TARLAC STATE UNIVERSITY COLLEGE

OF SCIENCE DEPARTMENT OF
NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and
Universities in the Philippines

CLINICAL CASE ANALYSIS

Name of Patient: Patient X Age: 2 months old Gender: Female
Address: Tarlac city, Tarlac Date Admitted: Time Admitted:
October 17, 2023
Diagnosis: The patient is 2 months old infant diagnosed with Ward: Pediatric ward
community-acquired pneumonia (CAP) moderate risk, covid
19 suspect.
Nursing History:
The patient, a 2-month-old female infant, was brought to the emergency department by
the parents with complaints of respiratory distress. According to the parents, the child has
been experiencing a cough, rapid breathing, and colds. The symptoms gradually
worsened, prompting the parents to seek medical attention. There were no known recent
illnesses or travel history.

Past medical history

The patient was born full-term via normal vaginal delivery and had an unremarkable
neonatal period. There were no known congenital abnormalities, chronic illnesses, or
previous hospitalizations. The infant received all recommended vaccinations per the
immunization schedule.
Present medical history
The patient was admitted to the ER on October 17, 2023, with a chief complaint of cough
and cold.
The patient was transferred to the pediatric ward shortly with ongoing euro-ion in D5
water to prevent electrolyte imbalance.

ANATOMY AND PHYSIOLOGY:

Functionally, the respiratory system can be divided into two main areas: the conducting
zones, which provide a passage for inhaled gases and extend from the nose to the
bronchioles, and the respiratory zone, where gas exchange occurs, encompassing the
alveolar ducts and alveoli. In terms of anatomy, the respiratory tract can be categorized
into the upper respiratory tract, which includes organs outside the thorax like the nose,
pharynx, and larynx, and the lower respiratory tract, consisting of organs within the thorax,
such as the trachea, bronchi, bronchioles, alveolar ducts, and alveoli.
The upper respiratory system organs include:
 Nasal Cavity: The nasal cavity consists of the nostrils and the nasal passages. It
serves several essential functions, including filtering, humidifying, and warming the
inspired air. It is lined with mucus and cilia that help trap and remove particles and
microbes.
 Pharynx (Throat): The pharynx is a muscular tube that connects the nasal cavity
and the oral cavity to the larynx and esophagus. It plays a role in both the
respiratory and digestive systems.
 Larynx (Voice Box): The larynx is located just below the pharynx and contains the
vocal cords. It serves as an important structure for speech production and also
plays a role in preventing food or liquids from entering the lower respiratory
system.

Upper Respiratory System: The upper respiratory system functions mainly in air
conditioning. The nasal passages filter, humidify, and warm the inhaled air. The mucus
and cilia in the nasal passages trap dust and microorganisms, which can then be expelled
or swallowed.

The following are the lower respiratory organs:

 Trachea (Windpipe): The trachea is a rigid, cartilaginous tube that connects the
larynx to the bronchi. It acts as a conduit for air to pass between the upper
respiratory system and the lungs.
 Bronchi and Bronchioles: The trachea divides into two primary bronchi, one
leading to each lung. These bronchi further branch into smaller bronchioles. They
are responsible for conducting air deep into the lungs. The bronchioles continue to
divide and become smaller as they penetrate the lung tissue.
 Alveolar Ducts and Alveoli: At the end of the bronchioles are the alveolar ducts,
which lead to tiny air sacs called alveoli. The alveoli are where the actual exchange
of oxygen and carbon dioxide occurs. They are surrounded by a network of
capillaries, facilitating the exchange of gases between the air and the bloodstream.

Lower Respiratory System: The primary physiological function of the lower respiratory
system is gas exchange. During inhalation, oxygen is transported from the alveoli into the
bloodstream, while carbon dioxide, a waste product of metabolism, is expelled from the
bloodstream into the alveoli to be exhaled.
DIAGNOSTIC PROCEDURE

Chest x-ray
Introduction/purpose: Chest X-rays, or CXRs, are essential medical imaging
procedures used to examine the chest's internal structures, including the lungs,
heart, and surrounding areas. Their primary purposes include diagnosing lung and
heart conditions, monitoring health, assessing injuries, preoperative evaluations,
screening for specific diseases like lung cancer or tuberculosis, and locating
foreign objects. Chest X-rays provide crucial insights for healthcare professionals,
aiding in timely diagnosis and patient care.
Procedure: The chest X-ray procedure involves the patient preparing by removing
metal objects, wearing a gown, and being positioned in front of an X-ray machine.
The radiologic technologist provides instructions, including breath-holding, while
the X-ray machine takes images from various angles. Afterward, a radiologist
reviews the images for diagnosis. The procedure is quick, minimally invasive, and
prioritizes patient safety by limiting radiation exposure to non-targeted areas of the
body.
 Complete blood count (CBC)
Introduction/purpose: A comprehensive blood analysis, known as a complete
blood count (CBC), assesses various components within the blood, including red
blood cells, white blood cells, mean corpuscular volume (MCV), hemoglobin,
platelets, and hematocrit. This test serves as a valuable diagnostic tool for
identifying a range of medical conditions, such as infections, anemia, immune
system disorders, and blood-related cancers.
Procedure: Prior to the test, the skin should be sanitized using either iodine or
alcohol. The individual should be in a reclined or relaxed seated position. A
healthcare professional will employ a small needle to extract blood from a vein in
the arm. Once the needle is in place, a small quantity of blood will be collected into
a test tube or vial. Subsequently, the blood sample will be sent to a laboratory for
analysis, typically using automated equipment. In cases where CBC and platelet
test results show abnormalities, a drop of blood might be scrutinized under a
microscope.

Blood component Result Reference range Remarks

Hemoglobin (Hb) 10.5 9.5 – 13.5 g/dL Normal
Hematocrit (Hct) 31% 30 – 40% Normal
RBC 3.7 million/mm3 3.5 – 5.5 million/mm3 Normal
WBC 14,000/mm3 6,000 – 17,500 /mm3 Elevated
- neutrophils 9,500/mm3 1,500 – 8,500 /mm3 Elevated
- lymphocytes 3,500/mm3 3,000 – 9,500 /mm3 Normal
- monocytes 800/mm3 200 – 1,200 /mm3 Elevated
- eosinophils 100/mm3 50-700 /mm3 Normal
- basophils 100/mm3 0 – 200 /mm3 Normal
Platelet count 350,000/mm3 150,000 – 450,000 Normal
/mm3

Pulse oximetry
Introduction/purpose: Pulse oximetry is a non-invasive medical technique used to
measure the oxygen saturation of a patient's blood. It assesses the percentage of
oxygen bound to hemoglobin (SpO2) and serves several crucial purposes,
including the early detection of low blood oxygen levels (hypoxemia), monitoring
respiratory and cardiac health, evaluating the effectiveness of oxygen therapy,
screening for sleep apnea, facilitating home monitoring, and assessing exercise
tolerance. Pulse oximetry is an essential tool in healthcare, providing real-time
information to ensure patients receive the appropriate oxygen levels and prompt
intervention when needed.
Procedure: Pulse oximetry is a simple and non-invasive procedure used to
measure a patient's blood oxygen saturation and pulse rate. The steps involve
selecting a suitable sensor site (usually the fingertip or earlobe), placing the
sensor, turning on the pulse oximeter, waiting for readings, recording the oxygen
saturation (SpO2) and pulse rate (PR), and interpreting the results. Pulse oximetry
is a quick and painless method to monitor oxygen levels, aiding in the assessment
of a patient's oxygenation status and timely interventions when necessary.

Patient X 2 months old, Female

Date and time October 17, 2023
Oxygen saturation (SpO2) 92%
Pulse rate 140 bpm

MEDICAL MANAGEMENT:
 Administration of Antibiotic such as Ampicillin and Gentamicin was administered to
the patient to treat bacterial infections of the respiratory tract, such as bronchitis,
 pneumonia, and sinusitis.
 Salbutamol was also administered to help relieve bronchospasm and improve
breathing. It can also be important for managing coexisting respiratory conditions
like asthma.

Name of Students: Clinical Instructor:

Ramos, Lorence F. Sir Al Francis Aguas, RN
Date Submitted: CI’s Signature: