CASE PRESENTATION PNEUMONIA

Antonio, Allein T
Guinto, Maria Victoria B. Palattao, Monalyn P.

INTRODUCTION
can develop in infants as young as 24hours old blood-borne infection have a mortality risk of 10 percent low-birth weight

premature/borderline
gestational maternal illness with an infectious organism known to be capable of crossing the placental barrier Structural and immunological defense mechanisms are not fully formed in neonates

OBJECTIVES
After the case presentation, nurses will be able to: Have an overview about the disease. Recall the signs and symptoms of the disease as well as the nursing intervention. Have an in depth knowledge about the disease.

SIGNS AND SYMPTOMS

Yellow-Green secretions Nasal flaring Dyspnea Grunting Tachypnea and tachycardia

PATIENT PROFILE
Patient Profile Name: Baby Boy G. Birthday: June 8, 2013 Address: Sto. Domingo, Angeles City Citizenship: Filipino Religion: Catholic Maternal History Name: Mrs. Girl G. Age: 31 years old Address: Sto. Domingo, Angeles City Citizenship: Filipino Religion: Catholic Status: Single LMP: September 12, 2012 AOG: 35-36 weeks EDC: July 7, 2013

HISTORY
History of Present Illness
6 hours PTA (+) cough (+) nasal congestion (+) yellow green secretions

(+) grunting
(+) skin rashes

Past Illness
3 months prior to the delivery, Mother G had a UTI during her pregnancy to Baby Boy The placenta ruptured 6 hours prior to the delivery. Emergency CS was done.

A N AT O M Y A N D P H Y S I O L O G Y

PATHOPHYSIOLOGY

DRUGS
Ampicillin 125mg/ml given from June 7 - June 13, 2013
Drug classes: Antibiotic Therapeutic actions: Bactericidal action against sensitive organisms; inhibits synthesis of

bacterial cell wall, causing cell death.

INTERVENTIONS: expected. Check IV site carefully for signs of thrombosis or drug reaction. Monitor intravenous sites. Culture infected area before treatment; reculture area if response is not as

DRUGS
Cefotaxime 125mg/ml given from June 7 June 13, 2013
Therapeutic actions: To reduce the development of drug-resistant bacteria and maintain the effectiveness of Cefotaxime sodium and other antibacterial drugs, it should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. INTERVENTIONS: expected. Check IV site carefully for signs of thrombosis or drug reaction. Monitor intravenous sites. Culture infected area before treatment; reculture area if response is not as

DRUGS
Ranitidine 1mg/ml given from June 7 June 11, 2013 Therapeutic actions: Ranitidine is a histamine H2-receptor antagonist that inhibits stomach acid production. It is commonly used in treatment of peptic ulcer

disease (PUD) and gastroesophageal reflux disease (GERD). Ranitidine is also used
alongside fexofenadine and other antihistamines for the treatment of skin conditions such as hives. INTERVENTIONS: Check IV site carefully for signs of thrombosis or drug reaction.

Monitor intravenous sites.

THERAPEUTIC MANAGEMENT

Antibiotic Therapy Antipyretics (if with fever) Intravenous therapy Oxygen therapy

LABORATORY FINDINGS
Blood Culture and Sensitivity Specimen: Blood Result: No growth after 5 days of incubation
Hemoglobin: 161 g/l Hematocrit: 0.47 White Blood Cells: 9.6 Neutrophils: 0.52 Lymphocytes: 0.41 Monocytes: 0.03 Eosinophils: 0.04 Platelet: 388 150 -220 0.33 -0.56 9.4 -34 0.53 -0.62 0.21 -0.34 0 -0.06 0 -0.03 84 -478

COMPLETE BLOOD COUNT

Hemoglobin: 183 g/l Hematocrit: 0.55 White Blood Cells: 13.6 Neutrophils: 0.78 Lymphocytes: 0.16 Monocytes: 0.04 Eosinophils: 0.02 Platelet: 329

150-220 0.33-0.56 9-30 0.67-0.87 0.22-0.37 0-0.05 0-0.02 84-478

BLOOD CHEMISTRY
Sodium: 139.1 Potassium: 5.61 Chloride: 100.2 Calcium: 1.39 134-146 mmol/L 3.9-5.9 97-110 1.7-3.00

NURSING CARE PLAN

Ineffective airway clearance related to increased sputum production in response to respiratory infection Impaired gas exchange related to collection of mucus in airways Ineffective breathing pattern related to production of mucus secretions.

C O N C L U S I O N A N D S U M M A RY
A. Nurse-centered The researchers were able to gain knowledge and deeper understanding of the disease process itself and impart health teachings regarding the clients condition in maintaining an optimum level of functioning. Plus, the researches were able to accomplish the following:

1. 2. 3. 4. 5. 6. 7.

Interpret the current trends and statistics regarding the disease condition; Relate the present state of the client with his personal and pertinent family history; Analyze and interpret the different diagnostic and laboratory procedures, its purpose and its Identify treatment modalities and its importance like drugs, diet and exercise; Formulate nursing care plans based on the prioritized health needs of the client; Gain knowledge on the acquisition and progression of the disease; Impart knowledge on colleagues in providing care for clients with the same illness.

essential relationship to clients disease condition;

B.

Patient-Centered The proponents were able to acquire knowledge on the risk factors that have contributed to the

development of the disease; also, gain understanding of the disease process and demonstrate compliance on the treatment management rendered by the health care team. In relation to the patients condition, the proponents were also able to accomplish these tasks: 1. 2. 3. 4. 5. 6. 7. follow up. Gain knowledge about the disease of patient. Identify different interventions in his condition; Gain knowledge on the importance of compliance to treatment regimen; Demonstrate compliance on the treatment management; Identify different measures to prevent further aggravation of condition; Participate in his plan of care; and Demonstrate independence on self-care and home management upon discharge and during