87760496 case-study-pneumonia

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CASE STUDYON

PNEUMONIA

OBJECTIVES Define what is Pneumonia Trace the Pathophysiology of Pneumonia Enumerate the different signs and symptoms of pneumonia Formulate the different signs and symptoms of pneumonia Formulate and nursing care plans utilizing the nursing process To learn new clinical skills as well as sharpen once current clinical skills

required in the management of the patient of pneumonia To develop our sense of unselfish love and empathy in rendering nursing

care plan to our patient so that we may be able to serve future clients with higher level of holistic understanding as well as individual care

INTRODUCTIONPneumonia 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.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. It’s 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.A case with a diagnosis of Pneumonia may catch one’s 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 toddler, an appropriate care has to be done to make the patient’s recovery faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.

PATIENT’S HISTORYa. Patient’s Profile

Name: R.C.S.B.Age: 1 yr,1 mo.Weight:10 kgsReligion: Roman CatholicMother: C.B.Address: Cebu CityFather: D.BAddress: California, USA

b.  Chief Complaint: Fever

Date of Admission: 1st admissionHospital Number: 060000086199

c. History of Present Illness2 days PTA – (+) cough(+) nasal congestion, watery to greenish(+) nasal dischargeTx: Disudrin ODLoviscol ODFew hrs PTA - (+) fever, Tmax= 39.3 C(+) difficulty of breathing(+) vomiting, 1 episodeTx: ParacetamolSought consultation at ER: Rx=BPN, Salbutamol neb.IE: T = 38.3C, CR= 122’s, RR= 73’s(+) TPCSCE, (-) retractions, clear BS, (-) cyanosis, (-) edema

d. Past Illness(-) asthma(-) allergies

e. Family HistoryPMHx: (-) Asthma

(+) smoke (grandfather) father’s side(+) smoke (father)(+) diabetes (grandmother) father’s side

f. Activities of Daily LivingSleeping mostly at night and during afternoonUsually wakes up early in the morning (5AM) to be milkfed.Eats a lot (hotdogs, chicken, crackers, any food given to her)Active, responsiveBM (1-2 times a day)Urinates in her diaper (more than 4 times a day)Likes to play with those around her

g. Review of SystemsNeuromuscular: weakness of musclesIntegumentary: (-) cyanosisRespiratory: tachypnea; (+) DOB; (+) coarse crackles, (+) wheezes,Digestive: food aversion, vomits ingested milk

GORDON’S FUNCTIONAL PATTERN

Before Hospitalization

During Hospitalization Interpretation

NUTRITION

ELIMINATION

EXERCISE

Patient eat her meals 3 times a day in almost ¼ of her mother’s meal. Commonly she drinks milk and eat rice.

Normally, consumes 4 diapers daily.

She is active and has long period of playing.

She only drink formulated milk 3 times a day in small bottle.

She consumes only 2 diapers.

Her play is limited. She doesn’t move too much.

There are big differences in her nutrition before and during hospitalization, she loss her appetite in almost 75%.Patients who are hospitalized may have an inadequate dietary intake because of the illness that necesitated the hospitalization or the hospital’s food is unfamiliar. The consumption of diapers before and during hospitalization was decreased.Decrease elimination is due to decrease food intake.Before she is active but her move during confinement becomes limited.Decreased activity is because of the intravenous fluid attach to her thus limiting her movement to prevent the intravenous line

REST AND SLEEP

HYGIENE

SUBSTANCE USE

She was able to consume 8 hours of sleeping normally.She had a schedule for naps, twice a day.

Regularly, she takes a bath early morning with the assistance of her mother.

Before admission: patient took

Patient takes a nap 20 to 30 minutes a day and she sleeps 3-4 hours only.

She never takes a bath. Her mother would do sponge bath for her.

Physician orders the ff:Salbutamol (ventolin)Cefuroxime (Zinacef)

to get tangle to her.Before hospitalization, she had a normal normal sleep pattern but during hospitalization he had abnormal sleep pattern.Respiratory condition can disturb an individual sleep. Shortness of breath often makes sleep difficult. Hospitals environment also affects the sleep. Environmental and lack of ventilation can affect sleep.Before hospitalization, the patient takes a bath regularly. But during confinement, she never takes a bath and thus needs the assistance of her mother for sponge bathing.This is due to environmental setiing. The hospital might not have available facilities for bathing.Medications before and during confinement

Disudrin once a dayLoviscol once a day

Paracetamol differed.During confinement, additional or revision of medications happen for it will be based on laboratory findings.

GENOGRAM

No hereditary illness in mother’s side. In her father’s side, her father and grandfather are occasional smokers. Her grandmother is dagnosed as diabetic.

PATIENT’S HEALTH ASSESSMENT

General Appearance Posture – the patient is crying and irritated when in lying position. Skin color – she has whitish skin color. Hygiene – sponge bath done by her mother, no unpleasant odor, wears

clean clothes. Verbal – she wants to be cuddled by her mother and cries when put in

bed. Non-verbal – the patient is rolling in the bed and grasping anything she

saw.

VITAL SIGNS

Normal Findings Actual Findings Interpretation

Temperature

Cardiac Rate

Respiratory Rate

36.5 – 37.5 ° C

120 – 160 bpm

30 – 60 cpm

38.3° C

122 bpm

73 cpm

The patient is having fever. Fever is a sign there is something wrong with the body system and her fever is due to her present illness.

Cardiac rate is within normal range.

Shows increased respiratory rate. Patient is experiecning tachypnea.

ANATOMY AND PHYSIOLOGYThe 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.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.

PATHOPHYSIOLOGY

Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells can’t work properly. Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects 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 B viruses. Among other agents are higher bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis 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 the upper 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 by pleurisy. Physical

examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.

NURSING ACTIONSINDEPENDENT positioning of the patient with head on mid line, with slight flexion

rationale: to provide patent, unobstructed airway , maximum lung excursion auscultating patient’s chest

rationale: to monitor for the presence of abnormal breath sounds provide chest and back clapping with vibration

rationale: chest physiotheraphy facilitates the loosening of secretions considering that the patient is an infant, and has developed a strong

stranger anxietyas manifested by “white coat syndrome” ,  it is a nursing action to play with the patient.rationale: to establish rapport, and gain the patients trust

DEPENDENT administer due medications as ordered by the physician, bronchodilators,

anti pyretics and anti bioticsrationale:  bronchodilators decrease airway resistance, secondary to bronchoconstriction,anti pyretics alleviate fever, antibiotics fight infection

placing patient on TPN  prnrationale:  to compensate for fluid and nutritional losses during vomiting

COLLABORATIVE assist respiratory therapist in performing nebulization of the patient

rationale:  nebulization is a favourable route of administering bronchodilatorsand aid in expectorating secretions, hence patient’s breathing

PHYSICIAN’S ORDER SHEET11/19/06          

Admit patient to CHH under the service of Dr. Vitan secure consent for  admission and management, TPR every shift then record. May have diet for age with strict aspiration precaution, IVF D5 0.3NaCl 500cc to run at 62-63mgtts/min.May give paracetamol 125mg 1supp/rectum if oral paracetamol is not tolerated.

11/20/06         

For urinalysis, IVF to follow D5 0.3 NaCl 500 at SR (62-63mgtt/m Use zinacef brand of cefuroxime 750mg- given ½ vial 375mg every 8hours, nebulize    (Ventolin 1 nebule) every 6 hours, paracetamol drugs prn every 4hours (Temp 37.8).

11/21/06         

Continue cefuroxine and nebulizer every 6 hours. May not reinsert IVF, revise Cefuroxime IV to Cefuroxime 500mg via deep Intramuscular BID,continue  management.

11/22/06          

Continue management and refer.

DISCHARGE PLANNING Take the entire course of any prescribed medications. After a patient’s

temperature returns to normal, medication must be continued according to the doctor’s instructions, otherwise the pneumonia may recur. Relapses can be far more serious than the first attack.

Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse.

Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs.

Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected. It’s important to have the doctor monitor his progress.

Encourage the guardians to wash patient’s hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter one’s body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk.

Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.

Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed.

Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isn’t possible, a person can help protect others by wearing a face mask and always coughing into a tissue.

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