Care Study Pneumonia Sample

8/11/2019 Care Study Pneumonia Sample

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I. INTRODUCTION:

Pneumonia is an inflammation of the lungs usually caused by infectionwith bacteria, viruses, fungi or other organism. Pneumonitis as a more general

term that describes an inflammatory process in the lung tissue that maypredispose a patient to or a place at risk of microbial invasion. Spread by infectedrespiratory droplets thru person-person contact.

Pneumonia is a particular concern for older adults and people withchronic illnesses or impaired immune systems, but it also can strike young,healthy people. Worldwide, it's a leading cause of death in children, many ofthem younger than a year old.

There are more than ! kinds of pneumonia ranging in seriousness frommild to life-threatening. "lthough signs and symptoms vary, many cases ofpneumonia develop suddenly, with chest pain, fever, chills, cough and shortnessof breath. #nfection often follows a cold or the flu, but it also can be associatedwith other illnesses or occur on its own.

II. A. OBJECTIVE OF THE STUDY:

# came up with the following ob$ectives of the study. "t the end%&!()!) idterm coverage, # will be able to*

(. +ind a case study.). "ssess thoroughly to gather the data needed for our documentation.. etermine the patients health history./. #dentify the present illnesses.. Perform an intervention to minimi0e the pain.1. &onduct a 2eath teaching to help promote wellness.

B. SCOPE AND LIMITATION OF THE STUDY:

The study was conducted to determine the heath needs of "ligsao, 3hod.The researcher conducted an interview to prioriti0e the necessity especially weare dealing with the disease that inflicted to the patient. ue to limited time andduty, the student only gathered the data necessary for the case study.

III. GROWTH AND DEVELOPMENT (DEVELOPMENTAL HISTORY):


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A. Sigmu! F"#u! ($%&'$*)

Psychosexual Theory

"n "ustrian neurologist developed the Psychoanalytic 4Psychose5ual6

theory which shares an emphasis on personality development and early

childhood e5periences. 2is theory comprises +ive stages, the Oral, Anal,

Phalli, Latent and Genital stage. The Libido changes its location of

emphasis within the body from one stage to another. Therefore, a particular

body area has a special significance to the client at his age right now. "nd in

the Psychoanalytic view, early e5periences shape ones personality for an

entire lifetime, and psychological problems in adulthood may have their

origins in difficult or traumatic childhood e5perience which we call Fi+,-i

4the immobili0ation or the inability of the personality to proceed to the ne5t

stage because of an5iety6.

B. E"i/0 E"i/01 ($23 4 $')

Psychosocial Theory

"n "merican psychoanalyst, 7rik 7rickson, proposed a related series of

psychosocial stages of personality growth that more strongly emphasi0e

social influences within the family. 2e believes that the greater the task

achievement, the healthier the personality of a person, failure to achieve a

task influences the persons ability to achieve the ne5t task. 7ricksons eight

stages span the entire life course, and, contrary to +reuds stages, each

involves a conflict in the social world with two possible outcomes. 7ricksons

theory thus emphasi0es the interaction of internal psychological growth and

the support of the social world.

C. J#, Pi,g#- ($%'$%2)

Cognitive Developental Theory

Swiss psychologist 8ean Piagets &ognitive evelopment refers to the

manner in which people learn to think reason and use language. 2e defined

four stages of cognitive development within each stage are finer units or

1/5#m,. #t involves a persons intelligence, perceptual ability to process

information. Piaget claimed that children construct new knowledge by

applying their current knowledge structures to new e5periences and modifying

them accordingly. 2is perspective, called constructivis, emphasi0ed the

active role children play in their own mental growth as in9uisitive thinkers.


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S-,g#1 6 Cgi-i7# D#7#89m#-. Piaget identified four stages in cognitivedevelopment*

(. S#1"im-" 1-,g# 4#nfancy6. #n this period 4which has 1 stages6,

intelligence is demonstrated through motor activity without the use of

symbols. :nowledge of the world is limited 4but developing6 because its

based on physical interactions ; e5periences. &hildren ac9uire ob$ect

permanence at about < months of age 4memory6. Physical development

4mobility6 allows the child to begin developing new intellectual abilities.

Some symbolic 4language6 abilities are developed at the end of this stage.

). P"#9#",-i,8 1-,g# 4Toddler and 7arly &hildhood6. #n this period

4which has two substages6, intelligence is demonstrated through the use

of symbols, language use matures, and memory and imagination are

developed, but thinking is done in a nonlogical, nonreversible manner.

7gocentric thinking predominates

. C/"#-# 9#",-i,8 1-,g#47lementary and early adolescence6. #n thisstage 4characteri0ed by < types of conservation* number, length, li9uid,

mass, weight, area, volume6, intelligence is demonstrated through logical

and systematic manipulation of symbols related to concrete ob$ects.

=perational thinking develops 4mental actions that are reversible6.

7gocentric thought diminishes.

/. F"m,8 9#",-i,8 1-,g# 4"dolescence and adulthood6. #n this stage,

intelligence is demonstrated through the logical use of symbols related to

abstract concepts. 7arly in the period there is a return to egocentric

thought. =nly > of high school graduates in industriali0ed countries

obtain formal operations? many people do not think formally during

adulthood.

D. R#"- H,7ig5u"1-

Developental Tas!

2avighurst believes that learning is basic to life and that people continue to

learn throughout life. 2e describes growth and development as occurring during

si5 stages, each associated from a task to be learned. 2avighurst promoted the

evelopmental Task in (@!s which arises at a certain period in the life of an

individual. Successful achievement of the task leads to happiness and to


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succeed in the ne5t task. +ailure to achieve a task leads to sadness of an

individual, disapproval in the society and difficulty with later task.

IV. HEALTH HISTORY:

A. P,-i#-;1 P"6i8#

N,m#: "ligsao, 3hod

D,-# 6 Bi"-5: ecember )A, )!!@

Ag#: ( Bear old

S#+: ale

Ci7i8 S-,-u1: &hild

H#ig5-: (!/ cm

W#ig5-: @.) kg

M-5#": :athleen "ligsao

O//u9,-i: 2ousekeeper

F,-5#": 7mmanuel "ligsao

O//u9,-i: Ta5i river

A!!"#11: Carangay (A, &agayan de =ro &ityR#8igi: 3oman &atholic

A88#"gi#1: %o known allergies

D,-# A!mi--#!: %ovember )), )!!@

Tim# A!mi--#!: !*!! pm

A!mi--ig Di,g1i1: Pneumonia

A--#!ig P5


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+inal iagnosis* Pneumonia

"dmitting Physicians* r. acatol

VI. MEDICAL MANAGEMENT

A. D/-"1 O"!#" R,-i,8#

$$ 33 322

TP3 every /hrs G to monitor patients vitals

iet* iet as tolerated G to supplement necessary nutrients as required for

growth and development

Hab e5ams*

CBC G to rule out any infection and other hematologic disorders. A sharpincrease in the number of white blood cells indicates infection.

URINALYSIS to determine kidney function & extent of infection. Determinethe causative agent so that appropriate antimicrobial agents can be

prescribed.

FECALYSIS to determine astro !ntestinal condition and any parasiticinfection.

CHEST =RAYG to determine the physical condition of the lungs.

#E* #C !!cc to regulate I /cc;hr G

eds*

&larythromycin- "n antibiotic inhibits protein synthesis in susceptible Cacteria,causing cell death.

Salbutamol 4uavent6 G A bronchodilator. "reatment for broncho#spasmassociated with pneumonia.

#;= Sheet G to monitor intake and output, and prevent hyper $hypovolemia.

Weight patient daily pre breakfast Gto determine changes in weight and

helps predict total fluid status.

2ydrotherapy for fever G to help reduce elevated body temperature.

onitor Eital signs to include respiratory status every /hrs and refer

accordingly G %lose monitoring of vital signs and detect every signs ofrespiratory compromise.


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$$ 3* 322

&ontinue eds - compliance of treatment regimen

VII. DIAGNOSTIC > LABORATORY E=AMINATIONS AND SIGNIFICANCE

U"i,8


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%ame* "ligsao,3hod ate*Eital Signs* Pulse*(/ CP 33* /! &P Temp*


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Nu"1ig A11#11m#- IISDC87&T#E7 =C87&T#E7

Cmmui/,-i:

K L hearing loss K L visual changes

K5L denied

&omments* %ot "pplicable

K L glasses K L language

K L contact lens K L hearing aide

3 H

Pupil si0e * )mm

3eaction* Pupils are e9ually round and

reactive to light accommodation.

K L speech difficulties

O+


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by physician..

SDC87&T#E7 =C87&T#E7

S0i I-#g"i-


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#nfectious organism lodges in bronchioles

"lveolar collapse

#nflammation of interstitial tissues of lungs

Eascular engorgement of alveoli with fluid

3CSs and fibrin move into alveoli

+ibrin accumulatesisintegration of 3C&s and fibrin

75udate digested by en0ymes

"ction provides e5cellent culture media to increase spread of organism

&onsolidation

3emoval of pathogenic mucus by coughing,acrophagic action

"ntimicrobial therapy

37S=HDT#=%

Sig1 ,! 1


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"n5iety, stress, and tension,

"bdominal pain

#nflammatory reaction can occur in the alveoli, producing e5udate thatinterferes with the diffusion of =) and &=). White blood cells, mostly neutrophilsalso migrate into the alveoli and fill the normally air-containing space. "reas ofthe lungs are not ade9uately ventilated because of secretions and mucosaledema that cause partial occlusion of the bronchi or alveoli, with a resultantdecrease in alveolar =) tension.

Eenous blood entering the pulmonary circulation passes thru the underventilated area and e5its to the left side of the heart poorly o5ygenated. Themi5ing of o5ygenated and uno5ygenated or poorly o5ygen in the blood eventually

results in arterial hypo5emia.

I=. NURSING MANAGEMENT

A. IDEAL NURSING MANAGEMENT

NURSING DIAGNOSIS: Ai",< C8#,",/# i#66#/-i7#M,< # "#8,-#! -Tracheal bronchial inflammation, edema formation, increased sputum productionPleuritic painecreased energy, fatigue

P11i8< #7i!#/#! FOLLOWUP)

The patients guardian was instructed to have a follow-up check-up a

week after the discharged in order to carefully assess the patients physicalstatus, monitoring for complications and reinforces previous teaching. They mustvisit r. acatol at %orthern indanao edical &enter 4%&6 for consultation.

=II. EVALUATION AND RECOMMENDATION

The patient was able to follow all the medications given and comprehendall the instructions and health teachings given to alleviate the pain and for faster

recovery. #nstructed patient about regular breathing e5ercises for properbreathing, encouraged to have an ade9uate rest and avoid getting fatigue,increased fluid intake for sufficient hydration and loosening of secretions,encouraged to eat nutritious foods such as oranges, mangoes which are rich invitamin & to prevent infections and boost immune system, high caloric diet whichis a good source of energy and high protein diet which helps maintain integrity ofalveolar walls.

=III. BIBLIOGRAPHY

www.healthcentral.com Pathophysiology, pages ()((-()(

edical Surgical Juide by uiambao-Ddan, first edition

edical Surgical by Smelt0er (!thedition, Eol. (
http://www.healthcentral.com/http://www.healthcentral.com/

Care Study Pneumonia Sample

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