T ABLE OF C ONTENTS

I. Introduction ----------------------------------------------------------- 1

II. Objectives ----------------------------------------------------------- 3

III. Patient's Data ----------------------------------------------------------- 4

IV. Genogram ----------------------------------------------------------- 5

V. Health History

i. Present Health Status ------------------------------------------------- 6

ii. Past Health History ------------------------------------------------- 6

VI. Physical Assessment ------------------------------------------------- 7

VII. Definition of Terms ------------------------------------------------- 12

VIII. Developmental Task ------------------------------------------------- 13

IX. Anatomy and Physiology ------------------------------------------------- 14

X. Pathophysiology ------------------------------------------------- 16

XI. Diagnostic Exams ------------------------------------------------- 20

XII. Laboratory Exams ------------------------------------------------- 21

XIII. Drug Study ------------------------------------------------- 23

XIV. Nursing Care Plan ------------------------------------------------- 26

XV. Discharge Planning Method --------------------------------------- 33

XVI. Prognosis ----------------------------------------------------------- 35

XVII. Bibliography ----------------------------------------------------------- 36

University of the Immaculate Conception

In partial fulfillment of the requirements

in NCM 101 – RLE 101

A Case Study:
Pneumonia

Submitted to:
Nena Evangelista, R.N.

Submitted by:

Montenegro, Roland Jireh

Cabuntalan, Amerah
Castillo, Manilyn
Masunag, Ronie
Cerdina, Jester
Pellegas, Chon

August 2009
 I. INTRODUCTION

Pneumonia is an inflammation of the lungs caused by an infection. It is also called

Pneumonitis or Bronchopneumonia. 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.
(www.msn.encarta.com/org)

There are many kinds of pneumonia that range in seriousness from mild to life-threatening.
In infectious pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to
inflammation that makes it hard to breathe. Pneumonia can affect one or both lungs. In the young
and healthy, early treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight
pneumonia are determined by the germ causing the pneumonia and the judgment of the doctor. It’s
best to do everything we can to prevent pneumonia, but if one do get sick, recognizing and treating
the disease early offers the best chance for a full recovery. (www.wikipedia,.com/org)

To know the disease, we have to anticipate its warnings. Symptoms would include fever,
chills, cough (non-productive or productive), tachycardia, a crackling sound would be noted and
some would show labored breathing. These symptoms are common to almost all upper and lower
respiratory infections so it is important that we know the diagnosis.

A case with a diagnosis of Pneumonia may catch one’s attention, though the disease is just
like an ordinary cough and fever, it can lead to death especially when no intervention or care is done.
Since the case is a pre-school, an appropriate care has to be done to make the patient’s recovery
faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them
as another victim of this illness.

1
 The death rate (or mortality) also depends on the underlying cause of the pneumonia.
Pneumonia caused by Mycoplasma, for instance, is associated with little mortality. However, about
half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia
while on a ventilator will die. In regions of the country without advanced health care systems,
pneumonia is even deadlier. Limited access to clinics and hospitals, limited access to x-rays, limited
antibiotic choices, and inability to treat underlying conditions can leads to higher rates of death from
pneumonia. For these reasons, the majority of deaths in children under five due to pneumococcal
disease occur in developing countries. (DOH.gov.ph)

In a worldwide aspect of the disease, according to the World Health Organization (WHO)
that one in three newborn infant deaths are due to pneumonia and over two million children under
five die each year. Mortality from pneumonia generally decreases with age until late adulthood.
(www.reuters.com)

Knowing this, it can be safe to say that pneumonia is not ‘just’ a disease but ‘it is’ a disease.
It will be a challenge to the group for the client of J.F.G, 5 years old, a Filipino male who was
admitted because of cough and fever and was diagnosed of having pneumonia.

This would be a great opportunity for the group to study this case since the concept for this
duty is about Oxygenation. This would also present an opportunity in applying the learned skills of
giving care to the client and the implications as nurses. We must know our roles efficiently in our
chosen field of profession.

2
II. OBJECTIVES
General Objective:

At the end of the rotation, the group will be able to come up with a case presentation aimed
to determine the subject’s health concern, underlying causes for the disease and the intervention
including medical and nursing interventions for any complications that may arise during the duration
and as partial fulfillment of the requirements in Related Learning Experience, B.S. in Nursing,
University of the Immaculate Conception, Philippines.

Specific Objectives:

1. To identify a qualified client to be the subject of this case study.

2. Gather the needed data regarding the subject and the family.
3. Assess the health status of the client, including the past and present illnesses that the
subject would have.
4. Review and familiarize the anatomy and physiology of the respiratory system regarding
the present complication of the patient.
5. Formulate a relevant Nursing Care Plan with the identified problems of the client.
6. Formulate Drug Studies for all the drugs given to the client and be able to explain why
such drug is given to the client; and
7. Provide the subject as well as the family with the support systems, health teaching
appropriate to the client’s needs and the family as well including the formulation of
discharge plans.

3
III. PATIENT’S DATA
Patient’s name : J. J. F. A.
Age : 5 years old
Sex : Male
Religion : Roman Catholic
Nationality : Filipino
Address : San Jose, Digos City
Birth date : October 10, 2003
Birth place : Digos City
Father’s name : J. G. A.
Mother’s name : A. A.
Date of Admission : August 2, 2009 / 2:45 p.m
Registry Number: : 3738
Chief complaint : fever and cough
Admitting Diagnosis : CAP
Attending Physician : Dr. Lutero

4
V. HEALTH HISTORY
Present Health Status

The client is a 2-year old female child. Upon admission at Gonzales Maranan Clinic and
Hospital, client was complaining of LBM, fever, anorexia and vomiting. Client is having persistent
diarrhea and has had fever with 38.3 celcius for temperature when admitted. The client is
ambulatory, coherent and v/s results showed an elevated RR of 37 rpm, pulse rate of 84. No
intestinal parasite as result for fecalysis on the first day would indicate. Soft diet was prescribed, has
a standing order of TSB for fever. Platelet is below normal but WBC count is within range and with a
medical diagnosis of Pneumonia.

Past Health Status

Cough and fever has been noted to have onset 4 days prior to admission. Client has history
of pneumonia and was admitted to the hospital when he was three years old. By then he was
prescribed with Montelukast as his medicine. He was also admitted again 4 months after that with
the same prescribed drug. Client has suffered asthmatic attack when he was 3 years old and was
admitted to the hospital and was given Ventolin for treatment but has no record of any onset after
that. Immunizations were completed when he was one year old. Patient has not yet visited a dentist.
Latest medicines prescribed are Cefuroxime, Albuterol, Montelukast, and Naproxen.

6
VI. PHYSICAL ASSESSMENT

Patient: J.J.F.A.
Unit / ward: NS 1
Age: 5 years old Sex: Male Civil status: Child / Single

I. Vital signs: (latest)

Temperature: 36.9 celcius (axilla)
Pulse rate: 115 bpm (radial) 103 bpm (apical)
Respiratory rate: 23 rpm
Blood pressure: 100/70 mmHg

First Day Second Day Third Day

Temp. 38.1 36.5 36.9
Respiratory rate 28 24 23
Pulse rate 115 98 115
Blood pressure 110/80 110/70 100/70

II. Integument

Client has fair complexion and is consistent throughout the body. Abrasions were noted at
the right outer hip related to bicycle accident 2 months ago. There were no lesions, rashes and
lacerations noted. Mucus membranes are intact, moist and has no lesions present. Nails are cleaned-
short with no lesions noted on fingers. Hair is colored black and is evenly distributed on the head
scalp. No noted parasite on the hair and patient has good grooming.

III. HEENT

Head
 Head circumference is 52 cm with normocephalic head configuration. No lesions, burns,
lacerations and cuts noted. Masses and depressions not noted on head.

Eyes
Pupils are black and equally rounded and constricts with light accommodation. Peripheral
vision and visual acuity were not assessed.

Ears

Auricle is symmetrical, tenderness were not noted. External surfaces are smooth with
discharges noted in small amount. Size of ears are symmetrical and proportional to the head. Ear
canal is pinkish in color.

Nose
Mucosal condition of nose is fine with pinkish color. No noted lesion but nasal flaring is
present. No profuse discharges present. Nose is symmetrical with the nasal septum at the midline and
intact with no lesions nor masses noted.

Mouth
Lips were pale in color and dry. Few cracks were noted but no lesions, cut nor ulcerations
noted. Gums are intact, pink in color and moist.

Pharynx
Pharynx located at the midline. Tonsils are non-palpable. No structural abnormalities noted.

IV. Neck / Lymph nodes

Trachea is at the midline. Range of motion for neck is normal. No reported stiff neck present
and was symmetrical. No signs of lesions, lacerations or pigmentation noted. Thyroid was non-
palpable and no enlargements noted. Carotid pulse is palpated with strong bounding pressure. No
distended neck vein noted.

V. Pulmonary breath sounds

Crackling breath sounds were heard with stethoscope when auscultated. Productive cough is
observed.

VI. Breast and Axillary Areas

Breast were normal and symmetrical with no lesion or masses noted. It has a lighter color
compared to face. Axillas does not have hair and is dry. Axillary lymph nodes were not palpable.

VII. Cardiovascular

The PMI (point of maximal impulse) was at the 5th intercostals space, left mid claviclar line
with cardiac rhythm as normal. Cardiac rate is 103 at apical pulse and 115 bpm for the radial. Heart
sounds are normal with S1 and S2 sounds heard. No murmurs noted.

VIII. Peripheral / Vascular

Pulse Grade Equal or not equal

Temporal 2+ equal
 Carotid 3+ equal
Radial 2+ equal

Peripheral pulses are strong and are equal. Varicosities, rashes and edemas were not noted.

IX. Abdomen

Skin integrity is normal, color is fair, masses and pulsation were not noted. Bowel sounds
were not assessed. Tenderness were not noted.

X. Musculoskeletal / Extremities

Range of motions was normal. Shoulders and arms were free from deformities. Nail beds are
pink in color with capillary refill of 2 seconds.

XI. Genitalis

Urinates 5 times a day with amber yellow and sometimes clear white urine. Appearance of
genitals was not assessed.

10

XII. Neuro-assessment Refer legend at last page of case study.

Eyes are open spontaneously. 5 pts.

Verbal response is Alert and oriented 5 pts.
Motor response is withdraws from pain 4 pts.
 Result 14 pts.

Patient’s neuro-assessment is lethargic.

11
VII. DEFINITION OF TERMS

There were several words whose definitions are vague that it needs to be defined in order for
the reader to understand the case study. The following are words used in this case study whose
definition has been provided for easier comprehension on the reader’s part.

Pneumonia
 - inflammation of the one or both lungs usually caused by an infection from a
bacteria, virus or from a parasite

Tachycardia
- increase in heart rate. An elevated heart / cardiac rate from the normal.

Palpitations
- fast or irregular beating that can be felt by the patient

Bronchus
- a tube leading from the windpipe to the lungs which provide passage of air

Contractions
- reduction in size

Pleura
- a thin transparent membrane that lines the chest wall and doubles back to cover the
lungs thus closing the narrow pleural cavity.

Dyspnea
- difficulty in breathing usually caused by a heart or lung disease

12

VIII. DEVELOPMENTAL TASK

Stages Developmental Task Evaluation

Erik Erikson's Goals: Patient has partially

Psychosocial Crisis: established what is
• Learning to do things on their expected at her age.
Initiative vs. Guilt own
• Begins to evaluate their own
behaviours
• Do things for a purpose
Patient is able to
stand, eat, play and
take a bath on their
own with any
assistance from his
parents and guardians.

Patient is
establishing his own
behaviours by applying
or doing what he
wants, saying what he
thinks and play what he
likes.

Freud’s Stages of Child’s genitals are the center for The child seeks
Development pleasure. Activities would include immediate pleasure and
fantasy, experimentation with other gratification by means
Phallic Stage peers. of his mother’s
attention and comfort.
Major conflict:
Has identified his
Oedipus complex father as his significant
person.

13
IX. 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 up to 20 times per minute taking in and disposing of those gases.

The first line of defense includes the hair in the nostrils, which serves as a filter for larger
particles. The epiglottis is a trap door of sorts, designed to prevent food and other swallowed
substances from entering the larynx and then trachea. Sneezing and coughing, both provoked by the
presence of irritants within the respiratory system, help to clear such irritants from the respiratory
tract.

Mucous, produced throughout the respiratory system, also serves to trap dust and infectious
organisms. Tiny hair-like projections (cilia) from cells lining the respiratory tract beat constantly,
moving debris, trapped by mucus, upwards and out of the respiratory tract. This mechanism of
protection is referred to as the mucociliary escalator.

14
 Cells lining the respiratory tract produce several types of immune substances which protect
against various organisms. Other cells (called macrophages) along the respiratory tract actually
ingest and kill invading organisms.

Air that is breathed 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
breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three
lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic,
spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the
lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli.
The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The
oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon
dioxide, which is then exhaled from the body.

Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling
results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the
pleura, that under normal circumstances has a very, very small amount of fluid between the layers.
The fluid allows the membranes to easily slide over each other during breathing.

15
 X. PATHOPHYSIOLOGY

Predisposing factors Precipitating factors

.
Lifestyle factors: Exposed to second-hand
Patient is 5 years old where pneumonia smoke (uncles and aunties).
is more common to these ages
Does not wash hands unless father is
present

Only eats meat and does not prefer eating

vegetables nor fruits.

Weakened immune system

Aspiration of organism inhabiting the upper airways

Organisms invade the lungs and conducts bacterial growth

Inflammation of the lungs Fever

Mucus production is increased and plugs the alveoli

and is further filled with fluid and debris from WBC’s
produced to fight the infection

16
 The alveoli (air sacs) of the lungs becomes blocked
with mucus secretions.

Crackling
breath 16
sound

If not treated.... If treated .......

The alveoli (air sacs) of the lungs Administration of anti-infectives

becomes blocked with mucus and bronchodilators to inhibit
secretion bacterial growth and promotes
Less functional are for oxygen- dilation of the bronchi
carbon dioxide exchange
Infection is stopped and
Patient becomes oxygen deprived inflammation is resolved.
and retention of Carbon dioxide

Patient becomes oxygen deprived Mucus secretions are loosened and

and retention of Carbon dioxide will be expectorated

Consolidation occurs Alveoli will be clear from

secretions

Atelectasis Lung activity will

return to normal

Respiratory failure

Death

17
Narrative
 A picture of a lung with
pneumonia with close-up for
alveolar sac filler with mucus
secretions

The lung is sterile. It is part of the lower respiratory tract. The upper respiratory tract has
bacteria for its normal flora. Factors such as being 5 years old increases that risk for pneumonia
(WHO) as well as exposure for second hand smoking, also not washing of hands and the imbalanced
nutrition increases the risk for the child to have pneumonia.

The bacteria in the upper respiratory tract gets aspirated in the lungs where it grows in
number and thus results in the inflammation of the lungs. This inflammation causes the body to
increase its temperature as it compensate in fighting for the infection. Mucus secretion is then
increased. Fluids and debris from WBC’s sent to fight the infection also invades the alveolar sac. The
alveoli then is plugged and blocked with secretions which causes the crackling breath sound. If it is
treated with anti-infectives to inhibit the bacterial growth and bronchodilators to dilate the bronchi
and for loosening the secretions, the infection is stopped and inflammation is resolved. This results in
secretion of the mucus and lungs will return to normal state.

18
 If untreated on the other hand, the child becomes oxygen-deprived and retention of CO2 will
result. After that, consolidation will occur which is when the alveoli becomes solid due to the
quantities of the fluids, debris and mucus secretions in it. (www.science.jrank.org)

When the alveoli becomes solid, this will cause lung collapse (atelectasis) which would later
then result to respiratory failure and when it is not treated immediately can cause death.

A comparison between clear alveoli and alveoli with

mucus secretions caused by pneumonia

19
 XI. DIAGNOSTIC TESTS

A chest x-ray is a routine radiographic method for evaluating the heart, lungs and other
organs found on and in the chest area. Since this case is about the lungs, A CXR would be
appropriate. It is an important test for pneumonia in unclear situations. CXR can reveal areas of
opacity which would represent consolidation.

Patient's radiology result showed heart normal in size, infiltrates on both upper and lower
lobes.

20

XII. LABORATORY EXAMS

 Several laboratory examination was done to the patient which the results are shown below
with their significances on her disease and condition.

Laboratory Result Normal Significance

Examination Values

Hematocrit test It is used to determine the packed-

Packed-cell cell volume which would indicate the
volume 42% 37 – 49 % hemoglobin in the blood. Any
increase in Hct will show a decrease
in volume plasma. An elevated Hct
will signify increase In Hgb. If Hgb is
elevated, that means that the body is
creating more Hgb to accommodate
the low level of oxygen in the body.

Fecalysis No intestinal Pneumonia can be caused by several

parasite factors, parasitic is one of them. This
test is done to check if there are
presence of parasites which would
cause the pneumonia.

Urinalysis 6.0 slightly Check the hydration status of the

8. pH acidic patient, if it is highly acidic –
dehydrated, if it is alkalinic – over
hydrated.

CBC
- Thrombocytes Used to determine the platelet count
 281 g / L and the coagulation time of the
patient’s blood. This test was done to
know if there is a need for platelet
transfusion.

- WBC 5.0 – 10.0 When WBC is above normal, this

12.4 k/uL indicates that an infection is present in
the body because it will try to fight
the foreign organism by creating more
WBC’s.

- Platelet 250 - 400 Test is done to indicate if there is the

244 k/uL need for platelet transfusion.

22
XV. DISCHARGE PLANNING METHOD
I. Medication

Before the patient is discharged, the mother must be encouraged to follow the prescribed
medications of her child with the right dose at the right time. This could be also enhanced by
explaining to the mother the reason why the drug is given and the possible effects that may occur. It
would also minimize the chances of stopping the medication once the mother understands them. Also
teach the mother that even if the child's symptoms have been relieved, medications must still be
continued according the doctor's instruction, otherwise pneumonia may recur and it will be worse
than the previous attack.

II. Exercise

Encourage the mother to let the child have frequent exercises such as walking, arm raising,
to enhance the lung function but inform the mother to avoid places that are prone to pollution, dust
and infections such as smoking places to prevent straining the child's lungs. Advise the mother to
balance the child's daily physical activities and provide adequate rest periods. Encourage the mother
to reposition the child from side to side turning into a favorable and comfortable position to promote
good circulation in the body.

III. Teaching

Inform the mother that the child needs to have adequate rest because it is important to
maintain progress toward full recovery. Ask the parents to have the child washed his hands
frequently to avoid further infections brought by other microorganisms. Ask the parents not to
expose the child in places with too much pollutions. Define the importance of increasing the oral
fluid intake of the child in his recovery as well as adequate rest. These are needed by the child to
maintain his optimum level of health.

33

IV. Out-patient instructions

 Remind the family to have follow-up check-ups with the doctor. Inform for any
appointments they may have and request the parents to bring the child to a health care facility as
soon as any problems will occur. Even though the patient may feel and look better, his lungs may
still be infected and it is important that the physician monitors the child.

V. Diet

Tell about the importance of eating a well-balanced diet. If asked if multivitamins can be
given, refer it to the physician. Remind about the increased fluid requirements and advise foods that
are rich in natural vitamins such as fruits.

34

XVI. PROGNOSIS
 J. J. F. A. was admitted due to fever and cough. He had a fever with a temperature of 38.1
celcius which was later resolved and lowered to 36.9. The patient is ambulatory, coherent and has an
IV tube inserted on his right arm. Current medicines are Cefuroxime = 750 mg, IVTT, Albuterol = 1
neb + 2cc NSS, q4 and Montelukast = 4mg O.D., HS, PO. The vital signs: Temperature is 36.9, pulse
rate is 115 bpm, respiratory rate is 23 rpm and Blood pressure is 100/70. Productive cough is still
noted but with fewer secretions expectorated. The patient is lethargic according to the neuro-
assessment, no noted abnormalities in physical assessment regarding the patient’s present condition.
Nasal flaring is reduced, the patient is currently on moderate high back rest position. Thus patient is
showing a good prognosis.

35
XVII. BIBLIOGRAPHY

Books

Carpenito-Moyet, L.J., Handbook of Nursing Diagnoses; (12 ed.), Philadelphia, 2008.

 Corbett, J.V., Laboratory Tests and Diagnostic Procedures with Nursing Diagnoses; (7th ed.),
San Francisco, California, 2008.

Doenges, M.E., et.al., Nurse's Pocket Guide; (11 ed.), California, 2007.

Deglin, J.H. & Vallerand, A.H.; Davis' Drug Guide for Nurses; (20 ed.), F.A. Davis
Company, Philadelphia, 2009.

Elsevier, M., Mosby's Pocket Dictionary of Medicince, Nursing and Health Professions; (5th
ed.), Elsevier Incorporated, Singapore, 2006.

Johnson, J.Y., Textbook of Medical-surgical nursing; (11 ed.), 2008.

Compilations, articles and etc.

Rosalejos, I.L., Growth and Development handouts; NCM 101, Davao City, 2009

Internet sites
www.scribd.com
www.wikipedia.com/org
www.nursingcrib.com
www.wrongdiagnosis.com
www.encarta.msn.com
www.medscape.com/nurse/Amoeba
www.science.jrank.org/pages/529/ /Diagnosis
www.reuters.com/org
41

IV. GENOGRAM
 Paternal Maternal

L. A. R.F.
V.A C.F.

J. A
A.F.
(client’s father) (client’s mother)

Legends:

Asthma J. J. F. A. J. F. A.
(client) (client’s brother)

Hypertensive