Saint Paul University Philippines

Tuguegarao City, Cagayan Valley 3500

School of Nursing and Allied Health Sciences

COLLEGE OF NURSING
CHED Center of Excellence in Nursing

PATIENT'S PROFILE

NAME: VV
AGE: 7 years old
GENDER: Male
ADDRESS: Enrile, Cagayan
DATE OF BIRTH: August 24, 2011
PLACE OF BIRTH: Enrile, Cagayan
RELIGION: Roman Catholic
HEIGHT: 119cm
WEIGHT: 21 kg
BMI: 14.38
NATIONALITY: Filipino
CHIEF COMPLIANT: Cough and fever with DOB
ADMITTING DIAGNOSIS: PCAP
FINAL DIAGNOSIS: PCAP
ATTENDING PHYSICIAN: Dr. R Amistad
DATE OF ADMISSION: November 25, 2016
DATE HANDLED: November 26, 2016

PNEUMONIA
Pneumonia

Lung inflammation caused by bacteria or viral infection, in which the air sacs fill with
pus and may become solid.
Inflammation may affect both lungs ( double pneumonia ), one lung ( single pneumonia ), or
only certain lobes ( lobar pneumonia ).
In most cases, the specific organism (such as bacteria or virus) cannot be identified even
with testing.1 When an organism is identified, it is usually the
bacteria Streptococcuspneumoniae.2
Many types of bacteria may cause pneumonia. Pneumonia caused by Mycoplasma
pneumoniae Mycoplasma pneumoniaeis sometimes mild and called "walking
pneumonia."
Viruses, such as influenza A (the flu virus) and respiratory syncytial virus (RSV) can
cause pneumonia.

SIGNS AND SYMPTOMS

The signs and symptoms of pneumonia vary from mild to severe, depending on factors
such as the type of germ causing the infection, and your age and overall health. Mild signs
and symptoms often are similar to those of a cold or flu, but they last longer.

Signs and symptoms of pneumonia may include:

Chest pain when you breathe or cough

Confusion or changes in mental awareness (in adults age 65 and older)

Cough, which may produce phlegm

Fatigue

Fever, sweating and shaking chills

Lower than normal body temperature (in adults older than age 65 and people with weak
immune systems)

Nausea, vomiting or diarrhea

 Shortness of breath

TYPES OF PNEUMONIA ACCORDING TO THE ILLNESS-CAUSING AGENT

A factor that has to be taken into consideration is the main agent that causes the infection. These
are just some of the main groups of pneumonia based on what ignites the disease:

Bacterial pneumonia: commonly caused by bacteria strains such as Streptococcus

pneumoniae, Chlamydophila pneumonia or Legionella pneumophila.
This affects people of all ages,4 leading to a weakened ability of the body to exchange oxygen
and carbon dioxide, breathlessness and pain when you try to take in oxygen.
Bacterial pneumonia cases can be mild or severe, depending on the strength of the bacteria
strain and how long until the disease is diagnosed and treated.

Viral pneumonia: triggered by viruses such as influenza, chickenpox, adenoviruses or

respiratory syncytial virus.7 You can catch viral pneumonia via coughing, sneezing or touching
an object that was contaminated by an infected person.
A patient with viral pneumonia doesnt just have swollen lungs, but blocked oxygen flow as
well.
Viral pneumonia is said to be responsible for one-third of all pneumonia cases. People who have
this type of pneumonia are also most likely to get bacterial pneumonia.

Mycoplasma pneumonia: generated by Mycoplasma pneumoniae, an atypical bacterium

thats considered to be one of the smallest agents that affect humans.10,11 This is why this type
of pneumonia is also called atypical or walking pneumonia.
Mycoplasma pneumonia affects people of all age groups,13 but its more common among
people who are less than 40 years old.14 The disease can be transferred easily via respiratory
fluids, leading to regular epidemics.
People who have this disease exhibit different symptoms and physical signs, but overall they
have mild and widespread pneumonia16 or dry cough.17 Most mycoplasma pneumonia cases
are mild.
Aspiration pneumonia: infections or inhalation of food, liquid, gases or dust lead to this type
of pneumonia.19 This illness goes by other names, such as necrotizing pneumonia, anaerobic
pneumonia, aspiration pneumonitis, and aspiration of vomitus.20 People with aspiration
pneumonia have inflammation minus the bacterial infection. Unfortunately, aspiration
pneumonia can be difficult to treat on some occasions because people who usually acquire this
disease are already sick to begin with.

Fungal pneumonia: produced by various endemic or opportunistic fungi. This causes fungal
infections, such as histoplasmosis, coccidioidomycosis, and blastomycosis that occur after
inhaling spores or conidia or reactivating a latent infection. It has to be noted that fungal
pneumonia cases are quite difficult to diagnose.
Although cases of fungal pneumonia are not so common in the U.S.,23 theyre prevalent in
Mexico and other South American countries, as well as African countries.

Types of Pneumonia According to Where the Infection Was Acquired

Another way to classify a pneumonia case is to know where you got infected with the
pneumonia-causing bacteria, virus or germ. There are three types of pneumonia that
are determined by the place where you acquired the disease:

Community-acquired pneumonia (CAP): happens after acquiring a common viral

infection, such as the flu. Patients who have CAP got the disease outside of hospitals or
other health care settings, such as at school or at work,26 and are consequently infected
with germs that are found in the mouth, nose or throat while they are sleeping.
Community-acquired pneumonia is the most common type of pneumonia, with
majority of the cases occurring during winter. According to the National Heart, Lung,
and Blood Institute, around 4 million Americans are affected every year, with 1 out of 5
people with CAP requiring hospitalization.

Hospital-acquired pneumonia (HAP): occurs when people are infected when theyre
admitted to a hospital for another illness. HAP tends to be more dangerous compared to
community-acquired pneumonia because youre already sick when youre infected with
HAP. Your risk for HAP even rises when you already use a ventilator. Plus, hospitals are
usually hotbeds for antibiotic-resistant germs.

Health care-associated pneumonia: refers to an infection in other health care settings

such as nursing homes, dialysis centers and outpatient clinic.

RISK FACTORS
No one is immune to pneumonia, but there are certain factors that can raise your risks:
 People who have had a stroke, have problems swallowing, or are bedridden can easily
develop pneumonia.
Infants from birth to age two are at risk for pneumonia, as are individuals age 65 or older.
People with weakened immune systems are at increased risk of pneumonia. This includes
people who take medications that weaken the immune system, such as steroids and certain
medications for cancer, and people with HIV, AIDS, or cancer.
Drug abuse increases risk. This includes excessive alcohol consumption and smoking.
Certain medical conditions raise your risks for pneumonia. These conditions include asthma,
cystic fibrosis, diabetes, and heart failure.
infants and children.
adults over age 65.
people who are ill or have impaired immunity.
long-term users of immunosuppressant drugs.
chronic obstructive pulmonary disease (COPD) patients who use inhaled corticosteroids
for long periods of time.
smokers.

DIAGNOSIS

Blood tests. Blood tests are used to confirm an infection and to try to identify the type of
organism causing the infection. However, precise identification isn't always possible.

Chest X-ray. This helps your doctor diagnose pneumonia and determine the extent and
location of the infection. However, it can't tell your doctor what kind of germ is causing
the pneumonia.

Pulse oximetry. This measures the oxygen level in your blood. Pneumonia can prevent
your lungs from moving enough oxygen into your bloodstream.

Sputum test. A sample of fluid from your lungs (sputum) is taken after a deep cough and
analyzed to help pinpoint the cause of the infection.

CT scan. If your pneumonia isn't clearing as quickly as expected, your doctor may
recommend a chest CT scan to obtain a more detailed image of your lungs.
 Pleural fluid culture. A fluid sample is taken by putting a needle between your ribs from
the pleural area and analyzed to help determine the type of infection.

MANAGEMENT AND TREATMENT

Oxygen therapy

While pulse oximetry

Any signs of dehydration and hypotension should be addressed where possible.

Intravenous (IV) access should be obtained and IV fluids should be administered

Nutrition

Antibiotic therapy should be commenced as soon as possibl

.Analgesia

Cough medicine.

Fever reducers/pain relievers.

HEALTH HISTORY
PAST HEALTH HISTORY

Patient VV completed all his vaccinations when he was 1 year old. He had chickenpox
and mumps when he's 3 years old. He has allergies to any kind of sea foods except fish. He
experiences rashes over his arm and chest whenever he eats such foods.

PRESENT HEALTH HISTORY

On November 23, 2016 afternoon, VV experienced high fever (38.4C) accompanied by

coughing. Her mother does TSB every 30 minutes to help in lowering the fever. The next
morning, VV is still in fever and his cough became productive which makes his difficulty in
breathing. In the afternoon, his temperature was 37.4C so her parents decided not to visit then
doctor yet.

November 25, 2016 morning, VV's temperature was 38.3 and his breathing was rapid as
described by her mother. This prompted her parents to bring VV in the Hospital. November 25,
2016 2:23 Pm, VV was admitted in St. Paul Hospital.

FAMILY HEALTH HISTORY

VV's paternal grandfather has died and reported to have asthma. His paternal
grandmother has died at the age of 78. His maternal grandfather has died at the age of 67 and his
maternal grandmother died at 66. VV's mother is 46 and reported to have asthma. His father is 49
and reported to have no illness.

GORDON'S 11 FUNCTIONAL HEALTH PATTERN

1. HEALTH PERCEPTION/ HEALTH MANAGEMENT

 VV was reported to be a picky eater and is very active in outdoor activities with his
parents. He was not as healthy as his elder sibling in terms of eating habits. When he is sick,
he tends to be inactive and wanted to carry the whole time. He is also difficult to take a
tablet medicine when he's sick so her mother prefers to buy the syrup or suspension. VV was
also afraid when a nurse comes near him. He cries a lot whenever he's sick and wanted only
his mother to be around him.

2. NUTRITIONAL METABOLIC
VV was a picky eater. He doesn't want to eat his meal if he sees a green color or any
veggies in his plate. He has no difficulty in swallowing or eating. He eats 3-5 times a day.
Before Hospitalization
VV takes his breakfast at around 7 am and eats and usually eats half cup of rice, 2 cuts of
meat/chicken\fish (fried) and sometimes with soup and a glass of milk. every 2-3 hours, he
drinks half glass of milk and a biscuits/cereals as his snack. He takes his lunch at 12nn with
half rice, a meat/fish/chicken and a glass orange juice. He takes his dinner at 7pm with the
same course of meal with milk as his "pampatulog".

During Hospitalization
VV's appetite has decreased as he eats only 1/4 cup of rice per meal. He preferred to eat
fried chicken or fried fish. He eats banana or apple in between meals.

3. ELIMINATION PATTERN
Before Hospitalization
VV was reported to defecate once a day every morning as soon as he wakes up. He also
has no difficulty in voiding as his parents doesn't forget to give him a half-full glass of water
to drink.
During Hospitalization
VV was reported to still have its normal bowel movement. He voids more often than
before as he was advised to increased his oral fluid intake. He was on diapers to avoid going
to the bathroom every now and then.

4. ACTIVITY EXCERCISE PATTERN

Before Hospitalization
VV wakes up at 6:30 Am to defecate and to take a bath. He takes his breakfast together
with his parents before his father go to work. Her mother quit her job to focus on VV. 2
hours after breakfast, her mom starts to give VV some work like picking dried leaves in the
garden, wiping tables and chairs and swiping the floor. After the chores, VV and her mom
will play in the garden as their daily routine.
During Hospitalization
VV is inactive in playing as well as communicating to her mom. He only use his hand
gesture to communicate. His toy car beside him is the only toy he wanted to play during his
hospital stay.
5. SLEEP-REST PATTERN
Before Hospitalization
On usual days, VV sleeps at around 9 after playing and taking a shower. Prior to sleeping,
he plays his toy train, drinks milk and watched some nursery rhymes on internet. He was
reported to be easily disturbed when sleeping, but easily gets his sleep back.
During Hospitalization
VV sleeps not more than 8 hours of sleep as a result of interruptions from any visit/meds
given to him. He also has difficulty in breathing which interrupts his sleep.

6. COGNITIVE-PERCEPTUAL PATTERN
VV is conscious and coherent. Also, he has no sensory deficits. He has clear visions and
good hearing. senses like smell and touch is normal. He has no difficulty in expressing
himself it's just that his speech is not clear to understand. He also follows what his mom
says. He loves when her mom or dad read fairytale stories while on bed.

7. SELF-PERCEPTION PATTERN

8. ROLE RELATIONSHIP PATTERN

VV and her elder sister was their parent's strength and weakness according to her mom.
Her mom described VV as a very loving son and sibling. He's 2 years old but can help in
other household chores.

9. SEXUALITY-REPRODUCTIVE PATTERN
VV had his circumcision when he was 1 year old.

10. COPING STRESS PATTERN

11. VALUE BELIEF PATTERN

VV is baptized as Roman Catholic when he is 8 months old. He was taught to pray and it
was added to his bedtime routines before sleeping. Their family goes to church every sunday.

ANATOMY AND PHYSIOLOGY

The respiratory system is situated in the thorax, and is responsible for gaseous exchange
between the circulatory system and the outside world. Air is taken in via the upper airways (the
nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and
bronchial tree) and into the small bronchioles and alveoli within the lung tissue. The lungs are
divided into lobes; The left lung is composed of the upper lobe, the lower lobe and the lingula (a
small remnant next to the apex of the heart), the right lung is composed of the upper, the middle
and the lower lobes.
The Nose

The uppermost portion of the human respiratory system, the nose is a hollow air passage
that functions in breathing and in the sense of smell. The nasal cavity moistens and warms
incoming air, while small hairs and mucus filter out harmful particles and microorganisms. This
illustration depicts the interior of the human nose. The prominent structure between the eyes that
serves as the entrance to the respiratory tract and contains the olfactory organ. It provides air for
respiration, serves the sense of smell, conditions the air by filtering, warming, and moistening it,
and cleans itself of foreign debris extracted from inhalations.

The Trachea, Bronchi Aviolar Ducts and Avioli

The trachea (windpipe) divides into two main bronchi (also mainstem bronchi), the left and the
right, at the level of the sternal angle at the anatomical point known as the carina. The right main
bronchus is wider, shorter, and more vertical than the left main bronchus. The right main
bronchus subdivides into three lobar bronchi while the left main bronchus divides into two. The
lobar bronchi divide into tertiary bronchi, also known as segmental bronchi, each of which
supplies a bronchopulmonary segment. A bronchopulmonary segment is a division of a lung that
is separated from the rest of the lung by a connective tissue septum.. This property allows a
bronchopulmonary segment to be surgically removed without affecting other segments. There are
ten segments per lung, but due to anatomic development, several segmental bronchi in the left
lung fuse, giving rise to eight. The segmental bronchi divide into many primary bronchioles
which divide into terminal bronchioles, each of which then gives rise to several respiratory
bronchioles, which go on to divide into 2 to 11 alveolar ducts. There are 5 or 6 alveolar sacs
associated with each alveolar duct. The alveolus is the basic anatomical unit of gas exchange in
the lung.

There is hyaline cartilage present in the bronchi, present as irregular rings in the larger bronchi
(and not as regular as in the trachea), and as small plates and islands in the smaller bronchi.
Smooth muscle is present continuously around the bronchi.
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.

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.

The Lungs

The lungs constitute the largest organ in the respiratory system. They play an important role in
respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The
lungs expand and contract up to 20 times per minute taking in and disposing of those gases.

Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one
of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the
breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three
lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of
elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go
through the lung tissue. The pathways are called bronchioles, and they end at microscopic air
sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in
these vessels. The oxygenated blood is then pumped by the heart throughout the body. The
alveoli also take in carbon dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling
results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or
the pleura, that under normal circumstances has a very, very small amount of fluid between the
layers. The fluid allows the membranes to easily slide over each other during breathing.

Mechanics of Breathing

To take a breath in, the external intercostal 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).

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 alveoli 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.