Introduction 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. (WHO, 2014) Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi. The most common are: Streptococus pneumonia, Staphylococcus aureus, hemophilus influenza, Klebsiela pneumonia. It can be transmitted via droplets and direct contact. Infants are very prone to infection and, one of the causes that contribute to pneumonia is aspiration during breastfeeding. Aspiration can lead to infections and inflammation of the lungs and this can result in pneumonia. (S. Nair, 2011) In relation to my patient, Baby Warren was diagnosed with neonatal pneumonia last January 17, 2014.

Initial Database Name: Age: Address: Religion: Civil Status: Birthday: Birthplace: Sex: Room: Date of Admission: Attending physician: Chief complaint: Admitting dx.: History of Present Illness On January 11, 2014, baby warren experienced fever that was eventually gone after given with Tempra. On the next day, he vomited twice, followed by coughing for 5 days PTA which was on January 17, 2014. He was diagnosed to have neonatal pneumonia under the service of Dr. Durico. Sumagka, Warren Kyle Garcia 22 days old Purok AMB Homes Labangal, General Santos City Roman Catholic Child January 2, 2014 General Santos City Male Room 244 January 17, 2014 Dr. Leopoldo Durico Cough x 5 days Neonatal Pneumonia

Reasons for Seeking Health Baby Warren was admitted to GSDH due to cough for 5 days.

Past Health History Baby Warren has undergone newborn testing; completely immunized. On January 2, 2014, he was diagnosed to have UTI and was treated.

Pathophysiology

Predisposing Factors - Age (22 days old)

Precipitating Factors - Living with infected person - Bacteria

Staphylococcus pneumoniae

Organism enter the respiratory tract via inspiration/aspiration

Infection

Invasion of the respiratory tract

Increased secretions of fluid in the alveoli

Exudates within the air space of the lungs

Cough/SOB

pneumonia

Lab Results COMPLETE BLOOD COUNT (January 18, 2014) WBC Segmenters Lymphocytes Monocytes Eosinophils Basophil Hemoglobin Hematocrit Platelet Count Red Blood Cells Interpretation: Decreased segmenters and basophil, and increased lymphocytes and monocyte may indicate an ongoing inflammation. Decreased hgb and htc may indicate anemia. Result 8.1 0.32 0.57 0.08 0.02 0.01 130 0.39 580 3.81 Normal Values 5-10 x 10^9/L 0.55-0.65 0.25-0.35 0.03-0.06 0.02-0.04 0.03-0.06 140-160 g/L 0.42-0.48 vol % 150-450 x 10^9/L 4.5-5.3 x 10^12/L

CHEST AP/L (January 18, 2014) Heart is within normal limits in size. Reticular densities are seen in the right lower lobe. Rest of the lung fields are clear. Hili are not enlarged. Sulci are intact. The rest of the included structure are remarkable.

Impression: Right Basal Pneumonia

Doctors Order Date January 17, 2014 10:40 am cc: cough x 5 days wt: 3.8 kg T: 37.5 P: 134 R: 32 O2: 98% January 18, 2014 January 19, 2014 January 20, 2014 afebrile January 21, 2014 January 22, 2014 January 23, 2014 afebrile January 23, 2014 Order

D5 IMB 500 cc 100 ml Q 8 D5 IMB 500 cc 100 ml Q 8 D5 IMB 500 cc 100 ml Q 8 Ceelin Plus drops 0.25 ml/mg daily D5 IMB 500 cc 100 ml Q 8 D5 IMB 500 cc 100 ml Q 8 MGH MGH as soon as antibiotics are completed Rx: Cefixime 0.5 ml twice daily 1 wk Ceelin Plus 0.25 ml/once daily

Medications: January 17, 2014 January 18, 2014 January 20, 2014 cefuroxime (Zefsur) 120 mg IV Q 8 ANST ( ) Tempra drops 0.5 ml Q 4 for fever cefortaxime (Claforan) 250 mg IV 8 Ceelin Plus 0.25 ml once daily

IVF: 0.3 NaCL 500 cc D5 IMB 500cc 100 ml Q 8

Drug Study DRUG # 1 Brand name: Generic name: Classification: Indications: Contraindications: Dosage: Mechanism of action: Side effects: Nursing responsibilities: Zefsur cefuroxime Antibiotic 2nd generation cephalosporins Treatment of infections due to sensitive gm +ve & gm -ve bacteria Hypersensitivity to drug Actual: 120 mg IV q 8 Inhibits bacterial cell wall synthesis causing cell death. Nausea, vomiting, anorexia diarrhea, phlebitis, erythematous rashes, temperature elevation - Do skin testing - Administer drug with food - Ensure pt receives full course of the cephalosporins as prescribed.

DRUG # 2 Brand name: Generic name: Classification: Indications: Tempra drops paracetamol Non opioid analgesic, antipyretics Fever, headache, muscular aches & pain, toothache, colds, earache, fever due to tonsillectomy, inoculations & vaccinations. Patients with a known hypersensitivity to acetaminophen (paracetamol). Actual: 0.5 ml q 4 Inhibits prostaglandin synthesis thereby causing vasodilation & sweating w/c reduce fever. Skin rashes - Check and record vital signs q 4 particularly temperature to monitor the therapeutic effect of the drug. - Administer drug as needed - Monitor for severe reactions Drug is given to pt in times of fever. It causes vasodilation that leads to treat loss subsequent.

Contraindications: Dosage: Mechanism of action: Side effects: Nursing responsibilities:

Rationale of giving the drug:

DRUG # 3 Brand name: Generic name: Classification: Indications: Contraindications: Dosage: Mechanism of action: Side effects: Nursing responsibilities: Claforan cefortaxime Antibiotic, 3rd generation cephalosporin infections due to sensitive gm -ve & gm +ve bacteria. Hypersensitivity to cephalosporins. Actual: 250 mg IV q 8 Inhibits bacterial cell wall synthesis Headache, dizziness, phlebitis, thrombophlebitis, nausea, vomiting, diarrhea, rashes - Do skin testing - Administer drug with food - Ensure pt receives full course of the cephalosporins as prescribed.

DRUG # 4 Brand name: Generic name: Classification: Indications: Contraindications: Dosage: Mechanism of action: Ceelin Plus ascorbic acid Vitamins &/or Minerals Prevention & treatment of deficiencies of vit C & Zn. Hypersensitivity to any of the excipients of Ceelin Plus. Actual: 0.25 ml once daily Essential for skin integrity and wound healing; it promotes tissue repair by stimulating cell division through proper connective tissue formation. Nausea, abdominal cramps, diarrhea, nosebleeds - Protect solution from light - Instruct pt that vit. C is readily absorbed from citrus fruits, tomatoes, potatoes, and leafy vegetables

Side effects: Nursing responsibilities:

Nursing Diagnosis Knowledge deficit r/t lack of information amb frequent questioning about the disease S: -tungod sa unsa pa man diay ng pulmonya maam? as verbalized by S.O O: -frequent questioning noted - S.O doesnt know about the other causes of the disease - Lack of information about the disease noted

Need S E L F A C T U A L I Z A T I O N N E E D

Desired Outcome After 8 of nursing interventions, the client will be able to verbalize understanding of the disease.

Interventions - Ask S.O regarding previous health teachings. - Provided information using explanation regarding the disease, causes, etiology, md of transmission, ssx - Listen to clients expression of feelings about the disease - Ask about the understanding of the disease

Rationale - Identifies what to add and to improve - Enhances clients knowledge

Evaluation statement Goal met. Client verbalized, a mao diay..nasabt an na nako mam, salamat.

Intervention modification

Rationale

- Provides cues on what to add in the health teaching - To know if method of teaching is effective and to know if the client have understood the given health teachings