Vous êtes sur la page 1sur 10

INTRODUCTION Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including

viruses, bacteria, fungi, and parasites. Most cases of pneumonia are caused by viruses, includingadenoviruses, rhinovirus, influenza virus (flu), respiratory syncytial virus (RSV), and parainfluenza virus (which causes croup). Often, pneumonia begins after an upper respiratory tract infection (an infection of the nose and throat), with symptoms of pneumonia beginning after 2 or 3 days of a cold or sore throat. Signs and Symptoms Symptoms vary depending on the age of the child and the cause of the pneumonia, but common ones include:

fever chills cough nasal congestion unusually rapid breathing (in some cases, this is the only symptom) breathing with grunting or wheezing sounds labored breathing that makes the rib muscles retract (when muscles under the ribcage or between ribs draw inward with each breath) and causes nasal flaring vomiting chest pain abdominal pain decreased activity loss of appetite (in older kids) or poor feeding (in infants), which may lead to dehydration in extreme cases, bluish or gray color of the lips and fingernails

Someone with pneumonia in the lower part of the lungs near the abdomen might have fever and abdominal pain or vomiting but no breathing problems.

Kids with pneumonia caused by bacteria usually becomes sick fairly quickly and will have a sudden onset of a high fever and unusually rapid breathing.

Kids with pneumonia caused by viruses probably will have symptoms that appear more gradually and are less severe, though wheezing can be more common in viral pneumonia.

Some types of pneumonia cause symptoms that give important clues about which germ is causing the illness. For example, in older kids and adolescents, pneumonia due to Mycoplasma (also called walking pneumonia) is notorious for causing a sore throat, headache, and rash in addition to the usual symptoms of pneumonia. In infants, pneumonia due to chlamydia may cause conjunctivitis (pinkeye) with only mild illness and no fever. When pneumonia is due to whooping cough (pertussis), a child may have long coughing spells, turn blue from lack of air, or make the classic "whoop" sound when trying to take a breath.

Name:patient X Address: Bokawkan Rd. Baguio City Age: 4yrs Birthday: December 28, 2007 Sex: Male Nationality: Filipino Religion: Roman Catholic Date & Time of Admission: Dec 5, 2011 Mode of Arrival: cuddled by mother Chief Complaint: abdominal pain, cough and colds Source of Information: patient, & chart, SO Admitting Diagnosis: severe Pneumonia Final Diagnosis: severe Pneumonia

NURSING HISTORY PAST MEDICAL HISTORY According to the patients SO, he had completed his childhood immunization. He had no allergy to foods or medications. He experienced common diseases such as fever, cough and colds he usually took OTC drugs (Paracetamol syrup, Neozep syrup) to manage his fever cough and colds. On June 2010 the patient was admitted at Government Hospital due to illness. HISTORY OF PRESENT ILLNESS According to the SO, 3 days prior to admission the patient experienced sudden onset of squeezing pain at Para gastric area aggravated by activity. No meds taken or consultation made. 2 days PTA the patient still has the same abdominal pain, this time was more severe, and associated with DOB and fever of 38C. His mother gave him paracetamol. No consultation was made. Few hours PTA, the patient could not any more tolerate the pain; he was brought to BGH-MC hence he was admitted. FAMILY HEALTH HISTORY According to the patient SO, both his maternal and paternal have a history of Cancer, PTB, and Bronchial Asthma. PTB is evident on the patients grand father and uncle while cancer and bronchial asthma is evident on the patient aunt. Personal/ Social History The patient is the 3rd among 4 siblings. He lived with 7 other households member. His father worked as a garbage collector and his mother is a housewife, they consume or use tap and not boiled water.


Date assessed: Dec 2011 Time: 7pm Initial vital signs: T=37.9 PR=140bpm RR=25cpm General Appearance: the patient is conscious and coherent with ongoing of D5NM 500ml at 750cc level hook at his left arm, intact and infusing well skin Skin normally dry Skin is moist d/t hyperthermia Normally warm 37.9 o C d/t hyperthermia Hair Texture Smooth Rough Due to poor hygiene Thorax and Lungs Auscultation Clear breath Sounds Presence of breath sound Due to congestion Nose and Teeth Nares Inspection Oval, symmetric and without discharge Oval, symmetric but with discharge Due to the presence of colds Teeth Inspection Firmly set, shiny Firmly set, shiny with tooth decay Due to poor hygiene

HEMATOLOGY RESULTS Dec.6, 2011Parameter Normal Value Results Analysis WBC 5-10 x 10 g/L 18.1 Increased due to infection Hgb M 140-170g/dl 165 Increased due to infection Hct M 39%-54% .30 Decreased RBC 4.6- 10 g/l 10.4 Increase due t o hypoxia Differential Count Lymphocytes 20%-40% .50 Increased due to infection

HEMATOLOGY RESULTS Dec.6, 2011Parameter Normal Value Results Analysis WBC 5-10 x 10 g/L 18.1 Increased due to infection Hgb M 140-170g/dl 165 Increased due to infection Hct M 39%-54% .30 Decreased RBC 4.6- 10 g/l 10.4 Increase due t o hypoxia Differential Count Lymphocytes 20%-40% .50 Increased due to infection

ASSESSMENT DIAGNOSIS Subjective: hindi ako makahinga ng mabuti as verbalized Objective: Use of accessory muscle. Dyspnea Fatigue. V/S taken as follows: T: 37.9 PR: 140 bpm RR: 25cpm - ( + ) crackles - tachypnea - ineffective cough Ineffective airway clearance r/t increase pulmonary secretion as evidenced by ( + ) crackles, tachypnea, ineffective cough PLANNING STO: After 4 hours of nursing interventions, the patient will be able to demonstrate cooperation on therapeutic regimens to be done INTERVENTION RATIONALE >auscultated breath > to ascertain sound and assessed status and note air movement progress >Lowers diaphragm, promoting chest expansion and expectoration of secretions. EVALUATION STO: After 4 hours of nursing interventions, the patient was able to demonstrate cooperation on therapeutic regimens to be done

>Elevated head of the bed, change position frequently.

LTO: After 3-4days of nursing interventions, the patient will display patent airway with breath sounds clearing airway and absence of dyspnea.

>Assist patient with deep breathing exercises.

>Coughing is a natural self cleaning mechanism.

>Forced fluids to at least 3000 ml per day and offer warm, rather than cold fluids.

>Provided supplemental fluids. .

>Fluids especially warm liquids aid in mobilization and expectoration of secretions. >Fluids are required to replace losses and aid in mobilization of secretion > To avoid irritation of airway caused by allergens. >to mobilized secretion

LTO: After 3-4 days of nursing interventions, the patient was able to display patent airway with breath sounds clearing airway and absence of dyspnea.

>| kept the environment allergens free

> gave expectorant ( bronchodilator ) as >Demonstrated or help patient learn to perform activity like splinting chest

>Splinting reduces chest

and effective coughing while in upright position.

discomfort, and an upright position favors deeper, more forceful cough effort.

Assessment Subjective: Mainit siya hawakan as verbalized by the mother

Diagnosis Hyperthermia r/t inflammatory response of the body as evidence by increase in core temperature

Planning After 2hours of nursing interventions the patient will have lowered temperature from 37.9-37.5 C

Intervention > monitored V/S > Performed tepid sponge bath > demonstrated proper performance of TSB > instructed the SO to keep the patient rested

Rationale > for baseline data > to facilitate heat loss through evaporation and conduction > to provide proper knowledge and to empower the SO in taking care of the patient To slow down the patient metabolism > aid in lowering down the temperature

Evaluation Goal met as evidenced by lowered temperature from 37.9-37.5 C

Objective Temp 37.9C Skin warm to touch Flushed skin Dry mouth

> administered antipyretics as ordered

Assessment Objectives:







Name of the Drug Dosage Mechanism of action 18 mg IV q 8 hours Ranitidine is a specific, rapidly acting histamine H2antagonist. It inhibits basal and stimulated secretion of gastric acid, reducing both the volume and the acid and pepsin content of the secretion. Duodenal & benign gastric ulcer Patients known to have hypersensitivity to ranitidine or to any component of Zantac Injection. > Immune System Disorders: (urticaria, angioneurotic edema, fever, bronchospasm, and hypotension and chest pain > Nervous System Disorders:Headache (sometimes severe), dizziness >Gastrointestinal Disorders: Acute pancreatitis, diarrhea Indication Contraindication Adverse effect Nursing responsibility

Generic name: ranitidine brand name: Zantac Classification: Antacids, Antireflux Agents & Antiulcerants

> assess patient abdominal pain. Not presence of blood in emesis, stool or gastric pain > drug may be added to total parenteral nutrition

Name of the Drug

Dosage Mechanism of action Facilitates/ potentiates the inhibitory activity of GABA at the limbic system and reticular formation to reduce anxiety, promote calmness and sleep


Contraindication Adverse effect

Nursing responsibility

3-12 Salbutamol yrs4mg tab BRAND BID NAME:Ventolin vilmax

Reversible airway obstruction including bronchial asthma, chronic brochitis


Fine tremor of skeletal muscle, feeling of tension, a compensory small increase in heart rate, headache, muscle cramps

> drug may be decrese sensitivity of spirometry used for diagnosis of asthma >syrup may be taken as young as age 2 >monitor for evidence of allergic rxn

Name of the Drug Cefuroxime Cefuroxime

Dosage Mechanism of action 750 mg IV q 6h Cefuroxime, a semisynyhetic, broadspectrum second generation cephalosporin antibiotic, exerts its bactericidal activity by interfering with the synthesis of the bacterial cell wall. It binds to penicillinbinding protein 3 responsible for the synthesis of peptidoglycan, a hetoropolymeric structure that gives the cell wall its mechanical stability.


Contraindication Adverse effect

Nursing responsibility

Indicated in the treatment of the following infections due to cefuroximesensitive organisms >Lower respiratory tract infections including pneumonia >Urinary tract infection >Skin and skin structure infections >Septicemia >Meningitis .Gonorrhea

Known allergy to the cephalosporin group of antibiotic

CV: phlebitis, thrombophlebitis GI: diarrhea, nausea, vomiting, anorexia Hematologic: hemolytic anemia, eosinophilia Skin: maculopapular and erythomatous rashes, urticaria, pain, indurations, sterile abscesses, temperature elevation

>Before giving drug, ask patient if he is allergic to penicillin or cephalosporin. >Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin while waiting the results >Monitor patient for signs and symptoms of super infection

Name of the Drug

Dosage Mechanism of action 1.2 mL q 4 hr PRN Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS

Indication Adverse effect

Nursing responsibility

Acetaminophen ( Paracetamol ) Classification: antipyretics, nonopioid analgesics

Mild pain Fever

Hema: hemolytic anemia, neutropenia, leukopenia, pancytopenia.Hepa: jaundice Metabolic: hypoGGI: HEPATIC FAILURE, HEPATOTOXICITY (overdose). GU: renal failure (high doses/chronic use). Derm:

BEFORE: > Advise parents or caregivers to check concentrations of liquid preparations. Errors have resulted in serious liver damage.~ Assess fever; note presence of

rash, urticaria.

associated signs (diaphoresis, tachycardia, and malaise). DURING: >Adults should not take acetaminophen longer than 10 days and children not longer than 5 days unless directed by health care professional.~ Advise mother or caregiver to take medication exactly as directed and not to take more than the recommended amount. AFTER: >Advise patient to consult health care professional if discomfort or fever is not relieved by routine doses of this drug or if fever is greater than 39.5C (103F) or lasts longer than 3 days.