a case study on pnuemonia

CAGAYAN COLLEGES TUGUEGARAO COLLEGE OF HEALTH

A case Study on Severe Pneumonia Submitted by: Dennis F. Gallardo Submitted to: Robert Balungaya, RN

GENERAL OBJECTIVE

After this case study, I will be able to know what Pneumonia is, causes of Pneumonia, how it is acquired and prevented, its treatments and prevention of the occurrence of Pneumonia SPECIFIC OBJECTIVES After the completion of this study, I will be able to: o

Define what is Pneumonia

o

Trace the pathophysiology of Pneumonia

o

Enumerate the different sign and symptoms of Pneumonia

o

Identify

and

understand

different

types

of

medical

treatment

necessary for the treatment of Pneumonia o

Formulate and apply nursing care plans utilizing the nursing process

INTRODUCTION

Pneumonia is characterized by inflammation of the alveoli and terminal airspaces in response to invasion by an infectious agent introduced into the lungs through hematogenous spread or inhalation. The inflammatory cascade triggers the leakage of plasma and the loss of surfactant, resulting in air loss and consolidation. This is in contrast to pneumonitis, which is caused by noninfectious agents such as radiation or chemicals. An inhaled infectious organism must bypass the host's normal nonimmune and immune defense mechanisms in order to cause pneumonia. The nonimmune mechanisms include aerodynamic filtering of inhaled particles based on size, shape, and electrostatic charges; the cough reflex; mucociliary clearance; and several secreted substances (eg, lysozymes, complement,

defensins).

Macrophages,

neutrophils,

lymphocytes,

and

eosinophils carry out the immune-mediated host defense. Conditions that allow pneumonia-causing infectious organisms to circumvent the upper airway defense mechanisms include the following: •

Intubation, tracheostomy, impaired cough reflex, and aspiration: These conditions provide infectious organisms with easier access to the alveoli and terminal airspaces.

•

Ciliary dyskinesia, bronchial obstruction, viral infection, cigarette smoke,

and

certain

chemical

agents:

These

conditions

create

disruption in the mucociliary blanket. •

Anatomic abnormalities (eg, sequestrations), gastric fluid aspiration or other causes of noninfectious inflammation, altered pulmonary blood flow,

and

pulmonary

edema:

These

conditions

increase

the

predisposition for pneumonia. •

Immunodeficiency and immunosuppression: These conditions increase predisposition for pneumonia.

Mortality/Morbidity The United Nations Children's Fund (UNICEF) estimates that 3 million children die worldwide from pneumonia each year. Although most fatalities occur in developing countries, pneumonia remains a significant cause of morbidity in industrialized nations.

I have chosen this case Pneumonia because it 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 this case is a child, 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.

PATIENT’S PROFILE Name: J.V.

Address: 181, Ninada Street, Lltex road, Quezon City Age: 4yrs. and 4 months Birthday: December 28, 2004 Sex: Male Nationality: Filipino Religion: Roman Catholic Date & Time of Admission: January 18, 2009 (07:00 am) Mode of Arrival: cuddled by mother Chief Complaint: abdominal pain, cough and colds Source of Information: patient, & chart, SO Admitting Diagnosis: severe Pneumonia Final Diagnosis: severe Pneumonia Attending Physician: Dr. Karen Lorenzo MD

NURSING HISTORY PAST MEDICAL HISTORY

According to the patient SO, he had completed his childhood immunization. He had no allergy to foods or medications. He experienced common diseases such as fever, cough and colds she usually took OTC drugs (Paracetamol syrup, Neosep syrup) to manage his fever cough and colds. On June 2006 the patient was admitted at Government Hospital due to ilues. HISTORY OF PRESENT ILLNESS According to the SO, 3 days prior to admission the patient experienced sudden onset of squeezing pain at Para gastric area aggravated by activity. No meds taken or consultation made. 2 days PTA the patient still have the same abdominal pain, this time was more severe, and associated with DOB and fever of 38°C. His mother gave him paracetamol. No consultation was made. Few hours PTA, the patient could not any more tolerate the pain; he was brought to EAMC hence he admitted. FAMILY HEALTH HISTORY According to the patient SO, both his maternal and paternal have a history of Cancer, PTB, and Bronchial Asthma. PTB is evident on the patient’s grand father and uncle while cancer and bronchial asthma is evident on the patient aunt. Personal/ Social History The patient is the 4th among 6 siblings. He was lived with 7 other households’ member. His father work as a garbage collector and his mother is a house wife they consumed or used tap not boiled water.

PATHOPHYSIOLOGY Predisposing factor Age Immune defenses

Etiology S. pneumoniae

Precipitating factor UPTI environment

Immune defenses Infecting organism enter in the airway Activation of defense mechanism Failure to penetrate the Pathogen

pathogen is secreted or dies

Pathogen reached the lungs Pathogen multiplies in the alveoli Inflammation

irritation of airway

Exudates come from Bacteria erode the lung

Goblet cell

Dead space happened CO2

mucus production

occluded the Air way Cough

pagocytosis

crackles

Hyperventilation WBC

fever

chill

altered LOC

Impaired O2 and CO2 exchange

consolidadtion Hypoxia Trigger the kidney

Released of erythropoietin Long bones

RBC

PHYSICAL ASSESSMENT Date assessed: May 25, 2009

RR

Time: 10:30pm Initial vital signs: T=37.9 PR=140bpm RR=25cpm General Appearance: the patient is conscious and coherent with ongoing of D5NM 500ml at 750cc level hook at his left arm, intact and infusing well. Area Assessed skin Moisture

Technique Inspection/ Palpation

Normal Actual Findings Findings Skin normally Skin is moist dry

Temperature

Palpation

Normally warm

37.9 o C

Hair Texture

Inspection/ Palpation

Smooth

Rough

Inspection

Oval, symmetric Oval, symmetric and without but with Due to the discharge discharge presence of colds Firmly set, shiny Firmly set, shiny Due to poor with tooth decay hygiene Clear breath Presence of Due to sounds breath sound congestion

Nose Teeth Nares

d/t hyperthermi a d/t hyperthermi a Due t o poor hygiene

and

Teeth Thorax Lungs

Evaluation

Inspection and Auscultation

LABORATORY RESULTS HEMATOLOGY RESULTS May 18, 2009 Parameter Normal Value WBC 5-10 x 10 g/L

Results 18.1

Hgb

M 140-170g/dl

165

Hct RBC

M 39%-54% 4.6- 10 g/l

.30 10.4

20%-40%

.50

Analysis Increased due to infection Increased due to infection Decreased Increase due t o hypoxia

Differential Count Lymphocytes

Increased due to infection

PEARSON’S FUNCTIONAL HEALTH PATTERN Date and Time of Interview: May 25, 2009 (11:00 PM)

Functional Pattern Psychological

Heath Before hospitalization

Elimination

Rest and Sleep

Safety and Security

Oxygenation Nutrition

Spirituality

During hospitalization

The patient is 4yrs and The patient looks pale 4 months old due to his current condition. According to the SO, the According to the SO, patient usually void 5 to the patient void 3-4 6 times a day. He times a day. Have a 240 doesn’t have any ml/ shift yellow amber problem in voiding. color urine and dark brown stool. According to the SO, the The patient can’t sleep patient usually spends well because of the his time for playing and hospital routines. sleeping. He sleeps for about 6-8 hours at night. His SO provides all the The SO together with safety and security that his health care providers he need make him safe and secured. The patient has The patient had difficulty in breathing difficulty of breathing prior to hospitalization due to his condition The patient usually eats The patient in on DAT. 2 -3 times a day He doesn’t have any problem m in swallowing According to SO, The The SO prays for the patient was baptized in sooner recovery of the Roman Catholic. They patient go to church every Sunday together with his friends, bothers and sisters

GROWTH AND DEVELOPMENT

Age 4 years month

Theorist and

4

Erik Erickson; Psychosocial Theory

Piaget: Cognitive Theory

Stage of Development Initiative vs. sense of guilt (mimics; more purposeful & active in goal setting)

Outcome

>Imaginary playmates or companions are common; holds conversations and shares strong emotions with this invisible friend. Boasts, >exaggerates, and "bends" the truth with madeup stories or claims of boldness; tests the limits with "bathroom" talk. >Cooperates with others; participates in group activities. Preoperational>Likes stories preconceptual about how things (egocentric, grow and how magical thinking; things operate. no cause-effect >Delights in reasoning; uses wordplay, symbols) creating silly Language. >Understands the concepts of "tallest," "biggest," "same," and "more"; selects the picture that has the "most houses" or the "biggest dogs." >Rote counts to 20 or more.

Freud:

Phallic

Psychosexual

(ego

According to the SO, The patient develops begins to fear

Theory

Kohlberg: Moral Reasoning

objective conscious reality; Opedipus complex - love of opposite-sex parent)

that his father is suspicious of his longing for his mother, and that the father will punish him for his desires. Preconventional According to the Morality SO, she punished her child if they (based on commit mistakes. external control; observe standards of others to avoid punishment or receive rewards)

ASSESSMENT Objective: •Use of accessory muscle. •Dyspnea •Fatigue. •V/S taken as follows: T: 37.9 PR: 140 bpm RR: 25cpm

DIAGNOSIS Acute pain r/t localized inflammation and persistent cough.

PLANNING After 1 hour of nursing interventions, the patient will display patent airway with breath sounds clearing and absence of dyspnea.

INTERVENTION >Elevated head of the bed, change position frequently. Assist patient with deep breathing exercises. >Demonstrated or help patient learn to perform activity like splinting chest and effective coughing while in upright position. >Forced fluids to at least 3000 ml per day and offer warm, rather than cold fluids. >Provided supplemental fluids.

RATIONALE >Lowers diaphragm, promoting chest expansion and expectoration of secretions.

EVALUATION After 1 hour of nursing interventions, the patient was able to display patent airway with breath sounds is a clearing and self absence of dyspnea.

>Coughing natural cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. >Fluids especially warm liquids aid in mobilization and expectoration of secretions.

>Fluids are required to replace losses and aid in mobilization of secretion.

Assessment Objective Temp 37.9ºC Skin warm touch

Diagnosis Hyperthermia r/t inflammatory to response of the body as evidence by increase in core temperature

Planning After 30 minutes of nursing interventions the patient will have lowered temperature from 37.9-37.5 ºC

Intervention > monitored V/S > Performed tepid sponge bath > demonstrated proper performance of TSB

> instructed the SO to keep the patient rested > administered antipyretics as ordered

Rationale > for baseline data > to facilitate heat loss through evaporation and conduction > to provide proper knowledge and to empower the SO in taking care of the –patient To slow down the patient metabolism > aid in lowering down the temperature > aid in lowering down the temperature

Evaluation Goal met as evidenced by lowered temperature from 37.9-37.5 ºC

Assessment Diagnosis Planning Intervention Rationale Evaluation Name of the Dosage Mechanism Indication Contraindication Adverse effect Nursing Objectives: Ineffective airway At the end of 15 >auscultated breath > to ascertain Goal met. The Drug of action responsibility - ( + ) crackles clearance r/t minutes the patient sound and assessed status and note patient was able to Generic name: 18 mg IV Ranitidine is Duodenal & Patients known to > Immune System > assess - tachypnea increase will be able to air movement progress demonstrate ranitidine q 8 hours a specific, benign have Disorders: (urticaria, patient - ineffective pulmonary demonstrate >elevated the head behavior to brand name: gastric hypersensitivity to angioneurotic abdominal cough secretion rapidly as behaviors to of the bed / change > to take maintain clear Zantac acting ulcer ranitidine or to edema, fever, pain. Not evidenced by maintain clear position advantage of airway. Classification: histamine any component of bronchospasm, and presence of ( + ) crackles, airway gravity decreasing Antacids, H2Zantac Injection. hypotension blood in tachypnea, pressure to and the Antireflux antagonist. chest pain emesis, stool ineffective cough diaphragm and Agents & It inhibits >enhancing Nervous System or gastric pain Antiulcerants basal and Disorders:Headache > drug may be ventilation stimulated (sometimes severe), added to total >encouraged deep- > to minimize long secretion of dizziness parenteral breathing and effort gastric acid, nutrition coughing exercise >Gastrointestinal reducing Disorders: Acute >instructed to both the pancreatitis, increased fluid >to liquefy diarrhea volume and intake secretion the acid and >| kept the pepsin environment > To avoid content of allergens free irritation of airway the caused by secretion. > gave expectorant allergens. ( bronchodilator ) as >to mobilized ordered secretion

Name of the Drug Ciprofloxacin BRAND NAME:Ciproba y

Dosage 250500mg BID

Mechanism of action Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria

Name of the Dosage Mechanism Drug of action Salbutamol 3-12 Facilitates/ BRAND yrs4mg tab potentiates NAME:Ventolin BID the inhibitory vilmax activity of GABA at the limbic system and reticular

Indication

Adverse effect Infections of Severe and Common:Na the resp. persistent diarrhea usea, tract, during and after diarrhea, middle treatment vomiting, ear,paranas rashUncom al sinuses, mon:Anorex eyes, ia, kidneys, headache,di urinary trac zziness, fever, GI and abdominal pain,

Indication Reversible airway obstruction including bronchial asthma, chronic

Contraindication

Nursing responsibility >Assess pt for previous sensitivity reaction>Assess pt for any s/s of infection before & during treatment>Assess for adverse reactions

Contraindication Adverse effect Hypersensitivity Fine tremor of skeletal muscle, feeling of tension, a compensory small increase

Nursing responsibility > drug may be decrese sensitivity of spirometry used for diagnosis of asthma>syrup

formation to bronchiti reduce anxiety, promote calmness and sleep Assessment Objectives: >weight loss > lack of interest in food

Diagnosis Altered Nutrition: less than body requirements r/t improper dietary pattern

Planning Within 8 hours of hospital duty, pt. will be able to: 1. Verbalize understanding of nutritional needs for his age. 2.Identify possible effects of improper eating habits

in heart rate, headache, muscle cramps

Intervention >Instructed client to eat smaller meals and supplemental snacks, as appropriate. >Established a minimum weight goal and daily nutritional requirements.

>Discussed with client the diet and snacks with substitutions of preferred foods when available. >Provided health

Rationale >Gastric dilation may occur if re feeding is too rapid following a period of starvation diet. > Malnutrition is mood-altering condition, leading to depression and agitation and affecting cognitive function/decision making. >Helps pt. understand the importance of proper nutrition and the consequences when it is altered. >for adequate

may be taken as young as age 2>monitor for evidence of allergic rxn

Evaluation Within 8 hours of hospital duty, pt. was : 1. Verbalized understanding of nutritional needs for her age.2. Identified possible effects of improper eating habits.

teachings about information and proper nutrition to promote compliance

Name of Dosage the Drug Cefuroxime Cefuroxime 750 mg IV q 6h

Mechanism of action Cefuroxime, a semisynyhetic, broadspectrum” second generation” cephalosporin antibiotic, exerts its bactericidal activity by interfering with the synthesis of the bacterial cell wall. It binds to penicillinbinding protein 3 responsible for the synthesis of peptidoglycan, a hetoropolymeric structure that gives the cell wall its mechanical stability.

Indication

Contraindication Adverse effect

Indicated in Known allergy to the the cephalosporin treatment of group of antibiotic the following infections due to cefuroximesensitive organisms >Lower respiratory tract infections including pneumonia >Urinary tract infection >Skin and skin structure infections >Septicemia >Meningitis .Gonorrhea

CV: phlebitis, thrombophlebitis GI: diarrhea, nausea, vomiting, anorexia Hematologic: hemolytic anemia, eosinophilia Skin: maculopapular and erythomatous rashes, urticaria, pain, indurations, sterile abscesses, temperature elevation

Nursing responsibility >Before giving drug, ask patient if he is allergic to penicillin or cephalosporin. >Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin while waiting the results >Monitor patient for signs and symptoms of super infection

Name of the Dosage Drug Acetaminophen 1.2 mL q ( Paracetamol ) 4 hr PRN Classification: antipyretics, nonopioid analgesics

Mechanism Indication of action Inhibits the Mild pain synthesis of Fever prostaglandins that may serve as mediators of pain and fever, primarily in the CNS

Adverse effect

Nursing responsibility

Hema: hemolytic anemia, neutropenia, leukopenia, pancytopenia.Hepa: jaundice Metabolic: hypoGGI: HEPATIC FAILURE, HEPATOTOXICITY (overdose). GU: renal failure (high doses/chronic use). Derm: rash, urticaria.

EFORE: > Advise parents or caregivers to check concentrations of liquid preparations. Errors have resulted in serious liver damage.~ Assess fever; note presence of associated signs (diaphoresis, tachycardia, and malaise). DURING: >Adults should not take acetaminophen longer than 10 days and children not longer than 5 days unless directed by health care professional.~ Advise mother or caregiver to take medication exactly as directed and not to take more than the recommended amount. AFTER: >Advise patient to consult health care professional if discomfort or fever is not relieved by routine doses of this drug or if fever is greater than 39.5°C (103°F) or lasts longer than 3 days.

LEARNING FEEDBACK DIARY Name: Dennis Gallardo

Date: May 24- 27, 2009

Area: EAMC

CI: Mr. Robert Balungaya, RN

General objective: At the end of the 4 days duty, I will be able enhance my knowledge skills and attitude regarding the delivery of health in the clinical area. Specific objectives: At the end of our 4 days clinical duty, I will be able to: - Carryout skills I learned from school - improve my skills regarding patient care - establish rapport with my patient as well as health team in the EAMC Insight: Experience comprises knowledge of or skill in or observation of some thing or some event gained through involvement in or exposure to that thing or event. Experience also is in deed the best teacher. I admit I really did learn a lot of skills and knowledge inside the school but learning through my experience in the actual hospital setting is really different. Gaining knowledge and skills in my actual duty is more different and effective. I have developed a more organized way of dealing with people that I never had before. Greatly I have many educational experiences throughout the duration of our duty. One of this was monitoring the I & O of my 3 patients. I also have been opened to the different needs of my patients that would sure benefit me in rendering a more quality care. For all this learning experience, I appreciated and love more my future profession. I have been realized that the greatest help we could offer to our patient is giving them attentions and best quality of health service. I also thank my CI because of assistance and learning he shared. It’s great under your supervision…. GOD BLESSES!!!!!!