PCAP Final

July 12, 2017 | Author: Amiebelle Naval | Category: Pneumonia, Lung, Health Sciences, Wellness, Clinical Medicine
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Introduction Community-acquired pneumonia (CAP) is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital.

SIGNS AND SYMPTOMS    

difficulty in breathing, fever, chest pains, cough

TYPES OF CAP 

Typical pneumonia usually is caused by bacteria such as Streptococcus pneumoniae. A



typical pneumonia usually is caused by the influenza virus, mycoplasma, chlamydia, legionella, adenovirus, or other unidentified microorganism.

The patient’s age is the main differentiating factor between typical and atypical pneumonia; young adults are more prone to atypical causes,5,6 and very young and older persons are more predisposed to typical causes.

CLINICAL PRESENTATION 

Pneumonia is an inflammation or infection of the lungs that causes them to function abnormally.



Pneumonia can be classified as typical or atypical, although the clinical presentations are often similar.

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Several symptoms commonly present in patients with pneumonia.

ETIOLOGY Bacterial       

Chlamydia species Haemophilus influenza Legionella species Moraxella catarrhalis Mycoplasma pneumonia Staphylococcus aureus Streptococcus pneumonia

Viral   

Adenovirus Influenza A B Parainfluenza Respiratorysyncytial virus

Endemic fungi   

Blastomycosis Coccidioidomycosis Histoplasmosis

EPIDEMIOLOGY The epidemiology of CAP is unclear because few population-based statistics on the condition alone are available. The Centers for Disease Control and Prevention (CDC) combines pneumonia with influenza when collecting data on morbidity and mortality, although they do not combine them when collecting hospital discharge data. In 2001, influenza and pneumonia combined were the seventh leading causes of death in the United States,3,4 down from sixth in previous years, and represented an age-adjusted death rate of 21.8 per 100,000 patients.3 Death rates from CAP increase with the presence of comorbidity and increased age; the condition affects persons of any race or sex equally. The decrease in death rates from pneumonia and influenza are largely attributed to vaccines for vulnerable populations (e.g., older and immunocompromised persons).

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RISK FACTORS           

Age older than 65 years Human immunodeficiency virus or immunocompromised Recent antibiotic therapy or resistance to antibiotics Comorbidities Asthma Cerebrovascular disease Chronic obstructive pulmonary disease Chronic renal failure Congestive heart failure DiabetesLiver disease Neoplastic disease

INCIDENCE/PREVALENCE The incidence of community-acquired pneumonia requiring hospitalization in the study counties in 1991 was 266.8 per 100,000 population; the overall case-fatality rate was 8.8%. Pneumonia incidence was higher among blacks than whites , was higher among males than females and increased with age 

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Patient’s Profile Name

:

C.G.

Birth date

:

April. 15. 2011

Address

:

Umboy San Antonio Biñan Laguna

Age

:

5 months

Gender

:

female

Religion

:

Catholic

Nationality

:

Filipino

Admitting diagnosis

:

Pneumonia

Final diagnosis

:

Community Acquired Pneumonia

Chief Complaint

:

Difficulty of Breathing

Attending Physician

:

Dra. A

Date of Admission

:

September, 12, 2011

Room Type

:

Pedia Ward

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Patient’s History 

HISTORY OF PRESENT ILLNESS One week prior to admission, the patient’s mother stated that her daughter has a cough, fever and experience difficulty of breathing; she also noticed that her daughter’s lips are turning blue (cyanosis). They consulted at ONB-ER and was given antibiotic then admitted at pedia ward with Dra. Manalo Arzola as attending physician. The patient admitted last September 12, 2011 at around 5:00 pm.



PAST MEDICAL HISTORY

No past medical history, first time admitted at the hospital.



FAMILY HISTORY

(+) hypertension – paternal side (+) asthma – maternal side



PERSONAL AND SOCIAL HISTORY

Patient’s mother stated that baby C.G is her 2nd child and has a twin which also experience having pneumonia before, she also stated that they live with her mother-inlaw which have a rugby factory.

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Physical Assessment VITAL SIGNS Temperature

Cardiac Rate

Respiratory Rate

36 °C

125 bpm

51 cpm

BODY PARTS Scalp

NORMAL FINDINGS

ACTUAL FINDINGS

size-varies somewhat

-Absence of masses

shape-symmetrical and round

-No Lesions -symmetrical

Hair

Face

Eyes

color-varies

-black

amount and distribution

-normal

texture-fine to coarse, pliant

- fine to course

presence of parasites-none

-with parasites

symmetry-symmetrical

-symmetrical facial movement

facial features-features vary, symmetrical, centered head position

-symmetrical

conjunctiva and sclera-bulbar and palpebral conjunctiva is pink with no discharge; sclera is white

-pinkish and no discharge

cornea-transparent, smooth, moist

Round, transparent, smooth and moist

-white sclera

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Nose

external nose -skin appearance-color: same as face -shape-symmetrical appearance

-color same as face -with clear watery discharge -not tender

internal nose -appearance-mucosa pink and moist with uniform color and no lesions

-mucosa pink and moist -no lesions

Mouth

Lips

Open and close mouth for symmetry and alignment-lips and surrounding tissue relatively symmetrical in net position and with smiling

-proportional and symmetrical with the face

color-

-pink

-no lesions, swelling, drooping

in white- pink in dark-may have bluish hue or frecklelike pigmentation

-smooth, no lesions

consistency- moist, smooth with no lesions Tongue

Ears

symmetry and texture-moist symmetrical appearance; midline fissure present

-in central position

movement-smooth

-moves freely

color-pink

-no lesions or swelling

size and shape- ears equal size and similar appearance

-equal

-moist

-similar in appearance -same color as facial skin

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Skin

generalized color

-light brown

light to dark brown

-smooth, soft

texture-smooth, soft

-warm

temperature and moisturewarm, dry

-pinched skin returns immediately to original position

turgor-pinched skin returns immediately to original position

-no edema and lesions

edema-no swelling, pitting, or edema Neck

appearance/movement-smooth, controlled movements; range of motion

-smooth no lesions

flexion, extension, lateral abduction, rotation

-can move in different direction

-no swelling

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Thoracic and lung

Inspection Anterior and posterior thorax-

-intercostal spaces even and relaxed

-symmetry equal Intercostals spaces-even and relaxed -sternum is level with the ribs Chest symmetry-equal

-shallow/labored breathing

Position of sternum-level with -crackles heard upon ribs auscultaion Position of trachea-midline Respiration patterns/auscultate

Abdomen

Contour-rounded or flat

-globular shape

Symmetry-symmetrical

-muscles used for labored inspiration

Surface motion-no movement or slight peristalsis visualized over aorta

Palms

Color-pink

-pink

creases

-(3)three

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Finger nails

Color-pink nail bed

-pink

Shape-round nail with 160 nail - round w/ 160° nail base base -long and dirty Texture-nail is round, hard, hard immobile in dark skin: -normal capillary refill may be thick Condition of nail bed-smooth, firm, and pink

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Review of Anatomy and Physiology

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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 twolayered 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.

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Pathophysiology Non Modifiable Factors:  Age

Modifiable Factors:  Environment  Diet  Bacteria and Viruses Entry of microorganism to nasal passages Invasion of the respiratory system

Activation of immune response (mucus production) Ineffective immune response results to overwhelming infection

cough

fever

Invading lung parenchyma Release of endotoxins and exotoxins Continues mucus production

dyspnea

exotoxins Massive inflammation (pneumonia Altered gas exchange

cyanosis

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NARRATIVE Infectious organism enter the lung when airborne droplets are inhaled, but can also reach the lung through the bloodstream when there is an infection in another part of the body. Many bacteria live in parts of the upper respiratory tract, such as the nose, mouth and sinuses, and can easily be inhaled into the alveoli. Once inside, bacteria may invade the spaces between cells and between alveoli through connecting pores. This invasion triggers the immune system to send neutrophils, a type of defensive white blood cell, to the lungs. The neutrophils engulf and kill the offending organisms, and also release cytokines, causing a general activation of the immune system. This leads to the fever, chills, and fatigue common in bacterial and fungal pneumonia. The neutrophils, bacteria, and fluid from surrounding blood vessels fill the alveoli and interrupt normal oxygen transportation.

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Medical Management

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DATE 9/12/11 2:05 pm

PROGRESS NOTES Wt : 5.3 kg

DOCTOR’S ORDER

RATIONALE

NURSING CONSIDERATIONS

Please admit under the service of Dra. Arzola

-Patients have different preferences and needs.

-Familiarize the patient’s mother with the room and hospital facilities

Secure consent for admission

-To ensure that the patient’s mother understood and agreed on everything explained by the physician regarding to her baby’s condition.

-The nurse’s responsibility is to ensure that an informed consent has been obtained voluntarily from the patient’s mother by the physician. The signed consent form is placed in a prominent place on the patient’s chart.

-To document acute changes and trends over time and unexpected changes and values that deviate significantly from a patient’s normal values are brought to the attention of the patient’s primary health care provider. Also for monitoring hemodynamic,

-The nurse assessed individual client and determined that the client is medically stable or in a chronic condition and not fragile and that the vital sign measurement is considered routine for the client.

Monitor VS q 4 hrs

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cardiac and ventilatory status.

NPO

-To prepare -Instruct the the patient for patient’s mother not diagnostic to feed the baby. procedure. It helps to prevent risks of aspiration. Aspiration pneumonia (where food particles can be regurgitated from the stomach into the lungs) is a life-threatening complication because it causes severe damage to the lungs requiring artificial ventilation and hospitalization.

IVF : D5 0.3 NaCl 500 cc, 39 > cc x 24 ° x a6.17 mcgtts/min

- Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

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Diagnostic tests: CBC

-Complete blood count is used to determine blood components and the response to inflammatory process and streptococcal infection.

-Explain test procedure to the patient’s mother. Apply manual pressure over the puncture site and monitor for oozing of blood or hematoma formation. Follow up results.

UA

-Urinalysis yields a large amount of information about possible disorders of the kidney and lower urinary tract, and systematic disorders that alter urine composition. Urinalysis data include color, specific gravity, pH, and the presence of protein, RBC’s,WBC’s, bacteria, Leukocyte, esterase, bilirubin, glucose, ketones, casts and crystals.

- Instruct and demonstrate on the patient’s mother how to get the midstream urine. Follow up results. The nurse should be able to establish a base line as guide for deviations and monitoring for stability of these values.

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For CXR

-It is used to rule out respiratory problems causes of referred pain. In some cases, chest abnormalities cause pain in the abdominal area.

-Tell the patient that he must wear gown and must remove all metal object and jewelry from his neck and chest. Assist patient in assuming appropriate position. Reassure the patient that the amount of radiation exposure s minimal. Follow-up results.

Medications:

Cefuroxime 150mg IV q 8 ANST (-)

-Cefuroxime is a cephalosporin antibiotic. It treats many kinds of infections such as cholecystitis.

Paracetamol 60mg -Paracetamol is a analgesics IV q 4° for fever T and > 38.5 °C

Antipyretics drugs use to relieve fever and mild to moderate pain.

Salbutamol ½ neb + 1 cc NSS q 390 cc x 3 dose

-Salbutamol is antiasthmatic drugs. It relieve

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bronchospasm in patient with acute respiratory infection

Moderate high back rest

-To provide patent, unobstructed airway , maximum lung excursion

-Instruct the patient’s mother to elevate head of the bed and do not leave her daughter unattended.

02 at 1-2 LPM

-To prevent hypoxemia; to provide more oxygen to the body in order to promote health.

- Instruct the patient’ smother on the method of administering oxygen safely.

Inform AP (attending physician)

-Attending Physician will be sufficiently comprehensive to describe the clinical problem, pertinent history, and physical findings to enable continuity of care by others who may be involved in the patient’s care.

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Nebulize ĉ salbutamol q 6°

-Salbutamol is antiasthmatic drugs. It relieve bronchospasm in patient with acute respiratory infection

Reassessment c/o NOD

-To evaluate patient’s condition and identify new patient problems needing different interventions according to a revised plan

-reassess the patient periodically, establish a plan of care based on the patient reassessment

High back rest

-facilitate chest expansion to improve ventilation.

-Instruct the patient’s mother to elevate head of the bed and do not leave her daughter unattended.

CPR PRN

-To restore and maintain circulation and to provide oxygen if the petient has stopped breathing (respiratory arrest)

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RR: 51 cpm (-) DOB

May have MF ĉ SAP

-The

patient is at a big risk of throwing up and it getting into their lungs which can cause aspiration pneumonia

Have the patient be fed, head elevated almost 90 degrees while feeding

9/13/11 9:35 am

TF: D5 0.3 NaCl 500 - Replacement cc x 16-17 therapy mcgtts/min particularly in extracellular fluid deficit accompanied by acidosis.

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

4:30 pm

IVF : D5 IMB 500 cc x 10 hrs

- Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

02 ĉ 4LPM thru funnel PRN

-To prevent hypoxemia; to provide more oxygen to the body in order to promote health.

- Instruct the patient’ smother on the method of administering oxygen safely.

May feed ĉ SAP

-The

-Have the patient be fed, head elevated almost 90 degrees while feeding.

9/14/11 9:07 am

patient is at a big risk of throwing up and it getting into their lungs

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which can cause aspiration pneumonia

9/15/11 6:45 am

IVF D5IMB 500 cc x 10°

- Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

TF: D5IMB 500 cc x 10°

- Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

Cefaclor drops 1ml TID x 5 days

-Cefaclor is a cephalosporin drugs. It used in the treatment of upper and lower respiratory infection

Salbutamol neb ½ + 1cc NSS TID x 5 days TF: OPD after 1 week

-Salbutamol is antiasthmatic drugs. It relieve bronchospasm in patient with acute respiratory infection

3:30 pm

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Diagnostic Exam

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hematology September 13,2011

Result

Normal values

Interpretation

Hemoglobin

115

110 – 140 gm / L

DECREASED Indicates decreased oxygen level in the blood/anemia

Hematocrit

0.36

0.37 – 0.47

NORMAL

RBC

4.1

4.5 – 5 x 1012 / L

DECREASED Indicate hypoxemia or decreased oxygen production

Total WBC

4.2

5 – 10 x 109 / L

DECREASED Indicates presence of infection

Platelet count

290

150 – 400 x 109 / L

NORMAL

Segmenters

0.30

0.50 – 0.70

NORMAL

Eosinophil

0.70

0.20 – 0.80

NORMAL

Differential count:

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urinalysis September 13,2011

Color Transparency Specific Garvity PH Albumin Sugar WBC RBC Bacteria Epithelial cells

Results Yellow Slightly Hazy 1.015 Neutral Negative Negative 0-2/ HPF 0-1 / HPF Negative Few

Normal Values Yellow Clear to slightly hazy 1.015-1.025 4.5-8.0 Negative Negative 0-2/ HPF 0-2/ HPF Negative Few

Interpretation NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

Fecalysis September 13,2011

Consistency

Color

Parasite seen

Characteristics

Results

Normal Values

Interpretation

Mucoid

formed

ABNORMAL Indicate presence of bacterial infection

Green

Yellow-brown

ABNORMAL Indicate diarrhea

Some found

Negative

ABNORMAL Indicate diarrhea NORMAL

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Drug study

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Nursing Care Plan

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