sh pneumonia jhay case

7/29/2019 SH Pneumonia Jhay Case

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URDANETA CITY, PANGASINANCOLLEGE OF NURSING

A CASE STUDY ONPNEUMONIA

SUBMITTED BY:Pangan, Jeusu O.

Bsn-3 SUBMITTED TO:

Lendl Deo Osias


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I. PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA1. Patients Name: B.C2. Address: Villasis, Pangansinan3. Age: 324. Sex: Female

5. Birth Date: January 26, 19816. Rank in the Family: Mother7. Nationality: Filipino8. Civil Status: Married9. Date of Admission: July 22,201310. Order of Admission: Please admin to Medical Ward, secure consent inserted IVF with D5LRS 1L to regulate @ 20-21 gtts/min.11. Admitting Diagnosis: PNEUMONIA12. Attending Physician: Dr. BUENCONCEJO

B. CHIEF COMPLAINTAccording to the patient is experiencing cough fever and dizziness

C. HISTORY OF PRESENT ILLNESS:Present condition started 2days prior to admission

D. PAST HEALTH HISTORY:

1. Childhood Illness: She experienced chicken pox, colds, cough and cold 2. Immunization: Complete3. Major Illness: None4. Current Medications: Paracetamol, Mefenamic Acid5. Allergies:Allergy to Tahong

E. FAMILY ASSESSMENT:

Name Relation Age Sex Occupation Educational Attainment

B.C Pt/Mother 32 Female None College Undergraduate

B.T Father 37 Male None College Undergraduate

B.O Son 1/8 Months old Male N/A N/A

.


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F. SYSTEM REVIEW :

1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN Clients perception of health: The client perceives health as if we take care of our self, we will be healthy Clients perception about illness : The client perceives illness as it was really hard to get sick if you dont have money Health maintenance and habits: In maintaining his health as well as his family, they have their check up and sometimes just have self-

medicated of the illness is not severe. Compliance with prescribed medications and treatment: according to the client they always follow the medication and treatment beingprescribed.

2. NUTRITIONAL METABOLIC PATTERN: Appetite : The smell and taste can trigger the clients appetite. According to the client, the usual diet is high in fiber and carbohydrates and eats

3 times a day with 2-3 cups of rice and 1 bowl of dish. Usual Daily Menu:

- Food : vegetables, fish and meet- Water : pt BC drinks 6-8 glasses of water per day- Beverage : she drinks coke and coffee

3. ELIMINATION PATTER

Bowel Habits : According to the client, he usually defecates once a day- Color : Brown- Odor : Aromatic- Consistency : Soft

4. ACTIVITY EXERCISE PATTERN0 Feeding 1- Dressing 0- Grooming0 Bathing 0- Toileting 0- Cooking1 Bed Mobility 1- Home Maintenance

Legend:0 Full Care

I Requires use of assistanceII Requires assistance and supervision by othersIII Requires assistance and supervision from another and equipments and devicesIV Dependent, Doest participate

5. COGNITIVE PERCEPTUAL PATTERN Hearing : Upon interviewing, Mrs. B.C can perceive sounds and hears all the questions that were being asked Vision: My client can read books and newspapers clearly.


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Sensory: Upon applying slight pressure with both arms of Mrs. B.C can differentiate the scent of alcohol from the smell of food. Learning Styles: The client can supervice his learning abilities and level of understanding through watching television and listening in the

radio. In tems of decision making, Mrs. B.C approaches her husband they make their decisions together.

6. SLEEP REST PATTERN Sleep habits: Mrs. B.C stated that before she goes to sleep she watches a television program Hours of sleep: She sleeps at 10pm up to 4am

Sleeping alteration: Mrs. B.C had alterations in sleeping because he usually work at night. Sleeping aids: her sleeping aids is only watching television

7. SELF PERCEPTION AND SELF CONCEPT PATTERN Felling about current state : Regardless of his situation Mrs. B.C still believed that God will help him in any situation. Description of self: She described herself as kind, loving mother and wife Known capabilities and weakness: As verbalized by the client my weaknesses are my family Self worth: The client sees herself as kind, loving mother and wife

8. ROLE RELATIONSHIP PATTERN

According to Mrs. B.C she is doing her responsibility to her son as well as to his husband

9. SEXUALTY REPRODUCTIVE PATTERNPhysical and psychological effect of the clients current health status on sexual expression:

Mrs. B.C stated that she can still performed sexual activity together with her husband but thers a limitation.

10. COPING STRESS TOLERANCE PATTERN Perception of stress and problems : Mrs. B.C perceives stress as a problem as we can easily solve our problems if we think for the solution Coping method and support system according to Mrs. B.C she prays all the time.

11. VALUE BELIEF PATTERN Values, goals and philosophical belief: According to the client she believes that GOD is always there for us Religious and spiritual beliefs: the client is Roman Catholic and believes that be contented f what GOD gave to you


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G. HEREDO- FAMILIAL ILLNESS

1. Paternal no known illness2. Maternal no known illness

H. DEVELOPMENTAL HISTORY

Theorist Age Sex Patients Description

Erik Erickson 32 Female

INTIMACY vs. ISOLATION- It is involves parenting care and

offers support and praise fordecision making

Jean Piaget 32 Female

Formal operation thought- First it relates how she really thinks

-2nd , how she solved/ handled problemsin a mature though and reasoning andlastly

- On how she accept opinions ofsignificant others

Lawrence Kohlberg 32 Male

Post conventional, Level 3 stages 6- It involves on how an individuals

internalized the standards of conduct andhow he apply/ put the standards conductinto her life

I. PHYSICAL ASSESSMENTA. General Survey

1. Overall appearance and grooming: The client is conscious and coherent2. Actual height and weight vs. ideal body weight: Height: 5ft and weight 65 kg.3. Symptoms of distress: none4. Posture and gait: The client has a good posture5. Affect and mood:According to the client he still shows great happiness


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6. Relevance and organization of thoughts: She can understand and answer all questions appropriately7. Vital signs of the day of physical examination

Temperature: 37.3 degrees Celsius Respiratory rate: 60 cycle per minutePulse rate: 86 beats per minute Blood pressure : 100/70

B. Regional exam- utilize IPPA technique

1. Hair: Upon inspection, Hair are evenly distributed, short and no presence of infection

Head : Head is round.

2. Eyes: Upon inspection of the clients eyes, eyebrows are evenly distributed,

3. Nose: Not performed

4. Ears: Not performed

5. Mouth and throat: Upon inspection, outer lips are uniform in color, soft and dry. Oral mucosa is also dry.

6. Neck and lymph nodes:The clients neck muscles are equal in size, no visible nodules or masses upon palpation

7. Skin: Brown in color, warm to touch

8. Nails: Fingernail plate shape convex, smooth texture

9. Thorax and lungs: With RR of 60 cpm, fast rhythm breath and has crackles upon inhalation.

10. Cardiovascular: With CR of : 86 beats per minute, lub/dub can be heard upon auscultation.

11. Abdomen: Not performed

12. Extremities: He was able to flex and extend his extremities actively but with weakness noted.

15. Neurological/Cranial nerves: Not performed


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II. PERSONAL/SOCIAL HISTORY

A. Habits:

a. Caffeine: She drinks 2 cups every dayb. Smoking: noc. Alcohol: She drinks alcohol occasionally

d. Tea: Sometimese. Drugs: The drug regimen prescribed to her by the doctor.

B. Lifestyle:According to the patient she does the Activities of Daily LivingC. Social Affiliation: The patient is obeying the rules and regulation in their barangayD. Rank in the family: MotherE. Travel (within 6 months): The patient dint travel to farF. Educational Attainment: College Undergraduate

III. ENVIRONMENTAL HISTORY

According to his mother, they are living with herhusbands family. Their house is located at the rice field. Its made of raw materials like cement and

hollow blocks; their using tricycle as their transportation going to market/town which about 5 km away from their house.

IV. INTRODUCTION

Pneumonia is an inflammatory condition of the lungaffecting primarily the microscopic air sacs known as alveoli. It is usually caused by infection with

viruses orbacteria and less commonly othermicroorganisms, certain drugs and other conditions such as autoimmune diseases. Pneumonia can be a serious threat

to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a

common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country.

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. The most common cause of bacterial

pneumonia in adult is a bacteria called streptococcus pneumonia or pneumococcal. Most viral pneumonias are patchy and the body usually fights them off withouthelp from medication or other treatments. Pneumococcus can affect more than the lungs. The bacteria can also cause serious infection of the covering of the brain

(meningitis ), the bloodstream, and other parts of the body.
https://en.wikipedia.org/wiki/Inflammationhttps://en.wikipedia.org/wiki/Lunghttps://en.wikipedia.org/wiki/Virushttps://en.wikipedia.org/wiki/Bacteriahttps://en.wikipedia.org/wiki/Microorganismhttps://en.wikipedia.org/wiki/Medicationhttps://en.wikipedia.org/wiki/Autoimmune_diseasehttps://en.wikipedia.org/wiki/Autoimmune_diseasehttps://en.wikipedia.org/wiki/Medicationhttps://en.wikipedia.org/wiki/Microorganismhttps://en.wikipedia.org/wiki/Bacteriahttps://en.wikipedia.org/wiki/Virushttps://en.wikipedia.org/wiki/Lunghttps://en.wikipedia.org/wiki/Inflammation


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V. 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 uo

to 20 times per minute taking in and disposing of those gases. Air that is

breath 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 pumped by the heart throughout the body. The

alveoli also take in carbon dioxide, which is then exhaled from the body.


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VI. Pathophysiology

Virulent Microorganism

Streptococcus Pneumoniae

Microorganism enters the nose (nasal passages )

Passes through the larynx, pharynx, tracheas

Microorganism enters and affects both airway and lung parenchyma

Airway damage Lung invasion

Infiltration of bronchi Flattening of epithelial

Infectious organism lodges Necrosis of bronchial tissues Macrophages and leukocytes

Stimulation in bronchioles Narrowing of air passage Mucus and phlegm production

Alveolar collapse Coughing

Increase pyrogen in the body DIFFICULTY OFBREATHING (Productive/ non-productive)

Fever

VII. Laboratory Test


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HEMATOLOGY

Test Result Normal values Significance

Hemoglobin 95 130.00 180.00 g/L Decreased hemoglobin levelsimply decrease oxygen carrying

capacity of the blood

Hematocrit 0.31 0.42 0.52 g/L A low hematocrit referred to as

being anemic caused by loss ofblood or dietary deficiency

Segmenters 0.59 0.50-0.70 Within normal range

Lymphocyte 0.39 0.20-0.40 Within normal range

Monocyte 0.02 0.00-0.07 Within normal values

Platelet 177 150-400 x 10 g/L Within normal values

IX. DRUG STUDY

Generic Name:AmpicillinBrand Name: Ampicillin Trihydrate


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Drug Classification:Anti-infective, bactericidalDosage: 150mg IVP every 6 ANST (-)Indication: respiratory tract or skin and skin-structure infection.

Mechanism of Action Side Effect Contraindication Adverse Effect Nursing Consideration

Inhibit cell-wall synthesisduring bacterial multiplication

Nausea and vomiting,diarrhea, abdominal

pain, fatigue,headache, dysuria,urinary retention

Contraindicated in patientshypersensitive to drug or other

penicillin and cephalosporins

CNS: dizziness, fatigue,agitation, confusion

Prior to administration,skin test is to be done

to determine signsand symptoms ofhypersensitivity;

Monitor seizures whengiving high doses.

Do not miss a doseunless ordered byphysician.

Instruct mother toreport signs andsymptoms of superinfection

Generic Name: Gentamycin sulfateBrand Name: GaramycinDrug Classification:Anti-bacterial

Dosage: 25 mg SIVP q 6oANSTIndication: to prevent enodocarditis before GI ir GU procedure

Mechanism of Action Side Effect Contraindication Adverse Reaction Nursing consideration


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Inhibits protein synthesis bybinding directly to the 5 oSribosomal subunit;bactericidal.

CNS: fever, headache,lethargy, confusion, dizziness,vertigoGI: Nausea, vomitingSkin: rash, urticaria, pruritus,injection site pain.

Contraindicated in patientshypersensitivity to drug ortother aminoglycosides

Use cautiously inneonates, infants, elderlypatients, and patient withimpaired renal function or

neuromascular disorder.

CNS: encephalopathy,seizuresGU: nephrotoxicityHematologic: leucopenia,thrombocytopenia,agranulocytosis.Respiratory: apnea

Other: anaphylaxis

Obtain specimen forculture and sensitivity testbefore giving first dose.Therapy may begin whileawaiting results.(Skin testis commonly done forhypersensitivity to drug)

Evaluate patients hearingduring therapy because of

ototoxicity Weigh patient and review

renal function studiesbefore therapy begins.

Instruct patient to promptlyreport adverse reactions,such as dizziness, vertigo,hearing loss, numbness ormuscle twitching

Encourage patient to drinkplenty of fluid

Warm patient to avoidhazardous activities ifadverse CNS reactionsoccur.

Check auditory functionbefore therapy thenrecheck again every 3 to 4weeks after the drug isdiscontinue.


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Generic Name: MetoclopramideBrand Name: ReglanDrug Classification:Anti-emeticDosage: O.3 ml SIVP every 6 hoursIndication: Prevention of nausea and vomiting associated with emetogenic cancer chemotherapy

Mechanism of Action Side Effect Contraindication Adverse Reaction Nursing consideration

Dopamine antagonist thatacts increasing sensitivity toacetylcholine; results inincreased motility of theupper GI tract and relaxationof the pyloric sphincter andduodenal bulb

Nausea, restlessnessand diarrhea

Contraindicated withallergy to metoclopramide,GI hemorrhage,perforation

Insomnia, dystoniaand akathesia

Give this drug exactlyas prescribed

Inject slowly to preventtransient feeling ofanxiety andrestlessness

Maintain fluid andelectrolyte balance


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Generic Name: ParacetamolBrand Name: MedamolDrug Classification: analgesic, antipyreticDosage: 90ml IV every 6 hoursIndication: treatment for mild fever

Mechanism of Action Side Effect Contraindication Adverse Effect Nursing Consideration

May produce analgesic effectby blocking pain impulses, byinhibiting prostaglandin, orpain receptor sensitizers. Mayrelieve fever by acting onhypothalamic heat-regulatingcenter. Relieves fever

Anemia

Jaundice

Rash

urticaria

Contraindicated in patientshypersensitive to drug or itscomponents.

Chest pain Headache

Dyspnea Monitor for S&S of

hepatotoxicity, evenwith moderateacetaminophendoses, especially inindividuals with poornutrition.

Patient & Family Education

Do not take othermedications (e.g., cold

preparations)containingacetaminophenwithout medicaladvice; overdosingand chronic use cancause liver damageand other toxic effects.

Do not self-medicatechildren for painwithout consulting aphysician

Do not give childrenmore than 5 doses in24 hours unlessprescribed byphysician

Monitor for


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temperature changes

X. LIST OF IDENTIFIED PROBL EMS ACCORDING TO PRIORITY

a. Fluid Volume Deficit related to fluid lose

b. Hyperthermia related to infection

c . Imbalanced nutrition less than body requirements related to inability to ingest food


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X. Nursing Care Plan

ASSESSMENT DIAGNOSIS SCIENTIFICBACKGROUND

PLANNING NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective: Walang ganang

dumede ang anakko as verbalized

Objective:

> Weak and palein appearance> Pallor> Loss of weightfrom 11 kg to 9 kg>>Vital signs asFollows:PR: 124 bpmRR: 37 cpmT: 38.8

oC

Imbalanced Nutritionless than body

requirements relatedto decrease ability toingest foods 2 hoursto vomiting and LBM

After 1-2 days ofnursing

intervention, themother will beable todemonstratebehavior thatmaintainappropriateamount.

> Monitor Vital Signs

> Assess weight, age,body built, strength,and activity

> Determine the abilityto swallow and taste

> Provide SFF withSAS

>Administerpharmacologicalagents as prescribedfor example:-medications-vitamin / mineralsupplements

>Promote adequatefluid intake

> To serve as baselinedata

> To providecomparative baseline

>To assess contributingfactors.

> To providepharmacologicaltreatment

>To replace fluids

Goal met after 1-2days of nursing

intervention themother was able todemonstratebehavior thatmaintain appropriateamount.


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> Encourage themother of the patient toeat foods that isnecessary to patientage such as cereals,mashed apples andbananas.

>To providenourishment





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Subjective:mainit ang akinganak asverbalized by themother of ourpatient

Objective:>slightly irritable>flushed skin>warm to touch>dry skin withpoor turgor>dry oralmucosa

>Vital signs asfollows:RR: 37 cpmPR: 124 bpm

T: 38.8

Hyperthermia r/tinfection processor dehydration

Infectiousagents stimulatemonocytes andreleasepyrogeniccytokines andmay stimulateanteriorhypothalamusresults inelevatedthermoregulatoryset point andleads toincreased heatconservationthen result infever

After 30 60minutes ofrenderingnursinginterventions,the patient stemperature willdecrease from38.8C to 37.6C

Monitor Vital signs

Provide properventilation.

Monitor heart rateand rhythm.

Promote surfacecooling by means ofcool environmentand/or fans.

Instruct client/SO toincrease fluid

intake.

Review signs andsymptoms ofhyperthermia.

Remove excessclothing and blanket

Administer anti-pyretic drugs asprescribed by the

doctor

Serve as baseline data

Proper ventilation mayreduce the temperatureof the patient.

Dysrhythmias arecommon due toelectrolyte imbalance,dehydration, and directeffects of hyperthermiaon blood and cardiactissue.

Heat loss by convention.

Adequate fluid intake

prevents dehydration.

These may indicateprompt interventions.

To relieve fever

After 30 60minutes ofrendering nursinginterventions, thepatientstemperaturedecreased from38.8C to 37.6C.


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Subjective:ilang araw ngngtatae atnagsusuka anganak ko as

verbalized bythe mother

Objective:>dry mucousmembrane>slightly irritable>seen vomitingthe milk>dry skin withpoor turgor>depressedfontanelles

>Vital Signs asfollows:RR: 37cpmPR: 124bpmT: 38.8

Fluid volumedeficit related tofluid loss

A state in whichanindividual isexperiencingvascular,

cellular, orintracellulardehydration duetoactive orregulatorylosses of bodywater inexcess of needsorreplacementcapability.

After 12 hoursof renderingnursingintervention, thepatient will be

able to replacelost fluidgradually orevidence by:a. drinking milkwithout vomitingb. patients IVFis adequatelyregulated asorderedc. increaseintake of waterfor 2ml per day

Monitor vitalsigns

Monitor input andoutput

Weigh daily andcompare with 24hours fluidbalance

Regulated IVFaccording tospecified flowrate basing onthe doctors order

Provide skin andmouth care

Advise mother orsignificant othersto increased fluidintake of hepatient

Instruct mother to

practice propermilk preparationof food handling

Encouragemother to offerbaby withmashed bananaor apple

Serve as baselinedata

Fluid replacementneeds are based oncorrection of current

deficits and ongoinglosses

Measurementprovides useful datafor comparison

Regulation of fluid iscritical inmaintainingadequate circulatingfluids to recover foramount of water lossthrough vomiting

Skin and mucousmembranes are drywith decreasedelasticity because ofvasoconstriction andreduced intracellularwater

To maintain fluidand electrolytebalance

After 12 hours ofrendering nursingintervention, thepatient replacedfluid loss.


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XII. ONGOING APPRAISA L

The patient shows progressive recovery and is responding well to both medical and nursing interventions.

XIII. DISCHARGE PLAN (HEALTH TEACHINGS)

Medication: Instruct mother of our patient to continue to give the medications and take medications on time.

Treatment: Instruct the mother of our patient to continue to give the medications of her baby

Clinical Follow-up: Instruct mother of the patient to have his follow-up check- up after one week.

Diet: Encourage mother to feed the baby which is rich in iron, vitamin C to avoid any problems to the baby.

Health Teachings:

Advised the mother to clean properly the bottle to use in feeding her baby.

Instruct mother to feed the baby through breastfeeding rather than bottle feeding.

Advised mother to maintain cleanliness of the objects around her baby to avoid ingestion of contaminated objects.

sh pneumonia jhay case

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