Case Study - Pneumonia (2)

PANPACIFIC UNIVERSITY NORTH PHILIPPINES Urdaneta City, Pangasinan

A CASE STUDY ON PNEUMONIA

Submitted by: GARCIA, Neil A. BSN-3E Group 6

Submitted to: Ms. Joann Guzman, RN Clinical Instructor

September, 2009

I.

PATIENT ASSESSMENT DATA BASE A.

GENERAL DATA 1. Patient’s Name: K. I. 2. Address: Sison, Pangasinan 3. Age: 1 y/o & 1 mo. 4. Sex: Female 5. Birth Date: July 18, 2008 6. Rank in the Family: 1st child 7. Nationality: Filipino 8. Civil Status: Single (child) 9. Date of Admission: August 30, 2009 10. Order of Admission: > Please admit order re service of Dr. Callanta > secure consent > I & O every shift & record > Monitor VS q 4° & record > DAT with SAP > Dx with CBC, CXR > IVF D5 0.3 NaCl 500cc X 37-38 ugtts/min > Cefuroxime 250mg IVP q 8° ANST (-) > Pediatapp drops 1ml TID > Salbutamol + Ipratopium ½ neb q 6° > Paracetamol drops 100mg/ml 1ml q 4° prn for fever > E-zinc drops 1ml OD > refer accordingly 11. Attending Physician: Dr. Callanta, MD

B.

CHIEF COMPLAINT

Cough and difficulty of breathing for one for three days prior to admission

C.

week,

fever

HISTORY OF PRESENT ILLNESS

One week prior to admission, K. O. had positive signs and symptoms of cough and yellowish phlegm followed with fever, three days before admission. Her mother knowing that these signs and symptoms were just the usual cough that her daughter had, she gave her carbocisteine drops for her cough and paracetamol drops for her fever. However, she noticed no changes so she decided to bring her to Pozorrubio Municipal Hospital. She was diagnosed of Pneumonia and because of the severity of the condition, she was admitted. She was given initial medications and has had her for further observations and laboratory exams.

D.

PAST HEALTH HISTORY/STATUS

K. O. had measles when she was around 10-month old. According to her mother, she frequently had colds which were almost every month. She said that her daughter only had BCG vaccine. She never brought her daughter back for other immunization. The mother told me that her daughter never had operations or injuries. Everytime her daughter got sick, she would ask medicines from their Barangay Health Center. These would include medicines like Ambroxol drops, Cotrimoxazole drops, and Paracetamol drops. She recalled buying Zeditapp (Phenylpropanolamine HCl) drops for her daughter’s colds. Sometimes they would result using boiled oregano leaves for her cough.

E.

FAMILY ASSESSMENT

Name

Relation

Age

Sex

Occupation Educational Attainment

Reynaldo Oligo

Father

25

Male

none

1st Year Highschool 4th Year Highschool

Marilyn Oligo

Mother

23

Female

none

F.

SYSTEMS REVIEW (applicable only for patients that are 3 years old and above)

G.

HEREDO-FAMILIAL ILLNESS Maternal – kidney diseases, asthma Paternal – hypertension, asthma

H.

DEVELOPMENTAL HISTORY

Theorist Erik Erikson’s Psychosocial Theory (Trust vs. Mistrust Stage)

Age

Sex

Birth to for both male and 12-18 female months

Patient Description I observed that she depends primarily to her mother to feed her. Yet there were times she would respond when her grandmother and aunt gives her

Jean Piaget’s Cognitive Development (Sensorimotor Stage)

for both male and female

Birth to age 2

Lawrence Kohlberg’s Moral Development (PreConventional Level)

for both male and female

food. I have seen that she is most calm when breastfeeding. I sometimes tried to make funny faces and she smiled once in a while. I noticed that she always play with her favorite toy. She pushes and pulls the toy car and knows what button to press so she can hear the sound. She could immediately recognize a syringe and cries. She always tried to reach out for my thermometer everytime I finished taking her temperature. I observed that the mother could not immediately make her daughter stop crying even if she would mention scary things that might show up if she did not stop.

for children

I.

PHYSICAL ASSESSMENT A. General Survey

The patient is awake and sitting on bed. She appeared to be clean with her unsoiled clothes on, well- trimmed nails and with baby cologne. There is no noticeable physical deformities or abnormalities. Her size is appropriate to her age. There is observable difficulty of breathing and coughing. She seemed to be irritable and exhausted from crying.

The patient’s weight is 9.3 kgs and her height is 71.12 cms. At one year and 1 month, the ideal body weight is 7.5 12 kgs and the optimal weight is 9 kgs, therefore she is within the range and very near the optimal weight. The ideal height at her age is within the range of 67 - 80 cms with the optimal height of 74 cms wherein the patient’s height is still within the range. B. Vital Signs T: 37.2 °C RR: 56 bpm CR: 140 bpm

C. Regional Exams Area Assessed

Techniques Used

Findings

Skin > color

inspection

> texture > temperature > moisture

palpation palpation palpation

fair-skinned, no discoloration and hyperpigmentations smooth, soft warm to touch moist due to perspiration

Nails > color of nailbed > texture > shape > nail base

inspection palpation inspection inspection

pink and clean smooth convex curvature firm

Hair > color > distribution > moisture > texture

inspection inspection inspection inspection

black evenly distributed not excessively dry or oily fine, silky, resilient

Eyes > eyebrows

inspection

> eyelashes > eyelids

inspection inspection

symmetrically aligned, equal movement slightly curved upward smooth, pink, close symmetrically

> ability to blink

inspection

> > > >

inspection inspection palpation inspection

ocular movement size texture conjunctiva

> cornea

inspection

> pupils

inspection

Nose > symmetry, shape, size and color > mucosa color > nasal septum > nasal discharge > sinuses

inspection inspection inspection inspection palpation

blinks voluntarily and bilaterally eyes move freely medium mobile, firm, not tender transparent with light color, shiny and smooth, no lesions clear, shiny, smooth, transparent equal size, round and constricts briskly, equally reactive light,

symmetrical, smooth and fair pinkish oval and symmetrical nares with clear discharges not tender

Mouth > lips

inspection

> > > > >

inspection inspection inspection inspection inspection

pinkish, symmetrical, soft and moist pinkish and moist pinkish, soft, moist pinkish, small, symmetrical at the midline 6 milk teeh

auscultation auscultation

140 bpm clear

inspection inspection inspection

symmetrical 56 bpm irregular, with effort

auscultation

wheezes

gums buccal mucosa tongue uvula teeth

Heart > heart rate > heart sounds Thorax and Lungs > symmetry > respiratory rate > breathing pattern > lung/breath sounds

Abdomen > contour > texture > frequency and character

inspection palpation auscultation

flat smooth soft gurgling sound

Upper Extremities > skin color > size

inspection inspection

> symmetry

inspection

fair equal and appropriate for her body symmetrical

Lower Extrremities > skin color > size

inspection inspection

> symmetry

inspection

Neurologic > level of consciousness > behavior and appearance > mood > mannerisms and actions

II.

interview interview interview interview

fair equal and appropriate for her body symmetrical

responds quickly when name was being called makes eye contact, normal behavior of a toddler irritable likes to cuddle to her mother

PERSONAL/ SOCIAL HISTORY K.O. is only 1 y/o and 1 month. Any data pertaining to this section cannot be established at her age.

III. ENVIRONMENTAL HISTORY (LIVING/NEIGHBORHOOD/CIRCUMSTANCES) The family belongs to the poverty line. They live in an area near mountainside. They need to walk far to be able to reach roads where they are vehicles going to the nearest town. That only means they have no immediate access to health centers and hospitals when they need to. They were not able to

meet some of their basic needs simply because of their living condition.

IV.

V.

PEDIATRIC HISTORY A.

Maternal and Birth History Date of birth: July 18, 2008 Birth weight: 6 lbs. (as recalled by the mother) Type of delivery: normal delivery Condition after birth: normal, no complications after birth Hospital: mother gave birth at their house by a “hilot”

B.

Mother Complications of delivery: there were no complications as recalled by the mother Anesthesia: no anesthesia Exposure to teratogens: none

INTRODUCTION Pneumonia is an inflammation of the lungs caused by an infection. Many different organisms can cause it, including bacteria, viruses, and fungi. It can range from mild to s severe, even fatal. The severity depends on the type of organism causing pneumonia, as well as our age and underlying health.

Causes of Pneumonia Pneumonia is not a single disease. It can have over 30 different causes. There are five main causes of Pneumonia. • • • • •

Bacteria Viruses Mycoplsmas Other infectious pneumocystis Various chemicals

agents

such

as

fungi

–

including

Symptoms The main symptoms of pneumonia are: • • • • •

Cough with greenish or yellow mucus; bloody sputum happens on occasion Fever with shaking chills Sharp or stabbing chest pain worsened by deep breathing or coughing Rapid, shallow brething Shortness of breath

Additional symptoms include: • • • • •

Headache Excessive sweating and clammy skin Loss of appetite Excessive fatigue Confusion in older people

Signs and Tests • • • • •

Chest x-ray Gram’s stain and culture of the sputum for the organism causing the symptoms CBC to check white blood cel count; if high, this suggests bacterial infection CAT scan on the chest Pleural fluid culture if there is fluid in the space surrounding the lungs

Treatment If the cause is bacterial, the goal is to cure the infection with antibiotics. If the cause is viral, antibiotics will not be effective. In some cases, it is difficult to distinguish between viral and bacterial pneumonia, so antibiotics may be prescribed. Many people treated at home with antibiotics. If there is an underlying chronic disease, severe symptoms, or low oxygen levels, it will likely require hospitalization for intravenous antibiotics and oxygen therapy. Infants and the elderly are more commonly admitted for treatment of pneumonia.

If at home: • • •

Drink plenty of fluids to help loosen secretions and bring up phlegm Get lots of rest. Have someone else do household chores Control your fever with aspirin or acetaminophen. Do not give aspirin to children.

When in the hospital, respiratory treatments to remove secretions mat be necessary. Occasionally, steroid medications may be used to reduce wheezing if there is an underlying lung disease. Complications Empyema or lung abscesses are infrequent, but serious, complications of pneumonia. They occur when pockets or pus around or inside the lung. These may sometimes require surgical drainage. Prevention •

• •

Wash hands frequently, especially after blowing the nose, going to the bathroom, diapering, and before eating or preparing foods. Don’t smoke. Tobacco damages the lung’s ability to ward off infection. Wear a mask when cleaning dusty or moldy areas

Vaccines can help prevent pneumonia in children, the elderly, and people with diabetes, asthma, emphysema, HIV, cancer, or other chronic conditions

• •

•

I.

Pneumococcal vaccine (Pneumovax, Prevnar) prevents Streptococcus pneumonia Flu vaccine prevents pneumonia and other infections caused by Influenza viruses. It must be given yerly to protect against new viral strains Hib vaccine prevents pneumonia in children from Haemophilus influenza type b.

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. 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.

II.

PATHOPHYSIOLOGY

Predisposing Factors Age Sex

Etiology

Virulent Microorganisms Streptococcus Pneumoniae

Precipitating Factors Lifestyle Environment

Microorganism enters the nose (nasal passages) Passes to the Pharynx, Larynx, Trachea Microorganism enters and affects both airway

and lung parenchyma

Airway Damage

Lung Invasion

Infiltration of Bronchi

Flattening of Epithelial Cells

Infectious organism lodges stimulation in bronchioles

macrophages and Leukocytes

Alveolar wall collapse mucus and phlegm production

Increase pyrogen in the body

COUGHING FEVER

necrosis of bronchial tissue narrowing of air passage DIFFICULTY OF BREATHING necrosis of pulmonary tissue overwhelming sepsis

DEATH

III. LABORATORY AND DIAGNOSTIC PROCEDURES Hematology Report Examination Requested: CBC

Parameter

Actual Result

Normal Values SI Units

Hemoglobin (Hgb)

128

M=140-170g/L; F=120-150g/L

Hematocrit (Hct)

0.39

M=0.40-0.50; F=0.37-0.42

5.9

5-10 X 109/L

Segmenters

0.64

0.55-0.65

Lymphocytes

0.36

0.25-0.35

White Cell Count

Differential Count

Chest X-ray Streaky densities are seen on both lung fields Heart is not enlarged with undilated aorta Lung vascularity is within normal Bone, soft tissue of the chest wall are unremarkable Impression :

IX.

Pneumonia

LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY (P + E) A. B. C. D. E.

Ineffective airway clearance related to increased sputum production in response to respiratory infection Impaired gas exchange related to collection of mucus in airways Infection related to invading bacterial organisms Discomfort related to respiratory distress High risk for altered nutrition (less than body requirements) related to lack of appetite

XII. ONGOING APPRAISAL

September 1, 2009 It was being recommended by the attending physician that the patient needs to stay at the hospital for further

observations since it was seen that the disease at this point of the treatment process still cannot be managed at home by medications only.

XIII. DISCHARGE PLAN (HEALTH TEACHINGS) •

Take the entire course of any prescribed medications. After a patient’s temperature returns to normal, medication must be continued according to the doctor’s instructions, otherwise the pneumonia may recur. Relapses can be far more serious than the first attack.

•

Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse.

•

Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs.

•

Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected. It’s important to have the doctor monitor his progress.

•

Encourage the guardians to wash patient’s hands. come in daily contact with germs that can cause These germs enter one’s body when he touch his eyes nose. Washing hands thoroughly and often can help risk.

•

Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.

•

Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed.

•

Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isn’t possible, a person can help protect others by wearing a face mask and always coughing into a tissue.

The hands pneumonia. or rub his reduce the