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LICEO DE CAGAYAN UNIVERSITY College of Nursing

In Partial Fulfillment of the requirements in NCM501202-Related Learning Experience

A CASE STUDY OF PNEUMONIA


Submitted By: Uba, Chrislyn B. BSN III student

Submitted To:

Clinical Instructor

II. HEALTH HISTORY

A. Patients Profile Name of Patient: Sex: Age: Birthday: Address: Birthplace: Religion: Mother: Father: Nationality: Date Admitted: Time Admitted: Temperature: Pulse Rate: Respiration: Attending Physician:
B. Family History and Personal Health History

Tatad, Angela Female 1 year old December 08,2009 Upper 20 St. Nazareth, CDOC Cagayan de Oro City Roman Catholic Mrs. Tatad Mr. Tatad Filipino January 9, 2011 11:00 AM 38. 0 C 105 bpm 45 cpm Dr. Estorba

The patient was born on the eighth of December 2009, she was delivered in a normal spontaneously vaginal delivery. She has no known food or drug allergy and she was not been able to received blood in the past. She had been previously hospitalized due to LBM. History of Present Illness

2 days prior to admission, their were positive onset of productive cough associated with intermittent fever Given Amroxol and Paracetamol to patient.

Chief Complaint The chief complaint of patient is her cough thus, for this condition persisted to admission. III. DEVELOPMENTAL TASK THEORY

Sigmund Freuds Theory (Psychosexual Theory) The psychosexual stages of Sigmund Freud are five different developmental periods during which the individual seeks pleasure from different areas of the body associated with sexual feelings. These stages are as follows:

Oral Anal Phallic Latency Genital

Birth to 2 4 6 13 Up 5 12 3

1 year years years years

Based on Freud s theory, the patient belongs to the Oral stage. The Mouth is the center of pleasure. FIXATION results in Difficulty in trusting others, nail biting, drug abuse, smoking, overeating, and alcoholism. Feeding produces pleasure and sense of comfort and safety. The oral stage lasts from birth to about 18 months. The focus of pleasure is, of course, the mouth. Sucking and biting are favorite activities.

Erik Ericksons Theory (Psychosocial Theory) Erik Erickson envisioned life as a sequence of levels of achievement. Each stage signals a task that must be achieved. He believed that the greater that task achievement, the healthier the personality of the person. Stages of Eriksons Psychosocial Theory are as follows:

Infancy Early Childhood Late Childhood School Age Adolescence Confusion Young Adulthood Adulthood Stagnation Maturity

Birth 18 months 18 mnths 3 years 3 5 years 6 12 years 12 20 years 18 25 years 25 65 years 65 years to death

Trust vs. Mistrust Autonomy vs. Shame & Doubt Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Intimacy vs. Isolation Generativity vs. Integrity vs. Despair

Based on this theory, the patient belongs to early childhood which is autonomy vs shame and doubt. Autonomy is the independence a toddler strives for from caregivers. Toddlers autonomous behavior is a way of forming their own identity away from their caregivers . This stage is a time where a toddler has the will to become independent. Shame and doubt is likely to occur when the toddler is not given any choices or boundaries because the toddler is determined to become independent. The strong will of a toddler may cause conflict between child and caregiver It is in this level that that the child begins to evaluate her own behavior. The mother does not scold the child whenever she commits mistake but corrects her because the mother believes that over restriction and over control of any activity can lead to lack of self confidence of the child when she grows up. She wants that her child will learn from her own mistakes and realize good from the bad. Autonomy can be gained for the toddler when given reasonable choices and proper guidance from the caregiver

Jean Piagets Theory (Cognitive Theory) Cognitive development refers to how a person perceives, thinks, and gains understanding of his or her world through the interaction and influence of genetic and learning factors. This is divided into five major phases:

Sensorimotor Phase Pre-conceptual Phase Intuitive Thought Phase Concrete Operations Phase Formal Operational Phase

Birth to 2 years 2 3 years 4 6 years 7 11 years 12 adulthood

Based on this theory, the patient belongs to the pre-conceptual phase. It was observed that the child associates words with objects and she learns to explore the environment. The child begins to move towards understanding the world through mental operations rather than purely through actions. The action being manifested by the child is a significant behavior by her age.

Developmental Task Theory of Robert Havighurst A developmental task is a task which arises at or about a certain period in the life of an individual. Havighurst has identified six major age periods: infancy and early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18 years), early adulthood (19-29 years), middle adulthood (30-60 years), and later maturity (61+). Based on this theory, the patient belongs in the early childhood (0-5 years) wherein she is in the stage of Infancy and late Childhood periods wherein the patient learns to walk, talk, and takes solid foods. It was observed that during assessment, the patient is weak, can take semisolid foods and can walk with assistance and says no as a resistance to request.

IV. MEDICAL MANAGEMENT A. MEDICAL ORDERS


Medical Orders Rationale

January 9 ,2011 11am Secure consent to care and management DAT with strict aspiration precaution Providing proper nursing care to patient Patient is allowed intake of food that he can tolerate but with strict precaution to avoid aspiration that may cause airway obstruction

Intake and output every shift

To check and note for imbalances in the intake and output

TPR every 4h To monitor any alterations and deviations in patients vital measurement

Watch out and refer if persistent SOB, cyanosis, and other unusualities To check for signs of inadequate oxygenation and impaired gas exchange

IVTF: D5 0.3% NaCl 500 cc @35 mgtts/min

To replace fluid loss and means to incorporate Intravenous drugs

LABORATORY RESULTS Date: January 16, 2011 CBC TEST RESULT

White Blood Cell Count Red Blood Cell Count Hemoglobin Count Hematocrit Count Platelet Count

30.5 4.40 12.5 37.4 330,000

Urine Test Date ordered: January 16, 2011 Color: yellow Specific gravity: 1.010 Transparency: slightly hazy Ph reaction: 6.5PH Sugar: Negative Albumin: negative Microscopic Cast: non seen Pus Cells: +(0-2 HPF) RBC: + (1-1 HPF) Epithelium: Squamous-rare Crystal: none Bacteria: none

Name of Drug Generic (Brand)

Date Classificatio Ordered n

Dose/ Frequency Route

Mechanism of Action

Specific Indication (why is ordered)

ContraIndication

Side Effects/Toxic Effects

Nursing Precaution

Cefaclor

Antiinfectives

1.5ml TID/q5h Bind ti bacterial cell wall membrane, causing cell death. Therapeutic Effects: Bactericidal action

Treatment of Respirator y tract infections.

Contraindicated in Hypersensitivity to cephalosporins and serious hypersensitivity to penicillins.

Name of Drug Generic (Brand)

Date Classificatio Ordered n

Dose/ Frequency Route

Mechanism of Action

Specific Indication (why is ordered)

ContraIndication

Side Effects/Toxic Effects

Nursing Precaution

Salbutam ol Sulfate Ventolin

Bronchodilator 1 neb/ q6h/ Relaxes bronchial Helps To patients steam inhalation smooth muscle by expectorate hypersensitive to acting on beta2mucous the drug and its adrenergic secretions components receptors; improves through ventilation dilation.

Tremor; Perform chest palpitations; tapping every after tachycardia; nausea nebulization and vomiting; irritation

Name of Drug Generic (Brand)

Date Classificatio Ordered n

Dose/ Frequency Route

Mechanism of Action

Specific Indication (why is ordered)

ContraIndication

Side Effects/Toxic Effects

Nursing Precaution

Paraceta mol Biogesic

Produces analgesic effect by Non-opioid 250/mg 1 tsp q4 blocking pain For fever analgesic;anti h, prn impulses, by pyretic inhibiting prostaglandins or pain receptors sensitizers; may relieve fever by acting in hypothalamic heat regulating center

To patients going long-term therapy for chronic noncongestive angle-closure glaucoma; hyponatremia; hypokalemia; hepatic impairment; adrenal gland failure hypechloremic acidosis

Confusion; anorexia; aplastic anemia; rash; renal calculi

Report signs of fluid and electrolyte imbalance

Name of Drug Generic (Brand)

Date Classificatio Ordered n

Dose/ Frequency Route

Mechanism of Action

Specific Indication (why is ordered)

ContraIndication

Side Effects/Toxic Effects

Nursing Precaution

Cefaclor

NURSING SYSTEM REVIEW CHART Specific Mechanism of Indicatio Action n (why is ordered)

Date Name Classificat Ordere of Drug ion d Generic (Brand)

Dose/ Frequency Route

ContraIndication

Side Effects/Toxic Effects

Nursing Precaution

Cefacl or

Name: Angela Tatad January 09, 2011 Vital Signs Pulse: 160bpm Height: RR: 36cpm Weight: 8.7kg BP: N/A Temp:

Date:

38.0 C

INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space


provided. Indicate the location of the problem in the figure using [X].

EENT: impaired vision blind pain reddened drainage _____________________ gums hard of hearing deaf 38.0 C________ FEBRILE =

burning edema lesion teeth Productive cough _______ Asses eyes, ears, nose sputum_____ throat for abnormality no problem crackles upon ausculation asymmetric tachypnea ____________________ apnea rales cough barrel chest ____________________ bradypnea shallow rhonchi _____________________ sputum diminished dyspnea _____________________ orthopnea labored wheezing _____________________ pain cyanotic _____________________ Asses resp, rate, rhythm, depth, pattern, _____________________ breath sounds, comfort no problem _____________________ CARDIO VASCULAR arrhythmia tachycardia numbness diminished pulses edema fatigue _____________________ irregular bradycardia murmur _____________________ tingling absent pulses pain _____________________ Asses heart sounds, rate rhythm, pulse, blood _____________________ pressure, fluid retention, comfort _____________________ no problem GASTRO INTESTINAL TRACT _____________________ obese distention mass _____________________ _____________________ _____________________ with whitish

dysphagia rigidity pain __________ Asses abdomen, bowel habits, swallowing, _____________________ bowel sounds, comfort no problem Fatigue_______________ GENITO-URINARY and GYNE _____________________ pain urine color vaginal bleeding _____________________ hermaturia discharge nocturia _____________________ Asses urine freq., color, control, odor, comfort/ _____________________ Gyn-bleeding, discharge no problem _____________________ NEURO _____________________ paralysis stuporous unsteady seizures _____________________ lethartic comatose vertigo tremors _____________________ confused vision grip _____________________ Asses motor function, sensation, LOC, strength, _____________________ Grip, gait, coordination, orientation, speech, no problem MUSCULOSKELETAL and SKIN _____________________ appliance stiffness itching petechiae _____________________ hot drainage prosthesis swelling _____________________ lesion poor turgor cool deformity _____________________ wound rash skin color flushed _____________________

_Weak body

_____________________

atrophy pain ecchymosis _____________________ diaphoretic moist Asses mobility, motion. gait, alignment, joint function _____________________ /skin color, texture, turgor, integrity no problem _____________________ _____________________

Nursing Assessment II
SUBJECTIVE Communication: [ ] hearing loss [ ] visual changes [ ] denied Comments: no subjective cues since patient is a child Oxygenation: [ ] dyspnea [ ] smoking history [ ] cough [ ] sputum [ ] denied Comments: no subjective cues since patient is a child Circulation: [ ] chest pain [ ] leg pain [ ] numbness of extremities [ ] denied Comments: no subjective cues since patient is a child OBJECTIVE [ ] glasses [ ] language [ ] contact lens [ ] hearing aide R L Pupil size : 2 mm Reaction: pupil equally round reactive to light & accommodation [ ] speech difficulties Respiratory [] regular [ x] irregular Describe: symmetrical lung expansion R right lung is symmetrical to left lung L left lung is symmetrical to right lung Heart Rhythm [x] regular [ ]irregular Ankle Edema: none Pulse Car. Rad. DP. Fem.* R + + + + L + + + + Comments: all pulses are palpable

Nutrition: DAT with aspiration precaution [ ] recent change in weight, appetite [ ] swallowing difficulty [ ] denied Comments: no subjective cues since patient is a child Elimination: Usual bowel pattern Once a day constipation remedy NONE

[ ] dentures [x] none Upper Lower Full [] [] Partial [] [] With Patient [] []

Urinary frequency 4-5/day [ ] urgency [ ] dysuria

Bowel sounds: hyperactive Abdominal Distention Present [ ] yes [x] no Urine* (color, consistency, odor)

Date of last BM January 8 ,2011 Diarrhea character Not applicable

[ ] hematuria [ ] incontinence [ ] polyuria [ ] foley in place [ ] denied Management of Health and Illness: [] alcohol [ x] denied (amount, frequency) Comments: Not applicable [ ] SBE Last Pap Smear: Not applicable LMP: Not applicable

The color of the urine is yellow *if they are in place Comments: patient changes diaper 2-3

times
Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). The mother is strictly following the treatment required of her child.

SUBJECTIVE Skin Integrity: [ x] dry [] itching [ ] other [ ] denied Comments: no subjective cues since patient is a child

OBJECTIVE [ x] dry [ ] cold [ ] pale [ x] flushed [ x warm [ ] cyanotic *rashes,ulcers, decubitus (describe size, location, drainage) The patients skin is dry,warm and flushed LOC and orientation:

Activity/ Safety: [ ] convulsion [ ] dizziness [ ] limited motion of joints Limitation inability to: [ ] ambulate [ ] bathe self [ ] other [ ] denied Comments: no subjective cues since patient is a child

Patient is conscious
Gait: [ ] walker [ ] cane [ ] other [ ]sensory and motor losses in face or extremities sensory and motor losses in face or extremities. [ ]ROM limitations: no limited range of motion.

Comfort/ Sleep/ Awake [ ] pain (location, frequency, remedies) [ ] nocturia [ ] sleep difficulties [ ] denied Comments: no subjective cues since patient is a child

[ x] facial grimaces [ ] guarding [ ] other signs of pain: [ ] siderail release None

Coping: Occupation: not aplicable Members of household: 3 members Most supportive person: parents: Mr. & Mrs.Tatad

Observed non- verbal behavior: Patient was playful. The person and his phone number that can be reached any time: not given

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) n/a Daily Weight: n/a ______ BP q Shift: n/a Neuro VS: n/a CVP/SG. Readin:

n/a n/a n/a n/a

PT/OT Irradiation Urine Test ________ 24h urine collection

Date Ordered 1/16/11

Diagnostic/laboratory Exams Urine exam

Date Done 1/16/11

Date Ordered 1/9/11

I.V. Fluids/blood D5 0.3%Nacl @35 mgtts/min

Date Disc. Ongoing

VII. NURSING MANAGEMENT 1. Ineffective Airway Clearance RT excessive mucous secretions and ineffective coughing

Interventions Independent: 1. Position head appropriate

Rationale

for To open or maintain open airway in atrest

age(midline)

2. Elevate head of bed/ change To enhance ventilation to different lung position every 2 hours and prn 3. Increase fluid intake within cardiac tolerance 4. Dicourage use of oil-based segments Hydration can help liquefy viscous secretions clearance To prevent vomiting and aspiration to lungs and improve secretion

products around nose

Dependent: 1. Administer prescribed medications as


ordered (bronchodilators)

To help maintain open airway

2. Impaired gas exchange with the collection of secretions affecting oxygen exchange across alveolar membrane
Interventions Independent: 1. Elevate head of bed/ position client appropriately 2. Encourage adequate rest and limit clients tolerance 3. Keep environment activity within client allergen/ To open or maintain open airway in at-rest Helps consumption To reduce irritant effect of dust Hydration can help liquefy viscous secretions clearance use of oil-based To prevent vomiting and aspiration to lungs Helps in improving stamina and reducing the work of breathing. Dependent: Administer medications as ordered(bronchodilators, antibiotics) To treat underlying conditions and improve secretion limit oxygen needs/ Rationale

pollutant free 4. Increase fluid intake within cardiac tolerance 5. Discourage

products around nose 6. Provide adequate food intake

3..Fluid volume deficit RT excessive loss of water secondary to amoebiasis as evidenced by dry mucous membrane, poor skin turgor

Interventions Independent:

Rationale

Establish 24 hour replacement needs and routes to be used. 2.Provide nutritious diet via appropriate route,give adequate free water with enteral feedings. 3. Maintain accurate intake and output

Prevents peaks/valleys in fluids level.

To gain energy and prevent fatigue

For comparison purposes and to know the fluid loss or gain

4.Bathe less frequently using mild cleanser and provide optimal skin care

To maintain skin integrity and prevent excessive dryness

5.Provide frequent oral care,eye care

To prevent injury from dryness.

Dependent: Administer metrronidazole

To kill protozoal microorganism thus preventing elimination of watery stools

4. Hyperthermia RT physiologic changes and suppressed immune system secondary to pneumonia and acute amoebiasis

Independent:

Rationale

Provide tepid sponge bath Increase fluid intake Remove unnecessary clothing

To reduce body temperature to normal range.

To help cool down the body temp. To help lessen body temp. due excessive use of clothing

To avoid crack lips Apply petroleum jelly

To prevent fatigue and loss of body Provide adequate rest energy

Dependent: Administer prescribed anti-pyretic medication as

To relieve fever

B. ACTUAL NURSING MANAGEMENT

S
O

No subjective cues since patient is a child

Dyspnea rr=45 cpm Crackles heard upon auscultation Cough with sputum Ineffective airway clearance RT excessive secretions and ineffective coughing Long term: At the end of 3 days, client will manifest patent airway. Shot term: At the end of 45 minutes, the client will manifest effective

A P

airway clearance and expectorate secretions.


I Independent: 1. Positioned the head midline

2. Elevated head of bed/ change position every 2 hours and prn 3. Increased fluid intake within cardiac tolerance 4. Dicouraged use of oil-based products around nose 5. Performed chest tapping therapy after nebulization, it uses force of gravity and motion to facilitate secretion removal. Dependent: 1. Given bronchodilators (Salbutamol ) as ordered, to relax bronchial smooth muscles thus facilitating airflow.
E After 45minutes, the clients cough was still productive with lessened mucous

secretions S O Dyspnea Tachypnea Pallor No subjective cues since patient is a child

Impaired gas exchange with the collection of secretions affecting oxygen exchange across alveolar membrane

Long Term: At the end of 3 days, the client will be able to maintain a normal body gas exchange with improve ventilation and absence of respiratory distress.

Short Term:At the end of 30 mins, the clients will manifest improvement of airway clearance

Independent: Elevated head of bed/ position client appropriately Encouraged adequate rest and limit clients activity within client tolerance Kept environment allergen/ pollutant free Increased fluid intake within cardiac tolerance Discouraged use of oil-based products around nose Provided adequate food intake

Goal was partially met. At the end of 30 mins, the client was able to manifest improvement of airway clearance as evidenced by lessened mucous production.

No subjective cues since patient is a child

Temp=38.0 C Warm, flushed skin Dry mucous membrane Hyperthermia RT physiologic changes and suppressed immune system secondary to pneumonia and acute amoebiasis

Long term: At the end of 1 day, client will have stable body temperature. Short term: At the end of 45 minutes, the clients temperature will be in normal range

Independent:

Provided tepid sponge bath

Increased fluid intake Removed unnecessary clothing Applied petroleum jelly


Provided adequate rest

Dependent: 1. Give antipyretics- to reduce body temperature to normal range E After 45 minutes, clients temperature lowered down from 38.9 C to 37.5 C

DISCHARGE PLAN Medication


Medication should be taken regularly as prescribed, on

exact dosage, time and frequency, making sure that the purpose of medication is fully disclosed by the health care provider such as:

Paracetamol 1 tsp q4h Other oral antibiotics Report any adverse effects and drug/food-drug interactions to the physician.

EXERCISE