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TABLE OF CONTENTS

TITLE

PAGE NO:

I. INTRODUCTION..1 II. OBJECTIVES...2

a. General objectives b. Specific objectives III. NURSING HEALTH HISTORY ......3-5 IV. Physical assessment.....6-8
V. Anatomy and Physiology ............9-13

VI. Pathophysiology, Etiology, ......14-15

VII. Laboratory Diagnostic result ..16-20 VIII. Medical management....21-25

a. Drug study IX. Nursing care plans...26-28 X. Prognosis...29 XI. Discharge plan and recommendations.30

I.INTRODUCTION
Pneumonia is an infection of the lung parenchyma. Community-acquired pneumonia refers to pneumonia acquired outside of hospitals or extended-care facilities

CAP is a common illness in all parts of the world. It is a major cause of death among all age groups. In children, the majority of deaths occur in the newborn period, with over two million worldwide deaths a year. In fact, the WHO estimates that one in three newborn infant deaths are due to pneumonia. Mortality decreases with age until late adulthood; elderly individuals are particularly at risk for CAP and associated mortality.

Although viral pneumonias are common in school-aged children and adolescents and are usually mild and self-limited, these pneumonias are occasionally severe and can rapidly progress to respiratory failure, either as a primary manifestation of viral infection or as a consequence of subsequent bacterial infection.

Despite a broad armamentarium of antimicrobials available to treat the disease, pneumonia remains the seventh leading cause of death in the United States. In 2003, the ageadjusted death rate caused by influenza and pneumonia was 20.3 per 100,000 persons. Estimates of the incidence of community-acquired pneumonia range from 4 million to 5 million cases per year, with about 25% requiring hospitalization.

The United Nations Children's Fund (UNICEF) estimates that 3 million children die worldwide from pneumonia each year; these deaths almost exclusively occur in children with underlying conditions, such as chronic lung disease of prematurity, congenital heart disease, and immunosuppression. According to the WHOs Global Burden of Disease 2000 Project, lower respiratory infections were the second leading cause of death in children younger than 5 years (about 2.1 million [19.6%])

It is due to the motive to learn and apply our knowledge and skills in caring the patient with pediatric community acquired pneumonia (PCAP). This is a rare case since the patient is only 6 month old..

II. OBJECTIVES
a. GENERAL OBJECTIVES

After this case study, we will be able to know what are Pneumonia, how it is acquired and prevented, its prevention and treatments of its occurrence.

b. SPECIFIC OBJECTIVES

Define what is Pneumonia

Trace the pathophysiology of Pneumonia

Enumerate the difference signs and symptoms of pneumonia

Formulate and apply nursing care plans, utilizing the nursing process

To learn new clinical skills as well as sharpen our current clinical skills required in the management of the patient with Pneumonia

To develop our sense of unselfish love and empathy in rendering nursing care to our patient so that we may able to serve future clients with higher level of holistic understanding as well as individualized care.

II. NURSING HEALTH HISTORY


A. BIOGRAPHIC DATA Client MT is a 6 month old, female, was born January 28, 2010 in Biday, San Feranando City La Union. She is the youngest daughter of Mr and Mrs NT. She is a Roman Catholic. She was admitted on July 31, 2010 9:40 PM at Lorma Medical Center by Dr. Rapisura, Carie Q.,MD and Dr. Orlindo, Maria Teresa V.,MD as her attending physician.

B. CHIEF COMPLAINT The patient was admitted due to the chief complaint of high grade fever, 38.6 C via axilla, productive cough and difficulty of breathing.

C. HISTORY OF PRESENT ILLNESS The present condition started 3 days prior to admission when the patient had dry cough with associated difficulty of breathing. No other associated signs and symptoms such as diarrhea and vomiting. No consultation done or medication taken. 2 days prior to admission, the above condition persisted associated with neither fever, still no consultation done nor medication taken. Few hours prior to admission, due to persistence of the above condition, she was then brought in the institution and was then admitted on July 31, 2010 at 9:40PM with the vital signs of T-38.6C, PR-135bpm, RR-68bpm, O2sat-98%, weight-6.4kg, height-58.5cm and a BMI of 18.90 kg/m2 (healthy weight) 22 as ideal with a range of 18.5-25

D. PAST MEDICAL HISTORY The mother stated that the patient was not hospitalized nor had illnesses before. The patient had no allergies to drugs. The mother also claimed that the patient already received her BCG and Hepa B vaccines, 1 dose each, 1 week after her birth at the health center, and had her vaccines in DPT and OPV with 1 dose each when she was 6 th week old.

E. PEDIA HISTORY

The patient was born to a 33 year old mother with a 38-39 weeks age of gestation via NSD at home. The mother stated that there were no complications happened nor the mother acquired illnesses during her pregnancy period.

F. FAMILY HEALTH HISTORY

The mother of the patient claimed that both sides of the patient has history of asthma. And no other hereditary illnesses present such as diabetes, cancer and hypertension.

G. LIFESTYLE

In an interview, mother said that their house is a concrete bungalow, located along the highway and near to other houses. The patient is a pure breastfed baby, the mother verbalized that she didn't introduced any solid foods yet. The family is using firewood in cooking their foods. While their drinking water comes from a well which the mother boils before giving to her children. They are also using dipper in taking a bath and flushing their toilet. The mother also claimed that the patient's uncle who lives with the family is an active smoker. And this can one of the precipitating factors that contributed on the patients cas e for her lungs are still sensitive since patient is still 6 month old. Health teaching was done to the mother by encouraging the mother to advice the uncle to minimize smoking and not to smoke near their house.

H. SOCIAL HISTORY

The mother also claimed that, their family are active and concern citizen of the community, they also mingles with their neighbors and always active participates in activities, education in their community. Just like a typical family relationships, there are some misunderstanding experienced by the family but usually it only lasted for a day, they fix the problem in a calm manner.

The patient's mother described their family as a traditional Filipino family, wherein they eat together, live together and giving respect with one another.

I. HEALTH PRACTICES

When a member of the family got sick, they always consult to a medical doctor. They don't have any private family physician. They also believe in hilot but they never use any herbal medicines that were being prescribed to them, they only taking medicines which are prescribed only by a physician.

IV. PHYSICAL ASSESSMENT


I. GENERAL STATISTICS A Filipino female client, conscious and with a normal body built.

A. Vital signs RR: 60 bpm TEMP: 36.5 C CR: 142 bpm OXYGEN SAT: 99% B. Height and weight: Height 58.5 cm Weight- 9kg

II. HEAD AND NECK A. Head The head is round with no nodules or masses and depressions. B. Eyes The eyes are symmetrically aligned and eyebrows are evenly distributed with no discharge or discoloration on the eyelids. Conjunctiva on both eyes is pinkish in color, and the sclera is normal in color. The pupils are black round and equal in size and are reactive to light and accommodation. C. Ears The ears are symmetrically aligned and the color is same as the facial skin, it is firm and not tender. No serum and discharges noted. D. Nose The nose is symmetrically aligned with the face, no discharges, with flaring nares. It is the same color with the face. It is not tender and no lesions present. The mucosa is pink. The sinuses are not tender when palpated. 7

E.

Mouth

The lips are pinkish in color and moist. No ulcerations or lesions noted. The tongue moves freely and not tender. The client possesses pink gums with no teeth yet.

III. INTEGUMENT: 1. Skin The skin of the client is moist, pale and has a good skin turgor. Has a fair skin complexion. 2. Hair and Scalp The hair are equally distributed with a thin hair strands; well kept; no lice or dandruff seen/noted. 3. Nails Clients nails are normally transparent and convex. The surrounding cuticles are intact and without inflammations noted. Has a normal capillary refill with 1 to 2 seconds. IV. THORAX and LUNGS The chest contour is symmetrical, the spine is vertically aligned. The chest wall is intact, no tenderness or no masses noted. Upon auscultation rales was being noted. V. HEART There is no presence of abnormal pulsations when the heart was auscultated. No murmurs and friction rubs heard upon auscultation.

VI. BREAST The breasts are even with the chest wall, skin is smooth and intact. Areola is round and bilaterally the same. The nipples are round and equal in size, no discharge noted. The breast are not tender, no masses or nodules noted.

VII. ABDOMEN The abdomen is intact, round and with normal bowel sound heard upon auscultation. Has a darken umbilicus. No deformities seen.

VIII. EXTREMITIES:

On the upper extremities no deformities noted. The has a D5IMB L at the left hand. While on the lower extremities, no deformities were noted.

IX. GENITAL AND RECTAL:

Upon inspection there were no deformities, no rashes, no abnormal secretions were present.

IV. ANATOMY AND PHYSIOLOGY

Anatomically, the respiratory system structures are divided into: Upper respiratory tract and Lower respiratory tract The upper respiratory tract is located in the head and neck and consists of the: Nose Pharynx Larynx

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NOSE: Regions of the nose include the external nose and the nasal cavity. Air moves from the nostrils to the back of the nasal cavity where it exits through the posterior nares. The function of the nasal cavity is to clean, warm and dampen the air that enters so that it can travel throughout the body. REGIONS OF THE PHARYNX: Air moves into the nasal cavity through the nostrils (nasopharynx). The oropharynx opens into the oral cavity which encloses the lips, teeth, cheek, hard and soft palates, tongue and tonsils. Extending from the tip of the epiglottis to the glottis and the esophagus is the laryngopharynx and positioned in the anterior neck is the larynx. LARYNX The larynx is a passageway between the pharynx and the lower airway structures. It is a short tube made up of supportive cartilage, ligaments, muscle and mucosal lining. The supportive cartilage prevents food and drink from entering the larynx while swallowing. The lower respiratory tract is located in the chest and makes up the: Trachea Bronchial tree Lungs Air passes from the larynx to the lungs (trachea).The trachea divides into the right and left primary bronchi (bronchial tree) and the large pair of spongy organs (lungs) are used for respiration. TRACHEA: Also known as the windpipe, the trachea is a 10-12cm tube that runs through the lower neck and chest. The wall of the trachea is made of hyaline cartilage which enables the trachea to stay open so that air can be conducted between the larynx and primary bronchi. BRONCHIAL TREE The bronchial tree consists of a primary, secondary (lobar) and tertiary bronchi (segmental bronchi). The trachea splits into the right and left bronchi at the level of the sternal angle. The secondary bronchi forms when the primary bronchus enters the lung; and conducts 11

air directly to one of the five lobes within the lung. Tertiary bronchi derive from the secondary bronchi and conduct air to and from the bronchial segment. There are 8 bronchial segments in the left lung and 10 in the right lung. LUNGS: The lungs are paired cone-shaped organs which take-up most of the space in the chest with the heart. Their role is to take oxygen into the body, which we need for the cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. There are two division of the lungs, the left and the right lung. These are divided up into lobes or big secretions of tissues separated by fissures or dividers. The right lung has three lobes but the left lung has only two, it is because the heart takes up some of the space in the left side of the chest. The lungs can also be divided up into even smaller portions, called bronchopulmonary segments. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives it's own blood supply and air supply. Air enters the lungs through a system pipes called the bronchi. Theses pipe start from the bottom of the trachea as the left and right bronchi and branch many times through out the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are important in the gas exchange where it takes place between the air and the blood. Covering alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can diffuse between them. Mechanics of Breathing To take a breath in, the external intercostals muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways. Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).

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Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over. Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.

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V. DISEASE ENTITY/ PATHOPHYSIOLOGY Precipitating Factor ENVIRONMENT LIFESTYLE

Predisposing Factor AGE (6months old)

Streptococcal Infection

Enters through nose or mouth by Inhalation

Passes to the pharynx, larynx & trachea

Microorganisms enters the affects both the lung parenchyma

Lung invasion Infection lodges and stimulates in the parenchyma Lung Invasion Leukocytes increased Narrowing of air passage Mucus and phlegm DIFFICULTY BREATHING

COUGHING INEFFECTIVEL Y

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Viral infections increase attachment of S. pneumoniae to the receptors on respiratory epithelium. Once inhaled into the alveolus, pneumococci infect type II alveolar cells. They multiply in the alveolus and invade alveolar epithelium. Pneumococci spread from alveolus through the pores of Kohn, thereby producing inflammation and consolidation along lobar compartments. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. Alveolar exudates tends to consolidate, so it is increasingly difficult to expectorate. Bacterial pneumonia may be associated with significant ventilation-perfusion mismatch as the infection grows.

Etiology : There are many causes of Pneumonia, including bacteria, viruses, mycoplasmas, fungal agents and protozoa. Pneumonia may also result from aspiration of food, fluids or vomitus or from inhalation of toxic or caustic chemicals, smoke, dusts, or gasses. Pneumonia may complicate immobility and chronic illnesses. Pneumonia often follows influenza and together they rank as the 7th leading cause of death in the US, and are the fifth leading cause in people older than 65.

Additional risk factors are dysphagia; exposure to air pollution; altered consciousness (from alcoholism, drug overdose, general anesthesia ,or a seizure disorder);inhalation of noxious substances; aspiration of food ,liquid or foreign or gastric material and residence in institutional settings, where transmission of the disease is more likely.

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VI. DIAGNOSTIC EXAMINATION / LABORATORY RESULTS


Cotabato Regional and Medical Center Laboratory Department HEMATOLOGY February 21, 2013 PARAMETERS RESULT REFERENCE RANGE Hemoglobin 117 115-155 -normal INTERPRETATION

Hematocrit

0.37

0.36-0.47 4.0 10.0

-normal

White Blood Cell

18.2

-Increase WBC may be due to inflammation

MCV

82.0

85.0-95.0

Low MCV indicates microcytic (small average RBC size),

MCH

25.7

28.0-32.0

Low MCH indicates low hgb content in RBC

MCHC

314

320-350

Low-MCHC red cells are hypochromic.

RDW-SD -segmenters

43 0.56

37-46 0.50-0.70

Normal Normal

-eosinophils

0.01

2..0-8.0

Decrease eosinophils may be due to inflammation

-basophils

0.2

0.00-0.5

Normal

-lymphocytes

23.7

19.0-48

Normal

-monocytes

7.9

3.0-9.0

normal

Platelet count

489

150-400

-high platelet count is a reaction to inflammation, infection, anemia,

Neutrophils

68.1

40.0-70.0

normal

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February 27, 2013

PARAMETERS

RESULT

REFERENCE RANGE

INTERPRETATION

Hemoglobin

106

115-155

-normal

Hematocrit

0.33

0.36-0.47 4.0 10.0

-normal

White Blood Cell

7.2

-Increase WBC may be due to inflammation

MCV

80.0

85.0-95.0

Low MCV indicates microcytic (small average RBC size),

MCH

26.0

28.0-32.0

Low MCH indicates low hgb content in RBC

MCHC RDW-SD -lymphocytes

321 43 23.7

320-350 37-46 19.0-48

Normal. Normal Normal

-monocytes

7.9

3.0-9.0

normal

Platelet count

507

150-400

-high platelet count is a reaction to inflammation, infection, anemia,

Neutrophils

68.1

40.0-70.0

normal

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March 6, 2013

PARAMETERS

RESULT

REFERENCE RANGE

INTERPRETATION

Hemoglobin

98

115-155

-normal

Hematocrit

0.31

0.36-0.47 4.0 10.0

-normal

White Blood Cell

5.2

-Increase WBC may be due to inflammation

MCV

80.0

85.0-95.0

Low MCV indicates microcytic (small average RBC size),

MCH

26.0

28.0-32.0

Low MCH indicates low hgb content in RBC

MCHC RDW-SD -lymphocytes

320 43 23.7

320-350 37-46 19.0-48

Normal. Normal Normal

-monocytes

8.0

3.0-9.0

normal

Platelet count Neutrophils

394 68.1

150-400 40.0-70.0

Normal normal

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Cotabato Regional and Medical Center

CHEST X-RAY

Chest x-ray including the anterior, posterior, and lateral was conducted last February 22, 2013. The result indicates hazy infiltrate on both lung fields. The heart is not enlarged. And the diaphragm and bony thorax are intact. The impression of the above results indicates that the patient has pneumonia.

IMPRESSION: PNEUMONIA

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