You are on page 1of 21

78614512.doc I. INTRODUCTION A.

Overview of the study Community-acquired pneumonia (CAP) is an infection of the alveoli, distal airways, and interstitium of the lungs that occurs outside the hospital setting. Characterized clinically by, Fever, chills, cough, pleuritic chest pain, sputum production and at least one opacity on chest radiography. Manifests as four general patterns : Lobar pneumonia: involvement of an entire lung lobe, Bronchopneumonia: patchy consolidation in one or several lobes, usually in dependent lower or posterior portions centered around bronchi and bronchioles, Interstitial pneumonia: inflammation of the interstitium, including the alveolar walls and connective tissue around the bronchovascular tree and Miliary pneumonia: numerous discrete lesions due to hematogenous spread

Epidemiology of Community acquired pneumonia incidence: U.S, 800 1500 cases per 100,000 persons annually, Affects 4 million adults per year, ~20% require hospitalization and annual cost: $9.7 billion : Incidence highest at extremes of age, rate higher among men than among women, more common among African Americans than among whites and more common during the winter months.

The pathogens that cause community-acquired pneumonia (CAP) are predictable; copathogens are involved rarely, if ever. Extrapulmonary clinical features are helpful in distinguishing between typical and atypical causes of CAP. Various clinical findings can also point to specific diagnoses, such as Klebsiella pneumonia or Legionella infection. Severe CAP suggests the presence of underlying problems in the patient, such as cardiopulmonary dysfunction or impaired splenic functioning. Empiric therapy should cover typical and atypical pathogens. Oral antibiotics should be used for as much of the treatment course as is practicable.

Page 1

78614512.doc B. Objectives and Purpose of the Study This study generally aims to investigate the condition of a client and further understand the extent of the case. Specifically the student nurse sought to: Perform Physical Assessment, Data Base and History Taking that solidifies the present diagnosis of the client. Identify Signs and Symptoms associated with the disorder. Identify priority nursing problems which will be the basis of the care plan. Develop Plan of Care and Implement nursing interventions relevant and suitable to the case. Evaluate the effectiveness of the interventions and detect any progress or regression of the clients disease condition. The purpose of the study is to gather significant data to broaden our knowledge of the disease process and to improve my abilities as future healthcare provider. This is done to be able to aid in the recovery process of the client. Moreover this case study will enable me to apply the acquired skills we have obtained in the classroom set-up. C. Scope and Limitation of the Study The scope of the study consists of one pedia ward client of the TalakagBukidnon Provincial Hospital. Significant others was interviewed specially her mother to know more about the client and her condition. The time period for which the study was conducted and completed, was constrained and limited to a span of 1 week. The first assessment done was last December 9, 2010, at around 8:00 am. Then continuous assessment was done in the span of my duty in the said ward from December 9 and 10 2011.The said assessment dates were maximized to gather of information including profile, data base, history of present illness, chart data and many others.

Page 2

78614512.doc

D. SPOT MAP

Page 3

78614512.doc

II. HEALTH HISTORY A. Patients Profile Name of Patient: XX Sex: female Age: 1 year and 5 months Birthday: July 15, 2009 Birthplace: Talakag, Bukidnon Religion: Roman Catholic Civil Status: Child Educational Attainment: Not applicable (our pt. is still an infant) Mother: MG Father: AG Number of Siblings: 1( she is the only child) Nationality: Filipino Date Admitted: December 9, 2010 Time Admitted: 12:15 am Informant: Mother Temperature: 36.0 C Pulse Rate: 138 bpm Respiration: 40 cpm Attending Physician: Dr. Joseph J. Borong, M.D.

B. Family & Past Health History My patient XX was born through a normal vaginal delivery. she had completed all her immunization. She has not received any blood from the past. It was his first time to be admitted in the hospital. She has no known food and medicine allergies. The patient had no previous history of surgery.She had experienced cough, colds, and fever that dont necessitate the patient to be admitted at the hospital. Although she had an asthma her mother manage it well at home. Page 4

78614512.doc

C. Chief Complains and History of Present Illness Patient XX, a 1 year and 5 month old child from Talakag, Bukidnon was admitted for the first time due to fever and productive cough , with the initial vital signs of: temperature- 36.0 C, respiratory rate- 44 cpm, and a pulse rate of 138 bpm. 2 days prior to her condition, XX experienced low-grade fever, productive cough with watery nasal discharge. Due to this instance, her mother brought her to BPH - Talakag and was then admitted with the diagnosis of Pedia Community-Acquired Pneumonia .

III. DEVELOPMENT DATA Sigmund Freuds Theory (Psychosexual Theory) The 0-2 years of age is under the oral stage of Freuds psychosexual theory. Early in your development, all of your desires were oriented towards your lips and your mouth, which accepted food, milk, and anything else you, could get your hands on (the oral phase). The first object of this stage was, of course, the mother's breast, which could be transferred to auto-erotic objects (thumbsucking). The mother thus logically became your first "love-object," already a displacement from the earlier object of desire (the breast). When you first recognized the fact of your father, you dealt with him by identifying yourself with him; however, as the sexual wishes directed to your father grew in intensity, you became possessive of your father and secretly wished your mother out of the picture (the Electra complex). This electra complex plays out throughout the next two phases of development. Feeding, crying, teething, biting, thumbsucking, weaning - the mouth and the breast are the centre of all experience. The infant's actual experiences and attachments to mum (or maternal equivalent) through this stage have a fundamental effect on the unconscious mind and thereby on deeply rooted feelings, which along with the next two stages affect all sorts of behaviours and (sexually powered) drives and aims - Freud's 'libido' - and preferences in later life. XX is under the oral Page 5

78614512.doc stage of Freuds psychosocial theory in which she find more pleasure in sucking his thumb every time she is going to bed. I had also observed that XX is a papas girl because she wont go to sleep unless her mother would carry her. Erik Eriksons Theory The infant will develop a healthy balance between trust and mistrust if fed and cared for and not over-indulged or over-protected. Abuse or neglect or cruelty will destroy trust and foster mistrust. Mistrust increases a person's resistance to risk-exposure and exploration. "Once bitten twice shy" is an apt analogy. On the other hand, if the infant is insulated from all and any feelings of surprise and normality, or unfailingly indulged, this will create a false sense of trust amounting to sensory distortion, in other words a failure to appreciate reality. Infants who grow up to trust are more able to hope and have faith that 'things will generally be okay'. This crisis stage incorporates Freud's psychosexual Oral stage, in which the infant's crucial relationships and experiences are defined by oral matters, notably feeding and relationship with mum. Erikson later shortened 'Basic Trust v Basic Mistrust' to simply Trust v Mistrust, especially in tables and headings. Hope & Drive (faith, inner calm, grounding, basic feeling that everything will be okay - enabling exposure to risk, a trust in life and self and others, inner resolve and strength in the face of uncertainty and risk). My patient is irritable and crying when she cannot see her mom or when her mom is not around. But when her mother came and he recognized the voice, the touch, XX will stop from crying. Jean Piagets Theory (Cognitive Theory) Sensorimotor stage. In this period, intelligence is demonstrated through motor activity without the use of symbols. Knowledge of the world is limited (but developing) because its based on physical interactions / experiences. Children acquire object permanence at about 7 months of age (memory). Physical development (mobility) allows the child to begin developing new intellectual abilities. Some symbolic (language) abilities are developed at the end of this stage. My patient learns many things by what she saw. At this Page 6

78614512.doc moment she is still developing his motor skills. she is aware only of their sensations, fascinated by all the strange new experiences his bodies is having. She like little scientists exploring the world by shouting at, listening to, banging and tasting everything. Robert Havinghursts Theory (Developmental Task) Havinghurst believes that learning is basic to life and people continue to learn throughout life. He describes growth and development as occurring in six stages, each associated from task to be learned. Havinghursts promoted the Developmental task in 1950s which arises at a certain period in the life of an individual. Successful achievement of the task leads to happiness and to succeed in the next task. Failure to achieve a task leads to sadness of an individual, disapproval in the society and difficulty with later task.

Kohlbergs Theory (Moral Development Theory)

The conventional level of moral reasoning is typical of adolescents and adults. Those who reason in a conventional way judge the morality of actions by comparing them to society's views and expectations. The conventional level consists of the third and fourth stages of moral development. Conventional morality is characterized by an acceptance of society's conventions concerning right and wrong. At this level an individual obeys rules Page 7

78614512.doc and follows society's norms even when there are no consequences for obedience or disobedience. Adherence to rules and conventions is somewhat rigid, however, and a rule's appropriateness or fairness is seldom questioned.

In Stage three (interpersonal accord and conformity driven), the self enters society by filling social roles. Individuals are receptive to approval or disapproval from others as it reflects society's accordance with the perceived role. They try to be a "good boy" or "good girl" to live up to these expectations, having learned that there is inherent value in doing so. Stage three reasoning may judge the morality of an action by evaluating its consequences in terms of a person's relationships, which now begin to include things like respect, gratitude and the "golden rule". "I want to be liked and thought well of; apparently, not being naughty makes people like me." Desire to maintain rules and authority exists only to further support these social roles. The intentions of actions play a more significant role in reasoning at this stage; "they mean well ...

Page 8

78614512.doc

IV. MEDICAL MANAGEMENT


A. DOCTORS ORDER IDEAL DOCTORS ORDER Therapeutics: 1.Antibiotic regimen as listed above for 7-14 days 2.Berodual nebulization (10 gtts in 3ml NSS) q 6 hours and prn 3.Switch therapy: Intravenous antibiotic treatment may be shifted to oral antibiotics after 48-72 hours if the following parameters are fulfilled(a)there is less cough and resolution of respiratory distress (normalization of respiratory rate),(b) the temperature is normalizing,(c) the etiology is not a high risk(virulent/resistant) pathogen, (d) there is no unstable co-morbid conditions or life-threatening complications, and (e) oral medications are tolerated. 4.Fo abundant secretions,may give Acetylcysteine (Fluimucil) 100mg or 200 mg sachet dissolved in glass H2O TID . Discontinue if patient has wheezing.

MEDICAL PROCEDURES
INTRAVENOUS THERAPY Intravenous therapy or IV therapy is the giving of liquid substances directly into a vein. It can be intermittent or continuous; continuous administration is called an intravenous drip. The word intravenous simply means "within a vein", but is most commonly used to refer to IV therapy. Therapies administered intravenously are often called specialty pharmaceuticals. Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body. Some medications, as well as blood transfusions and lethal injections, can only be given intravenously. Page 9

78614512.doc

NEBULIZATION It is the process of using a nebulizer that changes liquid medicine into fine droplets (in aerosol or mist form) that are inhaled through a mouthpiece or mask Nebulizers is used to deliver bronchodilator (airway-opening) medicines such as albuterol or ipratropium bromide. Nebulizers are hand-held machines with an airflow meter that measures oxygen flow. These machines administer a variety of medications. Nebulizers vaporize this mixture and deliver it as a fine mist or steam. Nebulizers are usually used in the hospital or nursing home setting.Disposable nebulizers are often sent home with a patient and are cleaned and reused for a limited time. TEPIDS SPONGE BATH Tepid sponging is a time honored and well known method of reducing the elevated temperature. Tepid sponging is useful as an immediate but transient measure in bringing down the temperature and it should always be supplemented with drugs like paracetamol for a longer antipyretic effect. A tepid sponge bath relieves fever without cooling the body too fast. Eighty degrees Fahrenheit is still 20oF below body temperature and yet warm enough not to drive blood from the skin, thereby preventing the cooling from getting to the body's core. Limbs are bathed first and then the chest, abdomen, back, and buttocks. Tepid baths should be 80-93oF (26.7-34oC). B. LABORATORY TEST (-Not assessed due to the unavailability of the results.)

Page 10

78614512.doc

V. PATHOPHYSIOLOGY & ANATOMY AND PHYSIOLOGY A. PATHOPHYSIOLOGY PNEUMONIA PEDIA COMMUNITY ACQUIRED

B. ANATOMY AND PHYSIOLOGY In humans, the trachea divides into the two main bronchi that enter the roots of the lungs. The bronchi continue to divide within the lung, and after multiple divisions, give rise to bronchioles. The bronchial tree continues branching until it reaches the level of terminal bronchioles, which lead to alveolar sacs. Page 11

78614512.doc Alveolar sacs are made up of clusters of alveoli, like individual grapes within a bunch. The individual alveoli are tightly wrapped in blood vessels and it is here that gas exchange actually occurs. Deoxygenated blood from the heart is pumped through the pulmonary artery to the lungs, where oxygen diffuses into blood and is exchanged for carbon dioxide in the hemoglobin of the erythrocytes. The oxygen-rich blood returns to the heart via the pulmonary veins to be pumped back into systemic circulation.

Human lungs are located in two cavities on either side of the heart. Though similar in appearance, the two are not identical. Both are separated into lobes by fissures, with three lobes on the right and two on the left. The lobes are further divided into segments and then into lobules, hexagonal divisions of the lungs that are the smallest subdivision visible to the naked eye. The connective tissue that divides lobules is often blackened in smokers. The medial border of the right lung is nearly vertical, while the left lung contains a cardiac notch. The cardiac notch is a concave impression molded to accommodate the shape of the heart. Lungs are to a certain extent 'overbuilt' and have a tremendous reserve volume as compared to the oxygen exchange requirements when at rest. Such excess capacity is one of the reasons that individuals can smoke for years without having a noticeable decrease in lung function while still or moving slowly; in situations like these only a small portion of the lungs are actually perfused with blood for gas exchange. As oxygen requirements increase due to exercise, a greater volume of the lungs is perfused, allowing the body to match its CO2/O2 exchange requirements. Page 12

78614512.doc Additionally, due to the excess capacity, it is possible for humans to live with only one lung, with the other compensating for its loss. The environment of the lung is very moist, which makes it hospitable for bacteria. Many respiratory illnesses are the result of bacterial or viral infection of the lungs. Inflammation of the lungs is known as pneumonia; inflammation of the pleura surrounding the lungs is known as pleurisy. Vital capacity is the maximum volume of air that a person can exhale after maximum inhalation; it can be measured with a spirometer. In combination with other physiological measurements, the vital capacity can help make a diagnosis of underlying lung disease. The lung parenchyma is strictly used to refer solely to alveolar tissue with respiratory bronchioles, alveolar ducts and terminal bronchioles.[4] However, it often includes any form of lung tissue, also including bronchioles, bronchi, blood vessels and lung interstitium.[4]

Page 13

78614512.doc VI. NURSING REVIEW CHART IV. PHYSICAL ASSESSMENT


NURSING SYSTEM REVIEW CHART Name: XX Date: December 9, 2010 Vital Signs: Pulse:138 bpm BP: N/a

Temp: 36.0

Respi: 40 cpm

EENT [] impaired vision [] blind [] pain reddened [] drainage [] gums [] hard of hearing [] deaf [] burning [] edema [] lesion teeth [] asses eyes, ears, nose [] throat for abnormality [X] no problem RESPIRATION [] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [X] cough [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [x] wheezing [] pain [] cyanotic [] assess resp rate, rhythm, depth, pattern [] breath sounds, comfort []no problem GASTRO INTESTINAL TRACT [] obese [] distention [] mass [] dysphagia [] rigidly [] pain [] asses abdomen, bowel habits, swallowing [] bowel sounds, comfort [X]no problem GENITO-URINARY and GYNE [] pain [] urine color [] vaginal bleeding [] hematuria [] discharge [] nocturia [] assess urine freq., control, color, odor, comfort [] grip, gait, coordination, speech, [X]no problem NEURO [] paralysis [] stuporous [] unsteady [] seizure [] lethargic [] comatose [] vertigo [] tremors [] confused [] vision [] grip [] assess motor function, sensation, LOC, strength [] grip, gait, coordination, speech, [X]no problem 2 MUSCULOSKELETAL and SKIN [] appliance [] stiffness [] itching [] petechiae [] hot [] drainage [] prosthesis [] swelling [] lesion [] poor turgor [] cool [] deformity [] atrophy [] pain [] ecchymosis [] diaphoretic [] assess mobility, motion, gait, alignment, joint function [] skin color, texture, turgor, integrity [x] no problem

Expelled white sputum Productive cough observed

Wheezing sound heard upon auscultation

Page 14

78614512.doc

VII. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT PATIENT XX CUES S: arang2x na gani ni yang ubo karon As verbalized by the mother O: cough restlessness expelled white sputum NURSING DX Ineffective airway clearance related to increased amount of secretion OBJECTIVES At the end of 30 mins the patient will be able to expectorate secretions & improve / maintain airway clearance.
> assist w/ coughing/ deep breathing exercises position changes > increase fluid intake >oral fluid intake may liquefy secretion/ enhance expectorant >administer Salbutamol per doctors order 1 neb q 6
o

INTERVENTIONS
> facilitate maintainace of patient upper airway by proper positioning

RATIONALE
> altered level of consciousness, sedation are some condition that alters pt. to project airways > for easy expectoration of secretions

EVALUATION Goal partially m pt. was able to expectorate secretion which is the white sputum & improve airway clearance

>to improve ventilation & facilitate removal of secretions

Patient: XX

Page 15

78614512.doc

CUES S: sige sya ug hilak, gipangita niya iya papa As verbalized by the mother O: crying restlessness

NURSING DX OBJECTIVES Anxiety related to At the end of 30 separation from support system in potential like hospitalization mins the patient will be able to demonstrate

INTERVENTIONS
> maintain home routines whenever possible. Encourage bring childs toys or pillows.

RATIONALE
> use of age appropriate object enhance sense of security when child is being hospitalized

EVALUATION > goal partially met, patient demonstrate from manifestation on anxiety

stressful situation relief from somatic manifestation of anxiety

> help family support child emotionally by being available, active and listening > provide child w/ choices when possible

> conveys acceptance of the child & confidence in ability to cope w/ situation >promotes sense of control, demonstrate regard for individual

> promote family interactions > family involvement in activities promotes continuity of family unity

Page 16

78614512.doc

B. ACTUAL NURSING MANAGEMENT

S O A P I

cough restlessness expelled white sputum Ineffective airway clearance related to increased amount of secretion

At the end of 30 mins the patient will be able to expectorate secretions & improve / maintain airway clearance.
> facilitate maintainace of patient upper airway by proper positioning - altered level of consciousness, sedation are some condition that alters pt. to project airways > assist w/ coughing/ deep breathing exercises position changes - for easy expectoration of secretions > increase fluid intake - oral fluid intake may liquefy secretion/ enhance expectorant >administer Salbutamol per doctors order 1 neb q 6o
-

to improve ventilation & facilitate removal of

secretions Demonstrate improved ventilation and oxygenation of tissues by ABG within clients acceptable range.

Page 17

78614512.doc

S O A P I

crying restlessness Anxiety related to separation from support system in potential stressful situation like hospitalization At the end of 30 mins the patient will be able to expectorate secretions & improve / maintain airway clearance.
> maintain home routines whenever possible. Encourage bring childs toys or pillows. - use of age appropriate object enhance sense of security when child is being hospitalized > help family support child emotionally by being available, active and listening - conveys acceptance of the child & confidence in ability to cope w/ situation > provide child w/ choices when possible -promotes sense of control, demonstrate regard for individual > promote family interactions - family involvement in activities promotes continuity of family unity

> goal partially met, patient demonstrate from manifestation on anxiety

Page 18

78614512.doc

C. DRUG STUDY
NAME OF DRUG DATE ORDERED CLASSIFICATION DOSE/ FREQUENCY/ ROUTE MECHANISM OF ACTION SPECIFIC INDICATION
CONTRAINDICATION

SIDE EFFECTS

NURSING PRECAUTION

SALBUTAMOL

December 9, 2010

Brochodilator

1 neb q 6

beta2adrenergic bronchodilator

Inhalation Solution is indicated for the relief of bronchospasm. This drug relaxes the smooth muscle in the lungs and dilates airways to improve breathing.

Contraindicated w/ hypersensitivity to salbutamol; tachyarrytmias, tachycardia causes by digitalis

Cases of urticaria, angioedema, rash, bronchospasm, hoarseness, oropharyngeal edema, and arrhythmias (including atrial fibrillation, supraventricular tachycardia, extrasystoles) have been reported after the use of salbutamol

- Do not take any of these medications without consulting your doctor (even if you never had a problem taking them before). - Do not allow anyone else to take this medication.

Page 19

78614512.doc

NAME OF DRUG

DATE ORDERED

CLASSIFICATION

DOSE/ FREQUENCY/ ROUTE

MECHANISM OF ACTION

SPECIFIC INDICATION

CONTRAINDICATION

SIDE EFFECTS

NURSING PRECAUTION

Ampicillin

December 9, 2010

Antibiotic

250 mg q8 IVTT

Bactericidal; inhibits synthesis of bacteria on the cell wall causing cell death

Treatment of infection caus strains of shigella salmonella, E.Coli, haemophillus influenzae

Allergy to penicillins

CNS: Lethargy CV: heartfailure GI: gastritis Hypersensitivity: Rashes, fever

>check IV site for signs of thrombosis >cultureinfected area

Gentamicin

December 9, 2010

Aminoglycoside

15 mg q 8 IVTT

Inhibits protein synthesis in susceptible gram neg. bacteria appears to disrupt functional integrity of bacterial cell membrane

Serious infection caused by pseumodomas, E.coli, serios infection when causative agent is not known

With allergy to drug aminoglycoside

CNS:Otoxicity CV: Palpitaion GI: Hepatic toxicity

>check for reaction of allegy to aminoglycoside > check the site of infection.

Page 20

78614512.doc

VIII. REFERRAL AND FOLLOW UP Once the client will be discharged, we had instructed her mother encouraged my client to drink her home medications religiously to prevent further infection. We have also instructed her mother to let her daughter have a daily exercise like deep breathing pattern and teach the mother some of the range of motion exercises in order to promote proper blood circulation and attain proper oxygenation. And We have also reminded her mother to stick with her diet and to have adequate amount of it to meet nutritional needs and attain full wellness. IX. EVALUATION AND IMPLICATION At the end of my hospital duty, We were able to render care to my patient to help him resolve his health condition. Through observing the patients status, we able to identify priority problems related to his health. The patients mother was willing to pursue the medical therapy just to promote health and wellness for the betterment of her sons condition. We have also made the patients mother realize the importance of completing the course of therapy by taking the medicines prescribed or ordered for her daughter by his physician. In addition, eating healthy or nutritious foods that were prescribed to her by the health providers was further been explained to her mother especially the benefits she will gain in eating those foods. Moreover, this several interventions given to the patient made her body conditioning normal and We can say that our patient has somehow recovered from her illness. X. DOCUMENTATION (None, we have no written consent that will allow us to take a picture/ photo of the said client.)

Page 21