T

I. Introduction II. Objectives III. Patient's Data IV. Genogram V. Health History

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OF

ONTENTS

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1 3 4 5

i. Present Health Status ------------------------------------------------ii. Past Health History ------------------------------------------------VI. Physical Assessment VII. Definition of Terms VIII. Developmental Task -------------------------------------------------------------------------------------------------------------------------------------------------

6 6 7 12 13 14 16 20 21 23 26 33 35 36

IX. Anatomy and Physiology ------------------------------------------------X. Pathophysiology XI. Diagnostic Exams XII. Laboratory Exams XIII. Drug Study XIV. Nursing Care Plan ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

XV. Discharge Planning Method XVI. Prognosis XVII. Bibliography

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University of the Immaculate Conception

In partial fulfillment of the requirements in NCM 101 RLE 101

A Case Study: Pneumonia

Submitted to: Nena Evangelista, R.N.

Submitted by: Montenegro, Roland Jireh Cabuntalan, Amerah Castillo, Manilyn Masunag, Ronie Cerdina, Jester Pellegas, Chon

August 2009

I. INTRODUCTION

Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or Bronchopneumonia. 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. (www.msn.encarta.com/org) There are many kinds of pneumonia that range in seriousness from mild to life-threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to breathe. Pneumonia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ causing the pneumonia and the judgment of the doctor. Its best to do everything we can to prevent pneumonia, but if one do get sick, recognizing and treating the disease early offers the best chance for a full recovery. (www.wikipedia,.com/org) To know the disease, we have to anticipate its warnings. Symptoms would include fever, chills, cough (non-productive or productive), tachycardia, a crackling sound would be noted and some would show labored breathing. These symptoms are common to almost all upper and lower respiratory infections so it is important that we know the diagnosis. A case with a diagnosis of Pneumonia may catch ones attention, though the disease is just like an ordinary cough and fever, it can lead to death especially when no intervention or care is done. Since the case is a pre-school, an appropriate care has to be done to make the patients recovery faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.

The death rate (or mortality) also depends on the underlying cause of the pneumonia. Pneumonia caused by Mycoplasma, for instance, is associated with little mortality. However, about half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a ventilator will die. In regions of the country without advanced health care systems, pneumonia is even deadlier. Limited access to clinics and hospitals, limited access to x-rays, limited antibiotic choices, and inability to treat underlying conditions can leads to higher rates of death from pneumonia. For these reasons, the majority of deaths in children under five due to pneumococcal disease occur in developing countries. (DOH.gov.ph) In a worldwide aspect of the disease, according to the World Health Organization (WHO) that one in three newborn infant deaths are due to pneumonia and over two million children under five die each year. Mortality from pneumonia generally decreases with age until late adulthood. (www.reuters.com) Knowing this, it can be safe to say that pneumonia is not just a disease but it is a disease. It will be a challenge to the group for the client of J.F.G, 5 years old, a Filipino male who was admitted because of cough and fever and was diagnosed of having pneumonia. This would be a great opportunity for the group to study this case since the concept for this duty is about Oxygenation. This would also present an opportunity in applying the learned skills of giving care to the client and the implications as nurses. We must know our roles efficiently in our chosen field of profession.

2 II. OBJECTIVES

General Objective: At the end of the rotation, the group will be able to come up with a case presentation aimed to determine the subjects health concern, underlying causes for the disease and the intervention including medical and nursing interventions for any complications that may arise during the duration and as partial fulfillment of the requirements in Related Learning Experience, B.S. in Nursing, University of the Immaculate Conception, Philippines. Specific Objectives: 1. To identify a qualified client to be the subject of this case study. 2. Gather the needed data regarding the subject and the family. 3. Assess the health status of the client, including the past and present illnesses that the subject would have. 4. Review and familiarize the anatomy and physiology of the respiratory system regarding the present complication of the patient. 5. Formulate a relevant Nursing Care Plan with the identified problems of the client. 6. Formulate Drug Studies for all the drugs given to the client and be able to explain why such drug is given to the client; and 7. Provide the subject as well as the family with the support systems, health teaching appropriate to the clients needs and the family as well including the formulation of discharge plans.

3 III. PATIENTS DATA

Patients name Age Sex Religion Nationality Address Birth date Birth place Fathers name Mothers name Date of Admission Registry Number: Chief complaint Admitting Diagnosis Attending Physician

: : : : : : : : : : : : : : :

J. J. F. A. 5 years old Male Roman Catholic Filipino San Jose, Digos City October 10, 2003 Digos City J. G. A. A. A. August 2, 2009 / 2:45 p.m 3738 fever and cough CAP Dr. Lutero

4 V. HEALTH HISTORY

Present Health Status The client is a 2-year old female child. Upon admission at Gonzales Maranan Clinic and Hospital, client was complaining of LBM, fever, anorexia and vomiting. Client is having persistent diarrhea and has had fever with 38.3 celcius for temperature when admitted. The client is ambulatory, coherent and v/s results showed an elevated RR of 37 rpm, pulse rate of 84. No intestinal parasite as result for fecalysis on the first day would indicate. Soft diet was prescribed, has a standing order of TSB for fever. Platelet is below normal but WBC count is within range and with a medical diagnosis of Pneumonia.

Past Health Status Cough and fever has been noted to have onset 4 days prior to admission. Client has history of pneumonia and was admitted to the hospital when he was three years old. By then he was prescribed with Montelukast as his medicine. He was also admitted again 4 months after that with the same prescribed drug. Client has suffered asthmatic attack when he was 3 years old and was admitted to the hospital and was given Ventolin for treatment but has no record of any onset after that. Immunizations were completed when he was one year old. Patient has not yet visited a dentist. Latest medicines prescribed are Cefuroxime, Albuterol, Montelukast, and Naproxen.

6 VI. PHYSICAL ASSESSMENT

Patient:

J.J.F.A.

Unit / ward: Age:

NS 1 5 years old Sex: Male Civil status: Child / Single

I. Vital signs: (latest) Temperature: Pulse rate: Respiratory rate: Blood pressure: First Day Temp. Respiratory rate Pulse rate Blood pressure 38.1 28 115 110/80 36.9 celcius (axilla) 115 bpm (radial) 23 rpm 100/70 mmHg Second Day 36.5 24 98 110/70 Third Day 36.9 23 115 100/70 103 bpm (apical)

II. Integument Client has fair complexion and is consistent throughout the body. Abrasions were noted at the right outer hip related to bicycle accident 2 months ago. There were no lesions, rashes and lacerations noted. Mucus membranes are intact, moist and has no lesions present. Nails are cleanedshort with no lesions noted on fingers. Hair is colored black and is evenly distributed on the head scalp. No noted parasite on the hair and patient has good grooming.

7 III. HEENT Head

Head circumference is 52 cm with normocephalic head configuration. No lesions, burns, lacerations and cuts noted. Masses and depressions not noted on head. Eyes Pupils are black and equally rounded and constricts with light accommodation. Peripheral vision and visual acuity were not assessed. Ears Auricle is symmetrical, tenderness were not noted. External surfaces are smooth with discharges noted in small amount. Size of ears are symmetrical and proportional to the head. Ear canal is pinkish in color. Nose Mucosal condition of nose is fine with pinkish color. No noted lesion but nasal flaring is present. No profuse discharges present. Nose is symmetrical with the nasal septum at the midline and intact with no lesions nor masses noted. Mouth Lips were pale in color and dry. Few cracks were noted but no lesions, cut nor ulcerations noted. Gums are intact, pink in color and moist. Pharynx Pharynx located at the midline. Tonsils are non-palpable. No structural abnormalities noted.

8 IV. Neck / Lymph nodes Trachea is at the midline. Range of motion for neck is normal. No reported stiff neck present and was symmetrical. No signs of lesions, lacerations or pigmentation noted. Thyroid was non-

palpable and no enlargements noted. Carotid pulse is palpated with strong bounding pressure. No distended neck vein noted.

V. Pulmonary breath sounds Crackling breath sounds were heard with stethoscope when auscultated. Productive cough is observed.

VI. Breast and Axillary Areas Breast were normal and symmetrical with no lesion or masses noted. It has a lighter color compared to face. Axillas does not have hair and is dry. Axillary lymph nodes were not palpable.

VII. Cardiovascular The PMI (point of maximal impulse) was at the 5th intercostals space, left mid claviclar line with cardiac rhythm as normal. Cardiac rate is 103 at apical pulse and 115 bpm for the radial. Heart sounds are normal with S1 and S2 sounds heard. No murmurs noted.

VIII. Peripheral / Vascular Pulse Temporal Grade 2+ Equal or not equal equal

Carotid Radial

3+ 2+

equal equal

Peripheral pulses are strong and are equal. Varicosities, rashes and edemas were not noted.

IX. Abdomen Skin integrity is normal, color is fair, masses and pulsation were not noted. Bowel sounds were not assessed. Tenderness were not noted.

X. Musculoskeletal / Extremities Range of motions was normal. Shoulders and arms were free from deformities. Nail beds are pink in color with capillary refill of 2 seconds.

XI. Genitalis Urinates 5 times a day with amber yellow and sometimes clear white urine. Appearance of genitals was not assessed.

10

XII. Neuro-assessment Eyes are open spontaneously. Verbal response is Alert and oriented Motor response is withdraws from pain

Refer legend at last page of case study. 5 pts. 5 pts. 4 pts.

Result Patients neuro-assessment is lethargic.

14 pts.

11 VII. DEFINITION OF TERMS There were several words whose definitions are vague that it needs to be defined in order for the reader to understand the case study. The following are words used in this case study whose definition has been provided for easier comprehension on the readers part.

Pneumonia

- inflammation of the one or both lungs usually caused by an infection from a bacteria, virus or from a parasite Tachycardia - increase in heart rate. An elevated heart / cardiac rate from the normal. Palpitations - fast or irregular beating that can be felt by the patient Bronchus - a tube leading from the windpipe to the lungs which provide passage of air Contractions - reduction in size Pleura - a thin transparent membrane that lines the chest wall and doubles back to cover the lungs thus closing the narrow pleural cavity. Dyspnea - difficulty in breathing usually caused by a heart or lung disease

12 VIII. DEVELOPMENTAL TASK

Stages Erik Erikson's Psychosocial Crisis: Goals:

Developmental Task

Evaluation

Patient has partially established what is Learning to do things on their expected at her age.

Initiative vs. Guilt

own Patient is able to Begins to evaluate their own stand, eat, play and behaviours take a bath on their Do things for a purpose own with any assistance from his parents and guardians. Patient is establishing his own behaviours by applying or doing what he wants, saying what he thinks and play what he likes.

Freuds Stages of Development Phallic Stage

Childs genitals are the center for The child seeks pleasure. Activities would include immediate pleasure and fantasy, experimentation with other gratification by means peers. of his mothers attention and comfort. Major conflict: Has identified his Oedipus complex father as his significant person.

13 IX. 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 up to 20 times per minute taking in and disposing of those gases. The first line of defense includes the hair in the nostrils, which serves as a filter for larger particles. The epiglottis is a trap door of sorts, designed to prevent food and other swallowed substances from entering the larynx and then trachea. Sneezing and coughing, both provoked by the presence of irritants within the respiratory system, help to clear such irritants from the respiratory tract. Mucous, produced throughout the respiratory system, also serves to trap dust and infectious organisms. Tiny hair-like projections (cilia) from cells lining the respiratory tract beat constantly, moving debris, trapped by mucus, upwards and out of the respiratory tract. This mechanism of protection is referred to as the mucociliary escalator.

14

Cells lining the respiratory tract produce several types of immune substances which protect against various organisms. Other cells (called macrophages) along the respiratory tract actually ingest and kill invading organisms. 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 two-layered 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.

15

X. PATHOPHYSIOLOGY

Predisposing factors . Patient is 5 years old where pneumonia is more common to these ages

Precipitating factors Lifestyle factors: Exposed to second-hand smoke (uncles and aunties). Does not wash hands unless father is present Only eats meat and does not prefer eating vegetables nor fruits.

Weakened immune system

Aspiration of organism inhabiting the upper airways

Organisms invade the lungs and conducts bacterial growth

Inflammation of the lungs

Fever

Mucus production is increased and plugs the alveoli and is further filled with fluid and debris from WBCs produced to fight the infection

16

The alveoli (air sacs) of the lungs becomes blocked with mucus secretions.

Crackling breath 16 sound If not treated.... The alveoli (air sacs) of the lungs becomes blocked with mucus secretion Less functional are for oxygencarbon dioxide exchange Patient becomes oxygen deprived and retention of Carbon dioxide Patient becomes oxygen deprived and retention of Carbon dioxide If treated ....... Administration of anti-infectives and bronchodilators to inhibit bacterial growth and promotes dilation of the bronchi Infection is stopped and inflammation is resolved.

Mucus secretions are loosened and will be expectorated

Consolidation occurs

Alveoli will be clear from secretions

Atelectasis

Lung activity will return to normal

Respiratory failure

Death 17 Narrative

A picture of a lung with pneumonia with close-up for alveolar sac filler with mucus secretions

The lung is sterile. It is part of the lower respiratory tract. The upper respiratory tract has bacteria for its normal flora. Factors such as being 5 years old increases that risk for pneumonia (WHO) as well as exposure for second hand smoking, also not washing of hands and the imbalanced nutrition increases the risk for the child to have pneumonia. The bacteria in the upper respiratory tract gets aspirated in the lungs where it grows in number and thus results in the inflammation of the lungs. This inflammation causes the body to increase its temperature as it compensate in fighting for the infection. Mucus secretion is then increased. Fluids and debris from WBCs sent to fight the infection also invades the alveolar sac. The alveoli then is plugged and blocked with secretions which causes the crackling breath sound. If it is treated with anti-infectives to inhibit the bacterial growth and bronchodilators to dilate the bronchi and for loosening the secretions, the infection is stopped and inflammation is resolved. This results in secretion of the mucus and lungs will return to normal state.

18

If untreated on the other hand, the child becomes oxygen-deprived and retention of CO2 will result. After that, consolidation will occur which is when the alveoli becomes solid due to the quantities of the fluids, debris and mucus secretions in it. (www.science.jrank.org) When the alveoli becomes solid, this will cause lung collapse (atelectasis) which would later then result to respiratory failure and when it is not treated immediately can cause death.

A comparison between clear alveoli and alveoli with mucus secretions caused by pneumonia

19

XI. DIAGNOSTIC TESTS

A chest x-ray is a routine radiographic method for evaluating the heart, lungs and other organs found on and in the chest area. Since this case is about the lungs, A CXR would be appropriate. It is an important test for pneumonia in unclear situations. CXR can reveal areas of opacity which would represent consolidation.

Patient's radiology result showed heart normal in size, infiltrates on both upper and lower lobes.

20 XII. LABORATORY EXAMS

Several laboratory examination was done to the patient which the results are shown below with their significances on her disease and condition.

Laboratory Examination Hematocrit test Packed-cell volume

Result

Normal Values

Significance

It is used to determine the packedcell volume which would indicate the 42% 37 49 % hemoglobin in the blood. Any increase in Hct will show a decrease in volume plasma. An elevated Hct will signify increase In Hgb. If Hgb is elevated, that means that the body is creating more Hgb to accommodate the low level of oxygen in the body.

Fecalysis

No intestinal parasite

Pneumonia can be caused by several factors, parasitic is one of them. This test is done to check if there are presence of parasites which would cause the pneumonia.

Urinalysis 8. pH

6.0

slightly acidic

Check the hydration status of the patient, if it is highly acidic dehydrated, if it is alkalinic over hydrated.

CBC - Thrombocytes Used to determine the platelet count

281 g / L

and the coagulation time of the patients blood. This test was done to know if there is a need for platelet transfusion.

- WBC 12.4 k/uL

5.0 10.0

When WBC is above normal, this indicates that an infection is present in the body because it will try to fight the foreign organism by creating more WBCs.

- Platelet 244 k/uL

250 - 400

Test is done to indicate if there is the need for platelet transfusion.

22 XV. DISCHARGE PLANNING METHOD

I. Medication Before the patient is discharged, the mother must be encouraged to follow the prescribed medications of her child with the right dose at the right time. This could be also enhanced by explaining to the mother the reason why the drug is given and the possible effects that may occur. It would also minimize the chances of stopping the medication once the mother understands them. Also teach the mother that even if the child's symptoms have been relieved, medications must still be continued according the doctor's instruction, otherwise pneumonia may recur and it will be worse than the previous attack. II. Exercise Encourage the mother to let the child have frequent exercises such as walking, arm raising, to enhance the lung function but inform the mother to avoid places that are prone to pollution, dust and infections such as smoking places to prevent straining the child's lungs. Advise the mother to balance the child's daily physical activities and provide adequate rest periods. Encourage the mother to reposition the child from side to side turning into a favorable and comfortable position to promote good circulation in the body. III. Teaching Inform the mother that the child needs to have adequate rest because it is important to maintain progress toward full recovery. Ask the parents to have the child washed his hands frequently to avoid further infections brought by other microorganisms. Ask the parents not to expose the child in places with too much pollutions. Define the importance of increasing the oral fluid intake of the child in his recovery as well as adequate rest. These are needed by the child to maintain his optimum level of health.

33 IV. Out-patient instructions

Remind the family to have follow-up check-ups with the doctor. Inform for any appointments they may have and request the parents to bring the child to a health care facility as soon as any problems will occur. Even though the patient may feel and look better, his lungs may still be infected and it is important that the physician monitors the child. V. Diet Tell about the importance of eating a well-balanced diet. If asked if multivitamins can be given, refer it to the physician. Remind about the increased fluid requirements and advise foods that are rich in natural vitamins such as fruits.

34 XVI. PROGNOSIS

J. J. F. A. was admitted due to fever and cough. He had a fever with a temperature of 38.1 celcius which was later resolved and lowered to 36.9. The patient is ambulatory, coherent and has an IV tube inserted on his right arm. Current medicines are Cefuroxime = 750 mg, IVTT, Albuterol = 1 neb + 2cc NSS, q4 and Montelukast = 4mg O.D., HS, PO. The vital signs: Temperature is 36.9, pulse rate is 115 bpm, respiratory rate is 23 rpm and Blood pressure is 100/70. Productive cough is still noted but with fewer secretions expectorated. The patient is lethargic according to the neuroassessment, no noted abnormalities in physical assessment regarding the patients present condition. Nasal flaring is reduced, the patient is currently on moderate high back rest position. Thus patient is showing a good prognosis.

35 XVII. BIBLIOGRAPHY Books Carpenito-Moyet, L.J., Handbook of Nursing Diagnoses; (12 ed.), Philadelphia, 2008.

Corbett, J.V., Laboratory Tests and Diagnostic Procedures with Nursing Diagnoses; (7th ed.), San Francisco, California, 2008. Doenges, M.E., et.al., Nurse's Pocket Guide; (11 ed.), California, 2007. Deglin, J.H. & Vallerand, A.H.; Davis' Drug Guide for Nurses; (20 ed.), F.A. Davis Company, Philadelphia, 2009. Elsevier, M., Mosby's Pocket Dictionary of Medicince, Nursing and Health Professions; (5th ed.), Elsevier Incorporated, Singapore, 2006. Johnson, J.Y., Textbook of Medical-surgical nursing; (11 ed.), 2008. Compilations, articles and etc. Rosalejos, I.L., Growth and Development handouts; NCM 101, Davao City, 2009

Internet sites www.scribd.com www.wikipedia.com/org www.nursingcrib.com www.wrongdiagnosis.com www.encarta.msn.com www.medscape.com/nurse/Amoeba www.science.jrank.org/pages/529/ /Diagnosis www.reuters.com/org 41 IV. GENOGRAM

Paternal

Maternal

L. A.

V.A

R.F.

C.F.

J. A (clients father)

A.F. (clients mother)

Legends: Asthma J. J. F. A. (client) J. F. A. (clients brother)

Hypertensive