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CASE PRESENTATION

Presented by:
Macute, Sarah G. Libetario, Gracechelle Lou Nadela, Grace Ortizuela, Vanessa Rudas, Rose May Sales Gria Amor Silvano, Maries Angel Soya, Neil Vergel Tagapan, Jay Ann Tagbac, Princess Rose Varon, Daryl Mr. Hernane Lubaton RN, MAN Clinical Instructor

Pediatric Community Acquired Pneumonia

General Objectives
Our group aims to formulate a comprehensive analysis That would provide essential knowledge and skills in delivering quality health care to patients diagnosis with PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

SPECIFIC OBJECTIVES

Specific case presentation the Objectives Within 3 hours of our



participantas will be able to: Describe the characteristic of P-CAP. Present the anatomy and physiology of Respiratory system related with our clientscondition Discuss the pathophysiology and clinical manifestation of our clients condition. Relate the significance of laboratory results to clients conditions or the disease process. Discuss comprehensively nursing care plans formulated specifically based on clients condition Discuss the Physical Assessment and

Patients Profile
Patient Name: Patient X Ward/service: Sw-Pedia Date of Birth: December 10, 2011 Age: 2 months old Address: Brgy. Lawis, Sindangan Z.N. Nationality : Filipino Admission Date: February 20, 2012 Admission Time: 9:00 Pm Attending Physician: Dr. R. Montecillo Type of admission : New Referred by: Sindangan District Hospital Admission Diagnosis: Pediatric Community Acquired Pneumonia Admitting Clerk: Gina S. Adriatico

Referral Form
Name of Hospital: Sindangan District Hospital Date: February 20, 2012 Chief Complaint: Cough and fever for week Treatment: Given Cefuroxime, Salbutamol, Paracetamol

Reason of Referral for further management Chief Complaint: Cough and dyspnea History of Present Illness: admitted for Cough for at 1month and 6days for 4days discharged recurrence one week and readmitted

What is Pediatric Community Acquired Pneumonia ?

Inroduction: P C.A.P.
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 often causes problems like difficulty in breathing, fever, chest pains, and a cough. 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. CAP is primarily treated with antibiotic medication. Some forms of CAP can be prevented by vaccination

Symptoms of P-Cap
dyspnea coughing that produces greenish or yellow sputum a high fever that may be accompanied with sweating, chills, and uncontrollable shaking sharp or stabbing chest pain rapid, shallow breathing that is often painful Less common symptoms include: hemoptysis headaches loss of appetite excessive fatigue cyanosis nausea vomiting diarrhea

Symptoms of P-Cap
diarrhea joint pain (arthralgia) muscle aches (myalgia) The manifestations of pneumonia, like those for many conditions, might not be typical in older people. They might instead experience: new or worsening confusion hypothermia falls* Additional symptoms for infants could include: being overly sleepy yellowing of the skin (jaundice) difficulties feeding

Causes:
There are over a hundred microorganisms which can cause CAP. The most common types of microorganisms are different among different groups of people. Newborn infants, children, and adults are at risk for different spectrums of disease causing microorganisms. In addition, adults with chronic illnesses, who live in certain parts of the world, who reside in nursing homes, who have recently been treated with antibiotics, or who are alcoholics are at risk for unique infections

Even when aggressive measures are taken, a definite cause for pneumonia is only identified in half the cases.

Cause Among Infants


Newborn infants can acquire lung infections prior to being born either by

breathing infected amniotic fluid or by blood-borne infection across the placenta. Infants can also inhale (aspirate) fluid from the b birth canal as they are being born. The most important infection in newborns is caused by Streptococcus agalactiae, also known as Group B Streptococcus or GBS. Other bacterial causes in the newborn period include Listeria monocytogenes and tuberculosis. Viruses can also be transferred from mother to child; herpes simplex virus is the most common and life-threatening, but adenovirus, mumps, and enterovirus can also cause disease.

Cause Among Infants


CAP in older infants reflects increased exposure to microorganisms. Common bacterial causes include Streptococcus pneumoniae, Escherichia colii , Klebsiella pneumoniae, Moraxella catarrhalis, andStaphylococcus aureus.

A unique cause of CAP in this group is Chlamydia trachomatis, which is acquired during birth but which does not cause pneumonia until 24 weeks later. Maternally-derived syphilis can be a cause of CAP in this age group.

Common viruses include respiratory syncytialy virus(RSV), metapneumovirus, adenovirus, parainfluenza, influenza, and rhinovirus. RSV in particular is a common source of illness and hospitalization.[4] Fungi and parasites are not typically encountered in otherwise healthy infants.

Some people have an underlying problem which increases their risk of getting an infection
Obstruction When part of the airway (bronchi) leading to the alveoli is obstructed The lung is not able to clear fluid when it accumulates. This can lead to infection of the fluid resulting in CAP. One cause of obstruction, especially in young children, is inhalation of a foreign object such as a marble or toy. The object is lodged in the small airways and pneumonia can form in the trapped areas of lung. Another cause of obstruction is lung cancer, which can grow into the airways block the flow of air.

Risk Factors

Lung disease people with underlying lung disease are more likely to develop CAP. Diseases such as emphysema or habits such as smoking result in more frequent and more severe bouts of CAP. In children, recurrent episodes of CAP may be the first clue to diseases such as cystic fibrosis or pulmonary sequestration

Immune problems People who have immune system problems are more likely to get CAP. People who have AIDS are much more likely to develop CAP. Other immune problems range from severe immune deficiencies of childhood such as Wiskott-Aldrich syndrome to less severe deficiencies such as common variable immunodeficiency

Diagnosis
Individuals with symptoms of CAP require further evaluation.

1.)Physical examination by a health provider --may reveal fever, an increased respiratory rate (tachypnea), low blood pressure (hypotension), a fast heart rate (tachycardia), and/or changes in the amount of oxygen in the blood. Feeling the way the chest expands (palpation) and tapping the chest wall (percussion) to identify dull areas which do not resonate can identify areas of the lung which are stiff and full of fluid (consolidated)

2.)Examination of the lungs with the aid of a stethoscope-- can reveal several things. A lack of normal breath sounds or the presence of crackling sounds (rales) when the lungs are listened to (auscultated) can also indicate consolidation. Increased vibration of the chest when speaking (tactile fremitus) and increased volume of whispered speech during auscultation of the chest can also reveal consolidation

Treatment
Administering an antibiotic which is effective in killing the offending microorganism as well as managing any complications of the infection. Most people will be fully treated after taking oral pills while other people need to be hospitalized for intravenous antibiotics and, possibly, intensive care. In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a macrolide antibiotic such as azithromycin or clarithromycin although a fluoroquinolone such as levofloxacin can substitute. Doxycycline is now the antibiotic of choice in the UK for complete coverage of the atypical bacteria. This is due to increased levels of clostridium difficile seen in hospital patients being linked to the increased use of clarithromycin. Newborns Most newborn infants with CAP are hospitalized and given intravenous ampicillinand gentamicinfor at least ten days. This treats the common bacteriaStreptococcus agalactiae Listeria monocytogenes and Escherichia coli If herpes simplex virus is the cause, intravenous acyclovir is administered for 21 days.

Complications....
Despite appropriate antibiotic therapy, severe complications can result from CAP, including: Sepsis can occur when microorganisms enter the blood stream and the immune system responds. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. Individuals with sepsis require hospitalization in an intensive care unit. They often require medications and intravenous fluids to keep their blood pressure from going too low. Sepsis can cause liver, kidney, and heart damage among other things. Respiratory failure Because CAP affects the lungs, often individuals with CAP have difficulty breathing. If enough of the lung is involved, it may not be possible for a person to breathe enough to live without support. Non-invasive machines such as a bilevel positive airway pressure machine may be used. Otherwise, placement of a breathing tube into the mouth may be necessary and a ventilator may be used to help the person breathe. Pleural effusion and empyema Occasionally, microorganisms from the lung will cause fluid to form in the space surrounding the lung, called the pleural cavity. If the microorganisms themselves are present, the fluid collection is often called an empyema. If pleural fluid is present in a person with CAP, the fluid should be collected with a needle (thoracentesis) and examined. Depending on the result of the examination, complete drainage of the fluid may be necessary, often with a chest tube. If the fluid is not drained, bacteria can continue to cause illness because antibiotics do not penetrate well into the pleural cavity. Abscess Rarely, microorganisms in the lung will form a pocket of fluid and bacteria called an abscess. Abscesses can be seen on an x-ray as a cavity within the lung. Abscesses typically occur in aspiration pneumonia and most often contain a mixture of anaerobic bacteria.

ANATOMY AND PHYSIOLOGY

RESPIRATORY SYSTEM

The integrated system of organs involved in the intake and exchange of oxygen and carbon dioxide between an organism and the environment.

ORGANS OF THE RESPIRATORY SYSTEM


NOSE PHARYNX LARYNX TRACHEA BRONCHI LUNGS ALVEOLI DIAPHRAGM

alveolus

EPIGLOTTIS

RESPIRATORY PHYSIOLOGY
PULMONARY VENTILATION EXTERNAL RESPIRATION RESPIRATORY GAS TRANSPORT INTERNAL RESPIRATION

2 PHASES OF BREATHING
INSPIRATION EXPIRATION

When air is flowing into the lungs.

When air is leaving the lungs.

NONRESPIRATORY AIR MOVEMENTS


COUGH SNEEZE CRYING LAUGHING HICCUPS YAWN

RESPIRATORY SOUNDS
BRONCHIAL SOUNDS are produced by air rushing through the large respiratory passageway(trachea & bronchi). VESICULAR SOUNDS occur as air fills the alveoli, it is soft and resemble a muffled breeze.

Drug Study

Drug name

Indications

Adverse Effect

Interventions

Teaching Points Tell patients to consults prescriber before giving drug to children younger than age 2. Advice patient that drug is only for short-term use and to consult prescriber if giving to children for longer than 5 days.

PARACETAMO L

Mild pain or fever, temporary relief of minor aches and pains caused by common colds and influenza, headache and soar throat.

CNS: headache CV: chest pain, dyspnea myocardial damage GI: hepatic toxicity and failure, jaundice GU: acute renal failure

Do not exceed for recommended dosage. Consult physician if needed for children less than 3 years, if continued fever, severe or recurrent pain occurs (possible serious illness) avoid using multiple preparations containing acetaminophen. Give drug with food if GI upset

Salbutamol

To prevent or treat bronchospas m in patients with reversible obstructive airway disease. To prevent exerciseinduced bronchospas m.

DIAZEPAM

Anxiety, muscle spasm, adjust treatment for seizure disorders, status epilepticus, severe recurrent seizures.

CV: CV collapse, bradycardia GI: constipation, diarrhea with rectal form. Skin: rash Hepatic: jaundice GU: incontinence, urine retention.

Do not administer intra-arterially; may produce arteriospasm, gangrene. Change from IV therapy to oral therapy as soon as possible. Reduced dose of opioid analgesics with IV diazepam; dose should be reduced by at least onethird or eliminated.

FUROSEMIDE

Oral, IV: edema associated with heart failure, cirrhosis, renal disease IV: acute pulmonary edema

CNS: dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss.

Administer with food or milk t prevent GI upset. Reduce dosage if given with other antihypertensi ve, readjust dosage gradually as BP respond. Do not expose to light, which may discolor tablets or solution, do not use discolored drugs or solutions. Measure and record weight to monitor

When possible, take the drug early so increased urination will not disturb sleep. Weight yourself in a regular basis, at the same time and in the same clothing, and record the weight. Report loss or gain of more than 1.5 kg in 1 day, swelling in youre ankles or fingers, unusual bleeding or bruising.

Clarithromycin Pharyngitis or tonsillitis. Acute maxillary sinusitis. Acute worsening of chronic bronchitis. Communityacquired pneumonia. Uncomplicated skin to skin structure infections.

CNS: dizziness, headache, vertigo, fatigue GI: diarrhea , vomiting SKIN: rash

Culture infection site before therapy. Do not cut or crush, and ensure that patient does not chew ER tablets. Monitor patient for anticipated response. Administer without regard to meals; administer with food if GI effects occur.

Take drug with food if GI effects occur. Take the full course of therapy. Do not drink grape fruit juice while taking this drug. Report severe or watery diarrhea, severe nausea or vomiting, rash or itching mouth sores, vaginal sores.

HYDROCORTISONE

Allergic state, hypercalce mia, ulcerative colitis,

CNS: vertigo, headache, paresthesias, insomnia, seizures, psychosis.

Space multiple doses evenly throughout the day. Do not give IM injections to avoid local atrophy. Use minimal doses for minimal duration to minimize adverse effects. Arrange for increased dosage when patient is subject to unusual stress.

Take the drug exactly as prescribed. Do not stop taking this drug without notifying your health care provider; slowly taper dosage to avoid problems. Take with meals or snacks if GI upset occurs. Frequent follow-up visits to your health care provider are needed to monitor drug

PIPERACILIN TAZOBACTAM

RANITIDINE

Treatment for heartburn, acid indigestion, sour stomach. Short-term treatment of active duodenal. Maintenance therapy for duodenal ulcer at reduced dosage

CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo.

Administer oral drug with meals and at bed time. Decrease doses in renal and liver failure. Provide concurrent antacid therapy to relieve pain.

Have regular medical follow-up care to evaluate your response. If you also are using antacid, take it exactly as prescribed, being careful of the times of administration.

Gordon`s Functional Health Pattern

Functional Health Pattern


Health Perception/ Health Management

Before Hospitalization

After Hospitalization

Nursing Diagnosis

According to his Mother, the patient has experienced ingestion of meconium at the time of birth. The patients has a low birth weight of 2500 grams. Client has received complete immunization such as BCG, Vitamin K, Hep. B vaccine, OPV.

Ga sige ra man ni sya

ug lisod ug ginhawa, mao pag-abot diri ospital mag oxygen as verbalized by his Father. The 2month old patient was having an oxygen and an IV IMB ingested at right metacarpal with 640 CC left. Seems irritable, unable to breathe completely. Occasionally cries. And has a shrill cry.

Ineffective Breathing Pattern

Functional Before Health Pattern Hospitalization Nutritional Metabollic Pattern


Patut-yon kada mata ani niya as verbalized by his Mother. The client has experienced initiation of breastfeeding after birth

After Hospitalization

Nursing Diagnosis Effective Breastfeeding

The 2month old client has an order of NPO, due to respiratory problems during the first admission with an aid of pacifier. After the second admission the client has slight recovery and can be breastfeed completely. Nah day! Perte kayo pod ni sya mag totoy, kusog jud pod ni sya mag-tutoy as verbalized by his mother. During my shift the patient is able to suck completely.

Functional Health Pattern


Metabollic Elimination Pattern

Before Hospitalization

After Hospitalization

Nursing Diagnosis Risk for Constipation

Activity and Exercise Pattern

Has passed meconium during at the time of birth and unfortunately ingested his own meconium. A diaper has been placed every now and then. Change every 4 hours whenever the patient defecates. Has a usual defecating patterns of thrice a week Having a voiding pattern of 5 times a day Before Hospitalization the patient is rarely activel. Sleeps too much besides her Mother and Father. Infant Perceived Ability: Feeding : 0 Bathing: 0 Toileting: 0 Sleeping: 0 General Mobility: 2

During my shift, the patient is in diaper. The patient has not defecated yet. Has urinated in the diaper.

During my shift the patient is in lethargic state, is always sleeping. With an IVF IMB hooked at the right metacarpal 640 CC left.

Impaired Physical Mobility

PATHOPHYSIOLOGY

o Most of the infectious agents that cause CAP are aspirated into the lung. This is especially the case for vulnerable individuals with an impaired immune system.

CAP that results from aspiration of oropharyngeal contents is the only form of CAP with multiple pathogens.

An infection usually occurs when one component of the defence mechanism is not functioning properly. This results in microbial colonisation of the upper respiratory tract. :

Microbes can enter and invade the lower respiratory tract by many methods, and 6 mechanisms have been identified in the pathogenesis of pneumonia in immunocompetent adults:

Inhalation of infectious particles

Aspiration of oropharyngeal or gastric contents

Haematogenous deposition of bacteria in the lung

Invasion from infection in contiguous structures

Direct inoculation

Reactivation.

Physical Assessment

Body Parts

Normal Findings

Actual Findings

Significance

Head

Normocephalic, No abnormal mass Normal Hair color Scalp is clean and dry Sparse dandruff may be visible Hair is smooth and firm

Normocephalic No abnormal mass Normal Hair color Scalp is clean but oily No dandruff Hair is smooth and firm

Normal

Hair and scalp

Normal

Eyes

Symmetric to the face Both eyes coordinated with parallel alignment

Eyes Dilated, wide open

External eye structure eyebrows

Hair evenly distributed, skin intact

Hair evenly distributed, skin intact

normal

Lacrimal Gland

No edema or tearing

No edema or tearing

normal

Pupils (color,shape,symm etry Size)

Black in color equal Black in color, in size, equal in size, Normally 3-7 mm in 4mm in diameter diameter, round smooth border, iris flat and round Symmetrically aligned to the face, firm and not tender, w/ no discharged noted Symmetric and straight, no discharges or flaring

Normal

Ears

Positioned Normal symmetrically to the face, no notable ear discharge, clean and dry Flared nose No nasal discharges noted Evidence of impaired gas exchange

Nose

Mouth Lips

Tongue

Uniform pink in color, Soft, moist and smooth Tongue at midline without lesion

Uniform, dark color Not normal due to dry dehydration

Dry and free of lesions

Normal

Teeth

Complete, white shiny tooth enamel, free of debris

No teeth

Patient is 2 month old

Neck

Coordinated smooth movement with no discomfort, No masses tenderness Pinkish in color

Coordinated movement with no discomfort, No masses, tenderness Pallor

Normal

Upper extremities

Not normal is a manifestation of inadequate circulating blood or hemoglobin

Heart

Normal heart rate 60-100bpm No lesion, can move freely, capillary refill: 1-2seconds

Cardiac rate of 80

Normal

Lower extremities skin

nails

Chest and Lungs

Smooth, highly vascular and intact epidermis Capillary refill of 1-2 seconds Symmetric chest expansion, quiet, rhythmic and effortless respiration Quiet rhythmic

No edema, no Normal deformities can move freely, capillary refill: 2 seconds Pink, smooth texture, Normal convex curvature Capillary refill: 2 seconds Forceful expansion of lungs Signs of dyspnea

Unbilicus

Normally firm, no Herniated Umbilicus contracture, no swelling, at the center

Not normal

Laboratory Results

Fecalysis
Date: February 21, 2012- Macroscopic Exam

Color Consistency

Yellow Soft

Hemochrome
Date: February 21, 2012

Sample Hemoglobin Hematocrit PLatelet

Result 11.1 L 32.1L 477 k UL

Normal range 11.5- 14.5 37.0- 45.0 150- 400

Significance Not normal Not normal Not normal

Urinalysis
February 23, 2012 Physical and Chemical Properties Color: Straw Transparency: Clear Specify Gravity: 1.005 Glucose: Negative Protein: Trace

Fecalysis
February 23, 2012 Macroscopic Exam Color: Greenish Consistency: soft

Hematology
Test Hgb Hct WCC Lymphocyte Result 7.7 23.0 10,650 33 Normal Range M:14-17 M:42-52 M:5-10x10(3) mm3 M: 25-30 Significance Not normal Not normal Not normal Not normal

Flagging
February 21, 2012 Test Na Flagging HI Result 148 mmol L Normal Range 137-145

HI

5.3 mmol L

3.5- 5.1

Nursing Care Plan


Assessment Diagnosis
Ineffective airway clearance related to retained mucus secretion

Planning
At the end of 1day of nursing care, the client will : Spontaneousl y display a patency of airway Clear secretions can be suction *absence of cyanosis The parents will able to

Intervention
ID : moderate high back rest position change Frequent change of clothing Provide an allergen-free environment Give comfort measure to the baby Keep an eye of the baby

Evaluation
At the end of 2 days of nursing intervention , patient maintained an airway patency and parents able to response the education given.

Subjective:
`` Sige man og gahangos akong anak sir, murag maglisod bitaw ug ginhawa `` as verbalized by the parents. Objective : RR : 72 cpm HR : 172 bpm Cough Awake and irritable Shrill cry

nasal flaring Cyanosis Restlessness, wide-eye Use of accesory muscle to facilitate inspiration
PE : Inspection : retraction of the intercostal spaces , ribs can be visible Auscultation : crackles sound over the chest Percussion : there is a dull sound Oxygen inhalation IVF

Verbalize understandin g of causes and therapeutic mngt. Parents can identify potential complication and how to initiate appropriate preventive or corrective action

health teaching about the baby D: Nebulization Suction secretion Oxygen inhalation CPT Pharmacolog ic therapy NPO IVF IMB 500cc

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Subjective data:
``init man akong anak maam`` as verbalized by the mother.

Hyperthermia related to infection

Objective data:
-Vital signs T 38.2 HR 172 cpm PR 72 bpm -

At the end of 3 hours rendering nursing care , the clients temperature will reduce to normal range. After the shift, the parent will identify underlying cause/ contributing factors and importance of treatment, as

ID: identify underlying cause Monitor core temperature Assess neurological response, noting level of consciousness and orientation, reaction to stimuli, reaction of pupils, presence of posturing or seizures.

After 3 hours of rendering nursing care , the clients temperature reduce to 37.3 degree celcius. done parent teaching when seizures occurs to the patient Instructed parents to perform TSB and immediately report any abnormalities.

Well as signs and symptoms requiring further evaluation and intervention. The client will be free of seizures activity

monitor VS and obtain To the baseline. health care Promotes surface cooling providers. by means of cool TSB or immersion Promote client safety Dependent : Administer antipyretic as ordered Administer medications antiseizures as ordered Admister medication , as indicated , such as antibiotics.(for infection) Dantrolene (for malignant hyperthermia) , as ordered.

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

EVALUATION

Subjective:
mahadlok ko nga matok-an siya inig magpatotoy naku as verbalized by the mother

Risk for Aspiration

At the end of 8 hours duty , of rendering holistic nursing care , the client/patient will be able to :

Objective :
Depress cough VS : T: 38.2 HR: 172 bpm RR : 72 cpm

Understand the clients condition and apply necessary techniques to prevent and/ or correct aspiration

After 8 hours of ID : giving Encourage appropriate baby to burp nursing care Appropriate action , the feeding postion client response Health to teaching interventions, teaching and actions D: performed bu Chest X-ray the S.O

DISCHARGE PLAN
M-edication : Advise parents to give the medicine to the patient as prescribed by the Physician. The following are the medication prescribed: FERLIN DROPS 0.5 ML to prevent iron deficiency anemia.

E- xercise :

Encourage parents to have their baby perform a dance and walkin place reflex by holding the baby to promote chest muscle expansion.

T-reatment : Medications should be


taken exactly as prescribed by a physician. Do not quit taking it unless told to do so by a doctor.

H-ealth Teaching :
Encourage breastfeeding.

Positions for effective breastfeeding


THE CRADLE HOLD :

The Cross-Over Hold :

The Clutch or Football Hold

Reclining Position

2. Proper hygiene must be maintained. A . wash hands before touching the baby B. sterilize bottles (aseptic/terminal method), pacifiers and other things used by the baby. C.Be aware that kissing can spread infection. D. Before initiating breastfeeding , encourage mother to wipe her nipple . .

3. encourage mother to have her baby immunized .

O-out patient department :


Comply to the scheduled follow-up check up.

D-iet : breastmilk is best for babies.