of studies. This will also be beneficial to other case studies related or similar to this. The case study could serve as a guide in making more improved and comprehensive study about the case.

Catanduanes State Colleges College of Health Sciences Department of Nursing

Case Study of Pneumonia

Submitted by: Carmina A. Aguilar BSN-2B Submitted to: Marilou Lopez, RN, MAN Clinical Instructor