I. Introduction Pneumonia is an illness of the lungs and respiratory system in which the alveoli (microscopic air-filled sacs of the lung responsible for absorbing oxygen from the atmosphere) become inflamed and flooded with fluid. Pneumonia can result from a variety of causes, including infection with bacteria, viruses, fungi, or parasites. Pneumonia may also occur from chemical or physical injury to the lungs. One can get pneumonia in daily life, such as at school or work. This is called community-based pneumonia. One can also get it in a hospital or nursing home. This is called hospital-based pneumonia. It may be more severe because one is already are ill. You may cough, run a fever, and have hard time breathing. For most people, pneumonia can be treated at home. It often clears up in 2 to 3 weeks. But older adults, babies, and people with other diseases can become very ill. It is one of the leading causes of death among the elderly and people who are chronically and terminally ill. People with infectious pneumonia often have a cough that produces greenish or yellow sputum and a high fever that may be accompanied by shaking chills. Shortness of breath is also common, as is pleuritic chest pain, a sharp or stabbing pain, either felt or worse during deep breaths or coughs. People with pneumonia may cough up blood, experience headaches, or develop sweaty and clammy skin. Other symptoms may include loss of appetite, fatigue, blueness of the skin, nausea, vomiting, mood
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
I. Introduction
Pneumonia is an illness of the lungs and respiratory system in which the
alveoli (microscopic air-filled sacs of the lung responsible for absorbing
oxygen from the atmosphere) become inflamed and flooded with fluid.
Pneumonia can result from a variety of causes, including infection with
bacteria, viruses, fungi, or parasites. Pneumonia may also occur from
chemical or physical injury to the lungs.
One can get pneumonia in daily life, such as at school or work. This is
called community-based pneumonia. One can also get it in a hospital or
nursing home. This is called hospital-based pneumonia. It may be more
severe because one is already are ill. You may cough, run a fever, and have
hard time breathing. For most people, pneumonia can be treated at home. It
often clears up in 2 to 3 weeks. But older adults, babies, and people with
other diseases can become very ill. It is one of the leading causes of death
among the elderly and people who are chronically and terminally ill.
People with infectious pneumonia often have a cough that produces
greenish or yellow sputum and a high fever that may be accompanied by
shaking chills. Shortness of breath is also common, as is pleuritic chest pain,
a sharp or stabbing pain, either felt or worse during deep breaths or coughs.
People with pneumonia may cough up blood, experience headaches, or
develop sweaty and clammy skin. Other symptoms may include loss of
appetite, fatigue, blueness of the skin, nausea, vomiting, mood swings, and
joint pains or muscle aches. Less common forms of pneumonia can cause
other symptoms. For instance, pneumonia caused by Legionella may cause
abdominal pain and diarrhea, while pneumonia caused by tuberculosis or
Pneumocystis may cause only weight loss and night sweats. In elderly people
the manifestations of pneumonia may not be typical. Instead, they may
develop new or worsening confusion or may experience unsteadiness leading
to falls. Infants with pneumonia may have many of the symptoms above, but
in many cases, they are simply sleepy or have decreased appetite.
According to the Unicef/WHO report, India, with 44 million pneumonia
cases, China with 18 million cases and Nigeria and Pakistan with seven
million cases top the chart.
The disease causes acute infections in any part of the respiratory system
— from the middle ear to the nose to the lungs. Acute respiratory infection is
also a serious problem in India, accounting for 14.3 per cent deaths during
infancy and 15.9 per cent deaths among children aged between 1-5 years in
India, claim studies undertaken by experts.
It is estimated that more than 150 million cases of pneumonia occur
every year among children under five in developing countries, accounting for
more than 95 per cent of all new cases worldwide. Between 11 million and 20
million children with pneumonia will require hospitalization, and more than
two million will die from the disease, the report warns.
According to Dr. Josefina Cadorna-Carlos, associate professor at the
University of the East Ramon Magsaysay Memorial Medical Center, that the
characteristics of Streptococcus pneumoniae and atypical bacterial
pneumonia in children may be difficult to distinguish. The question now is,
“how is one going to suspect atypical pneumonia?” "When there is delay in
resolution of symptoms, [presence of] diffuse bilateral infiltrates, and if it's
refractory to standard treatment," Carlos pointed out.
In the 2004 Philippine Consensus Guidelines in the Evaluation and
Management of Pediatric Community Acquired Pneumonia, amoxycillin
remains the drug of choice against pneumonia. Macrolides, quinolones,
and tetracyclines are the drugs useful against atypical pathogens.
Clarithromycin answers the need for a better macrolide. It has 50-percent
bioavailability with significantly fewer GI adverse effects, and has increased
activity against H. influenzae due to the active metabolite 14-
hydroxyclarithromycin. Compared with time-dependent erythromycin,
clarithromycin is concentration dependent, which provides for better
compliance at twice-daily dosing. In vitro, potency is marked by lower
minimum-inhibitory-concentration (MIC) values at 50 and 90 percent against
M. pneumoniae and C. pneumoniae. Against common respiratory tract
infections, clinical success is achieved with 93- to 97-percent alleviation of
symptoms (Germany, Italy, 1994).
The primary role of nurses is to provide care to all their patients. They
play an important role for patient’s survival. As aspiring nurses, it is best that
we are now practicing the core of nursing, which is caring.
The case of Clark Kent, an eleven-month old baby boy, is common
among infants these days. It is an acute pneumonia with spells of cough and
fever. It is also one of the leading causes of morbidity. The researchers will
expand their knowledge regarding the pathophysiology of the disease,
develop their critical thinking about the essential interventions when dealing
with pneumonia, and most importantly, be able to appreciate the fact that
they are already handling real patients in which individuality of each persons
is highly regarded.
The researchers are fortunate to have the chance to apply their skills
and knowledge while delivering or rendering essential health care to the
patient. Given the opportunity to handle a client with the same condition in
the future, the researchers can take care of the client with competence and
can provide the best possible care in attaining the optimum health for their
client.
OBJECTIVES
A. Student-Nurse Centered
After the completion of the case study, the researchers will be able
to:
General Objective:
Gain knowledge and deeper understanding of the disease
process itself, be able to provide the best nursing care for the client,
and impart health teachings regarding the client’s condition in
maintaining an optimum level of functioning.
Specific Objectives:
1. Interpret the current trends and statistics regarding the
disease condition;
2. Relate the present state of the client with his personal and
pertinent family history;
3. Analyze and interpret the different diagnostic and laboratory
procedures, its purpose and its essential relationship to
client’s disease condition;
4. Identify treatment modalities and its importance like drugs,
diet and exercise;
5. Identify surgical management and its purpose that is
applicable with the disease condition;
6. Formulate nursing care plans based on the prioritized health
needs of the client;
7. Gain knowledge on the acquisition and progression of the
disease;
8. Impart knowledge on fellow students in providing care for
clients with the same illness.
B. Patient-Centered
After the completion of the study, the patient will be able to:
General Objective:
Acquire knowledge on the risk factors that have contributed to
the development of the disease, gain understanding of the disease
process and demonstrate compliance on the treatment management
rendered by the health care team.
Specific Objectives:
1. Gain knowledge about the disease;
2. Identify different interventions in his condition;
3. Gain knowledge on the importance of compliance to treatment
regimen;
4. Demonstrate compliance on the treatment management;
5. Identify different measures to prevent further aggravation of
condition;
6. Participate in his plan of care; and
7. Demonstrate independence on self-care and home
management upon discharge and during follow-up home visits.
II. Nursing Assessment
A. Personal History
A.1.Demographic Data
Clark Kent is an eleven month old baby boy and he is the
youngest in his family. He was born as a Filipino citizen on July 7,2006
at their home somewhere in Magalang, Pampanga. He was admitted at
a hospital in Magalang, Pampanga last June 23, 2007 with a chief
complaint of cough, cyanosis, and fever. His admitting diagnosis is
Pneumonia with Anemia.
A.2. Socio-economic, Environmental, and Cultural Factors
Baby Clark Kent in an extended type of family specifically
composed of his father, mother, one sibling; also includes his
grandfather, grandmother, aunties, uncles, and cousins on the
maternal side. With regards to their operating cost only a total amount
of P 2,000-P3,000 is spent to suffice for their daily needs for a month.
His father, who is said to be a construction worker, earns about P7,000
per month. The members of the family pools together the money that
they can get to supply for the monthly needs. The family is affiliated to
“Iglesia Ni Cristo.” With regards to culture, they believe that whenever
a child is sick, he should not take a bath during Fridays and Tuesdays,
plus, he shouldn’t cut his nails. They also embrace the healing powers
of “manghihilot.
With regards to their resettlement area, the place is said to be
clean although it is not yet developed. Also, the houses aren’t evenly
spaced. They have poor mode of transportation, and they are remote
from the market and church.
Baby Clark Kent’s activities of daily living includes the following:
• 6am – Baby Raven wakes up
• 7am – 8am – Breakfast
• 8am – 10am – Plays with his older sister
• 10am – 11am – Takes a bath
• 11:30am – Lunch
• 12pm - 2pm – Siesta for Baby Raven
• 2pm – 4:30pm – Plays again
• 4:30pm – 5pm – Snack Time
• 5:30pm – Another bath session
• 6pm – 6:30pm – Dinner
• 7pm - Sleep
B. Maternal and Child Health History
Obstetric History
According to Martha, a 20 year old mother, she had an obstetric
history of 2 gravidarum (number of pregnancy), 2 parity (number of
pregnancy in which the fetus reach the age of viability whether or not the
baby was born alive or not), 1 term (number of infants born at 37 weeks or
after), 1 preterm ( number of infants born before 37 weeks), 0 for abortion,
(number of spontaneous or induced abortion), and 2 for living children.
Prenatal History
According to Martha, she had her prenatal check up a month. In every
pregnancy that she had, she takes ferrous sulfate capsule for her daily
supplement that is taken once a day.
Antepartal History
She had chicken pox during her first pregnancy. While on her second pregnancy,
she had fever on the first trimester, and she had cough and cold on the second trimester
for a month. She described that she had really difficulty in laboring the second baby.
Erik Eriksson
(Theory of Trust
and Mistrust)
-1 year old
An infant depends
almost exclusively
on parents,
specially the
mother, for food,
sustenance and
comfort. Parents
are the primary
representatives of
society to the
child. If the
parents would be
discharging their
infant-related
duties with
warmth, regularity
and affection, the
infant will develop
the feeling of trust
towards the world,
a trust that
someone will
always be around
to care for one’s
needs.
Alternatively, a
sense of mistrust
develops if the
Normal
The infant would
be able to
develop the sense
of trust with his
parents/ world
because they are
able to support
the infants’ needs
in his life.
Abnormal
The infant was
not able to
develop his trust
with his parents/
world because
they are not able
to support the
infants’ needs in
his life.
Client’s
response
In relation to
Baby Clark
Kent’s case, the
researchers
discovered that
he could
manifest a
feeling of trust
towards the
world. This is
evident in a way
that his parents
are providing
him his basic
needs such as
love and safety
as well as
physiologic
needs (food,
proper home,
etc.)
parents fail to
provide for the
infant’s needs in
their roles as
caregivers.
Erik Eriksson
(Theory of shame
and doubt)
-2 to 3 years old
The infant gains
control over
eliminative
functions and
motor abilities. At
this point, children
show a strong
push for exploring
their world and
assessing their
will. Parents who
are encouraging
and patient allow
the child to
develop a sense of
autonomy, but
parents who are
highly restrictive
and impatient
promote a sense
of shame and
doubt.
Normal
The infant has
developed a
sense of
autonomy and
gains control over
eliminative
functions and
motor abilities.
Abnormal
The infant hasn’t
developed a
sense of
autonomy and
gains control over
eliminative
functions and
motor abilities
because of some
restrictions being
given to him.
Client’s
response
In the case of
Baby Clark Kent,
it is possible that
he will develop
shame and
doubt because
of the way his
parents restrict
him in being
playful. This was
seen during the
nurse-patient
interaction while
carrying out the
interview.
Jean Piaget
(Sensorimotor
Stage)
-birth to 2 years
old
The infant
constructs an
understanding of
the world by
coordinating
sensory
experiences such
as seeing and
hearing with
physical and
motoric actions,
hence, the term
sensorimotor. At
the beginning of
the stage, the
newborn has little
more than
reflexive patterns
with which to
work; at the end of
the stage, the two
year old has
complex
sensorimotor
patterns and is
beginning to
Normal
The infant is able
to constructs an
understanding of
the world by
coordinating
sensory
experiences such
as seeing and
hearing with
physical and
motoric actions.
Abnormal
The infant is not
able to constructs
an understanding
of the world by
coordinating
sensory
experiences such
as seeing and
hearing with
physical and
motoric actions.
Client’s
response
In Baby Clark
Kent’s case, he
can be depicted
as a very
responsive
infant. Unlike
other tots, he
can be
considered as an
extrovert; this is
because of the
way he deals
with new faces.
operate with
primitive symbols.
Sigmund Freud
(Psychosexual
theory)
-birth to 1 year old
This theory
thought that our
adult personality
was determined
by the way
conflicts between
these early
sources of
pleasure (the
mouth, the anus
and the genitals),
and the demands
of the reality were
resolved when
these conflicts are
not resolved, the
individual may
become fixated at
a particular stage
of development.
During birth to the
first year of life,
the activities that
bring the greatest
amount of
Normal
During the
infants’
development, he
should be able to
develop the said
activities in his
life. He should be
able to complete
the said stage
with the help of
the people
surrounding him.
Abnormal
The infant has not
completed the
said stages of
development in
his life maybe
because of lack of
support from his
family.
Client’s
response
With regards to
Baby Clark
Kent’s case, he
was able to
demonstrate the
first stage which
is the oral face
(sucking, biting
and chewing).
pleasure center on
the mouth; in the
oral stage of
development,
chewing, sucking
and biting are the
chief pleasure
sources. This
action reduce the
infants tension
while the anal
stage which is
from 1 to 3 years
of life of the
infant, it is in this
stage that the
infant is being
toilet train by his
parents.
According to Baby Clark Kent’s mother, she had a history of parasitism when she was young and she has
only one brother who has asthma, her father had a history of appendectomy and her mother has
hypertension and cardiomegaly. Her younger sister was hospitalized due to cough and colds and was born
premature while on Baby Clark Kent’s paternal side, his grandfather has renal failure and his grandmother
suffers from diabetes mellitus and asthma that led to his father having asthma. One of Baby Clark Kent’s
cousin on the paternal side suffers with asthma too.
Jonathan28 years old
-Asthma
GrandfatherPreston Burke50 years old-Renal Failure
GrandmotherCristina Yang49 years old
-Diabetes Mellitus-Asthma
Father’s Side
Lionel27 years old
-history of smoking and alcoholism
Clark Kent11 months
-Fever-Cough &
ColdPneumoniaPre-mature (3 weeks)
Lois3 years
old-Asthma
Lana8 years old
Lex6 years
old-Asthma
Alex21 years
old-Asthma
GrandfatherDerek Shepherd
42 years old-history of appendectomy
GrandmotherMeredith Grey40 years old
-Hypertension-Cardiomagaly
Mother’s Side
Clark Kent
11 months-Fever
-Cough & Cold
PneumoniaPre-mature (3 weeks)
George10 years old
-Asthma
Martha20 years old-history of parasitism
Elizabeth16 years old
Caley3 months
-hospitalized due to cough &
colds-premature (3 weeks)
Lois3 years old
-Asthma
E. History of Past Illness
It was reported that after Baby Clark Kent was born, he had
experienced difficulty of breathing which was manifested by cyanosis. Other
than that, he also experienced hyperthermia, cough, colds, asthma, and
lastly, jaundice.
F. History of Present Illness
Prior to admission to the hospital in Magalang last June 23,2007, Baby
Clark Kent had experienced fever and cough.
G. Physical Examination
☼ Upon Admission (lifted from the chart): June 23, 2007
Vital Signs:
T - 40°C
☼ First Nurse-Patient Interaction: June 26, 2007
Vital Signs:
T – 38.1°C,
P - 150,
R - 23
Physical Assessment:
SKIN: no odor; pale; unblemished; goes back when pinched; with
temperature within normal limit.
HAIR: thick; black in color; short; evenly distributed; no dandruff or lice
upon inspection
HEAD: symmetrical & normocephalic; no mass noted upon palpation
expands the thoracic cavity. The increased volume of the thoracic cavity
causes air to rush into the lungs. The nervous stimulation is brief, and when it
ceases, the diaphragm and rib muscles relax and exhalation occurs. Under
normal conditions, the respiratory center emits signals 12 to 20 times a
minute, causing a person to take 12 to 20 breaths a minute. Newborns
breathe at a faster rate, about 30 to 50 breaths a minute.
The diaphragm works by creating a negative pressure area. When
pulling downward it makes the thoracic cavity have a substantially lower
internal pressure than what exists out side the cavity. Air rushes into the
respisrtory system.
When the diaphragm relaxes it pushes upward causing the pressure in
the thoracic cavity to become greater than exists outside the cavity. Air is
forced out of the respiartory system.
The rhythm set by the respiratory center can be altered by conscious
control. The breathing pattern changes when a person sings or whistles, for
example. A person also can alter the breathing pattern by holding the breath.
The cerebral cortex, the part of the brain involved in thinking, can send
signals to the diaphragm and rib muscles that temporarily override the
signals from the respiratory center. The ability to hold one’s breath has
survival value. If a person encounters noxious fumes, for example, it is
possible to avoid inhaling the fumes.
A person cannot hold the breath indefinitely, however. If exhalation
does not occur, carbon dioxide accumulates in the blood, which, in turn,
causes the blood to become more acidic. Increased acidity interferes with the
action of enzymes, the specialized proteins that participate in virtually all
biochemical reaction in the body. To prevent the blood from becoming too
acidic, the blood is monitored by special receptors called chemoreceptors,
located in the brainstem and in the blood vessels of the neck. If acid builds up
in the blood, the chemoreceptors send nervous signals to the respiratory
center, which overrides the signals from the cerebral cortex and causes a
person to exhale and then resume breathing. These exhalations expel the
carbon dioxide and bring the blood acid level back to normal.
A person can exert some degree of control over the amount of air
inhaled, with some limitations. To prevent the lungs from bursting from
overinflation, specialized cells in the lungs called stretch receptors measure
the volume of air in the lungs. When the volume reaches an unsafe threshold,
the stretch receptors send signals to the respiratory center, which shuts
down the muscles of inhalation and halts the intake of air.
In pulmonary circulation, deoxygenated blood returning from the
organs and tissues of the body travels from the right atrium of the heart to
the right ventricle. From there it is pushed through the pulmonary artery to
the lung. In the lung, the pulmonary artery divides, forming the pulmonary
capillary region of the lung. At this site, microscopic vessels pass adjacent to
the alveoli, or air sacs of the lung, and gases are exchanged across a thin
membrane: oxygen crosses the membrane into the blood while carbon
dioxide leaves the blood through this same membrane. Newly oxygenated
blood then flows into the pulmonary veins, where it is collected by the left
atrium of the heart, a chamber that serves as collecting pool for the left
ventricle. The contraction of the left ventricle sends blood into the aorta,
completing the circulatory loop. On average, a single blood cell takes roughly
30 seconds to complete a full circuit through both the pulmonary and
systemic circulation.
A Diagram showing both the process of Pulmonary Circulationand Systemic Circulation
Gas exchange or respiration takes place at a respiratory surface - a
boundary between the external environment and the interior of the body. For
unicellular organisms the respiratory surface is simply the cell membrane,
but for large organisms it usually is carried out in respiratory systems.
In humans and other mammals, respiratory gas exchange or
ventilation is carried out by mechanisms of the lungs. The actual exchange of
gases occurs in the alveoli.
Convection occurs over the majority of the transport pathway.
Diffusion occurs only over very short distances. The primary force applied in
the respiratory tract is supplied by atmospheric pressure. Total atmospheric
pressure at sea level is 760 mm Hg, with oxygen (O2) providing a partial
pressure (pO2) of 160 mm Hg, 21% by volume, at the entrance of the nares,
and an estimated pO2 of 100 mm Hg in the alveoli sac, pressure drop due to
conduction loss as oxygen travels along the transport passageway.
Atmospheric pressure decreases as altitude increases making effective
breathing more difficult at higher altitudes.
A Diagram showing gas exchange that
occurs only at pulmonary and systemic capillary beds near the alveoli.
CO2 is a result of cellular respiration. The concentration of this gas in
the breath can be measured using a capnograph. As a secondary
measurement, respiration rate can be derived from a CO2 breath waveform.
Trace gases present in breath at levels lower than a part per million
are ammonia, acetone, isoprene. These can be measured using selected ion
flow tube mass spectrometry.
Blood carries oxygen, carbon dioxide and hydrogen ions between
tissues and the lungs.
The majority (70%) of CO2 transported in the blood is dissolved in
plasma (primarily as dissolved bicarbonate; 60%). A smaller fraction (30%) is
transported in red blood cells combined with the globin portion of hemoglobin
as carbaminohemoglobin.
Hemoglobin in the red blood cells increases the carrying capacity of
oxygen hundreds of times greater than plain water.
CO2 that diffuses into the blood enters red blood cells where an
enzyme converts the CO2 into bicarbonate ions (HCO3-). Converting the
CO2 into Bicarbonate ions increases the carrying capacity of CO2 molecules.
In addition, formation of bicarbonate ions offers the body an effective
method of regulating blood pH. CO2 will react with water to produce carbonic
acid. If carbonic acid were to increase (which can occur as a result of
increased cellular activity) blood pH would lower which could effect enzyme
activity. The fact that red blood cells convert CO2 into Bicarbonate ions,
which are basic, enables the body to maintain a constant pH in the blood.
IV THE PATIENT AND HIS ILLNESS
SCHEMATIC DIAGRAM OF PNEUMONIA(Book-Based)
Modifiable Factors Non-modifiable Factors
-Poor Diet -Age: 11 months
-Unhygienic Practices based on culture -Sex: Male
-Place of residence is far from market-Underdeveloped place of residence
Body’s defense is lowered/ low immune system
Failure of the respiratory tree to be free of infection
Exposure to an environment which serves as niche for M.O. (microorganisms
Acquisition of M.O.s (bacterial, viral, fungal)
Inhalation of M.O.s and become lodged Aspiration of foreign body, food, vomit or In naso pharyngeal secretions other irritating substances such as products (cleaners) into the lungs
PATHOGENS BEGIN TO COLONIZE
Infection Starts
Bacteria reaches Tracheo- Virus attacks Irritation to the airway mucosa bronchial Tree Bronchiolar epithelial cells and lung parenchyma