case study pneumoni

8/2/2019 Case Study Pneumoni

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Patients Data

Name of Patient: Peach Twinkle T. Abundo

Age: 1

Sex: Female

Address: Calatagan Virac, Catanduanes

Religion: Roman Catholic

Medical Data:

Date of Admission: September 17. 2011

Time of Admission: 12:25 PM

Hospital Number: 557

Attending Physician: Dr. Louie Panti

Chief Complaint: Vomiting

Diagnosis: Pneumonia, Intestinal Parasitism

Health History

Present Health History

Peach Twinkle T. Abundo, 1 years old, female from Calatagan Virac, Catanduanes was admitted at EBMC on September 17,2011 at 12:25 PM with a chief complaint of vomiting.


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Upon admission baby Peach Twinkle T. Abundo is conscious and coherent. Her CR is 101 bpm, RR is 25 bpm and T of 37.1 C.She weighs 8 kg. Upon auscultation fine crackles is noted. Cough and colds are present. She also vomits and her mother claimed thatthere is a change in her bowel habit. Dr. Panti, as an Attending Physician, requested for laboratory examinations such as CBC andStool Examination. The result of the Hematology revealed an increased in WBC counts therefore the patient have an infection.

Past Health History

The patient is born through CS. Her feeding is composed of breastmilk and also formula milk. Her immunization is complete.The patient dont have any past confinement after she was born.

Developmental Task

Autonomy vs. Shame & Doubt is Eriksons second developmental stage, as the child gains control over eliminative functionsand motor abilities, they begin to explore their surroundings. The parents still provide a strong base of security from which the childcan venture out to assert their will. The parents' patience and encouragement helps foster autonomy in the child. Children at this agelike to explore the world around them and they are constantly learning about their environment. Caution must be taken at this agewhile children may explore things that are dangerous to their health and safety. At this age, children develop their first interests. Forexample, a child that enjoys music may like to play with the radio. Children that enjoy the outdoors may be interested in animals andplants. Highly restrictive parents, however, are more likely to instill the child with a sense of doubt and reluctance to attempt newchallenges. As they gain increased muscular coordination and mobility, toddlers become capable of satisfying some of their ownneeds. They begin to feed themselves, wash and dress themselves, and use the bathroom. If caregivers encourage self-sufficient

behavior, toddlers develop a sense of autonomy- a sense of being able to handle many problems on their own. But if caregiversdemand too much too soon, refuse to let children perform tasks of which they are capable, or ridicule early attempts at self-sufficiency; children may instead develop shame and doubt about their ability to handle problems.


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Anatomy and Physiology of the Affected

Organ


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The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen

into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We

each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The

right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can

also be divided up into even smaller portions, called 'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each

segment receives its own blood supply and air supply.

Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right

bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The

alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of

little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the

blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in,

air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel

across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the

capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid

of the waste product carbon dioxide.


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Phatophysiology


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Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygenhas trouble reaching your blood. If there is too little oxygen in your blood, your body cells cant work properly. Because of this andspreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumoniaaffects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs.

Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most common. Other

pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia pneumoniae, C. psittaci, C.trachomatis, Moraxella (Branhamella) catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gram-negative bacilli.Major pulmonary pathogens in infants and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and Bviruses. Among other agents are higher bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacteriumtuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis,Cryptococcus neoformans, Aspergillus fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever).

The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions from theupper airways. Other means include hematogenous or lymphatic dissemination and direct spread from contiguous infections.

Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure,chronic obstructive airway disease, age extremes, debility, immunocompromise (as in diabetes mellitus and chronic renal failure),compromised consciousness, dysphagia, and exposure to transmissible agents.

Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes accompanied bypleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. Thissyndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.


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Laboratory Results and Diagnostic Exams

CBC Result

Diagnostics Done SI Values Significance

Hematocrit

Hemoglobin

0.40 0.54

120 140 g/L

Increased in: polycythemia, dehydration, Addisons disease,acute thermal injury, Extreme physical exertion, COPD

Decreased in: hemorrhage, anemia, hemolytic anemia, fluid

overload, fluid retention, cirrhosis, leukemia, lymphoma

Increase d in: polycythemia, dehydration, acute thermal injury, COPD

Decreased in: hemorrhage, bleeading, anemia, hemolytic anemia,

fluid overload, fluid retention, pregnancy, cirrhosis of the liver,

hyperthyroidism

Increase indicates presence of systemic infections.


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WBC Count

Segmenters

Lymphocytes

Eosonophil

5.0 10 x 10 /L

0.58 0.66

0.21 0.3

0.02 0.04

Increase indicates presence of bacterial infections.

Increased in: infectious mononucleosis, infectious hepatitis,cytomegalo virus infection, pertussis, brucellosis, tuberculosis,syphilis, lymphocytic leukemia,

Decreased

in: thoracic duct drainage, right-sided heart failure Hodgkins

disease,SLE,aplastic anemia, HIV infection, military TB,renal

failure,Terminal cancer

Increased in: skin diseases, trichinosis, scar let fever,

CML, MPD, Hodgkins disease, malignancy, rheumatoid arthritis,sarcoidosis, allergic reaction to drugs, allergies

Decreased in: pyrogenic infection, shock, postsurgical

response

Stool ExaminationColor:Yellow


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Non-pharmacological Treatment:Health Teachings ImpartedRoutine Nursing Care

Drug StudyName of Drug: Cefuroxime

Dosage: 270 mg

Indications: Listed in Dosage.

Administration: Should be taken with food.

Contraindications: Hypersensitivity to cephalosporins.

Special Precautions: Severe renal impairment; pregnancy, lactation; hypersensitivity to penicillins.

Adverse Drug Reactions: Large doses can cause cerebral irritation and convulsions; nausea, vomiting, diarrhoea, GI disturbances; erythemamultiforme, Stevens-Johnson syndrome, epidermal necrolysis.

Potentially Fatal: Anaphylaxis, nephrotoxicity, pseudomembranous colitis.

MIMS Class: Cephalosporins

Name of Drug:Metronidazole

Dosage: 140mg

Indications: Listed in Dosage.

Administration: Tab: Should be taken with food.Susp: Should be taken on an empty stomach. (Take at least 1 hr before meals.)
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Contraindications: History of hypersensitivity to metronidazole or other nitroimidazole derivatives. Pregnancy (1st trimester) and lactation.

Special Precautions: Patients with CNS diseases; discontinue IV therapy if abnormal neurologic symptoms occur. History of seizure disorder.Evidence or a history of blood dyscrasias; perform total and differential leukocyte counts before and after treatment. Severe hepatic

impairment; monitor plasma levels. Predisposition to oedema (inj contains sodium). Prolonged use may result in fungal or bacterial

superinfection.

Adverse Drug Reactions: GI disturbances e.g. nausea, unpleasant metallic taste, vomiting, diarrhoea or constipation. Furred tongue, glossitis,and stomatitis due to overgrowth of Candida. Rarely, antibiotic-associated colitis. Weakness, dizziness, ataxia, headache, drowsiness,insomnia, changes in mood or mental state. Numbness or tingling in the extremities, epileptiform seizures (high doses or prolonged

treatment). Transient leucopenia and thrombocytopenia. Hypersensitivity reactions. Urethral discomfort and darkening of urine. Raised liver

enzyme values, cholestatic hepatitis, and jaundice. Thrombophlebitis (IV).

Potentially Fatal: Anaphylaxis.

MIMS Class: Other Antibiotics / Antiamoebics / Preparations for Vaginal Conditions / Topical Antibiotics

Name of Drug: Combivent Nebule

Dosage: Neb

Indications: COMBIVENT (ipratropium bromide and albuterol sulfate) Inhalation Aerosol is indicated for use in patients with chronic obstructivepulmonary disease (COPD) on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and who require a second

bronchodilator.

Administration: It is recommended to test-spray three times before using for the first time and in cases where the aerosol has not been usedfor more than 24 hours. Avoid spraying into eyes.

Contraindications:Combivent Inhalation Aerosol is contraindicated in patients with a history of hypersensitivity to soya lecithin or related foodproducts such as soybean and peanut. Combivent Inhalation Aerosol is also contraindicated in patients hypersensitive to any other

components of the drug product or to atropine or its derivatives

Special Precaution: Effects Seen with Anticholinergic Drugs: Combivent Inhalation Aerosol contains ipratropium bromide and, therefore, should

be used with caution in patients with narrow-angle glaucoma, prostatic hyperplasia, or bladder-neck obstruction.

Adverse Drug Effects: Additional adverse reactions, reported in less than two percent of the patients in the Combivent Inhalation Aerosoltreatment group include edema, fatigue, hypertension, dizziness, nervousness, paresthesia, tremor, dysphonia, insomnia, diarrhea, dry
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mouth, dyspepsia, vomiting, arrhythmia, palpitation, tachycardia, arthralgia, angina, increased sputum, taste perversion, and urinary tract

infection/dysuria.

Name of Drug: Metoclopramide

Dosage: 1 ml

Indications:Disturbances of GI motility Relief of symptoms of acute andrecurrentdiabeticgastroparesis Nausea and vomiting Metabolicdiseases Short-term therapy for adults with symptomatic gastroesophageal reflux who fail to respond to conventional therapy. Prophylaxis

of postoperative nausea and vomiting when nasogastric suction is undesirable.

Contraindications:Contraindicated with allergy to metoclopramide GI hemorrhage Mechanical obstruction or perforation Epilepsy Usecautiously with previously detected breast cancer, lactation, pregnancy, fluid overload, renal impairment

Side Effects:CNS: restlessness, drowsiness, fatigue, Insomnia, dizziness, anxiety CV: transient hypertension GI: nausea and diarrhea

Name of Drug: Paracetamol

Dosage: 4ml

Indications: Mild to moderate pain and fever.

Administration: May be taken with or without food

SpecialPrecautions: Renal or hepatic impairment; alcohol-dependent patients; G6PD deficiency.

AdverseDrugReactions: Nausea, allergic reactions, skin rashes, acute renal tubular necrosis.PotentiallyFatal: Very rare, blood dyscrasias (e.g. thrombocytopenia, leucopenia, neutropenia, agranulocytosis); liver damage.

MIMSClass: Analgesics (Non-Opioid) & Antipyretics

Name of Drug: Efamed Plus
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Dosage:3ml

Indications: Resp disorders complicated by bronchospasm & excessive secretion of tenacious mucus, bronchial asthma, chronicbronchitis & emphysema.

Administrations:Should be taken on an empty stomach (Take on an empty stomach 1 hr before or 2 hr after meals.).

Contraindications: -blocker therapy, thyrotoxicosis. Pregnancy

Adverse Drug Reactions: Efamed syr Fine tremor, tension, angioedema, urticaria, bronchospasm, hypertension, collapse. Efamed Plus tab &syr Confusion, irritability, tremor, insomnia & restlessness; loss of appetite, nausea & vomiting, feeling of tension, peripheral vasodilation,

slight increase in heart rate, headache, transient muscle cramps, hypersensitivity reactions, hyperactivity in childn, risk of dental caries.

MIMS Class: Cough & Cold Preparations

Nursing Care Plan

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO

N

RATIONALE EVALUATION

Subjective:

Nasakitan pa siyamakahangos asclaimed by mother

Ineffecti

ve

breathi

ngpattern

Excess of fluidin the lungs

Short term goal:

After 3-4 hours ofnursinginterventions, the

patients respirationwill improve anddifficulty of breathing

Independent:

Establish

rapport topatient

andwatcher

Independent:

To gain the

trust andcooperation

Short term

goal:

After 3-4 hours ofnursing

interventions, thepatientsrespiration was
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Objective:

- (+) DOB

- Cracklesnoted

- (+)Wheezing

- V/S taken:

T: 37.2

P: 100

R: 39

related

to

pulmon

ary

infectio

n

Resulting froman inflammatory

process

Inflammation istriggered by

many infectiousorganisms and

inhalation ofirritating agents

Alveolar wallsthickened and

become irritated

will be relieved.

Assess

patientscondition

Monitor

and recordV/S

Auscultate

lung fields,notingareas of decreased/absentairflow andadventitious breathsounds

Assist

patient tochangeposition

To know and

determinepatientsneeds

To establish

base linedata

To identifyareas of consolidation anddeterminepossiblebronchospasm orobstruction

able to improveand difficulty ofbreathing wasrelieved.


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Accumulation of

mucus andinflammatory

cells

Leads to

Pneumonia

every 30minutes

Encourage

to increase

fluidintake.

To mobilize

secretions

To liquefy

secretions

Impaired

gas

exchang

e r/t

collectio

n of

secretio

ns

affecting

Short term goal:

After 2-4 hours ofnursinginterventions, thepatient will achievetimely resolution ofcurrent infection

withoutcomplications.

Independent:

Assess

respiratoryrate, depthand ease.

Independent:

Manifestatio

n ofrespiratorydistress isdependenton

indicative ofthe degreeof lung

Short term

goal:

After 2-4 hours ofnursinginterventions,the patient was

able to achievetimely resolutionof current


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oxygen

exchang

e across

alveolar

membra

ne.

Monitor

bodytemperature

Dependent:

Administer

antimicrobi

als asprescribed

involvementandunderlyinggeneralstatus.

High fever

greatlyincreasesmetabolicdemandsand oxygenconsumption and alterscellularoxygenation

.

Dependent:

These drugs

are used tocombatmost of themicrobialpneumonias

.

infection withoutcomplications.


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Administer

nebulizertreatmentasprescribed

Facilitates

liquefactionand removalofsecretions.

Ineffecti

ve

airway

clearanc

e related

to

excessiv

e,

thickene

d mucus

secretio

ns

Short term goal:

After 4 hours ofnursing interventionsthe patient will :

Demonstrateimprovedventilationand adequateoxygenation.

Arterial blood

gases (ABGs)within normalrange.

No signs ofrespiratory

Independent:

Assess

respiratoryrate,depth.Note use

ofaccessorymuscles,pursed lipbreathing.

Routinely

monitorskin andmucus

membranecolor.

Independent:

Useful in

evaluatingthe degreeorrespiratory

distress andchronicity ofthe diseaseprocess.

Cyanosis

may beperipheral

in nail bedsor central inlips or


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distress.

Long term:

After months of

nursinginterventions, thepatient:

Ventilation or

oxygenation isadequate tomeet self careneeds.

Evaluate

sleeppatterns,note reportofdifficultiesandwhetherpatient

feels wellrested.

Collaborative:

Administer

supplemental oxygenasindicated

by ABGresults andpatients

earlobes.Duskinessand centralcyanosisindicateadvance

hypoxemia.

Multiple

externalstimuli andpresence ofdyspneamaypreventrelaxation

and inhibitsleep.

May correct

or preventworseningof hypoxia.


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tolerance.

Nursing Implications

Nursing Practice

It is essential to be able to understand contemporary nursing practice, which looks at the overall aspects of the nursingprofession. This study enhances the quality and effectiveness of nursing care that will rendered to the clients with similar condition.Nursing practice itself could also be evaluated in this case

This case study will be beneficial to nursing practices. This implies that the health care providers must become more dedicatedin rendering nursing care but there must be no exceptions upon rendering services regardless of the case handled by the caregiver.The greatest impact of the implication is the equality in treatment upon rendering nursing care, that all patients must be entitled to aquality and effective care regardless of who they are and what their health problem is.

Nursing Research

This case study is equipped with useful information, ample opportunities and responsibilities to the nurses, not exempting theaffiliating student nurses in order for them to be well-informed and competitive in this field. Research findings will provide them abroader knowledge of the said case and will enhance their skills for them to be globally competitive in the profession.


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Nursing Education

Education is one of the important processes of learning because it is continuous and it can help achieve the optimum level ofknowledge to every individual in all aspects of life not just in the field of nursing.

This case study is accomplish through the thorough research and studies made intentionally for other proponents who willhandle same case for them to be encouraged and aim for the best to further go through series of studies.

This will also be beneficial to other case studies related or similar to this. The case study could serve as a guide in making moreimproved and comprehensive study about the case.

Catanduanes State Colleges

College of Health Sciences

Department of Nursing


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Case Study of Pneumonia

Submitted by:Carmina A. Aguilar

BSN-2B

Submitted to:

Marilou Lopez, RN, MANClinical Instructor

case study pneumoni

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