Final case study PCAP..docx

University of Perpetual Help System Laguna Dr. Jose G. Tamayo Medical University Sto. Niño, Biñan, Laguna

COLLEGE OF NURSING

Pediatric Community-Acquired Pneumonia (PCAP – C) In Partial Fulfillment of the Requirements in NCM 107 B A Case Presented By Group 1 - 3/ N4X

Abellar, Justine A. Acabado, Melanisol C. Delfin, Gian Carlo D. Fermindoza, Jenny Gay S. Garcia, Leslie M. Gutierrez, Joana G. Olay, Nicole Neil N. Regis, Melanie B. Santos, Jeffrey M.

August 15, 2013

CONTENTS I.

Introduction

II.

Patient’s Profile

III.

Physical Assessment

IV.

Anatomy and Physiology

V.

Pathophysiology

VI.

Medical Management

VII.

Laboratory and Diagnostic Tests

VIII.

Drug Study

IX.

Nursing Care Plan

INTRODUCTION

I. Introduction Pediatric community-acquired pneumonia (PCAP) Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites. Pneumonia is the infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles. Pneumonia can be community-acquired or hospitalacquired. Community acquired pneumonia occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization. Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi. The most common are: Streptococcus pneumoniae – the most common cause of bacterial pneumonia in children; Haemophilusinfluenzae type b (Hib) – the second most common cause of bacterial pneumonia; respiratory syncytial virus is the most common viral cause of pneumonia. Environmental Risk Factors include: indoor air pollution caused by cooking and heating with biomass fuels (such as wood or dung), living in crowded homes, parental smoking. Signs and Symptoms vary depending on the age of the child and the cause of the pneumonia, but common ones include: fever, chills, cough, nasal congestion, unusually rapid breathing (in some cases, this is the only symptom), breathing with grunting or wheezing sounds, labored breathing that makes the rib muscles retract (when muscles under the ribcage or between ribs draw inward with each breath) and causes nasal flaring, vomiting, chest pain, abdominal pain, loss of appetite (in older kids) or poor feeding (in infants), which may lead to dehydration, in extreme cases, bluish or gray color of the lips and fingernails. Incidence: Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.2 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide. Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa.

PATIENT’S PROFILE

Name

:

C.R.

Age

:

2 years old 9 months

Gender

:

Female

Status

:

Child

Nationality

:

Filipino

Religion

:

Roman Catholic

B-date

:

November 5, 2010

B-place

:

Binan,Laguna

Address

:

Cabuyao, Laguna

Admission date and time : Attending Physician

Initial Diagnosis

:

PCAP-C

Final Diagnosis NONE

:

:

August 4, 2013/ 9:42am Dra. G.M.

Chief Complaint Cough

History of present illness: Two weeks prior to admission, patient experienced cough, productive, no fever noted, no difficulty of breathing. Patient was given Cefexime 2.5 ml and cetirizine 2.5 ml which give temporary relief. One day prior to admission suddenly experienced fever, temperature maximum of 39 degree Celsius, patient was given Paracetamol suppository which gave temporary relief, associated with appearance of petechial rashes on the periorbital area. Persistence of the symptom, prompted to have the admission.

Maternal and obstetric history: Patient was born to a 27 years old G2P2 (2002) mother who had regular prenatal checkup and regular intake of vitamins. No history and exposure to radiation and teratogenic drugs. Patient had history of UTI during the course of pregnancy and asthma at 7 months.

Birth History: Patient was delivered live, via Caesarian Section attended by obstetrician and pediatrician with no noted complications. Routine newborn screening was done.

Neonatal History: Patient has no history of jaundice and cyanosis. Meconium was passed out within 24 hour of life.

Immunization History: (+) BCG

(+) DPT 3 doses (+) OPV 3 doses (+) Hep B 3 doses (+) Varicella Vaccine (+) Pneumonia Vaccine

Past Medical History: (+) Hospitalization = 2012 Aug ; cough, UPHS (+) Seizure at 5 months (+) Asthma, 2012, Montelukast and prednisone

Family History:

(+) HPN = Paternal (+) DM = Paternal (+) Seizure = Paternal (+) Asthma = Both (-) CVD (-) PTB

Aug. 8, 2013 vital signs:

Temperature

:

36.1°C

Cardiac Rate

:

107 bpm

Respiratory Rate

:

35cpm

Blood pressure

:

90/60

Weight

:

14.1kg

Physical assessment

Psychological and social examination  she is conscious and coherent

Erik Erikson Stages of psychosocial development  Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt  Toilet Training-Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.

Freud’s Stages of Psychosexual Development

 Anal Stage: Age Range 1 to 3 years old  The child begins to toilet train, which brings about the child's fascination in the erogenous zone of the anus. The erogenous zone is focused on the bowel and bladder control. Therefore, Freud believed that the libido was mainly focused on controlling the bladder and bowel movements. The anal stage coincides with the start of the child’s ability to control their anal sphincter, and therefore their ability to give or withhold gifts at will. If the children during this stage can overcome the conflict it will result in a sense of accomplishment and independence.

PHYSICAL ASSESSMENT (Cephalo-caudal) August 8, 2013 Body Parts

Technique

Normal Findings

Actual Findings

Skin (General)

Inspection Palpation

-light to dark brown

- light to dark brown

-no swelling

-no swelling

-good skin turgor

- with good skin turgor.

-no lesion

-no lesion

Hair and scalp

Inspection

Analysis

Head

Inspection

Neck

Inspection

- hair distribution, -color black equal. - Equal and healthy hair and distribution. -face is -face is symmetrical symmetrical -no lesion

-no lesion

-no swelling -symmetrically align -blinking symmetrically -Evenly distributed

-no swelling -symmetrically align -blinking symmetrically - Turned outward eyelashes; hair equally distributed -eyelashes are short

Eyes

Inspection

Eye brows

Inspection

Eye lashes

Inspection

Eye lids

Inspection

-eye lid margins are moist

- Moist

Sclera

Inspection

-white in color

-white in color

Pupil

Inspection

-equally round and reactive to light and accommodation

- Pupils equally reactive to light and accommodation.

Ears

Palpation

-equal in size

-equal and symmetrical

Inspection

-symmetrically align -no lesion -no swelling - no discharge

-no lesion -no swelling - no discharge

Nose

Inspection

-Symmetric and straight; no discharge or flaring; Uniform color

-Symmetric and straight; no discharge or flaring; Uniform color

Lips

Inspection

-pink, moist and smooth in texture. -no lesion, no sores.

Buccal mucosa

Inspection

-Pink in color, soft, moist, smooth texture, asymmetry of contour, ability to purse lips - Pink in color, soft, moist, smooth, glistening, and elastic texture.

- Pink color and moist. - no lesions and sores noted

Tongue

Inspection

-no lesion -no swelling - moisten

-no lesion -no swelling -moist - no sores noted

Gums

Inspection

-pink and moist

-pink and moist, - healthy gums.

Teeth

Inspection

-symmetrically aligned, no tooth decay

-Good set of milk teeth.

Nails Capillary refill

Inspection

-Pink in color