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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
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Page 1: Case Study

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.

Page 2: Case Study

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

Page 3: Case Study

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.

Page 4: Case Study

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:

Page 5: Case Study

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.

Page 6: Case Study

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

Page 7: Case Study

• 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.

Page 8: Case Study

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.)

Page 9: Case Study

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.

Page 10: Case Study

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.

Page 11: Case Study

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).

Page 12: Case Study

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.

Page 13: Case Study
Page 14: Case Study

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.

Page 15: Case Study

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

Page 16: Case Study

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

Page 17: Case Study

HEAD: symmetrical & normocephalic; no mass noted upon palpation

FACE: symmetric features; facial movement

EYEBROWS: hair evenly distributed; skin intact; symmetrically aligned;

equal movement

EYELASHES: equally distributed; curled slightly upward

EYELIDS: skin intact; no discharge; no discoloration; lids close

symmetrically; involuntary blinks approximately 15 to 20 per minute

EYES: sclera appears white no discharges noted; pale palpebral conjunctiva;

no edema or tenderness over the lacrimal glands; transparent, smooth

and shiny, details of iris are visible; the client blinks when cornea is

touched; pupils black in color, equal in size; smooth border; iris flat and

round

NOSE: symmetrical in shape and size; nasal flaring and secretions noted upon

inspection; uniform

MOUTH: symmetric; uniform pink; moist, smooth; no lesions

TONGUE: central position; pink; moist; slightly rough; thin whitish coating;

no lesions

EARS: symmetrical; no lesions noted upon inspection; same color as facial

skin, auricle is aligned with the outer canthus of the eye; mobile; firm; non

tented; pinna recoils after it is folded

NAILS: short with minimal dirt; capillary refill time less than 3 seconds;

convex curve; intact epidermis

NECK: symmetrical; with no lesions noted upon inspection, muscles equal

in size; head centered; coordinated, smooth movement with no discomfort

CHEST: symmetrical expansion,

LUNGS: adventitious breath sounds (rales)

HEART: no pulsations heard upon auscultation; symmetric pulse volumes;

full pulsations; thrusting quality; quality remains same when client

breaths, turns head and changes from sitting to supine position; elastic

arterial wall

Page 18: Case Study

ABDOMEN: symmetric contour, no evidence of enlargement of liver and

spleen, symmetric movements caused by respiration, audible bowel

sounds; unblemished skin; uniform color

EXTREMITIES: (-) edema

☼ Second Nurse-Patient Interaction: June 27, 2007

Vital Signs:

T – 37.4°C,

P -150 bpm ,

R -23cpm

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

FACE: symmetric features; facial movement

EYEBROWS: hair evenly distributed; skin intact; symmetrically aligned;

equal movement

EYELASHES: equally distributed; curled slightly upward

EYELIDS: skin intact; no discharge; no discoloration; lids close

symmetrically; involuntary blinks approximately 15 to 20 per minute

EYES: sclera appears white no discharges noted; pale palpebral conjunctiva;

no edema or tenderness over the lacrimal glands; transparent, smooth

and shiny, details of iris are visible; the client blinks when cornea is

touched; pupils black in color, equal in size; smooth border; iris flat and

round

Page 19: Case Study

NOSE: symmetrical in shape and size; nasal flaring and secretions noted upon

inspection; uniform

MOUTH: symmetric; uniform pink; moist, smooth; no lesions

TONGUE: central position; pink; moist; slightly rough; thin whitish coating;

no lesions

EARS: symmetrical; no lesions noted upon inspection; same color as facial

skin, auricle is aligned with the outer canthus of the eye; mobile; firm; non

tented; pinna recoils after it is folded

NAILS: short with minimal dirt; capillary refill time less than 3 seconds;

convex curve; intact epidermis

NECK: symmetrical; with no lesions noted upon inspection, muscles equal

in size; head centered; coordinated, smooth movement with no discomfort

CHEST: symmetrical expansion,

LUNGS: adventitious breath sounds (rales)

HEART: no pulsations heard upon auscultation; symmetric pulse volumes;

full pulsations; thrusting quality; quality remains same when client

breaths, turns head and changes from sitting to supine position; elastic

arterial wall

ABDOMEN: symmetric contour, no evidence of enlargement of liver and

spleen, symmetric movements caused by respiration, audible bowel

sounds; unblemished skin; uniform color

EXTREMITIES: (-) edema noted

Page 20: Case Study

Reflexes Description Appea-

ance

Disappear-

ance

Baby Clark

Kent

Babinski Toes fan upward when

sole of the foot is

stroke.

Birth 9 months Absence

of

Babinski

Reflex

Galant Arching of trunk toward

stimulated side when

infant is stroke along

the spine.

Birth Neonatal

Period

Absence

of Galant

Reflex

Moro (startle) Sudden outward

extension of arms with

midline returns when

startled by loud noise

or rapid change in

position.

Birth 4months Absence

of Moro

Reflex

EXTREMITIES: (-) edema noted

Page 21: Case Study

Righting Attempting to maintain

head in an upright

position.

Birth 24

months

Presence

of

Righting

Reflex

Rooting Turning head toward

stimulated side of

cheek.

Birth 6 months Absence

of Rooting

Reflex

Sucking Initiation of sucking

when an object is place

on the mouth.

Birth Indefinite Presence

of Sucking

Reflex

Swimming Mimicking swimming

movement when held

horizontally in wate.

Birth 4 months Absence

of

Swimming

Reflex

Walking Making stepping

movements when held

upright with feet

touching the surface.

First

weeks;

reappe

ars at

4-5

months

12

months

Presence

of

Walking

Reflex

Page 22: Case Study
Page 23: Case Study

H. Diagnostic and Laboratory Findings

Diagnostic/ Laboratory Procedures

Date Ordered & Date

Result(s) In

Indication(s) or Purpose(s)

Results (1st, 2nd) Normal Values Analysis & Interpretation of Results

1. CBC or

Hematology

To determine

whether specific

blood levels are

higher or lower

than normal and

can be useful in

the diagnosis of

such diseases as

anemia, leukemia

and infection.

Analysis of

RBCs, WBCs,

PT, PTT,

Erythrocyte

Sedimentation

Rate, Platelets,

Hemoglobin

is the iron-

containing

oxygen-

transport

metalloprotein

in the red

blood cells of

the blood in

vertebrates

and other

animals.

120 – 160 Low Hb concentration may indicate

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DO:

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DRI:

06/23/07

H/H 88

9 – 6

Hematocrit

is the

measures of

the proportion

of blood

volume that is

occupied by

red blood

cells.

g/L

mg% (12 –

16 mg%)

anemia, recent hemorrhage or fluid

retention, which can cause

hemodilution.

Low Hct suggests anemia,

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DRI:

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0.29

31 – 0

WBC or

leukocytes

are cells of

the immune

system which

defend the

body against

both

infectious

disease and

foreign

materials.

11.8

0.40 – 0.50

vol% (37 –

47 vol%)

5.0 – 10 x

106/

hemodilution or massive blood loss.

A low WBC count (leukopenia)

indicates bone marrow depression,

which may result from viral

Page 26: Case Study

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DRI:

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3.6

Differential

Count

Neutrophils

are the most

abundant type

of white blood

cells and form

an integral

part of the

immune

system.

w/cu.mm

(5000 –

10000/

cu.mm)

infections or from toxic reactions,

such as those following treatment

with antineoplastics, ingestion of

mercury or other heavy metals or

exposure to benzene or arsenicals.

Normal. Neutrophils are

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.62

68

Lymphocyte

is a type of

white blood

cell in the

vertebrate

immune

system. By

their

appearance

under the

.45 – .65

% (60 – 70)

phagocytes, capable of ingesting

microorganisms or particles. They

can internalise and kill many

microbes, each phagocytic event

resulting in the formation of a

phagosome into which reactive

oxygen species and hydrolytic

enzymes are secreted.

Page 28: Case Study

light

microscope,

there are two

broad

categories of

lymphocytes,

namely the

large granular

lymphocytes

and the small

lymphocytes.

Functionally

distinct

subsets of

lymphocytes

correlate with

their

appearance.

.33

.25 – .40

% (30 – 40)

Normal. Most, but not all large

granular lymphocytes are more

commonly known as the natural

killer cells (NK cells). The small

lymphocytes are the T cells and B

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91

Monocyte is

a leukocyte,

part of the

human body's

immune

system that

cells. Lymphocytes play an

important and integral role in the

body's defenses.

An increase in lymphocytes may

indicate infection: tuberculosis,

hepatitis, infectious mononucleosis,

mumps, rubella, cytomegalovirus

Thyrotoxicosis, hypoadrenalism,

ulcerative colitis, immune diseases,

lymphocytic leukemia

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protects

against blood-

borne

pathogens

and moves

quickly to

sites of

infection in

the tissues.

.05

none

Eosinophils

are white

blood cells of

.02 – .06 Normal. A monocyte count is part of

a complete blood count and is

expressed either as a ratio of

monocytes to the total number of

white blood cells counted, or by

absolute numbers.

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migrating into

blood.

none

01

Platelets or

thrombocyte

% (0 – 3) Normal. Eosinophils produce and

store many secondary granule

proteins prior to their exit from the

bone marrow. After maturation,

eosinophils circulate in blood and

migrate to inflammatory sites in

tissues, or to sites of helminth

infection in response to chemokines

like CCL11 (eotaxin) and CCL5

(RANTES), and certain leukotrienes

like leukotriene B4 (LTB4).

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DO:

06/26/07

s are the cell

fragments

circulating in

the blood that

are involved

in the cellular

mechanisms

of primary

hemostasis

leading to the

formation of

blood clots.

153

184

150 – 450 x

106/mL

150 – 450 x

106/mL

Normal. Normal platelet counts are not

a guarantee of adequate function. In

some states the platelets, while being

adequate in number, are dysfunctional.

For instance, aspirin irreversibly

disrupts platelet function by inhibiting

cyclooxygenase-1 (COX1), and hence

normal hemostasis; normal platelet

function may not return until the

aspirin has ceased and all the affected

platelets have been replaced by new

ones, which can take over a week.

Similarly, uremia (a consequence of

renal failure) leads to platelet

dysfunction that may be ameliorated

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DRI:

06/26/07

by the administration of desmopressin.

NURSING RESPONSIBILITIES1. Prior

☺ Note current drug therapy before procedure.

☺ Check the physician’s order.

☺ Identify the client.

☺ Prepare the needed materials.

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☺ Explain the procedure, its purpose and how it is done.

☺ Inform the patient/SO that there are no food or fluid restrictions.

☺ Inform the patient that the test may require blood specimen and might bring a little pain to the punctured site.

☺ Wash hands.

2. During

☺ Collect approximately 5 to 10 ml of venous blood in a purple top tube.

☺ Avoid hemolysis.

☺ Maintain aseptic technique.

3. After

☺ Apply pressure to the punctured site to prevent bleeding.

☺ Discuss with SO signs of inflammation of punctured site and advice to report immediately.

☺ Check the site for bleeding after procedure.

☺ Wash hands.

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Diagnostic/

Laboratory

Procedures

Date

Ordered

& Date

Result(s)

In

Indication(s) or

Purpose(s)Results Normal Values Analysis & Interpretation of Results

2.

Urinalysis

DO:

06/23/0

7

DRI:

06/23/0

7

Determination

of urine

composition

and possible

abnormal

components

(e.g. protein

or glucose) or

infection

To screen for

metabolic and

kidney

disorders and

for urinary

Color: Yellow

Transparency:

Clear

pH: 7.5

Specific

Gravity: 1.010

Albumin:

Negative

Sugar: Negative

Microscopic

Exam

Pus Cell:

Color: Yellow

Transparency:

Clear to faintly

hazy

pH: 4.5 – 8.0

Specific

Gravity:

1.003 – 1.030

Albumin:

Negative

Sugar: Negative

A normal urinalysis also does

not guarantee that there is no

illness. Some people will not

release elevated amounts of a

substance early in a disease

process and some will release

them sporadically during the

day (which means they may be

missed by a single urine

sample).

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tract

infections

0-3/hpf

RBC: 2-5/hpf

Epithelial Cells:

Rare

Pus Cell:

0-1/hpf

RBC: < 4

cells/hpf

Epithelial Cells:

< 11 cells/hpf

Mild infection

An elevated RBC count may

indicate absolute or relative

polycythemia.

NURSING RESPONSIBILITIES

1. Prior

☺ Tell the patient to avoid stress and strenuous exercise before the test.

☺ Check for drugs that influence urinalysis.

☺ Explain the procedure to the mother.

2. During

☺ Collect a random urine specimen of at least 15 ml, preferably a first-voided morning specimen.

☺ If the patient is being evaluated for renal colic, strain the specimen to catch stones or stone fragments.

☺ Refrigerate the specimen if analysis will be delayed longer than 1 hour.

☺ Maintain aseptic technique.

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3. After

☺ Send specimen to the laboratory immediately.

☺ Perform proper hand-washing.

☺ Document.

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Diagnostic/

Laboratory

Procedures

Date

Ordered &

Date

Result(s) In

Indication(s) or

Purpose(s)Results Normal Values

Analysis &

Interpretation of

Results

3. X-ray or

Rontgen

Rays

DO:

06/25/07

DRI:

06/25/07

To determine

pulmonary edema or

congestion

To identify the

abnormalities of the

lungs and the

structures on the

thorax. And also to

identify the size of the

heart and the

abnormalities in the

ribs and diaphragm.

Hazy infiltrates are

noted on both lower

lungfields

Heart is normal in size

Diaphragm and sulci

are intact

Other chest structures are

Normal lung

fields.

Pneumonia,

bilateral

Visible in the

anterior left

mediastinal

cavity; appears

solid because of

blood contents

Page 40: Case Study

remarkable

NURSING RESPONSIBILITIES

1. Prior

☺ Check the doctor’s order.

☺ Identify the client.

☺ Describe the procedure to the patient.

☺ Determine the patient’s ability to inhale and hold breath.

☺ Explain to the mother that this test assesses respiratory status.

☺ Tell the mother that no fasting is required.

☺ Inform the mother that the test takes 5 to 10 minutes.

☺ Describe the test to the mother including who will perform it and when will it take place.

☺ Assist transporting the client in going to the x-ray room.

2. During

☺ Provide a gown without snaps, and ask the patient to remove all jewelry in the radiographic field. Tell

him he’ll be asked to take a deep breath and hold it momentarily while the film is being taken, to

provide a clear view of pulmonary structures.

☺ If the patient is intubated, check that no tubes have been dislodged during positioning.

☺ To avoid exposure to radiation, leave the room or the immediate area while the films are being taken. If

you must stay in the area, wear a lead-lined apron.

☺ Assist and keep patient still as possible during the procedure.

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3. After

☺ Inform the mother the possible need for additional x-ray.

☺ Document.

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III. Anatomy and Physiology

The Respiratory System

The respiratory System of the Human body is primarily for the sole

purpose of facilitating respiration. This includes the exchange of gases

between the environment and the lungs through the process of ventilation.

Also, it provides a mechanism for the body’s exchange of oxygen and carbon

dioxide in the lungs and in the blood. As the oxygen being inspired travel to

the bloodstream to allow for cellular exchange, carbon dioxide, which is a

waste material of a cell, is replaced by oxygen to attain maximum

functioning.

Other than respiration, the human body’s respiratory system is also

responsible for regulation of blood pH, voice production, olfaction, and innate

immunity.

The respiratory system is divided into two, namely: the upper and the

lower respiratory tract. Under the upper respiratory tract refers to the nose,

nasal cavity, and pharynx. While the lower respiratory tract refers to the

larynx, bronchi, the trachea, and the lungs; Pneumonia, a very serious

disease causes inflammation in the 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.

Bronchi and Bronchial Tree

In the mediastinum, at the level of the fifth thoracic vertebra, the trachea

divides into the right and left primary bronchi. The bronchi branch into

smaller and smaller passageways until they terminate in tiny air sacs called

alveoli.

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The cartilage and mucous membrane of the primary bronchi are similar to

that in the trachea. As the branching continues through the bronchial tree,

the amount of hyaline cartilage in the walls decreases until it is absent in the

smallest bronchioles. As the cartilage decreases, the amount of smooth

muscle increases. The mucous membrane also undergoes a transition from

ciliated pseudostratified columnar epithelium to simple cuboidal epithelium to

simple squamous epithelium.

The alveolar ducts and alveoli consist primarily of simple squamous

epithelium, which permits rapid diffusion of oxygen and carbon dioxide.

Exchange of gases between the air in the lungs and the blood in the

capillaries occurs across the walls of the alveolar ducts and alveoli.

Lungs

The two lungs, which contain all the components of the bronchial tree

beyond the primary bronchi, occupy most of the space in the thoracic cavity.

The lungs are soft and spongy because they are mostly air spaces

surrounded by the alveolar cells and elastic connective tissue. They are

separated from each other by the mediastinum, which contains the heart.

The only point of attachment for each lung is at the hilum, or root, on the

medial side. This is where the bronchi, blood vessels, lymphatics, and nerves

enter the lungs.

The right lung is shorter, broader, and has a greater volume than the left

lung. It is divided into three lobes and each lobe is supplied by one of the

secondary bronchi. The left lung is longer and narrower than the right lung. It

has an indentation, called the cardiac notch, on its medial surface for the

apex of the heart. The left lung has two lobes.

Each lung is enclosed by a double-layered serous membrane, called the

pleura. The visceral pleura is firmly attached to the surface of the lung. At the

hilum, the visceral pleura is continuous with the parietal pleura that lines the

wall of the thorax. The small space between the visceral and parietal pleurae

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is the pleural cavity. It contains a thin film of serous fluid that is produced by

the pleura. The fluid acts as a lubricant to reduce friction as the two layers

slide against each other, and it helps to hold the two layers together as the

lungs inflate and deflate.

A Diagram showing the

Trachoebronchial Tree and the Diaphragm

Oxygen Transport System

The flow of air in and out of the lungs is controlled by the nervous

system, which ensures that humans breathe in a regular pattern and at a

regular rate. Breathing is carried out day and night by an unconscious

process. It begins with a cluster of nerve cells in the brain stem called the

respiratory center. These cells send simultaneous signals to the diaphragm

and rib muscles, the muscles involved in inhalation. The diaphragm is a large,

dome-shaped muscle that lies just under the lungs. When the diaphragm is

stimulated by a nervous impulse, it flattens. The downward movement of the

diaphragm expands the volume of the cavity that contains the lungs, the

thoracic cavity. When the rib muscles are stimulated, they also contract,

pulling the rib cage up and out like the handle of a pail. This movement also

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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

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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.

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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.

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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.

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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.

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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

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Bacteria reaches Tracheo- Virus attacks Irritation to the airway mucosa bronchial Tree Bronchiolar epithelial cells and lung parenchyma

Mucosal Edema Desquamation

(peeling off of mucous

membrane in lungs

Impairment of the Invasion in mucous glands

Mucociliary escalator goblet cells (produces mucus)

Absence of major barrier Reaches alveoli (fills with blood/fluid)

against infection

Further infection Interstitial inflammation with

Infiltrates in the alveolar walls (no exudates)

Local pulmonary defenses Infects alveoli No. of WBC in the

Resists infection peripheral blood is higher than normal

Cough Reflex Triggers alveolar inflammation Elevated temperature

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Chills

Stress in the lungs; disrupts function Produces an area of low ventilation w/ normal perfusion

Injury reduces normal blood flow to lungs Introduction of fluids on tissues by their injection into

blood vessels (veins)

Platelets aggregate and release histamine, capillaries become engorged with blood

Serotonin, & bradykinins

Stasis (cessation of flow of blood/ body fluids)

Alveolocapillary membrane breaks down Increase capillary permeability

Alveoli fills with blood and exudate Proteins and fluids Leak out

Atelectasis( gas exchange is not accomplished Cont. Hypoxemia

by the shrunken alveoli) Reaches Pleural surface

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in some areas Decrease pulmonary

compliance

Diminished O2 in body (cyanosis) Irritation and inflammation of the pleura Crackles and

ronchi

Inflammatory exudates accumulates Hypoxemia in the Pleural surfaces

Hypoxia in muscles and brain Consolidation Friction in the pleura upon respiration

Vascular changes in Body malaise Partial loss of lung function Chest pain Cephalic area

Headache Decrease Brain impulses Oxygenation of blood is impaired Cont. Increase in interstitial In taste buds’ function osmotic

pressure

Loss of appetite Shortness of breath Pulmonary Edema

Heart pumps more blood Decreased Blood flow (compensatory mechanism) and fluids in the alveoli damage

Surfactant

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Tachycardia Impairs cells’ ability to produce more

Alveoli collapses

Sufficient O2 can’t cross the Increase in respiratory distress Impaired gas

exchangealveolocapillary membrane

Fibrosis

CO2 is lost w/ every exhalation Hypoxemia Metabolic acidosis develops Atelectasis

Hemorrhage

Tissue necrosis

Acute Respiratory Failure Formation of exudates

Further pulmonary Edema

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SCHEMATIC DIAGRAM OF PNEUMONIA(Client-Centered)

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 In naso pharyngeal secretions

PATHOGENS BEGIN TO COLONIZE

Infection Starts

Bacteria reaches Tracheo- Virus attacks Irritation to the airway mucosa bronchial Tree Bronchiolar epithelial cells and lung parenchyma

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Desquamation (peeling off of mucous membrane in lungs

Invasion in mucous glands goblet cells (produces mucus)

Reaches alveoli (fills with blood/fluid)

Interstitial inflammation with Infiltrates in the alveolar walls (no exudates)

Local pulmonary defenses Infects alveoli Resists infection

Cough Reflex Triggers alveolar inflammation

Stress in the lungs; disrupts function Produces an area of low ventilation w/ normal perfusion

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Injury reduces normal blood flow to lungs Introduction of fluids on tissues by their injection into

blood vessels (veins)

Platelets aggregate and release histamine, capillaries become engorged with bloodSerotonin, & bradykinins

Stasis (cessation of flow of blood/ body fluids)

Alveolocapillary membrane breaks down

Alveoli fills with blood and exudate

Atelectasis( gas exchange is not accomplished

by the shrunken alveoli) Reaches Pleural surface in some areas

Diminished O2 in body Irritation and inflammation of the pleura

Inflammatory exudates accumulates Hypoxemia in the Pleural surfaces

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Hypoxia in muscles and brain Headache Decrease Brain impulses

Vascular changes in Body malaise In taste buds’ function Cephalic area

Loss of appetite

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Synthesis of the Disease (Book-Centered)

Pneumonia is the inflammation of the lung parenchyma and also of the

interstitium of the lungs. It is acquired either in the community, where a host

is exposed to and together with lowered immune system could cause an

infection, or in the hospital where immunocompromised patients such as

pediatrics, and geriatrics where there is failure of the body to be free of

infection.

A lot of different factors may have a contribution in the development of

the disease. Among the factors are, poor diet, unhygienic practices based on

culture, and an underdeveloped place of residence. Also, in addition to that,

the presence of non-modifiable factors such as age of the client ad the sex

(e.i. to which sex is the disease condition more prominent).

Baby Clark Kent is an eleven month old baby boy, living in an

underdeveloped place of residence which is far from the market. They

observe unhygienic practices under the influence of culture. With all these

combined, the defense mechanism of the client is lowered or impaired, there

is failure of e respiratory tract to be free of infection. Upon exposure to an

environment that serves as a niche for microorganisms, pathogens begin to

start colonizing the body when the body undergoes two processes. First,

inhalation of microorganisms in which they become lodged in the

nasopharyngeal secretions. Second, Aspiration of foreign body, food, vomit or

other irritating substances such as cleaning products into the lungs.

There are three modes in which infection may start. First, a bacterium

reaches the tracheobrochial tree. By then, local pulmonary defenses resists

infection as manifested in coughing. The alveoli become infected and it

triggers alveolar inflammation. With this, the number of WBC in the

peripheral blood is higher than normal. And so there is elevated temperature

plus chills may also be seen as a form of involuntary compensatory

mechanism.

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When the alveoli inflames, there is a presence of stress in the lungs

that disrupts respiration. Therefore normal blood flow to the lungs is reduced.

So what happens is that, platelets aggregate and release histamine,

serotonin and bradykinins as an inflammatory response. Alveolar capillary

membrane breaks down which will eventually lead to the filling of blood and

exudates in the alveoli and increase capillary permeability. In the mean time,

when alveolar inflammation occurs, there is a production of an area of low

ventilation with normal perfusion which means that there is an introduction of

fluids on tissues by their injection into blood vessels (veins). Capillaries now

becomes engorged with blood so its flow will stop, thus stasis will occur.

Atelectasis impairs gas exchange because the alveoli had already been

shrunken when the alveoli was filled with blood and exudates. So what

happens is that there is diminished oxygen in the body, which is evident in

the occurrence of cyanosis; because of this there would be hypoxemia in the

entire body which leads to hypoxia in the muscles and brain. Due to this

occurrence, there would be vascular changes in the cephalic area which leads

to headache and loss of appetite (decrease brain impulses in taste buds),

body malaise will also be experienced.

Also, when alveoli fill with blood and exudates pleural surfaces are

being irritated and inflamed. Production of inflammatory exudates

accumulates in the pleural surfaces; this causes consolidation of exudates

which leads to partial loss of lung function in which oxygenation of blood is

impaired. Therefore, there will be shortness of breath. Heart pumps more

blood as a compensatory mechanism which leads to tachycardia.

Furthermore, inflammatory exudates cause friction in the pleura upon

respiration instigates chest pain.

In relation to the increase in capillary permeability, proteins and fluids

leak out; this increases interstitial osmotic pressure causing pulmonary

edema. Pulmonary edema is an abnormal buildup of fluid within the tissues of

the lung. Fluid can build up in the lungs for many reasons. This fluid makes it

difficult for the lungs to give oxygen to the blood. There will be low oxygen in

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the blood and the fluid itself; this damages the surfactant. When this

happens, cells’ ability to produce more surfactant is impaired which leads to

alveoli collapses. Gas exchange is impaired and respiratory distress

increases. Sufficient Oxygen can’t cross the alveolocapillary membrane; CO2

is lost with every exhalation. Hypoxemia occurs and metabolic acidosis

develops soon after. When this happens, the client is at risk for having

Fibrosis, Atelectasis, Hemorrhage, Tissue Necrosis, formation of exudates,

and further Pulmonary Edema.

In relation to the onset of infection, viruses attacks bronchiolar

epithelia cells causing mucosal edema which impairs the mucociliary

escalator. This leads to further infection because of the absence of a major

barrier.

Another factor when pathogens begin to colonize is the irritation to the

airway mucosa and lung parenchyma. This directs to desquamation, which is

the peeling off of mucous membrane in the lungs. This leads to invasion of

mucous glands and goblet cells, which produces the mucous. Then, it fills the

alveoli with blood and fluid when reached, and there will be interstitial

inflammation with infiltrates in the alveolar walls; there are no present

exudates.

Synthesis of the Disease (Client-Centered)

Baby Clark Kent is an 11-month old baby boy living in an

underdeveloped residence which is far from market. His diet is poor and their

family performs unhygienic practices based on their culture.

All of the above mentioned factors contributed to the lowered body

defense of baby Clark. He failed to have a respiratory tree that is free from

infection.

Upon exposure to an environment which serves as a niche for

microorganisms (M.O.), baby Clark had acquired these MO’s because of

lowered immunity. He acquired it through inhalation in which the MO’s

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became lodged in the nasopharyngeal secretions. Pathogens began to

colonize and infection has started.

Bacteria which is the tracheobronchial tree causing coughing reflex as

a defense mechanism. Baby Clark was infected with quite a number of a MO’s

therefore he became susceptible and the alveoli in his lungs became infected

causing an inflammation. Because of the inflammation the alveoli was filled

with blood and exudates. Gas exchange is compromised leading to

diminished oxygen in the body. There is low oxygen in the blood which leads

to hypoxia in the muscles and brain causing headache and body malaise. Plus

a decrease in appetite was attributed to that cause; since there is a decrease

in the nerve impulses that stimulate the tastebuds’ function.

Because of viral attacks to the bronchiolar epithelial cells, there was an

impairment of the mucocilliary escalator which adds up to further infection.

In addition to the blood and exudates that had filled the alveoli, pleural

surfaces had been irritated and inflamed causing an accumulation in the

inflammatory exudates leading to consolidation resulting in poor oxygenation

in blood. This will pilot the body to have shortness of breath, and as a

compensatory mechanism, the heart pumps more blood and the outcome will

be tachycardia.

Lastly, due to the irritation in the airway mucosa and lung

parenchyma, interstitial inflammation with infiltrates in the alveolar walls

occurs when the alveoli is filled with blood or fluid. This action is due to the

invasion of M.O.s in the mucous glands which stimulates the goblet cells to

produce more mucus.

Modifiable and Non-modifiable Factors

1. Poor Diet is a modifiable factor in which this is crucial in the

strengthening of the immune system of the client. Without the

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sufficient intake of vitamins and minerals that are present in the diet,

the defense mechanism of the body is weakened; making it

susceptible to infection and invasion of possible microorganisms that

are present in the environment. This can be attributed to the possibility

that these microorganisms are dwelling in the environment itself.

Specifically, fruits and vegetables such as oranges, apples and green

leafy vegetables would be helpful in strengthening the immune

system. Plus, the compliance of the mother in giving due amount of

breast milk to the client, who is Baby Clark Kent.

2. Unhygienic Practices based on culture is a modifiable factor

because it may or may not be done. It was found out that during

Fridays and Tuesdays Baby Clark Kent is prohibited from taking a bath

whenever he is sick. It is important to take a bath everyday and if this

will be continually practiced, possible microorganisms could thrive on

moist environments in the body making the client susceptible for

diseases.

3. Place of residence is underdeveloped is another modifiable factor

since crowdedness of the people living in a particular geographical

area would facilitate direct contact mode of transmission of possible

microorganisms or through droplet infection, as well. This will make the

client susceptible for acquiring a disease from someone proximal to

him; therefore, a disease may or may not develop depending on the

distance of the client from an infected person and the virulence of the

disease.

4. Place of residence is far from market is a modifiable factor; this

factor is very important because the food that are said to be essential

for the strengthening of the immune system of the child is present in

the market. If it will be distal to the client’s place of residence, then it

will be hard for the family to supply for the needs of the client in terms

of food. This difficulty lessens the food that Baby Clark Kent could have

eaten should they live in a close proximity to the market.

Page 66: Case Study

5. Age is a non-modifiable factor in which the client’s immunity against

possible diseases is not that developed in comparison to adults.

6. Sex is a non-modifiable factor in which the occurrence of the said

disease in prevalent in males more it is in females.

Signs and Symptoms

1. Cough an important way to keep your throat and airways clear.

However, excessive coughing may mean you have an underlying

disease or disorder. Some coughs are dry, while others are considered

productive; a reflex which is said to be a natural defense mechanism

because of its action of expulsing bacteria out of the tracheobronchial

tree.

Manifestation in baby Clark:

Baby Clark seldom coughs as a form of resistance to infection because the

bacteria has already reached the tracheobronchial tree.

2. Cyanosis refers to a blue or purple hue to the skin. It is most easily

observed on the lips, tongue and fingernails. Cyanosis indicates there

may be decreased oxygen in the bloodstream. It may suggest a

problem with the lungs, but most often is a result of mixing blue and

red blood due to defects of the heart or great vessels. Cyanosis is a

finding based on observation, not a laboratory test. Cyanosis is usually

caused by either serious lung or heart disease, or circulation problems.

3. Loss of Appetite is a result of decrease in the brain impulses that

stimulates the function of the taste buds. It is because of the vascular

changes in the cephalic area. Since the alveoli where filled with fluids

and exudates, gas exchange was not accomplished well; so what

happened was, there was diminished Oxygen in the body, as it was

manifested by the presence of cyanosis. Hypoxemia had erupted

resulting to low oxygen in the brain and muscles which eventually lead

to the vascular changes.

Page 67: Case Study

Manifestation in baby Clark:

As a result of loss of appetite, baby Clark had a weight reduction as

verbalized by the mother. It is because of the decrease brain impulses in

taste bud’s function because of low oxygen in the body tissues particularly

in the brain.

4. Headache is the outcome when there is low oxygen in the brain.

There are vascular changes in the cephalic area.

Manifestation in baby Clark:

Baby Clark had experienced headache because of the vascular changes in

the cephalic area when there is low oxygen in the head. This can be

attributed to the diminished oxygen in the body due to the fluid that filled

the alveoli.

5. Body Malaise had resulted out of low oxygen content in the muscles.

Since the cells in the body require sufficient amount in oxygen, it

cannot work properly if its level is decrease resulting to malaise.

Page 68: Case Study

V. THE PATIENT AND HIS CARE

A. Planning

a. Nursing Care Plan

ASSESSME

NT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIO

N

OBJECTIVES INTERVENTI

ONS

RATIONALE EXPECTED

OUTCOME

S> the S.O

verbalized

“manguku

ya ampong

lalagnat”

O> the

patient

manifested

>Flushed

skin

>skin warm

to touch

>with body

Hyperther

mia

When the

causative

agent enters

the body and

invades the

respiratory

system, the

inflammatory

process is

triggered

releasing

platelets,

WBC, RBC,

which

Short term:

After 6 hours

of nursing

interventions

the patient

will maintain

core

temperature

within the

normal

range.

Long Term:

1.Measure

temperature

2. Assess skin

temperature

and color.

3. Monitor

WBC count.

1. Indicates if

fever exists

and its extent.

2. Warm, dry,

flushed skin

may indicate

a fever.

3. Leucocytes

indicate an

inflammatory

and infectious

process

Short term:

The patient

shall have

maintained

core

temperature

within the

normal

range.

Long term:

The patient

shall have

been free of

Page 69: Case Study

temperature

of 38.1ºC

> with skin

rashes

present in

the

abdomen,

back and

face

> rales on

both lung

field

-The

patient

may

manifest

>dehydratio

n

>Irritability

produces

exudates of

fibrin, which

enhances the

spread of

microorganis

m, causing

infection. In

response to

infection, the

individual

WBC release

pyrogens.

These

pyrogens

affect the

body

temperature-

regulating

mechanism in

After 1 day

of nursing

intervention

the patient

will be free

from

hyperthermi

a.

4. Encourage

fluid intake

orally or

intravenously

as ordered.

5. Measure

intake and

output.

6. Give tepid

sponge bath.

presence.

4. Replaces

fluid lost by

insensible loss

and

perspiration.

5. Determine

fluid balance

and need to

increase fluid

intake.

6. To facilitate

heat loss

through

evaporation.

7. To facilitate

hyperthermi

a.

Page 70: Case Study

the

hypothalamus

of the brain.

As a

consequence,

heat

production

and

conservation

increase, a

body

temperature

increases.

Fever

promotes

activities of

the immune

system, such

as

phagocytosis,

7. Apply an

ice bag

covered with

towel to the

axilla and

groin.

8. Administer

antipyretics

as ordered.

heat loss

through

conduction.

8. To interrupt

the growth of

microorganis

m.

Page 71: Case Study

inhibits the

growth of

some

microorganis

m.

Page 72: Case Study

ASSESSM

ENT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATI

ON

OBJECTIVES INTERVENTI

ONS

RATIONALE EXPECTED

OUTCOME

S>

O>the

patient

manifested

>fever of

38.4ºC

>presence

of

adventitiou

s sounds in

both lung

field.

>productiv

e cough

>skin pale

in color

Risk for infection

(spread) related

to inadequate

secondary

defenses(decreas

e hemoglobin,

hematocrit and

immunosuppressi

on)

Immuno-

suppression

due to

decrease in

hemoglobin,

leukopenia,

and suppress

inflammator

y response

gives a

greater

opportunity

for

pathogenic

bacteria to

invade and

Short term:

After 6 hours

of nursing

interventions

the patient’s

S.O will

verbalize her

understandin

g of

individual

causative/risk

factors and

demonstrate

lifestyle

changes to

prevent

1. Monitor v/s

closely,

especially

during

initiation of

therapy.

2. Instruct the

S.O

concerning

about the

disposition of

secretions

and report

changes in

color, amount

1. To know

potential

fatal

complication

that may

occur.

2. To

promote

safety

disposal of

secretions

and to

assess for

the

resolution of

Short

term:

The patient’s

S.O shall

have

verbalized

her

understandin

g of

individual

causative/risk

factors and

demonstrate

lifestyle

changes to

prevent

further

Page 73: Case Study

>restlessn

ess

-The

patient

may

manifest

>body

malaise

>activity

intolerance

>decrease

oxygen

level

inoculate in

a specific

body part of

a susceptible

human body.

Thus,

leading to a

further

damage or

infection.

further

infection.

Long term:

After 1-2 days

of nursing

interventions

the patient will

be free from

possible

spread of

infection.

and odor of

secretions.

3. Encourage

good hand

washing

techniques.

4. Encourage

adequate

rest.

5. Stress the

importance of

increasing the

childs

pneumonia

or

development

of secondary

infection.

3. To reduce

spread or

acquisition

of infection.

4. To enhance

fast recovery

and regain

strength.

5. A good

nutritional

intake can

strengthen

body

infection.

Long term:

The patient

shall have

been free

from

possible

spread of

infection.

Page 74: Case Study

nutritional

intake.

6. Encourage

the mother to

keep an eye

to the baby

and observe

anything that

the baby is

putting in his

mouth.

7. Administer

antimicrobials

as ordered.

immune

defense.

6. To

prevent

entry of

microbes.

7. To combat

microbial

pneumonias.

Page 75: Case Study
Page 76: Case Study

ASSESSME

NT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVE

S

INTERVENTI

ONS

RATIONALE EXPECTED

OUTCOME

S> the S.O

verbalized

“masalese

neng

mangan,

kayamu

sasanat

yapa

ampong

sisispun.”

O>the

patient

manifested

>pale

palpibral

conjunctiva

Ineffective

Airway

Clearance

related to

retained

secretions

When the

causative agent

triggers the

inflammatory

process of the

lungs, exudates

of fibrin

containing fluid,

polymononuclea

r leucocytes and

erythrocytes is

produce.

Furthermore, the

mucous produce

joins it by the

goblet cells in

response to the

Short

term:

After 4-6

hours of

nursing

intervention

s the

patient will

maintain

airway

patency.

Long

term:

After 1-2

days of

nursing

1. Auscultate

lungs for

crackles,

consolidation

and pleural

friction rub.

2. Assess

characteristic

s of

secretions:

quantity,

1. To

determine

the

adequacy of

gas

exchange

and extent

of airways

obstructed

with

secretions.

2. Because

presence of

infection is

suspected

when

Short term:

The patient

shall have

maintained

airway

patency.

Long term:

The patient

shall have

expectorated

secretions

readily.

Page 77: Case Study

>rales on

both lung

fluid

>restless

-The

patient

may

manifest

>dyspnea

>cyanosis

>chest pain

>headache

invading

microorganism,

this combination

produce and

increase in the

tracheo-

bronchial tree.

intervention

s the

patient will

expectorate

secretions

readily.

consistency,

color, and

odor.

3. Keep the

environment

allergen free

according to

the individual

needs.

4. Encourage

the mother to

increase the

fluid intake of

the child.

secretions

are thick,

yellow or

rust in color

and foul

smelling.

3. To

prevent

allergic

reactions

that may

cause

bronchial

irritation.

4. As to

liquefy

secretions so

that they are

Page 78: Case Study

5. Position the

patient in

HOB.

6. Encourage

eating high

caloric foods,

food rich in

iron like liver

and dark

green leafy

vegetables,

and foods rich

in vitamin C.

easy to

expectorate.

5. To

Facilitate

optimal

breathing.

6. To

supplement

the iron

needs of the

child as well

as to

facilitate

absorption

and

strengthenin

g his

immune

Page 79: Case Study

7. Perform

and instruct

chest-

physiotherapy

after

nebulization.

8. Administer

meds per

doctor’s

order.

system.

7. For easy

secretion

expulsion.

8. To

facilitate fast

recovery.

ASSESSME

NT

NURSING

DIAGNOSIS

SCINETIFIC

EXPLANATION

OBJECTIVES INTERVENTIO

NS

RATIONALE EXPECTED

Page 80: Case Study

OUTCOME

S>the S.O

verbalized

“meyayat

ya”

O>the

patient

manifested

>Pale

conjunctiva

and mucous

membranes

>Sunken

eyes

>Lethargy

-The

patient may

manifest

>Anorexia

>Malnutritio

Imbalance

nutrition:

less than

body

requiremen

ts related

to loss of

appetite.

Many taste

sensations are

strongly

influenced by

olfactory

sensations.

This influence

can be

demonstrated

by comparing

the taste of

some food

before and

after pinching

your nose it is

easy to detect

that the sense

of taste is

reduce will the

nose is pinch.

Thus having

Short term:

After 5-6

hours of

nursing

interventions

the patient

will

demonstrate

increase

appetite.

Long term:

After 2-3 days

of nursing

interventions

the patient

will maintain

normal body

weight.

1. Monitor and

record vital

sign.

2. Assess for

patient’s BMI.

3. Instruct the

S.O to give food

to the infant in

an appetizing

manner.

4. Encourage

small frequent

feeding.

1. To establish

baseline data.

2. To know the

nutritional

status of the

client.

3. To boost

patient’s

appetite.

4. To enhance

intake even

though

appetite may

be slow to

return.

Short term:

The patient

shall have

demonstrated

an increased

in appetite.

Long term:

The patient

shall have

maintained

normal body

weight.

Page 81: Case Study

n

>Gastric

irritation

secretions in

the nasal cavity

will impede

your taste buds

from giving you

the appetite

you need.

Physical illness,

unfamiliar or

unpalatable

food,

environmental

and

psychologic

factors and

physical

discomfort or

pain may

depress the

appetites of

may clients.

5. Monitor

electrolyte

values and

report any

abnormalities.

6. Promote

adequate rest.

7. Encourage

the mother to

give the child

multivitamins.

5. Poor

nutritional

status may

cause

electrolyte

imbalances.

6. To reduce

fatigue and

improve the

child’s ability

and desire to

eat.

7. To

supplement

the nutritional

needs of the

child.

Page 82: Case Study
Page 83: Case Study

ASSESSM

ENT

NURSING

DIAGNOSI

S

SCIENTIFIC

EXPLANATI

ON

OBJECTIVE

S

INTERVENTIO

NS

RATIONALE EXPECTED

OUTCOME

S>

O> the

patient

manifested

>restlessn

ess

>irritability

>nasal

flaring

-The

patient

may

manifest

>diaphores

Impaired

gas

exchange

related to

alveolar

capillary

membran

e changes

secondary

to

inflammat

ion.

Bronchospas

m, which

occurs in

many

pulmonary

diseases,

reduces the

caliber of

the small

bronchi and

may cause

dyspnea,

static

secretions

and

infections.

Short term:

After 6 hours

of nursing

intervention

s the patient

will

demonstrate

ease in

breathing.

Long term:

After 2-3

days of

nursing

intervention

s the

1. Monitor vital

signs and

assess

patient’s

conditions.

2.Auscultate

lungs for

crackles

, consolidation

and pleural

friction rub.

1. To

establish

baseline

data.

2. Determine

adequacy of

gas

exchange

and detect

areas of

consolidation

and pleural

friction rub.

Short term:

The patient shall

have

demonstrated

ease in

breathing.

Long term:

The patient’s

S.O will

verbalized

understanding

of the causative

factors that

Page 84: Case Study

is

>tachycard

ia

>dyspnea

Bronchospas

m can

sometimes

be detected

by

stethoscope

when

wheezing or

diminished

breath

sounds are

heard.

Increase

mucous

production

along with

decrease

mucous

ciliary’s

action,

patient’s S.O

will verbalize

understandi

ng of the

causative

factors that

could

aggravate

the

condition

and

appropriate

factors that

could help

the patient

relive from

gas

exchange

impairment.

3. Assess LOC,

distress and

irritability.

4. Observe skin

color and

capillary refill.

5. Encourage

rest.

3. This signs

may indicate

hypoxia.

4. Determine

circulatory

adequacy,

which is

necessary for

gas

exchange to

tissues.

5. Rest

prevents

tissue o

xygen

demand and

enhances

tissue

could aggravate

the condition

and appropriate

factors that

could help the

patient relive

from gas

exchange

impairment.

Page 85: Case Study

contributes

to further

reduction in

the caliber

of the

bronchi and

results in

decrease air

flow and

decrease

gas

exchange.

6. Encourage

elevated HOB.

7. Perform

chest

physiotherapy

after

nebulisation.

8. Administer

oxygen as

ordered.

oxygen

perfusion.

6. To

facilitate lung

expansion to

enhance

breathing.

7. To

dislodge the

secretions,

for easy

expectoration

8. Improves

gas-

exchange

decrease

work of

Page 86: Case Study

breathing.

Page 87: Case Study

B. Implementation

B.1. Medical Management

B.1.a. IVF’s and Nebulization

Medical

Management/

Treatment

Date Ordered

Date Performed

Date Changed/DC

General

Description

Indication(s) or

Purpose(s)

Client’s Response

to the Treatment

Intravenous

Fluids

D5IMB 500cc ×

28-29 µgtts/min

D5LRS 500cc ×

28-29 µgtts/min

DO: 06-23-07

DP: 06-23-07

DC: 06-26-07

DO: 06-26-07

DP: 06-26-07

It is a hypertonic

solution, which

makes the cells

shrink, composes of

water and

carbohydrates, as

source of energy

and both cations

and anions.

It is a hypertonic

solution, which

draws fluid out of

It is use to supply

the necessary

nutrients.

And this solution is

given usually when

serum osmolality

has decreased to

dangerously low

levels.

It provides caloric

Client fluid loss due

to insensible fluid

loss was replaced

and nourished.

Client fluid loss due

to insensible fluid

Page 88: Case Study

DC: 06-28-07 the intracellular

and interstitial

compartments into

the vascular

compartment,

expanding vascular

volume.

nutrients, thus

resembles the

electrolyte

composition of the

normal blood

serum and plasma.

loss was replaced.

Nursing Responsibilities:

Prior to the procedure:

Check doctor’s order. Check for ordered IVF.

Check for the patency of the IV tubing, cloudiness and expiration date.

Explain the procedure.

During the procedure:

Clean the site of administration. Choose a vein in the distal arm.

Support client hand and maintain aseptic technique.

Page 89: Case Study

After the procedure:

Monitor rate as ordered, flow and patency.

Document the time and date.

Medical

Management/

Treatment

Date Ordered

Date Performed

Date Changed/DC

General

Description

Indication(s) or

Purpose(s)

Client’s Response

to the Treatment

Nebulization DO: 06-23-07

DP: 06-24-07

DC: 06-28-07

Adding medication

or moisture to

inspired air by

mixing particles of

various sizes with

air.

It aids bronchial

hygiene by

restoring and

maintaining

mucous blanket

continuity,

hydrating dried,

retained secretions,

promoting

expectoration of

secretions. To

relive

bronchospasm, to

The client still

manifested rales

even though

nebulization is

given. And was able

to cough out

secretions. On the

other hand his

respiratory rate

decreases from

37cpm as of 06-24-

07 to 27cpm as of

Page 90: Case Study

provide relief to a

hyperresponsive

airway and to

liquefy and clear

tenacious

secretions.

06-28-07.

Nursing Responsibilities:

Prior to the procedure:

Check doctor’s order.

Check for the amount of medication that is to be incorporate in the procedure.

Explain the procedure to the patient’s S.O.

Arranged all the material needed. Wash hand.

During the procedure:

Hold the mouthpiece of the nebulizer upright to avoid spilling of medicines.

Continue nebulization until the medication is already nebulized.

Do chest physio-therapy after nebulisation.

After the procedure:

Assess the client’s vital signs after nebulisation, especially the respiratory rate.

Document the time of the procedure was done.

Page 91: Case Study

B.1.b Drugs

Name of Drugs

Generic Name

Brand Name

Date Ordered

Date Taken/Given

Date Changed/DC

Route of

Administration,

Dosage and

Frequency of

Administration

Indication(s) and

Purposes(s)

Client Response

to the Medication

with Actual Side

Effects

CEPHALOSPORIN

Ceftazidime

DO: 06-23-07

DP: 06-23-07

DC: 06-28-07

IV 300mg every 8

hours

An anti-infective

drug which

eliminates bacteria

that cause many

kinds of infections,

including lung, skin,

bone, joint,

stomach, blood,

gynecological, and

urinary tract

infections.

The patient had

skin rashes on his

face, abdomen and

back for the first 3

days of medication.

The patient

manifested a

decrease infection

as evidence by

absence of fever as

of 06-27-07 until

discharged.

Nursing Responsibilities:

Page 92: Case Study

Prior to the procedure:

Check doctor’s order.

Check patient’s sensitivity to penicillin and to other cephalosporins.

Explain to the action of the drug.

During the procedure:

Recompute the drug formula and inspect for the patency of the needle.

Check for any resisitence.

Clean the IV port with an alcohol before injecting the medication.

Push the IV medication slowly as possible.

After the procedure:

Observe for any discomfort in the IV insertion site.

Tell the S.O to immediately report any signs of adverse effect.

Document.

Page 93: Case Study

Name of Drugs

Generic Name

Brand Name

Date Ordered

Date Taken/Given

Date Changed/DC

Route of

Administration,

Dosage and

Frequency of

Administration

Indication(s) and

Purposes(s)

Client Response

to the Medication

with Actual Side

Effects

ALBUTEROL

Salbutamol

DO: 06-23-07

DP: 06-23-07

DC: 06-28-07

Inhalation

(nebulizer) 1 every

4 hours.

Salbutamol is used

in cases of

bronchospasm in

patients with

reversible airway

obstruction: mild

and moderate

attacks of dyspnea

in patients suffering

from bronchial

asthma; mild and

moderate

bronchoobstruction

in patients with

After the each

medication the

patient feels relief

and able to

expectorate

secretions easily.

Page 94: Case Study

chronic bronchitis

and lung

emphysema.

Nursing Responsibilities:

Prior to the procedure:

Check doctor’s order.

Assess for the lung sounds, pulse and blood pressure before administration.

Warn the S.O for possible paradoxical bronchospasm.

During the procedure:

Put the medication into the inhaler and shake it well.

Clear nasal passenges and throat.

Place the mouthpiece well into mouth as dose from the inhaler is released, and instruct the patient to inhale

deeply. Perform chest-physio therapy.

After the procedure:

Instruct the S.O on how to perform nebulisation.

Emphasize to the S.O to take missed dose as soon as remembered, spacing remaining doses at regular

interval.

Do not double the dose or increase the dose or frequency of dosage.

Document.

Page 95: Case Study

Name of Drugs

Generic Name

Brand Name

Date Ordered

Date Taken/Given

Date Changed/DC

Route of

Administration,

Dosage and

Frequency of

Administration

Indication(s) and

Purposes(s)

Client Response

to the Medication

with Actual Side

Effects

ACETAMINOPHEN

Paracetamol

Tempra

DO: 06-23-07

DP: 06-23-07

DC: 06-23-07

DO: 06-23-07

DP: 06-24-07

DC: 06-28-07

V 90cc every 4

hours if

temperature

is > 38.8 degree

Celsius

Oral (drops) 1ml or

1 tsp. every 4 hours

It is a common

analgesic and

antipyretic drug

that is used for the

relief of fever,

headaches, and

other minor aches

and pains.

The patient’s body

temperature

decreases from 40

degree Celcius to

37.5 degree

Celcius.

The client’s body

temperature was

maintained within

the normal range.

Page 96: Case Study

Nursing Responsibilities:

Prior to the procedure:

Check doctor’s order.

Explain the action of the drug.

Assess fever note presence of associated signs like diaphoresis, tachycardia and malaise.

Tell the S.O that this drug can be taken with food or an empty stomach.

During the procedure:

IV: Clean the IV port before slowly injecting the medication.

ORAL (drops): Drop medication at the side of the cheeks to prevent aspiration.

After the procedure:

Advice the S.O to check concentrations of liquid preparations. Errors have resulted in serious liver damage.

Have the S.O determine the correct formulation and dose for their child.

Document.

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B.1.c Diet

Type of Diet Date OrderedDate

PerformedDate

Changed/DC

General Description

Indication(s) and

Purpose(s)

Specific Food Taken

Client’s Response

and/or Reaction to

the DietDAT

REGULAR DIETDIET AS

TOLERATED

DO: 06-23-07DP: 06-23-07DC: 06-28-07

Ordered when the client’s

appetite, ability to eat, and

tolerance for certain food may change.

To increase the caloric intake of

food to maintain or

achieve optimal health status.

This diet is indicated to

ambulatory or bed patients

whose conditions to

not necessitate a modified diet.

Food rich in iron such as liver

and dark green leafy

vegetables.

The client appetite was increased.

Nursing Responsibilities:

Prior to the procedure:

Check doctor’s order.

Advice the S.O to give the food to the patient in an appetizing manner.

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Instruct the S.O to give nutritious and balance foods to the patient.

During the procedure:

Stress the importance of compliance to the diet.

If the patient loss his appetite, instruct the S.O to give food to the patient in a small frequent feeding.

After the procedure:

Assess the patient’s health status.

Compare previous health status from the present.

Document.

B.1.d Activity Exercise

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Type of Exercise Date Ordered

Date Performed

Date Changed/DC

General

Description

Indication(s) and

Purpose(s)

Client’s Response

and/or Reaction

to the

Activity/Exercise

CBR with

elevated HOB

DO: 06-23-07

DP: 06-23-07

DC: 06-28-07

The patient is

required to stay in

bed to reduce

metabolic activity

and to facilitate

proper lung

expansion for easy

breathing.

Bed rest- rest

prevents tissue

oxygen demand

and enhances

tissue oxygen

perfusion. While

elevated head of

bed facilitates lung

expansion to

enhance breathing.

The client reached

his optimum level

of recovery.

Nursing Responsibilities:

Prior to the procedure:

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Check doctor’s order.

Explain the importance of complying in the said exercise.

Monitor patient’s vital signs.

During the procedure:

Provide a relaxing resting environment to the patient.

Observe the patient for any difficulty in performing the said exercise.

After the procedure:

Assess patient condition after the exercise.

Document.

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B.2 Nursing Management

Actual Nursing Care

(SOAPIE)

June 26, 2007 Tuesday

S> “Manguku ya ampong lalagnat” as verbalized by the S.O

O> received patient lying on bed in a supine position with mother,

restless, conscious, with an IVF out of D5IMB, skin warm to

touch, with skin rashes on face, abodomen and back, febrile, with

productive cough, (-)DOB, pale, with rales on both lung field, with

vital signs as follows T:38.1ºC CR:150bpm RR:29cpm

A> Hyperthermia

P> After 6 hours of nursing interventions, patients temperature will

decrease from 38.1 ºC to 37.5 ºC.

I> >Established rapport.

>Monitored and recorded vital signs.

>Assessed patient’s condition.

>Provided comfort measures such as changing patient’s clothes.

>Maintained back dry and encouraged loosen patient’s clothing.

>Performed TSB.

>Emphasized to the mother the importance of increasing the

fluid intake of the child.

>Encouraged the mother to give the child nutritious foods rich in

iron such as liver and dark green leafy vegetables.

>Instucted and performed chest physiotherapy after

nebulization.

>Reinfused IVF @ 9:00am and regulated.

>Administered medications per doctors order.

E> Goal met. As evidence by decreased patients body temperature

to 37.5 ºC.

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June 27, 2007 Wednesday

S> “Masalese ne, okay neng mangan, kayamu nengkayi sasanat

yapa ampong sisispun” as verbalized by the S.O

O> received patient lying on bed in a supine position with mother,

aware, conscious, with IVF of D5IMB 500cc ×28-29 µgtts/min @

200cc level, infusing well at his right foot, with pale palpebral

conjunctiva, with rales onboth lung field, with vital signs as

follows T: 37.4 ºC CR:150bpm RR:23cpm

A> Ineffective airway clearance related to retained secretions.

P> After 4-6 hours of nursing interventions the patient will maintain

airway patency.

I> >Established rapport.

>Monitored and recorded vital signs.

>Assessed patient condition.

>Maintained back dry.

>Auscultated lungs for crackles, consolidation and pleural

friction rub.

>Assessed characteristics of secretions, quantity color

consistency and odor.

>Stressed the importance of increasing fluid intake.

>Positioned patient in elevated HOB for optimal breathing

pattern.

>Encouraged the S.O to give the patient high caloric foods.

>Instructed the S.O to give foods rich in Iron like liver and dark

green leafy vegetables and Vitamin C.

>Performed and instructed chest-physio therapy and postural

drainage after nebulization.

>Encourage bed rest.

>Administered meds per doctor’s order.

E> Goal met. As evidence by patient’s maintenance patent airway.

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VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL

1. Clients Daily Progress chart (from admission to discharge)

DAYS June 23,

2007 24-Jun-07 25-Jun-07 26-Jun-07 27-Jun-07June 28.

2007

Nursing ProblemsIneffective Airway

Clearnce * * * * *  Imbalace Nutrition:

less than body requirements * * *

 

 Risk for Infection

(spread) * * * *    Impaired Gas

Exchange * * * *    

Hyperthermia * * *    

Vital SignsT: 40ºC 37.8 ºC 38.4 ºC 38.1 ºC 37.4 ºC 37.3 ºC

CR: 101bpm 150bpm 150bpm 129RR: 37cpm 29cpm 23cpm 27cpm

Diagnostic ExamsCBC  Hematocrit:

0.29Hemoglobin:

     Hemoglobin: 9-6

Hematocrit:

   

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88WBC: 11.8

Neutrophils: .62

Lymphocytes: .33

Monocytes: .05

Platelet:153

31-0WBC: 3.6

Differential count

Polys: 68Lymphocyte

: 91Eosinophil:

01Platelet: 184

X-tray    

Hazy infiltrates are noted on both lower

lungfields; Heart is

normal in size;

Diaphragm and

sulci are intact; Other chest

structures are

remarkable      

Urinalysis Color: Yellow          

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Transparency: ClearpH: 7.5Specific Gravity: 1.010

Albumin: NegativeSugar:

NegativeMicroscopic

ExamPus Cell: 0-

3/hpfRBC: 2-5/hpf

Epithelial Cells: Rare

Medical ManagementIVF            D5 IMB * * * *D5 LRS * * *NebulizationNebulization * * * * * *Drugs

Acetaminophen          Paracetamol IV *Tempra PO * * * * *

Albuterol          

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Salbutamol * * * * * *Cephalosporin

Ceftazidime * * * * * *Diet          Diet as tolerated * * * * * *Exercise/ActivityCBR with elevated HOB * * * * * *

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VII. DISCHARGE PLANNING

A. General condition about the client upon discharge.

The client achieved his optimum health status after his

hospitalization. He has already adequate ventilation and oxygenation.

There were no complications noted. Still, on the process of recovery.

B. METHOD

M> Vitamin C 1 tsp once a day

Nebulization: Salbutamol once a day

E> >Deep breathing exercise.

>have adequate rest

T> >Instruct to follow treatment regimen.

>Instruct the S.O to perform chest physiotheraphy after nebulisation.

>Emphasize that too much nebulization my cause paradoxymal

spasm.

H> >Increase fluid intake

>Avoid strenuous activities

>Eat high caloric foods, rich in iron and vitamin C

>Maintain back dry

>Warn the S.O to report any signs and symptoms of the disease

condition that she had observed immediately to the physician or nurse.

Like elevated temperature, diaphoresis, difficulty of breathing,

persistent cough and cold or flu.

>Encourage proper handwashing.

>Have an adequate rest.

O> >Instructed to come back after a week for check up.

D> >DAT

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VIII. CONCLUSION AND RECOMMENDATION

The proponents of this study conclude about the effect of low socio-

economic status and nutritional deficiency to the vulnerability of an

individual against microorganisms. They are as follows:

• The environment plays a vital role in the health of a person.

• The viruses and bacteria that cause pneumonia are contagious and are

usually found in fluid from the mouth or nose of an infected person.

• Illness can spread when an infected person coughs or sneezes on a

person, by sharing drinking glasses and eating utensils, and when a person

touches the used tissues or handkerchiefs of an infected person.

• Risk for infection will always be blamed to the decrease in the primary

defenses as well as with the virulence of a microorganism.

The proponents of this study recommends the following:

If your child's doctor has prescribed antibiotics for bacterial

pneumonia, give the medicine on schedule for as long as the doctor

directs. This will help your child recover faster and will decrease the

chance that infection will spread to other household members.

Don't force a child who's not feeling well to eat, but encourage your

child to drink fluids, especially if fever is present. Ask your child's

doctor before you use a medicine to treat your child's cough because

cough suppressants stop the lungs from clearing mucus, which may

not be helpful in some types of pneumonia.

If your child has chest pain, try a heating pad or warm compress on the

chest area. Take your child's temperature at least once each morning

and each evening, and call the doctor if it goes above 102 degrees

Fahrenheit (38.9 degrees Celsius) in an older infant or child, or above

100.4 degrees Fahrenheit (38 degrees Celsius) in an infant under 6

months of age.

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Check your child's lips and fingernails to make sure that they are rosy

and pink, not bluish or gray, which is a sign that your child's lungs are

not getting enough oxygen.

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VIII. CONCLUION AND RECOMMENDATION

A. Nurse-centered

The researchers were able to gain knowledge and deeper understanding

of the disease process itself and impart health teachings regarding the

client’s condition in maintaining an optimum level of functioning. Plus, the

researches were able to accomplish the following:

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

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.

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In relation to the patient’s condition, the proponents were also able to

accomplish these tasks:

1. Gain knowledge about the disease of Baby Clark Kent;

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.

The proponents of this study conclude about the effect of low

socio-economic status and nutritional deficiency to the vulnerability of

an individual against microorganisms. They are as follows:

The environment plays a vital role in the health of a person.

The viruses and bacteria that cause pneumonia are contagious and are

usually found in fluid from the mouth or nose of an infected person.

Illness can spread when an infected person coughs or sneezes on a

person, by sharing drinking glasses and eating utensils, and when a

person touches the used tissues or handkerchiefs of an infected

person.

Risk for infection will always be blamed to the decrease in the primary

defenses as well as with the virulence of a microorganism.

The proponents of this study recommends the following:

If your child's doctor has prescribed antibiotics for bacterial

pneumonia, give the medicine on schedule for as long as the doctor

directs. This will help your child recover faster and will decrease the

chance that infection will spread to other household members.

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Don't force a child who's not feeling well to eat, but encourage

your child to drink fluids, especially if fever is present. Ask your child's

doctor before you use a medicine to treat your child's cough because

cough suppressants stop the lungs from clearing mucus, which may

not be helpful in some types of pneumonia.

If your child has chest pain, try a heating pad or warm compress

on the chest area. Take your child's temperature at least once each

morning and each evening, and call the doctor if it goes above 102

degrees Fahrenheit (38.9 degrees Celsius) in an older infant or child, or

above 100.4 degrees Fahrenheit (38 degrees Celsius) in an infant

under 6 months of age.

Check your child's lips and fingernails to make sure that they are

rosy and pink, not bluish or gray, which is a sign that your child's lungs

are not getting enough oxygen.

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