Case Study Pneumonia)

I. Introduction: This is a case of a 1 year old child who was diagnosed Pneumonia with Bronchial Asthma. Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other foreign substances. In all cases, the lungs' air sacs fill with pus , mucous, and other liquids and cannot function properly. This means oxygen cannot reach the blood and the cells of the body. Most pneumonias are caused by bacterial infections.The most common infectious cause of pneumonia in the United States is the bacteria Streptococcus pneumoniae. Bacterial pneumonia can attack anyone. The most common cause of bacterial pneumonia in adults is a bacteria called Streptococcus pneumonia or Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form. An increasing number of viruses are being identified as the cause of respiratory infection. Half of all pneumonias are believed to be of viral origin. Most viral pneumonias are patchy and the body usually fights them off without help from medications or other treatments. Pneumococcus can affect more than the lungs. The bacteria can also cause serious infections of the covering of the brain (meningitis), the bloodstream, and other parts of the body. Asthma is a chronic, reversible, obstructive airway disease, characterized by wheezing. It is caused by a spasm of the bronchial tubes, or the swelling of the bronchial mucosa, after exposure to various stimuli. Asthma is the most common chronic disease in childhood. Most children experience their first symptoms by 5 years of age. Asthma commonly results from hyperresponsiveness of the trachea and bronchi to irritants. Allergy influences both the persistence and the severity of asthma, and atopy or the genetic predisposition for the development of an IgE-mediated response to common airborne allergens is the most predisposing factor for the development of asthma.

II. Goals and Objectives:

GOAL:

We, the student nurses of Capitol University, aim to develop essential as well as skillful pediatric nursing care which is based on the better and effective approach ---that will serve as a catalyst to promote health, reduce illness and/or completely eliminate such diseases. We are also up to in knowing the nature of the disease and on how to manage it in such a way that it would be therapeutic to both mother and child.

Objectives:

By the end of this whole rotation, we, the student nurses of Capitol University, will be able to:

1. Enhance our ability to manage the said disease in regards to their cultural beliefs and lifestyle. 2. Develop an independent and collaborative work together with the medical health team members. 3. Prioritize things which are essential in assessing and developing proper interventions in treating or alleviating the illness. 4. Improve the use of the nursing process that would include assessment, diagnosis, planning, implementation and evaluation into a more useful and more effective in doing the patient’s care. 5. Apply the core and fundamental systematic approach of the nursing profession in promoting health unto the clients.

III. Client’s Profile

A. Socio-demographic data

Patient X is a 1- year old Filipina female who is living with her family at Zone 1 Agusan, Cagayan de Oro City. Her religion is Roman Catholic. She has no allergies reported. Patient has a Pneumonia, Bronchial Asthma. Patient X was admitted last February 9, 2010 at NMMC-P3F3 Pediatric Respiratory Ward because of having an onset productive cough associated with fever. With that, patient X was admitted. B. Vital signs The patient vital signs are one of the most important data that should be given a direct attention because it will serve as basis in determining any risk factors towards the patient. The increase and decreased of the vital sign of the patient must be monitored in order to determined whether the patient is at risk or not. The patient had the following vital signs upon admission: PR- 165 bpm ; RR- 68 cpm; and temp- 36.5°C .

IV. Physical Assessment

These portions of the chapter will present the normal and regressed health function of patient X arranged in a cephalocaudal approach to present a more organized and convenient documentation. •

Health perception and management pattern (pre-hospitalization) She was hospitalized due to difficulty in breathing. Patient was apparently well

until 4 days prior to admission (PTA), there was an onset of non productive cough associated with fever (undocumented) low bowel movement with 2 episodes of soft stool yellow in color, non bloody. Patient was given with amoxicillin 4.4 kg/g/dose and salbutamol 0.14 dose with no relief. No vomiting noted. Persistence of above condition brought the patient on the setting and have their admission. There are no previous hospitalization reported. •

Nutrition-Metabolic Pattern (MGH – still in) Patient is breastfed 5 times a day and also ate solid foods but when the onset of

underlying condition takes place, the patient has lost her appetite •

Elimination pattern (pre-hospitalization) A patient defecates 1-2 times a day, formed and green in color. Since she’s still 1

year old, she is not yet capable of controlling her urinary sphincter thus, the patient experiences urinary incontinence. •

Activities of daily living (ADL) (pre-hospitalization) Regarding with the patients condition, she cannot perform activities of daily living

without any assistance not to mention the capabilities of the patient. For that reason, her mother is always behind her whenever she is performing various activities.

•

Self-perception and self-concept pattern (while confined) Due to the age of the patient, she still can’t verbalized anything because she is

not capable of talking but based on her actions, she seems to be afraid of what will happen as manifested by always crying during the assessment phase. •

Activities Tolerance-Exercise pattern (while confined) Because the patient was experiencing difficulty in breathing and during

auscultation, there was a presence of wheezing sounds during expiration due to her bronchial asthma thus, the patient usually stays on her bed. •

Sleep rest pattern (while confined) She had a difficulty in sleeping during the first day of admission because she was

experiencing difficulty in breathing. In the ward, she still cannot sleep continuously since some of her medication schedule must be administered during at night and dawn. The parents of the patient also verbalized that the environment is not soothing for their child’s sleeping pattern because of its hot and noisy environment. •

Cognitive-Perception (while confined) The patient was conscious but suggest anxiety because she often cries

especially when she sees people wearing white clothes. She is not mingling with other children but rather choose to stay on her bed. •

Role-Relationship Pattern (while confined) The patient has good sound relationship with her parents as seen during the

assessment she always stick to her mother and cries when she is being left alone. •

Values – Belief Pattern The client is a Roman Catholic because her parents are Roman Catholic too.

They often pray and go to church as well.

V. Neurological Assessment Orientation Appropriate behavior/communication Level of Consciousness Emotional State

Not applicable Crying Conscious Anxious

Skin General Color Texture Turgor Temperature Moisture

Pallor Smooth Supple Warm Dry

Head Facial Movements Fontanels Hair Scalp

Symmetrical Closed Fine Clean

Eyes Lids Preorbital Region Conjunctiva Sclera Reaction to light

Symmetrical Intact/full Pale Anicteric R- Brisk

Reaction to accommodation Visual Acuity Peripheral Vision

L- Brisk Uniform constriction / Convergence Grossly Normal Intact/full

Nose

Septum Mucosa Patency Gross Smell Sinuses

Midline Pinkish Both patent Normal/symmetrical Non-tender

Ears External Pinnae Tympanic Membrane Gross Hearing

Normoset; Symmetrical Intact Normal

Mouth Lips Mucosa Tongue Teeth Gums

Pallor Pinkish Midline Missing teeth/ erupting Pinkish

Neck Trachea Thyroids Others

Midline Non-palpable Normal ROM

Pharynx Uvula Tonsils Posterior Pharynx Mucosa

Midline Not Inflamed Not Inflamed Pinkish

Abdomen General Configuration Bowel Sounds Percussion Back and Extremities

Normal Symmetrical Normoactive Tympanitic

Range of Motion Muscle tone and strength Spine Gait

Normal Fair Midline Coordinated

Cardiovascular Status Precordial Area Point of Maximal Impulse (PMI) Heart Sounds Peripheral Pulses Capillary Refill

Flat 5th ICS, midclavicular line Regular Regular 2 seconds

Respiratory Status Breathing Pattern Shape of Chest Lung Expansion Vocal/Tactile Fremitus Percussion Breath Sounds Cough

Irregular AP:L:2:1 Symmetrical Symmetrical Resonant Wheezing during expiration Non-productive

VI. Anatomy and Physiology RESPIRATORY SYSTEM. Introduction. The respiratory system includes tubes that remove particles from incoming air and transport air to and from lungs and the air sacs where gases are exchange.Respiratory is the entire process of gas exchange between the atmosphere andbody cells. Respiratory is biological system for all organisms that involve gas exchange. Body tissues received the oxygen by respiratory system and the rate of oxygen is increased during exercise. Organs of the Respiratory System. The organs of the respiratory system can be divided into two groups. The upper respiratory tract includes the nose, nasal cavity, and pharynx and the lower

respiratory tract includes the larynx, trachea, bronchial tree and lungs.

ORGANS OF THE RESPIRATORY SYSTEM

THE UPPER RESPIRATORY

NOSE NASAL CAVITY PHARYNX

THE LOWER RESPIRATORY

LARYNX BRONCHIAL TREE LUNGS

NOSE. Bone and cartilage support nose internally. Its two nostrils are openings through which air can enter and leave the nasal cavity. Many internal hairs guard the nostril for preventing entry large particles carried in the air.

NASAL CAVITY The nasal cavity is a hollow space behind the nose. The nasal septum, composed of bone and cartilage, divides the nasal cavity into right and left portions. Nasal conchae are bones that curl out from the lateral walls of the nasal cavity on each side, dividing the cavity into passageways. Nasal conchae also support the mucous membrane that line the nasal cavity and help increase its surface.

The mucous membrane filters, warms, and moistens incoming air. Ciliary action carries particles trapped in mucus to the pharynx, where they are swallowed.

PHARYNX. The pharynx or throat is behind the oral cavity, the nasal cavity and the larynx. It is a passageway for food travelling from the oral cavity to the

esophagus and for air passing between the nasal cavity and the larynx. It also helps produce the sounds of speech.

Pharynx are consists 3 parts. Those are nasopharynx, oropharynx and laryngopharynx.

LARYNX. The larynx is an enlargement in the airway at the top of the trachea and below the pharynx. It is composed of muscles and cartilages and is lined with mucous membrane.

The larynx contains the vocal cords, which vibrate from side to side and produce sounds when air passes between them. Inside the larynx, two

pairs of horizontal vocal folds. The upper folds are called false vocal cords and the lower folds are called true vocal cords. The glottis and epiglottis help prevent foods and liquids from entering the trachea.

TRACHEA. The trachea is a flexible cylindrical tube about 2.5 cm in diameter and 12.5cm in length. It extends downward anterior to the esophagus and into the thoracic cavity, where it splits into right and left bronchi.

A ciliated mucous membrane with many goblet cells lines the trachea’s inner wall. This membrane filters incoming air and moves entrapped particles upward into the pharynx, where the mucus can be swallowed. The cartilaginous rings prevent the trachea from collapsing and blocking the airway. The soft tissues that complete the rings in the back allow the nearby esophagus to expand as food moves through it to stomach.

BRONCHIAL TREE.

The bronchial tree consists of branched airways leading from the trachea to the microscopic air sacs in the lungs. Its branches begin with the right and left primary bronchi, which arise from trachea at the level of fifth thoracic vertebra. Each primary bronchus divides into secondary bronchi, which in turn branch into tertiary bronchi and then into finer and finer tubes.

Among the smaller tubes are bronchioles that continue to divide, giving rise to terminal bronchioles, respiratory bronchioles and finally to very thin tubes called alveolar ducts. These ducts lead to thin-walled outpouchings called alveolar sacs. Alveolar sacs lead to smaller microscopic air sacs called alveoli.

The branches of the bronchial tree air passages whose mucous membranes filter incoming air and distribute the air to alveoli throughout the lungs. The alveoli provide a large surface area of thin simple squamous epithelial cells through which gases can easily be exchanged.

LUNGS. The lungs are soft, spongy, and cone-shaped in the thoracic cavity. The mediastinum separates the right and left lungs medially and diaphragm and thoracic cage enclose them.

Visceral pleura firmly attach to each lung surface and folds back to become the parietal pleura.

A major branch of the bronchial tree supplies each lobe. A lobe also has connections to blood and lymphatic vessels and lies within connective tissues. Thus, a lung includes air passages, alveoli, blood vessels, connective tissues, lymphatic vessels and nerves.

XI. Discharge Planning M-edication to take Instruct and explain the patient's mother that the medication is very important to continue depending on the duration that the doctor ordered for the total recovery of the patient, otherwise it may recur. Relapses can be far more serious than the first attack. •

Teach patient and her family or significant others the proper dosage and the right time to take the medication.

•

Emphasize to the patient the importance of obediently taking the prescribed medications and the disadvantages or complications that may arise if these are not taken properly.

•

Inform and discuss the possible side effects and reactions that these drugs might produce and seek medical attention immediately is these arise.

•

Rescue medications that act quickly to halt asthma symptoms once they start. Some medications can be used as needed to stop asthma symptoms (such as wheezing, coughing, and shortness of breath) when a person first notices them. These medications act fast to stop the symptoms, but they're not long lasting. They are also known as "reliever," "quick-relief, " or "fast-acting" medications.

•

Controller medications to manage asthma and prevent symptoms from occurring in the first place. Many people with asthma need to take medication every day to control the condition overall. Controller medications (also called "preventive" or "maintenance" medications) work differently from rescue medications. They treat the problem of airway inflammation instead of the symptoms (coughing, wheezing, etc.) that it causes. Controller medications are slow acting and can take days or even weeks to begin working. Although you may not notice them working in the same way as rescue medications, regular use of controller medications should lessen your need for the rescue medications. Doctors also prescribe controller medications as a way to minimize any permanent lung changes that may be associated with having asthma.

E-xercise Instruct mother to let her child play but it should be limited to a short period of time only to prevent the occurrence of shortness of breathing.

In the case of exercise-induced asthma, the trigger (physical activity) needs to be managed rather than avoided. Exercise can help a person stay healthier overall, and doctors can help athletes find treatments that allow them to them participate in their sports. T-reatment Your doctor will help you learn how to keep asthma symptoms under control and will prescribe pills or an inhaler for attacks. Advice the mother to keep the baby relax in order to recover in her present condition. Instruct the mother to minimize the patient from exposure to an open environment such as dusty and smoky area, which airborne microorganism are present that can be a high risk factor that may cause severity of his condition. Avoid exposing the patient to an environment too much of pollution (e.g. smoke). Smoke damages one's lungs natural defences against respiratory infection. Avoid the things that can cause their symptoms. Of course, some things that can cause symptoms can't be completely avoided (like catching a cold!), but people can control their exposure to some triggers, such as pet dander, for example. Drink lots of fluid, especially water. Liquids will keep the patient from becoming dehydrated and help loosen mucus in the lung. If you have bronchial asthma, make sure your doctor shows you how to use the inhalers. Be sure to keep your rescue inhaler with you in case of an asthma attack or asthma emergency. While there is no asthma cure yet, there are excellent asthma medications that can help with preventing asthma symptoms and asthma support that can help you live a normal, active life. H-ygiene Encourage and explain to the patient's mother that it is important to maintain proper hygiene to prevent further infection. Instruct the patient's mother to bath her baby everyday and explain that bathing early in the morning is not a factor or cause of having pneumonia. Instruct to increase fluid intake of the patient's condition. Encourage the guardians to wash patient's hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter one's body when she touch her eyes or rub her nose. Washing hands thoroughly and often can help reduce and often can help reduce the risk. 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.

O-ut patient follow up Regular consultation to the physician can be a factor for recovery and to assess and monitor the patient's condition. Even though the patient feels better her lungs may still be infected. It is important to have the doctor monitor her progress. D-iet Diet as tolerated, meaning, the patient can eat everything until she can. Diet plays a big role in fast recovery so instruct the mother to give nutritious foods intended for respiratory problems. M-edications •

Teach patient and her family or significant others the proper dosage and the right time to take the medication.

•

Emphasize to the patient the importance of obediently taking the prescribed medications and the disadvantages or complications that may arise if these are not taken properly.

•

Inform and discuss the possible side effects and reactions that these drugs might produce and seek medical attention immediately is these arise.

E-xercise •

The child may resume regular activities gradually upon returning home.

•

Quiet activities are recommended for the first post-op week.

•

Avoid rough housing and sports.

•

No swimming until the first post-op appointment.

•

Avoid exertion, heat, stress and fatigue.

XII. HEALTH TEACHING The best way to control this is prevention. •

Teach the family about the management required for the disorder.

•

Keep your environment clear of potential allergens.

•

Pay attention to the weather and take precautions when you know weather or air pollution conditions may affect you. You may need to stay indoors or limit your exercise to indoor activities.

•

Be smart about exercise.

•

Encourage significant others to do chest tapping to facilitate mobilization of secretion.

•

Encourage to change patient's position regularly to facilitate drainage and mobilization of secretion.

•

Encourage to provide well ventilated area.

•

Instruct to give medications at the right route, dose, and time.

•

Remind significant others to always assess to patient needs.

•

Instruct significant others to keep child always clean and dry.

•

Advise to go to the physician if signs and symptoms of pneumonia and bronchial asthma are observed.

•

Teach the folks the importance of monitoring the progress and compliance with the treatment regimen.

•

Patient needs health promotions activities and health screening.

•

Emphasize to the significant others the importance of having regular check-up to know her present condition.

XIII. LEARNING EXPERIENCE

In our daily lives, we encounter many kinds of experience that we didn’t expect to come. We cannot predict what will happen in the near future. In our duty experience in Pedia ward at Northern Mindanao Medical Center (NMMC) we’ve encounter so many kind of things, which are often unexpected and were full of lessons that must be inculcated in our hearts and minds like giving medication to our patients it was the first time for us, having a bedside care, regulating the IVF every 1 hour, monitoring the patients vital signs, and so many more. In our first duty in pedia ward we committed so many kinds of errors and we are all guilty for that but for that errors we’ve learn a lot and gradually we are learning to improve our work in order to follow the mission of the nursing profession, which is to give care to the patient. We’ve learn that not at all the times we will be perfect on what we will be doing, we’ve learn that the pediatric patients are so sensitive than other patients. In our skills, we’ve improve and we’ve got a new knowledge for what we are doing like calculating the drops of the IVF either it is micro drops or macro drops that bis

being administered in our patients and also monitoring the intake and output to our patients. In making this case study, our friendship and our relationship as members of this group was strengthen and really proves that all things are done together even in the hardest part of it. We know for the fact that this study requires a lot of sacrifices and fortunately we did survive of what we have done. And last we learn the real value of being a student nurse that we should control our temper, our emotion while we are on our patients side, we have to adjust the in environment where we belong it is because we didn’t know the feelings of the watchers. Thank you…………